One in six women has chronic pelvic pain, substantially affecting every aspect of millions of women's personal, family, sexual, social, and work lives. Indeed, chronic pelvic pain often becomes so integrated into daily life that its cause cannot be separated from its effects, one problem becoming superimposed on and then woven into another, so that recognition, diagnosis, and treatment become almost infinitely complex. As a result, this most challenging of clinical problems is often ignored, misdiagnosed, and mistreated, leading to frustration on the part of both the care giver and the patient. The most common conclusion of the search for a cause, and one that profoundly affects the patient-physician relationship, is the physician's stating that "it's all in your head," which absolves the physician (having made the diagnosis and indicated that the patient needs to cure herself) of further responsibility and solidifies the intellectual, emotional, and social isolation of the patient in crisis. Not surprisingly, the resulting anger, frustration, depression, and hopelessness lead to poorer control of the event that initiates the pain, and the vicious circle is further reinforced. Effective intervention in patients with chronic pelvic pain requires a high level of knowledge, clinical skills, and empathy delivered in a comprehensive, integrated manner.
Two excellent textbooks can now help the practitioner who is dealing with patients with chronic pelvic pain. The purpose of Chronic Pelvic Pain: Evaluation and Management is "to furnish the practitioner with a working guide to the diagnosis and management of chronic pelvic pain." This objective is accomplished through thorough chapters on basic anatomy and physiology, evaluation and management, and the role of various organ systems and pathologic processes. The authors document the inadequacies of our current understanding of the problem and critique the available data. Case histories, diagrams, tables, and color photographs add to the presentation.
The role of the mental health professional is recognized, and an important concept is presented: "The model of chronic pain held by a physician influences how a pain problem is evaluated. The physician's behavior, choice of tests, way of educating the patient, and offering recommendations, all communicate his or her way of thinking about pain." Excellent chapters on new interventional techniques in office-based laparoscopy and anesthesiology give a promise of more effective treatments in the future.
Chronic Pelvic Pain: An Integrated Approach is an outstanding textbook whose focus is an integrated approach to chronic pelvic pain. It emphasizes this in chapter 2, "Basic Philosophy of the Integrated Approach: Overcoming the Mind-Body Split," and in the 33 subsequent chapters, comprehensively discussing theories of pain and pain management, anatomy, physiology, pathophysiology, history taking, the physical examination, testing, specific clinical conditions and dilemmas, psychological and social factors, and new interventions. Chapters of special interest include "Pain after Hysterectomy," "Pelvic Congestion," "Taking Care of Patients: The Caregiver's Perspective," and "Research Directions." Throughout this textbook, a comprehensive, holistic, empathetic, yet clinically meaningful approach to the patient with chronic pelvic pain is reinforced by numerous excellent tables and diagrams, algorithms, guidelines, and practical suggestions. The authors are experts who are knowledgeable about clinical practice yet provide the basic science to help one understand a condition in which much of the data are equivocal. They recognize the serious limitations of our current knowledge of chronic pelvic pain, yet focus on what we can accomplish with an integrated mind-body approach. Some topics that should be considered for future editions include dealing with the litigious patient, the use of the Internet in pain management, educating health care professionals about the management of chronic pelvic pain, and issues of cost.
Chronic pelvic pain continues to be a poorly diagnosed and treated clinical condition with incalculable physical, emotional, and economic costs for the affected women; their families, friends, and employers; and society. Both these textbooks will be of value to all practitioners who are trying to help women with the extremely challenging problem of chronic pelvic pain and will help us to improve the management of this condition in the future.
Reviewed by G. David Adamson, M.D.
Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
