Ploteau Stéphane, Labat Jean Jacques, Riant Thibault, Levesque Amélie, Robert Roger, Nizard Julien
Department of Anatomy, Faculty of Medicine; Federative Center of Pelvi-Perineology; and Department of Gynecology, Obstetrics and Reproductive Medicine; University Hospital, Nantes, France.
Federative Center of Pelvi-Perineology, University Hospital, Nantes, France.
Discov Med. 2015 Mar;19(104):185-92.
The management of chronic pelvic and perineal pain has been improved by a better understanding of the mechanisms of this pain and an optimized integrated multidisciplinary approach to the patient. The concept of organic lesions responsible for a persistent nociceptive factor has gradually been replaced by that of dysregulation of nociceptive messages derived from the pelvis and perineum. In this setting, painful diseases identified by organ specialists are usually also involved and share several common denominators (triggering factors, predisposing clinical context). These diseases include painful bladder syndrome, irritable bowel syndrome, vulvodynia, and chronic pelvic pain syndrome. The painful symptoms vary from one individual to another and according to his or her capacity to activate pain inhibition/control processes. Although the patient often attributes chronic pain to a particular organ (with the corollary that pain will persist until the organ has been treated), this pain is generally no longer derived from the organ but is expressed via this organ. Several types of clinical presentation of complex pelvic pain have therefore been pragmatically identified to facilitate the management of treatment failures resulting from a purely organ-based approach, which can also reinforce the patient's impression of incurability. These subtypes correspond to neuropathic pain, central sensitization (fibromyalgia), complex regional pain syndrome, and emotional components similar to those observed in post-traumatic stress disorder. These various components are also often associated and self-perpetuating. Consequently, when pelvic pain cannot be explained by an organ disease, this model, using each of these four components associated with their specific mechanisms, can be used to propose personalized treatment options and also to identify patients at high risk of postoperative pelvic pain (multi-operated patients, central sensitization, post-traumatic stress disorder, etc.), which constitutes a major challenge for prevention of these types of pain that have major implications for patients and society.
对慢性盆腔和会阴疼痛机制的更好理解以及针对患者的优化综合多学科方法,改善了对这种疼痛的管理。由持续伤害性因素引起的器质性病变概念,已逐渐被源自骨盆和会阴的伤害性信息调节异常的概念所取代。在这种情况下,器官专科医生所识别出的疼痛性疾病通常也会涉及其中,并具有几个共同特征(触发因素、易感临床背景)。这些疾病包括疼痛性膀胱综合征、肠易激综合征、外阴痛和慢性盆腔疼痛综合征。疼痛症状因人而异,并取决于其激活疼痛抑制/控制过程的能力。尽管患者常常将慢性疼痛归因于某个特定器官(必然结果是,在该器官得到治疗之前疼痛将持续存在),但这种疼痛通常不再源于该器官,而是通过该器官表现出来。因此,已从实用角度确定了几种复杂盆腔疼痛的临床表现类型,以促进因单纯基于器官的方法导致治疗失败的管理,而这种方法也可能强化患者的不治之症印象。这些亚型对应于神经性疼痛、中枢敏化(纤维肌痛)、复杂性区域疼痛综合征以及类似于创伤后应激障碍中观察到的情绪成分。这些不同成分也常常相互关联且自我持续存在。因此,当盆腔疼痛无法用器官疾病解释时,使用这四个与特定机制相关的成分中的每一个的这种模型,可用于提出个性化治疗方案,还可识别术后盆腔疼痛高危患者(多次手术患者、中枢敏化、创伤后应激障碍等),这对预防这类对患者和社会有重大影响的疼痛构成了重大挑战。