French Urology Journal Puts Focus on Chronic Pelvic Pain

In its special report from the Association Française d’Urologie (AFU) 2010 meeting, the French journal Progrès en Urologie published 46 articles in its November issue on chronic pelvic and perineal pain. The AFU has made a commitment to improving chronic pelvic pain management in urology and developing means of evaluating professional practices. The authors of the article on optimizing urologic care pointed to the need to develop professional guidelines and initial and continued training for providers and to apply professional practice assessment and accreditation in chronic pelvic pain care.

A survey of French urologists demonstrated the need. The survey, answered by 352 urologist members of AFU, showed that chronic pelvic and perineal pain does consume a small, although not insignificant, proportion of their practices. More than half the urologists took care of 20 to 100 new cases every year. But more than two-thirds of the urologists said their knowledge was fair to insufficient. Three-quarters said they would like to get another specialist’s opinion for more than a quarter of their pelvic and perineal pain patients. More than half said that the organization of their daily consult activity was inadequate to manage pelvic and perineal pain, and most said additional specific training programs would be useful.

The AFU recognizes more than IC (termed “painful bladder syndrome”) and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) as pelvic and perineal pain syndromes that urologists need to recognize and treat. The organization also deems pudendal nerve entrapment syndrome, vulvar pain syndrome (vulvodynia), epididymotesticular pain syndrome, and complex pelvic pain syndrome to be conditions that should be included in urologists’ pelvic and perineal pain knowledge and expertise. Based on a literature review, an article proposes treatment algorithms for each of these conditions while emphasizing that these are clinical aids and don’t constitute a comprehensive approach to management.

Other articles recognize the contributions of endometriosis, adhesions, irritable bowel syndrome, proctalgia fugax (severe rectal pain), and musculoskeletal dysfunctions, such as levator ani syndrome, and posterior ramus syndrome (a problem at a vertebral facet joint that can refer pain), to chronic pelvic and perineal pain. Treatments from drugs to physical therapy and neurologic approaches are discussed.

Likely because of work of French pudendal nerve entrapment syndrome pioneer Professor Roger Robert, a number of articles focus on nerve damage as a source of pelvic and perineal pain and give guidance on treatment. Articles are included on nerve damage from surgery and how to manage it, how to test for nerve problems, how to use nerve blocks (which are called an integral part of pelvic and perineal pain management), and when pudendal nerve surgery is appropriate (when all other treatments have failed) and the ways it is performed.

Two articles emphasize the importance of understanding anatomy (including neuroanatomy) well, doing thorough examinations, and taking thorough patient histories so urologists can diagnose the sources of pain correctly and decide on the best treatment approaches. Another article, on the doctor-patient relationship, emphasizes that doctors should believe the patient, avoid making the patient feel responsible for failure, avoid overestimating the secondary benefits, avoid making the patient passive and dependent, learn to reinterpret the patient's symptoms, ask “how” the pain persists rather than “why,” clearly define the patient’s needs, and adapt management to realistic and accessible goals. Because pain is an emotional experience, the type of relationship the doctor has with the patient determines the quality of management, said the authors.

You can read summaries for professionals of each article in the issue at this web page http://www.sciencedirect.com/science/journal/11667087. Click on “show preview” and scroll down for the English-language summary.

Posted November 23, 2010