Development of a centre for interdisciplinary care of patients with pelvic pain and endometriosis

Abstract: Pelvic pain and endometri­osis affect many women in British Columbia. The new BC Women’s Cen­tre for Pelvic Pain and Endometrio­sis provides interdisciplinary care for women, including minimally invasive surgery, medical management, pelvic physiotherapy, and cognitive approaches to chronic pain. The centre is also actively involved in re­search and teaching.


Women in British Columbia are benefiting from the surgical, medical, nursing, physiotherapy, and counseling services provided by the BC Women’s Centre for Pelvic Pain and Endometriosis.


Chronic pelvic pain (CPP) is defined as pelvic pain of 3 to 6 months duration. Present in 10% to 20% of reproductive-aged women, CPP has a major impact on women’s health.[1-4] While endometriosis is the most common gynecological cause of CPP, res­ponsible for $1.8 billion in total annual costs in Canada, chronic pelvic pain can also result from musculoskeletal, gastrointestinal, urological, or sometimes psychological comorbidity.[3,5,6

Management of CPP can be challenging because of difficulties in establishing a diagnosis and the complexity of surgical treatments. As well, the development of  central sensitization can result in hy­peralgesia, chronic pain syndrome, and dysfunction in multiple body systems.[7-9

Optimal management of pelvic pain and endometriosis requires an integrated, interdisciplinary approach at a centre offering advanced diag­nostics, a full range of medical and surgical treatments, dedicated nursing services, physiotherapy, counseling, patient education, and small group sessions for patients.

One randomized trial has shown the benefit of an interdisciplinary approach,[10] and the Society of Obstetricians and Gynaecologists of Canada (SOGC) has produced guidelines for CPP that support interdisciplinary care.[5,11] In recognition of the need for such care, the BC Wo­men’s Centre for Pelvic Pain and Endometriosis was launched to provide integrated health services and undertake research. 

Development of the centre
For the past 15 years, specialized care for CPP in the province has been provided by two gynecologists at BC Women’s Hospital and Health Centre. Over time it has become evident that increased capacity and interdisciplinary resources are required to meet the growing demand and to provide optimal care. 

Previously, there was a wait list of 6 to 9 months for a gynecological consultation plus an additional wait of 6 months for surgery if required. Because care was not optimal and many patients could not afford interdisciplinary services in the community, a business case was de­veloped for the creation of the BC Women’s Centre for Pelvic Pain and Endometri­osis. The centre was funded by the Provincial Health Services Authority in 2011 and launched in October 2012. 

Today the centre provides nursing, physiotherapy, and counseling services, and operates with the benefit of administrative infrastructure, much-needed new equipment, expanded OR capacity, and support for a third gynecologist and specialized anesthetic consultation. 

Interdisciplinary care
Patients referred to the BC Women’s Centre for Pelvic Pain and Endomet­riosis undergo comprehensive history taking and examination, including Carnett’s test,[12] bedside endovaginal ultrasound (EVUS) to screen for endometriomas, adenomyosis, and other structural abnormalities, and an EVUS-assisted pain mapping pelvic exam. This exam relies on palpation of the different pelvic structures in order to establish the cause(s) of pain, and was found in a recently completed study at our centre to increase sensitivity for abnormalities later found on laparoscopy. 

After examination, patients may be offered hormonal treatment to manage pelvic pain and endometriosis, or neuromodulators, including tricyclics, SNRIs, and anti-epileptics, if there is evidence of central sensitization. If pain management strategies and nonopioid analgesics are insufficient, the team at the centre may collaborate with the patient’s family phy­sician to consider the judicious use of opioids. When opioids are used, the centre utilizes the Opioid Manager,[13] establishes a narcotic contract, and does urine drug screening. 

As well as medical management, the centre offers a full-range of minimally invasive surgeries, from conservative to definitive (hysterectomy with or without bilateral salpingo-oophorectomy). The primary conservative procedure undertaken is laparoscopic excision of endometriosis tissue using monopolar electrosurgery and a needle-tip L-hook instrument, with the goal of leaving no visible residual disease. Cochrane reviews of conservative surgical treatment of endomet­riosis have confirmed its benefit for both pain and fertility.[14,15

In addition, advanced laparoscopic management is offered for complex cases, including those involving deep infiltrating endometriosis nodules, bowel endo­metriosis and ovarian endometriomas, and severe adhesions. For the most severe cases, an interdisciplinary ap­proach is employed, as recommen­d­ed by the SOGC endometriosis guidelines,[16] with members of the centre team working alongside laparoscopic specialists in general surgery and urology. 

