Evaluation of laparoscopy results for the patients with chronic pelvic pain

laparoscopy results


INTRODUCTION
Chronic pelvic pain (CPPS) is any pain in the pelvic area unrelated to pregnancy, menstruation, and sexual intercourse, which has lasted at least six months or more and has no known organic cause (1)(2)(3).Gynecological, urological, digestive, and musculoskeletal factors and psychological issues have been proposed as effective causes of this complication (3)(4)(5).The complexity of the variety of pelvic pain causes these patients not to receive a definitive diagnosis in more than 60% of cases, and this point is especially evident in the case of musculoskeletal factors (5)(6)(7).The prevalence of this pain in different societies, according to the characteristics of the studied society and the method of conducting the study, has been reported to be between 8.3-39% (7,8).Diagnosing and treating CPPS accounts for 10% of visits to obstetricians and gynecologists, 20% of all laparoscopies, and 12-16 hysterectomies, which in the United States cost over $2.8 billion per year (5).According to an estimate (8), 158 million pounds are spent annually on diagnosing and treating this condition in the British National Health Service.This pain affects women's daily activities and quality of life and negatively affects their mental and physical health (8,9).Mak et al. (10) reported the prevalence of CPPS as 39% in a hospital-based study of 559 people.A study by Faul et al. (11) on 581 women showed that 39% had pelvic pain, 46 had painful intercourse, 9% had painful menstruation, and 12 had irritable bowel syndrome.Horne et al. (9) reported an annual incidence of CPPS in the UK of 38 cases per 1,000 women aged 15-73.In another study, among 3916 women aged 18-49 years, the prevalence of CPPS in the form of recurring pain with a fixed duration and at least six months unrelated to sexual intercourse, pregnancy and dysmenorrhea were reported as 24% (6).Argentino et al. (3) reported a study in New Zealand on 2,261 women aged 18-50 years that among the participants, the three-month prevalence of chronic pelvic pain was 25.4%, and about half of these women (47.7%) were undiagnosed.Singh et al. (12) showed that until that date, only 18 epidemiological studies were conducted on the frequency of non-periodic pelvic pain, which was reported as 1.2-24%.The studies conducted on the frequency of CPPS while expressing the importance and extent of the issue and the need to address it, indicate that there is still no consensus among researchers, even on the basic concepts and definition of CPPS, which causes dispersion in the findings of epidemiological studies.Therefore, the necessity of further investigations considering the diversity of demographic indicators in terms of the living environment, especially in developing societies, is raised.
Patients with unknown pelvic pain are a typical case of visiting the emergency room, which has always been a problem.These patients are hospitalized for several days without a diagnosis or by taking various radiographs, tests, sonography, and computed tomography scan, or even surgery without pathology, suffer a lot of cost and waste of time.Laparoscopy, a relatively less invasive new method, allows access to the entire abdominal and pelvic cavity except for the kidneys with multiple magnifications (5)(6)(7).This is a diagnostic and therapeutic method with a high percentage and can be an alternative to diagnostic laparotomy (13).The study aims to retrospectively evaluate the laparoscopy results of patients who underwent laparoscopy with the diagnosis of CPPS.

MATERIAL AND METHOD
The study was carried out with the permission of Bezmialem Vakıf University Non-interventional Clinical Research Ethics Committee (Date: 6/9/2022, Decision No: 2022/261).All procedures were carried out in accordance with the ethical rules and the principles of the Declaration of Helsinki.With the ethics committee approval, the data were scanned retrospectively using the hospital ınformation management system between December 2017-March 2022.
A total of 170 patients who underwent laparoscopy due to CPPS were included in the study.The patients were divided into two groups: the CPPS and unexplained infertility group (n: 83) as the case group and the chronic pelvic pain fertile group (n: 87) as the control group.Women aged 25-40 years with unexplained infertility and chronic pelvic pain were included in the study.Those with a previous history of laparoscopy, diagnosed with endometriosis, male infertility, tubal factor, or ovulatory dysfunction were excluded from the study.
The Visual Analogue Scale (VAS) measures pain intensity.The VAS consists of a 10cm line, with two endpoints representing 0 ('no pain') and 10 ('pain as bad as it could possibly be').VAS scores were found in patient files and recorded.

Statistical Analysis
The Kolmogorov-Smirnov test was performed to check the normality, and the nonparametric tests were performed given the groups' non-normality before the statistical analyses.Mean and standard deviations (SD) were measured to check each continuous variable, including age, body mass index (BMI), the duration of pain, CA-125, VAS.The Mann-Whitney U test was performed to study the difference between the two groups.SPSS v22 was used for statistical analyses.A value of p<0.05 was accepted as statistically significant.
To calculate the sample size with the G-Power 3.1 program, two groups' total mean was measured based on the Mann-Whitney test with the power of 95%, effect size of 50%, and 0.05 type 1 error for at least 92 patients (11).

