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CPP a form of reflex sympathetic dystrophy? (Small Study).

SAN DIEGO -- Chronic pelvic pain that does not respond to standard treatments such as surgery or drug therapy may be a form of reflex sympathetic dystrophy, according to Dr. Thomas Janicki.

This distinction could have important therapeutic implications, Dr. Janicki said at a meeting sponsored by the International Pelvic Pain Society.

Reflex sympathetic dystrophy represents a maladaptation of the autonomic nervous system, so management of these patients should incorporate strategies that can restore the balance between internal and external environments, such as psychotherapy and stress-reduction techniques.

In a comparison of 16 patients with chronic pelvic pain (CPP) that's lasted at least 1 year and 15 age-matched healthy controls, the CPP patients scored significantly higher on a questionnaire designed to assess the degree of autonomic dysfunction, said Dr. Janicki of Case Western Reserve University in Cleveland.

The mean weighted score among women with CPP was 43, compared with 14 in the control group, indicating higher autonomic dysfunction in the CPP group. To his knowledge, this is the first study to suggest that some cases of CPP may be neurologic in origin.

Clues that a patient may have autonomically related CPP include congestion of pelvic vessels without a clear source of pain and inability to reproduce the pain during an examination.

Several similarities exist between this form of CPP and other pain syndromes that result from autonomic dysfunction. For example, patients with CPP often are extremely sensitive to relatively minor pain stimuli: What's more, the CPP itself may be triggered by conditions such as occult hernias or minimal endometriosis or adhesions. In some patients, transection of the superior hypogastric plexus--part of the autonomic nervous system--reduces pain by more than 50%.

The autonomic nervous system "is the operating system of our body" Dr. Janicki explained. It governs routine functions such as breathing, digestion, and temperature control, and helps the body adapt to unexpected changes in the environment. If those changes become permanent, they can lead to new neuronal connections. He used Pavlov's dog as an example: As it learned to associate food with the sound of a bell, the dog salivated when it heard the bell, suggesting that its autonomic nervous system had developed new synapses. Sometimes those new adjustments are maladaptive. Chronic pain may occur "when an environment is created in which even small impulses are registered and amplified, leading to the perception that physiologic conditions like distention of the bowels or bladder or ovulation are painful," Dr. Janicki said.

In cases that are related to reflex sympathetic dystrophy the autonomic nervous system has developed a maladaptive routine that has pain as an integral component. Frequently these patients have a history of physical or sexual abuse and coexisting conditions such as vulvar vestibulitis, fibromyalgia, or interstitial cystitis.

To test the theory that autonomic dysfunction may cause some cases of CPP, Dr. Janicki and his associates used the Autonomic Symptom Profile, a 169-item questionnaire to cover various aspects of autonomic dysfunction such as orthostatic intolerance, vasomotor problems, autonomic diarrhea and constipation, and sleep disorders. They also used the Composite Autonomic Symptom Scale (COMPASS), a rating system the Mayo group devised from the symptom profile, in which a higher score denotes more autonomic dysfunction. When he and his associates used the COMPASS to compare 16 patients with CPP and 15 controls, there was no difference between the groups in psychosomatic categories.

Further studies will be required to determine if, in a patient scheduled to undergo laparoscopy, it might be helpful to rate her using the COMPASS system first to see if she will improve from surgery alone or if she'll need additional treatment that focuses on stress reduction and developing more effective coping skills, he said.

A description of the Autonomic Symptom Profile and the COMPASS was published in Neurology 52(3):523-28, 1999.
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Author:MacReady, Norra
Publication:OB GYN News
Date:Nov 1, 2002
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