Other procedures offered include laparoscopic ovarian suspension for adhesion prevention,[17] uterine sus­pension for symptomatic uterine ret­roversion[18-20] and inguinal canal de­compression and mesh placement for pa­tients with inguinal tenderness on pelvic exam.[21

In recognition of the role musculo­skeletal causes may play in CPP, des­cribed in the SOGC guidelines,[1] a mus­culoskeletal assessment of the spine, hip, pelvis (sacroiliac and symphysis joints), and pelvic floor is performed. Treatment may include manual therapy (joint, soft tissue, neural mobilization), motor control exercises, posture and positioning recommendations, and bladder/bowel strategies. Surface electrode EMG biofeedback and real-time ultrasound may also be utilized. 

Patient education
Education is key to managing pelvic pain, whatever the cause. At the centre patients are educated about aggravators of their pain, and are taught techniques to independently manage their pain, including relaxation, mindfulness, and pacing and grading. Pa­tients learn about pain theory, the link between mood and pain, and the im­pact of sexual pain. 

Patients are also offered counseling on both an individual and a small group basis. Pa­tients with poor function may be refer­red to community resources for people living with disabilities, chronic pain, or both. A dedicated RN coordinates all the interdisciplinary activities at the centre.

Provincial initiatives
To improve knowledge translation and link between different services for patients with chronic pain, Pain BC was formed in 2009. Other initiatives followed, including a province-wide pain specialist hotline, community-based undertakings such as the Chronic Pain Self-Management Program offered through the University of Victoria, and patient-led organizations such as the People in Pain Network. Work also began in September 2012 on a province-wide Practice Support Program for continuing education in pain management for family physicians. 

Members of the team at BC Wo­men’s Centre for Pelvic Pain and Endometriosis are actively involved in engaging with all these province-wide initiatives and integrating them into care offered at the centre. Recently, the centre developed an online needs assessment survey for all obstetrician/gynecologists in BC, and initiatives involving phone support, videoconferencing, and online re­sourc­es are being developed for both rural and urban communities throughout the province.

Research and teaching
Members of the team at the centre are actively involved in research and have conducted retrospective studies of pelvic pain and endometriosis.[21-23] Over the last year, the team established standardized protocols for clinical care, including the use of validated questionnaires.[24,25] Ethics approval has been obtained for prospective data collection to evaluate patient outcomes and to develop clinical pathways for the management of pelvic pain and endometriosis. The database is expected to serve as a springboard for future randomized trials. 

In addition, a translational re­search program has begun at the centre in collaboration with pathologists at Vancouver Hospital and the BC Ovarian Cancer Research team. After patient consent is obtained, endometriosis specimens collected during surgery are banked for genomic studies. These specimens will be key to the development of a UBC endometriosis tissue bank. 

The centre also continues to be ac­tively involved in the training of medical students, residents, and fellows.

Summary
Pelvic pain and endometriosis have a major impact on the lives of women in their reproductive years and result in significant costs to the Canadian health care system. The BC Women’s Centre for Pelvic Pain and Endomet­riosis aims to be a useful resource for both health care practitioners and the women of British Columbia by providing effective and comprehensive care and engaging in high-quality research. The centre also aims to further the education of both patients and health care providers in endometriosis and chronic pelvic pain. 

Acknowledgment
Thanks to Catherine Maurer, RN, for re­viewing the manuscript.


References

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Dr Yong is a member of the team at the BC Women’s Centre for Pelvic Pain and Endometriosis. He is also an assistant professor in the Division of Gynaecologic Specialties, Department of Obstetrics and Gynaecology, University of British Columbia. Dr Williams is a member of the team at the BC Women’s Centre for Pelvic Pain and Endometriosis. She is also a clinical associate professor in the Division of Reproductive Endocrinology and Infertility at UBC. Ms Houlihan is an administrator at the BC Women’s Centre for Pelvic Pain and Endometriosis, while Ms Yager is a counsellor at the centre, and Ms Britnell is a physiotherapist at the centre. Dr Lau is a consultant for the BC Women’s Centre for Pelvic Pain and Endometriosis. She is also a clinical associate professor in the Department of Anesthesiology, Pharmacology, and Therapeutics at UBC. Dr Allaire is a member of the team at the BC Women’s Centre for Pelvic Pain and Endometriosis. She is also a clinical associate professor in the Division of Reproductive Endocrinology and Infertility.

Paul J. Yong, MD, PhD, FRCSC,, Christina Williams, MD, FRCSC,, Edwina Houlihan, BScN,, Holly Yager, MEd,, Susannah Britnell, BSc(Hons)PT,, Brenda Lau, MD, FRCPC, FFPMANZCA, CGMIS, MM, Catherine Allaire, MDCM, FRCSC,. Development of a centre for interdisciplinary care of patients with pelvic pain and endometriosis. BCMJ, Vol. 55, No. 5, June, 2013, Page(s) 244-247 - Clinical Articles.



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