Looking Outside The Pelvis In Persistent Pelvic Pain

To achieve positive outcomes for those suffering with PPP, clinicians need to have a strong understanding of the pain system in general. This leads to effective assessment, classification and phenotyping of pain presentations, application of interventions which are person centred and follow principles of best practice precision medicine. 

 

It is important when exploring pelvic pain that we reflect on the contemporary understanding of pain. In 2020 the International Association for the Study of Pain (IASP) updated their definition of pain; 

 

An unpleasant sensory AND emotional experience associated with, or resembling 

that associated with, actual or potential tissue damage².

 

They then outlined 5 key considerations;

This definition and key considerations highlight that a variety of factors will influence an individual’s pain experience, which is why WMHP is committed to utilising a biopsychosocial framework for assessment and treatment of people with persistent pelvic and sexual pain.  

 

The IASP also released a set of clinical criteria that classifies pain into 3 main subtypes²:

 

Nociceptive Pain: Pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors.

Eg Pain around an episiotomy site in the early post-natal period

 

Neuropathic Pain: Pain caused by a lesion or disease of the somatosensory nervous system. 

Eg Pudendal neuralgia  

 

Nociplastic Pain: Pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence of disease or lesion of the somatosensory system causing the pain.

Eg Provoked or Unprovoked Vulvodynia, Bladder pain syndrome,  Endometriosis-Associated Pain, Persistent Pelvic Pain (Primary/Secondary)

 

Mixed Pain: Pain arising from a combination of the above classifications³.

 

Both Primary and Secondary Persistent Pelvic Pain presentations are often nociplastic in nature.  

 

There may also be nociceptive components eg if the presence of endometrial lesions is identified, or if thrush has been confirmed for someone with vulvodynia. Sometimes pain persists despite the nociceptive driver being addressed, eg pain continuing after adequate surgery and hormonal suppression for endometriosis, or vulvodynia symptoms persisting after the infection has been appropriately treated. This may indicate the pain is more nociplastic in nature.  It is important to assess for the presence of nociplastic pain, as poor outcomes are common due to both conservative and surgical treatments targeting a presumed source of nociception³.  

 

There are a number of tools and methods available to identify possible nociplastic pain.  

 

Central Sensitisation Inventory:

The Central Sensitisation Inventory (CSI) is a questionnaire validated in the chronic pain population that has also been studied to help identify nociplastic pain in endometriosis⁴.  A score ≥ 40 on Part A  or 1 or more of the conditions in Part B is strongly correlated with central or nociplastic mechanisms.  

 

Clinical Examination:

Two of the hallmark features of nociplastic pain are allodynia and hyperalgesia:

• Allodynia: Pain due to a stimulus that does not normally provoke pain².  In PPP, one of the tests for allodynia is a Cotton Swab Test (Q-tip test) as well as palpation.  

• Hyperalgesia: Increased pain from a stimulus that normally provokes pain².  

 

Other indicators that suggest Nociplastic Pain:

• Diffuse, widespread pain

• Increased sensitivity to sound and/or light and/or odours

• Sleep disturbance with frequent nocturnal awakenings

• Fatigue

• Cognitive problems such as difficulty with focus and attention, memory disturbances

• Pain modulated by nervous system processing via the following factors; stress, nutrition, sleep, physical activity, cognitions, threatening experiences.  

 

Psychosocial Assessment for PPP

Whilst we ensure the use of objective tests with our biological assessment, too often health professionals make assumptions regarding a persons’ emotional state without accurately having assessed it.  The emotional and psychological burden on the individual is significant, with PPP shown to be associated with depression, anxiety, fatigue, poorer quality of life, difficulty performing activities of daily living, relationship breakdown, sexual dysfunction, and feelings of isolation, hopelessness, and worthlessness.

 

For this reason, the 2022 European Association of Urology guidelines for PPP recommend early assessment of the associated cognitive, behavioural, and emotional factors so that appropriate models of care can be provided to individuals² . There are many well-established and validated screening questionnaires available that assess psychological factors in people with persistent pain but not many of these questionnaires have been specifically designed or tested in the PPP population⁵. 

 

As part of a comprehensive biopsychosocial assessment of nociplastic pain and central modulation, all WMHP Pelvic Health Physiotherapists have been inviting our patients to complete a suite of 11 psychosocial screening questionnaires (that also includes the Insomnia Severity Index and Adverse Childhood Experiences) with all of our PPP patients and others with a sensitised nervous system. We have found patients to be very open to completing these screening tools as they help us to remove any judgement or use of “intuition” around the emotions, thoughts and beliefs that they may have. We use the results of these questionnaires not to diagnose mental health conditions but to help us and our patients have a greater understanding of the factors contributing to their symptoms and to individualise shared decision making around treatment choices. It helps us not just target the tissues with bottom up strategies but to incorporate top down strategies such as pain education, sensory-motor rich exercises, stress management, sleep training and communication skills. It has been our experience that this approach has a significantly positive impact on outcome and achievement of pelvic health goals.

 

In the first study to investigate which psychological factors are the most appropriate to screen for in those with PPP, a group of Health Practitioners from WA, NSW and SA aimed to develop a concise questionnaire.⁵ They hoped the 3PSQ would encourage increased utilisation by clinicians, be user-friendly for patients and specifically target relevant psychological factors in the PPP population⁵. Through an e-Delphi process, they determined which psychological factors should be included and using validated questionnaires, agreed on the most appropriate statement for each factor.⁵ The final list of statements and what they assess from a psychosocial perspective are included in the table below.

 

Anxiety, depression and stress are known to be more prevalent in people with PPP and we see a link between stress and pain-modulating systems, contributing further to persistent pain. Increased levels of health anxiety lead to avoidance, hypervigilance and safety-seeking behaviours. Higher rates of physical and sexual abuse and other trauma are also found in women with PPP⁵.  

 

 

A Call to Action

References