RESULTS
This study included one hundred seventy age-matched (32.46 ± 3.43) and BMI-matched (24.65±2.08)women.Table 1 shows descriptive statistics of study parameters.The average pain duration in women was 5.06±1.71.The average CA-125 score in women was 27.91±13.69).The average women's VAS of pain score was 6.3±1.34).Table 2 shows the comparison of laboratory findings of the nominal study parameters.
As stated in Table 2, a chi-square test found a statistically significant association between infertility in women and laparoscopy results (p<0.001).The Pairwise Z-Tests found that the ovarian cyst in women in the control group was significantly higher than in the case group.The Pairwise Z-Tests found that the Adhesion in women in the control group was significantly higher than in the case group.The Pairwise Z-Tests found that the hydrosalpenx in women in the case group was significantly higher than in the control group.The Pairwise Z-Tests found that the endometriosis in women in the case group was significantly higher than in the control group.The Pairwise Z-Tests found that the no pathology detected in patients in the control group was significantly higher than in the case group.Table 2 shows that the history of previous surgery was significantly higher in the case group(p<0.05).There was no statistically significant association between infertility in women and symptoms (p> 0.05).There was no statistically significant association between women's infertility and smoking status (p> 0.05).Table 3 shows the comparison of laparoscopy results case and control groups on the numeric study parameters.As stated in Table 3, a Mann-Whitney test did not find a statistically significant association between case and control regarding age and BMI (p>0.05).There was a statistically significant difference between groups in terms of the duration of pain (p<0.05).The duration of pain in the case group 5.34±1.67 was higher than the duration of pain in controls 4.8±1.72.
There was a statistically significant difference between groups regarding the CA-125 (p>0.05).The mean CA-125 score in case group 28.77±13.41was comparable to controls 27.09±13.98.There was a statistically significant difference between the case group and controls regarding the VAS (p<0.05).The VAS in the case group 6.05±1.3)was lower than controls 6.54±1.34.

DISCUSSION
The present study investigated the laparoscopy results of two fertile and infertile groups with CPPS.The results showed that the duration of pain in the infertile group was significantly higher than in the fertile group.The findings of this study are consistent with previous studies (7-9, 13-16).Sallis et al. (17), in a similar study, pointed out the positive relationship between infertility and CPPS.Also, the studies in this field generally prefer laparoscopy over the laparotomy method due to fewer complications and injuries (13)(14)(15)(16).
Since endometriosis was a known pathology in more than 75% of the participants in the infertile group, endometriosis can be introduced as one of the leading causes of CPPS in infertile patients.Pain is a serious concern for women with endometriosis and may affect the quality of life in various ways.More than 50% of women with endometriosis suffer from pain during intercourse (dyspareunia) (10,18).In our study, 32.9% of the participants suffered from dyspareunia.Several studies show a correlation between dyspareunia and uterosacral or rectovaginal endometriosis (10,(13)(14)(15)(16)(18)(19)(20).
According to studies, psychological factors, along with physical causes, which cause chronic pelvic pain, affect the differential diagnosis of this disease.The psychological factors, such as the quality of sleep, the existence of stressful factors, anxiety, and depression, and the physical factors, such as sexual abuse experience and sexual complications, such as decreased sexual desire, painful intercourse, and orgasm problems, are the mentioned causes of CPPS (19,20).According to the studies, psychological factors sometimes make a person prone to CPPS or are involved in accelerating the illness and pushing the illness towards its chronicity (21,22).
The present study showed a significant relationship between infertility, endometriosis, and dyspareunia.Painful intercourse can cause anxiety and fear of pain, aggravate spasms of pelvic floor muscles, and as a result, cause CPPS (22).Also, endometriosis, similar to pain, has an effect on people's mental states and personalities (21).Previous studies have shown that endometriosis negatively affects a person's self-image and causes loss of physical strength and fertility (17,22,23).Mothers who have daughters are concerned that their daughters may develop endometriosis in the future and suffer from pain and infertility (17).It should be noted that not only the pain caused by endometriosis but also the emotional problems associated with this disease, such as feelings of guilt and distress at work, are effective on the quality of life, and all these cases can be effective in aggravating CPPS (12,24).
Although, according to the general definition, CPPS is defined as pain with no structural cause (13), in some sources, endometriosis, adhesions, irritable bowel syndrome, and interstitial cysts have been proposed as four common causes of this complication (12).In the present study, 35.3% of the studied women suffered from dysmenorrhea, which was significantly higher in the infertile group.These findings were consistent with the findings of previous studies (8,12,(16)(17)(18)21).Also, there was a significant correlation between the history of surgery between the two groups with CPPS, which is consistent with previous studies (24,25).
Since all the people participating in this study were selected retrospective, the above findings can be limited to the study community's scope.Comparative and community-based studies with more samples are recommended for more accurate conclusions about the findings based on geographical differences.

CONCLUSION
The present study results showed that the duration of pain in the infertile group was significantly higher than in the fertile group, which could mainly be attributed to endometriosis.In order to reach a definitive diagnosis and plan the treatment, laparoscopy is necessary to investigate the etiology of CPPS in cases where no pathology is detected by pelvic examination and ultrasonography.

Table 2 .
Comparison of laparoscopy results of the nominal study parameters *Pearson Chi-Square Test, † The Pairwise Z-Tests, PCOS: Polycystic ovary syndrome , PID: Pelvic inflammatory disease , GIS: Gastrointestinal symptoms

Table 3 .
Comparison of laparoscopy results of the numeric study parameters M, Mean; N, number of subjects; BMI, body mass index; All variables were tested by a Mann-Whitney U test.
The study was carried out with the permission of Bezmialem Vakıf University Noninterventional Clinical Researches Ethics Committee (Date: 6/9/2022, Decision No: 2022/261).Informed Consent: Because the study was designed retrospectively, no written informed consent form was obtained from patients.Referee Evaluation Process: Externally peer-reviewed.Conflict of Interest Statement: The authors have no conflicts of interest to declare.Financial Disclosure: The authors declared that this study has received no financial support.Author Contributions: All of the authors declare that they have all participated in the design, execution, and analysis of the paper, and that they have approved the final version.
Ethics Committee Approval: