Adhesions and Chronic Pelvic Pain (CPP)
ADHESIONS are believed to cause pelvic pain by tethering
down organs and tissues, causing traction (pulling)
of nerves. Nerve endings may become entrapped
within a developing adhesion. If the bowel becomes
obstructed, distention will cause pain.
Some patients in whom chronic pelvic pain has lasted
more than six months may develop "Chronic Pelvic
Pain Syndrome. In addition to the chronic
pain, emotional and behavioral changes appear due to
the duration of the pain and its associated stress.
According to the International
Pelvic Pain Society:
"We have all been taught
from infancy to avoid pain. However, when
pain is persistent and there seems to be
no remedy, it creates tremendous tension.
Most of us think of pain as being a symptom
of tissue injury. However, in chronic pelvic
pain almost always the tissue injury has
ceased but the pain continues. This leads
to a very important distinction between
chronic pelvic pain and episodes of other
pain that we might experience during our
life: usually pain is a symptom, but in
chronic pelvic pain, pain becomes the disease."
Chronic pelvic pain is estimated to affect nearly 15%
of women between 18 and 50 (Mathias et al., 1996).
Other estimates arrive at between 200,000 and 2 million
women in the United States (Paul,
1998). The economic effects are also quite
staggering. In a survey of households, Mathias
et al. (1996) estimated that direct medical costs for
outpatient visits for chronic pelvic pain for the U.S.
population of women aged 18-50 years are $881.5 million
per year. Among 548 employed respondents, 15%
reported time lost from paid work and 45% reported reduced
Not all ADHESIONS cause pain, and not all pain is
caused by ADHESIONS.
Not all surgeons, particularly general surgeons, agree
cause pain. Part of the problem seems to be
that it is not easy to observe ADHESIONS non-invasively,
for example with MRI or CT scans. However, several studies
do describe the relationship
between pain and adhesions. According to an early
study (Rosenthal et al., 1984) of patients reporting
CPP, about 40% have adhesions only, and another 17%
have endometriosis (with or without adhesions).
Kresch et al., (1984) also studied 100 women and found
ADHESIONS in 38% of the cases and endometriosis in another
32%. Overall estimates (Howard, 1993) of the percentage
of patients with CPP and ADHESIONS is about 25%, with
endometriosis accounting for another 28%. These
figures must be understood in their context, and I recommend
highly Howard's article.
It is important to recognize that emotional stress
contributes greatly to the patients perception
of pain and her/his ability to deal with the pain.
Rosenthal et al. (1984) found that of the patients
in whom a possible physical cause of pain (including
ADHESIONS) could be identified, 75% had evidence of
psychological influences on the pain.