Which women are most at risk for pain after gynecologic laparoscopy? Although pelvic pain may be caused by a preexisting condition, it is a diagnostic challenge, because pelvic surgery is often used to treat painful conditions. Therefore, continuing pain may be attributed to the persistence or recurrence of the condition or to the laparoscopy, say researchers from University of Calgary and University of Alberta, both in Canada, and University of Chieti in Italy.
The researchers gave 77 women questionnaires measuring depression, perception of pain, and tendency to catastrophize. The researchers also did preoperative tests for sensitivity to pain. All the women were invited to return to the gynecology clinic 6 months after surgery at which point the questionnaires and sensitivity tests were repeated.
Of the participants, 61 had undergone laparoscopic gynecologic surgery for painful conditions and 16 had undergone tubal ligation. Only the women with pain were using narcotics and analgesics. More than half of those women reported having had other abdominal surgery, including laparoscopy, laparotomy, and adnexal surgeries.
Preoperatively, the average pain rating was 5 (range, 0-8.5). After the surgery, the median pain rating was 3 (range, 0-8.0), for a mean change of -1.8 (P < .001). Reported average pain dropped significantly, mainly in women who had reported continuous pain (P = .003). (In women who underwent tubal ligation, pain levels were low before and after the procedure.)
Ten women had more pain after surgery; 46 had less pain. Depression, catastrophizing, disability, and quality of life were all significantly improved. Women with preoperative pain had a significant reduction in pain at 6 months (P < .001) but still had higher levels than did women without preoperative pain. Among women who underwent laparoscopy for nonacute pain, most reported less pain. Baseline pain score, catastrophizing score, and the presence of allodynia significantly predicted pain levels at 6 months (P = .629).
Positive sensitization results were associated with a greater reduction in average pain than when those tests were negative. The reduction in pain was associated primarily with a reduction in women who experienced continuous pelvic pain rather than cyclic or sporadic pain. This suggests, the researchers say, that continuous pain may be another aspect of sensitization.
The objective of the laparoscopic approach is to remove sources of pain from visceral structures such as endometriotic nodules, the researchers note. That kind of pain has been identified as related to inflammation, so surgery to remove such nociceptive foci might have an effect on visceral pain. In this study, 10 of 25 women with signs of sensitization had those signs eliminated, a finding that was “not completely unexpected,” the researchers say.
Interestingly, allodynia developed de novo postoperatively in 7 women. The researchers say that may indicate that one possible reason for persistent pain in pelvic visceral surgery may be the de novo development of a nociceptive focus.
The test for cutaneous allodynia is simple—requiring only a simple swab test—and readily accepted by patients, the researchers say. Using that test along with psychological tests may help improve surgical outcomes.
Source
Jarrell J, Ross S, Robert M, et al. Am J Obstet Gynecol. 2014;211(4):360.e1-360.e8.
doi: 10.1016/j.ajog.2014.04.010.