Pelvic pain factors associated with poorer quality of life after surgery

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According to a recent survey published in the American Journal of Obstetrics & Gynecology, pelvic pain factors before endometriosis surgery are associated with pain-related quality of life following surgery.

About 1 in 10 women of reproductive age are impacted by endometriosis, which is commonly treated through surgery. Surgery methods for treating endometriosis include fertility-sparing and hysterectomy. Fertility-sparing reduces pain but is associated with a 50% reoperation rate within 5 years because of recurrent pain, and hysterectomy has a 20% recurrent pain rate.

Research on predictors of pain-related outcomes following surgery for endometriosis are limited. Investigation into these factors is complicated because the pathophysiology of endometriosis pain is multifactorial.

To evaluate pain-related quality of life following endometriosis surgery, investigators conducted a prospective longitudinal study. Participants included individuals visiting the BC Women’s Hospital Centre for Pelvic Pain and Endometriosis who were enrolled in the Endometriosis Pelvic Pain Interdisciplinary Cohort (EPPIC).

Baseline data was gathered through patient-reported questionnaires, real-time clinician-reported variables, and surgical findings. Participants were aged 50 years or less and were recruited to EPPIC from December 2013 to December 2018.

Endometriosis was determined by previous diagnosis, diagnosis based on current ovarian endometrioma on ultrasound, or clinical suspicion from assessing gynecologist based on pelvic examination. Participants were also required to receive an index surgery and complete a pain-related quality of life questionnaire. Questionnaires were completed at baseline and follow-up.

Exclusion criteria included undergoing a past hysterectomy or bilateral salpingo-oophorectomy, diagnostic laparoscopy without treatment, or vaginal procedures only, and completing the follow-up questionnairein less than 4 months after index or undergoing reoperation before completing the follow-up questionnaire.

Index surgeries included fertility-sparing surgery or hysterectomy. Gynecologists from the center performed the surgery.

The primary outcome of pain impacting quality of life was measured using an 11-item pain subscale included in the questionnaire. Questions were answered on a 5-point Likert scale, with 0 meaning never, 1 meaning rarely, 2 meaning sometimes, 3 meaning often, and 4 meaning always. Higher scores indicated a poorer quality of life.

Pelvic pain comorbidities evaluated at baseline included abdominal wall pain, pelvic floor myalgia, painful bladder syndrome (PBS), irritable bowel syndrome, Patient Health Questionnaire 9 (PHQ-9) for depression,Generalized Anxiety Disorder 7 (GAD-7) for anxiety, and Pain Catastrophizing Scale (PCS).

There were 44 patients in the analysis, with a 70.4% follow-up rate. Patients were aged a mean 33.7 years at baselines, and a median 18 months occurred between baseline and follow-up. Of index surgeries, 99.1% were performed laparoscopically. Fertility-sparing surgery was seen in 75.2% of patients and hysterectomy in 24.8%.

Complete excision of visible endometriosis disease was reported after 84.8% of surgeries. A complication rate of 2.3% was reported before discharge and 10.6% after discharge. Significant improvements in pain-related quality of life were observed, decreasing from a median 54.6% at baseline to a median 25% after baseline.

Higher abdominal wall pain, pelvic floor myalgia, PBS, PHQ-9 score, GAD-7 score, and PCS score were all associated with increased follow-up questionnaire scores, which indicated lower pain-related quality of life. Compared to fertility-sparing surgery, hysterectomy had lower follow-up scores, indicating a higher pain-related quality of life.

These results indicated decreased pain-related quality of life after surgery in patients with certain pelvic pain conditions. Investigators recommended these factors be considered by clinicians and patients with preoperative pelvic pain conditions when predicting prognosis after endometriosis surgery.

Reference

Tucker DR, Noga HL, Lee C, et al.Pelvic pain comorbidities associated with quality of life after endometriosis surgery. American Journal of Obstetrics & Gynecology. 2023;229(2). doi:10.1016/j.ajog.2023.04.040