Urogenital Pain in Clinical Practice PDF

Preface

It is difficult to get a handle on the true incidence and prevalence of urogenital pain. However, the general consensus is that chronic pain is one of the most common reasons for seeking primary care medical advice, and that appears as true for urogenital visits as for any other system disorder. In a proportion of cases, the pain will be indicative of a pathological process that is amenable to evidence-based management, with the condition and disease mechanisms being clearly defined. This book is not about that group of patients; it is about the even larger group of patients where the diagnosis is not clear-cut, and the mechanisms of the pathology and pain are even more obscure. This book aims to help professionals who are called upon to manage that group of patients-specialists from many fields: pain medicine, urology, gynecology, internal medicine, neurology, psychology, counseling, nursing, and family medicine, to name but a few. We have tried to be comprehensive so that basic principles are covered for those with limited experience in the field, and also to present the specialist end to support specialists in an evidenced-based approach. Because this book is the first attempt to be truly multidisciplinary and comprehensive in managing all the needs of this group of patients, we have divided it into four parts: (i) General Mechanisms-Anatomy, Physiology, and Pathophysiology; (ii) The Multidisciplinary Approach; (iii) The Pain Syndromes; and (iv) The Therapeutic Spectrum.

Doctors offer this group of suffering patients poorly defined conditions with names like prostatitis, orchitis, and vulvodynia that have no relationship to underlying mechanisms. Such spurious terms may result in inappropriate investigations as well as treatments, unreasonable doctor and patient expectations. Doctors send patients from one specialist to another in the hope that the specialist will find a cause and also to pass on the responsibility of caring for the patient. Patients "doctor shop," a phenomenon that is fueled by the internet and, on occasion, by other patients. The article, "A New Classification is Needed for Pelvic Pain Syndromes-Are Existing Terminologies of Spurious Diagnostic Authority Bad for Patients?" [to which the three editors of this book contributed (1)] highlights this problem and makes a plea for a chronic pelvic pain disorders classification system that is easy to use and reflects the limitations of our current understanding.

We hope that this book takes up the theme of that editorial in which a new approach to the management of chronic urogenital pain is suggested. The editors have a long history of trying to move this process forward, and they have also contributed to several reviews and guidelines with the aim of seeing improvement in the management of this difficult area (2-4).

Pain is a symptom, and, in the absence of a classical disease process that requires treatment in its own right, the symptom needs to be managed. There are two aspects to this:

1. The mechanism of the pain can be managed.

2. The effects of the pain on the patient can be managed.

Part of this book covers urogenital pain mechanisms and their management. In certain cases, recent understanding of what was a poorly understood disease process has led to a better description of the underlying disease (for instance, pudendal neuralgia or pelvic floor muscle triggerpoints), and specific treatments related to that process have been suggested (e.g., pudendal nerve blocks and decompressive surgery, or trigger-point release, respectively). In many cases, the evidence base remains weak, but progress is being made. In many other cases, the pathology remains a complete mystery. Many chapters deal with such pain conditions, trying to lay out clearly what is known and to provide an evidence-based approach to management. Major advances in understanding the nature of pain, its pathways, and its chemical neuromodulation are likely to lead to new interventions. Pain can thus be treated as a disease process in its own right. Several of the chapters in this book cover that.

This book also looks at the effect of the pain on the patient and its impact on the patient's family, society, and the medical profession. Multiple chapters cover the emotional and sexual problems associated with chronic urogenital pain. It is well established that management of secondary effects can produce major benefits for patients by reducing disability (physical, emotional, and sexual), and thereby improving quality-of-life. This section of the book is as important as the sections on physical mechanisms and their management. Many would say more important!

Much of the work of the editors over the years has involved trying to rationalize the management of this group of patients. There are two important processes that need to be undertaken. Firstly, a better classification system of the pain syndromes needs to be developed. Secondly, the need for multidisciplinary integrated management has to be taken on board.

The International Continence Society document (Abrams) recognized that when the mechanism for a patient's urogenital pain condition cannot be clearly defined, it is better to present the patient as suffering with a pain syndrome that describes the symptoms and anatomical site, if possible, of the perceived pain. This process was adopted, along with the International Association for the Study of Pain classification (5), in the European Association of Urology guidelines on chronic pelvic pain (3) and is currently being developed to include the multidimensional aspects of pain such as psychological, sexual, and social.

In classifying a person and his or her pain this way, it is intended that the patient is managed in a holistic way and that the role of the multidisciplinary group is clearly identified.