Chronic Pelvic Pain (CPP)
In the next few months nearly 3 years of focused effort will come to fruition, with the publication of this book (by Elsevier/ChurchillLivingstone) – coedited by Dr Ruth Lovegrove and myself, with input from around 20 experts including:
Rodney Anderson, Andrew Baranowski, Andry Vleeming, Howard Glazer, Christopher Gilbert, Maria Adele Giamberardino, Diane Lee, Linda-Joy Lee, Bill Taylor, Stephanie Prendergast, Elizabeth Rummer, Cesar Fernandez de las Penas, Andrzej Pilat, Maeve Whelan, Michael Seffinger, Melicien Tettambel, Hallie Robbins, Jan Dommerholt, Tracey Adler and Eric Blake
Dr Lovegrove and I start the book with these words – which gives a fair representation of the aims:
“This book has a single primary aim – to offer a one-stop source of relevant information for clinicians – specialists, practitioners and therapists – on the subject of non-malignant chronic pelvic pain (CPP), with particular emphasis on current trends in physical medicine approaches to assessment, treatment, management and care.“
Traditional methods have failed
There would be little need for this book, were current treatment strategies that focus on CPP, proving successful.
Anderson (2006) has observed that traditional medical therapy to treat CPP conditions has failed, ‘whether involving antibiotics, anti-androgens, antiinflammatories, a-blockers, thermal or surgical therapies, and virtually all phytoceutical approaches’.
Shoskes & Katz (2005) concur – demonstrating that a series of monotherapies, used to treat hundreds of men with prostatitis, resulted in only 19% reporting any relief of symptoms.
Successful physical therapy approach
In contrast a randomized clinical trial designed to assess the feasibility of conducting a full-scale trial of physical therapy methods in 48 patients with urological CPPS has shown promise (Fitzgerald et al. 2009).
This study compared two methods of manual therapy; myofascial physical therapy and global therapeutic massage. The global response assessment response rate of 57% in the myofascial physical therapy group was significantly higher than the rate of 21% in the global therapeutic massage treatment group (P = 0.03) suggesting a beneficial effect for myofascial physical therapy.
Not all somatic
But a purely somatic approach is also flawed.
Pontari & Ruggieri (2008) note that the symptoms of CP/CPPS appear to result from interplay between psychological factors and dysfunction in the immune, neurological and endocrine systems.
It therefore seems unarguable that therapeutic approaches should adopt strategies that take account of these multiple interacting factors. And this is precisely the approach that this book takes.
Throughout the book, there is an emphasis on a background of different influences that may accompany the evolution of CPP, and its associated symptoms.
Identifying the particular influences that have caused, maintained and/or exacerbated a CPP patient’s condition is therefore an appropriate clinical ambition.
In the context of this book, a further ambition is the identification of those influences that may be amenable to therapeutic attention involving physical medicine.
Ideally the patient and therapist can move away from the solely structural pathological model, to one that considers for example, the brain in pain, their beliefs about their pain, nutritional issues, in addition to any pathology or motor control issues.
For example, there is evidence that understanding pain reduces the threat of it, altering patients’ attitudes and beliefs, increasing pain thresholds, and when combined with physiotherapy, reduces pain and disability (Moseley 2007).
It is therefore important to understand what the patient believes the pain means and help explain modern pain biology, thereby reducing the patients’ attitude and beliefs.
Currently most treatment options for CPP are empirical, so there is a great requirement for careful clinical reasoning when approaching the management of a patient with CPP, if indeed we are to do no harm.
These thoughts have been considered by all the contributors and both editors – with Diane Lee and Linda Joy Lee providing an excellent chapter to guide the reader through the CPP maze towards clearer clinical decision making.
A quote from their chapter offers a flavor of the guidance on offer:
“As clinicians have long recognized, it is now widely accepted that patients with pain do not form homogeneous populations, but consist of multiple subgroups with different combinations of underlying impairments (physical and psychosocial), and these subgroups require different treatment approaches for best outcomes. Furthermore, given that multiple factors contribute to pain, it is also unrealistic to expect that one single type of treatment modality will resolve a patient’s presenting pain and functional limitations………….In our experience, there are no recipes, prediction rules or guidelines for patients presenting with chronic pelvic disability with or without pain and it is likely that a multimodel approach will always be more effective for long-term success.”
Anderson, R., 2008. The Role of Pelvic Floor Therapies in Chronic Pelvic Pain Syndromes Current Prostate
Reports. 6, 139–144.
Fitzgerald, M.P., Anderson, R., Potts, J., et al., 2009. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. J.Urol. 182 (2), 570–580.
Moseley, G.L., 2007. Reconceptualising pain according to modern pain science. Phys. Ther. Rev. 12 (3), 169–178.
Pontari, M., Ruggieri, M., 2008. Mechanisms in prostatitis/chronic pelvic pain syndrome. Urology 179, S61–S67.
Shoskes, D., Katz, E., 2005. Multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome. Curr. Urol. Rep. 6 (4), 296–299.