Chronic Pelvic Pain (CPP) is a common and often perplexing condition affecting an estimated 15-24% of women age 18-59 years old [1,2]. It can have devastating effects on a woman’s general health and quality of life. Because there are many possible causes and contributors to pelvic pain, it can be difficult to diagnose and treat. Laparoscopy is part of the evaluation and treatment of CPP, when empiric medical management is not successful or not desired by the patient. The most common cause of pelvic pain in women is endometriosis [3]. Endometriosis requires surgical biopsy for formal diagnosis, and is thought to occur in 10% of reproductive age women and therefore carries a considerable health burden [4]. It accounts for $22 billion in annual costs in the United States [5], and results in an average of 10.8 hours lost work per week for each woman with endometriosis [6]. Endometriosis and a variety of other conditions that cause CPP are in the realm of expertise of Obstetrician-Gynaecologists (OB-GYNs), and therefore CPP accounts for an estimated 30% of visits to OB-GYN’s offices. There are only a few published surveys of physicians involving CPP [7-10]. These surveys were done in Europe and Brazil, and may not be applicable to the Canada.

For 15 years, British Columbia Women’s Hospital in Vancouver, Canada, has housed 2 gynaecologists (CA, CW) who have a special interest and active clinical practice in the management of endometriosis and CPP. In 2011 funding was obtained through the Provincial Health Services Authority for the creation of a tertiary referral centre, the British Columbia Women’s Centre for Pelvic Pain and Endometriosis. The funding includes support for nursing, physiotherapy and counselling services, administrative infrastructure, equipment, expansion of OR capacity, and support for a third gynaecologist (PY) and anaesthesiologist consultation (BL). As the Centre is under the umbrella of the Provincial Health Services Authority, there is a clear mandate to service the entire Province of British Columbia for these conditions and provide outreach, support and clinical pathways for our health care colleagues managing these patients.

To better understand the current practices and needs of our specialist community and to help fulfill our Provincial mandate, a needs assessment survey was created and deployed by e-mail to the OB-GYNs of British Columbia in June 2012.

Ethics approval was sought and granted by the University of British Columbia Research Ethics Board (H12-00820). An online needs assessment survey for OB-GYNs in British Columbia, Canada, was developed to assess the clinical burden of CPP and endometriosis, to review practice patterns in diagnosis and management of CPP, to assess OB-GYNs attitudes and opinions with respect to CPP, and to identify educational gaps and resource needs. The questionnaire was developed by reviewing literature on physicians’ practice challenges with regards to CPP [7-10] and by consulting specialists working in the field. The questionnaire was also pretested with several OB-GYNs to assess ease of understanding and appropriateness of question items.

We used the FluidSurvey platform for the online survey based on ease of use for survey developers and respondents, the low cost of the technology, and privacy issues (since the data is kept on a Canadian server). An email invitation including a link to the survey was sent to OB-GYNs in British Columbia via the University of British Columbia’s Department of Obstetrics and Gynaecology listserv and the British Columbia Medical Association OB-GYN section mailing list. There are 276 registered OB-GYNs in British Columbia (128 in the Vancouver Coastal Authority Health region, 60 in the Fraser Health Authority, 39 in the Interior Health Authority, 36 in the Island Health Authority, and 13 in the Northern Health Authority). We reached an estimated 180 of the 276 OB-GYNs (65%) with our survey email. In order to increase response rate, one reminder email was also sent to the OB-GYNs. In addition, all of the survey invitees were offered to enter a draw to win a $200 gift certificate.

Data were analyzed using the FluidSurvey analysis tool, SPSS Statistics 21, and the VassarStats Website for Statistical Computation (http://vassarstats.net), to provide descriptive statistics. Open-ended comments were analyzed thematically.

Study sample

Forty-four OB-GYNs responded to the survey (24%; 44/180). Close to one-half of the respondents (47%; 16/34) were from the Vancouver Coastal Health Authority region, and the rest were from the Fraser Health Authority (26%; 9/34), Interior Health Authority (25%; 6/24), Vancouver Island Health Authority (6%; 2/34), and the Northern Health Authority (6%; 2/34). This geographic distribution of respondents was not significantly different from the distribution of registered OB-GYNs in the province (see Methods) (chi-square=1.93, df=4, p=0.75). Fifty six percent (19/34) of respondents were male, and one-half of the respondents were 50 years of age or older with 41% (17/34) of them being in practice for 20 years or more. Close to two-thirds of the respondents (21/34) were in solo practice.

Clinical burden

Respondents saw an average of 34 patients (std dev 31; range 0-120) with CPP in the past year. For each CPP patient, the average number of visits per year was 5 visits (std dev 6; range 0-40). Most (82%; 36/44) responded was that these patients require more visits than their average patient. The most common reasons for the increased visits were the following: patient not improving (80%; 28/35), ongoing medical management (69%; 24/35) and pain management (63%; 22/35), and unclear diagnosis (57%; 20/35). Less frequent reasons were factors relating to pending surgery (46%; 16/35), awaiting referral (23%; 8/35), or no GP for follow-up (17%; 6/35).

Practice patterns

Despite a high rate of laparoscopy (67%; 28/42) and ultrasound imaging (90%; 38/42), only 5% of respondents (2/41) were able to make a diagnosis in more than 70% of their CPP patients. None felt that they had successfully treated more than 70% of their CPP patients. Endometriosis was the most frequently diagnosed condition in this patient population (47%). Other causes such as adhesions, interstitial cystitis, pelvic floor muscles, irritable bowel syndrome, prolapse, adenomyosis and masses were found much less frequently.

When CPP patients do not improve, the actions taken by respondents are outlined in Table 1. Most respondents stated that they refer to another health care professional (Table 1). In a follow-up question, in the last year, the respondents had referred an average of 11 patients (std dev 12.2, range 0-50) to another physician and 14 patients (std dev 13.7, range 0-50) to an allied health care provider

Table 1: In CPP cases with minimal or no improvement, what course of action(s) do you typically take?

While 21% of respondents (8/38) felt comfortable prescribing narcotics for pain management, the vast majority felt either only somewhat comfortable (21%; 8/38) or not comfortable (58%; 22/38). Concerns about addiction (64%; 18/28) or misuse (61%; 17/28) were the most common stated reasons for discomfort, followed by perceived lack of knowledge (43%; 12/28). Other stated reasons for discomfort included too many patient visits to monitor opioid use (25%; 7/28), not believing in opioids for CPP pain management (25%; 7/28), and the amount of time for counseling and writing prescriptions (18%; 5/28).

Physician attitudes and opinions about CPP

We asked for narrative comments from physicians about their experiences, negative or positive, treating patients with CPP. Of the 33 responders who provided comments, 13 had overall positive comments and the other 20 comments were classified as negative.

Some of the positive comments included: “rewarding when pain is gone”, “high maintenance but gratifying”, “support and exclusion of significant pathology goes a long way to solve the problem”, “I have good success with physiotherapy…. explaining to patients that my goal is to help control their pain but not necessarily make them pain free”, “even when I can’t make a diagnosis, I have been able to help patients understand that they have had a thorough assessment”

The remainder of the responders had negative experiences to relate. Their comments included: “I HATE this aspect of my practice”, “very challenging to treat, long counseling sessions and teaching sessions required”, “they are demanding and I can rarely help them”, “most seem to have underlying poor coping skills and depression or anxiety. They are exhausting to have in the office”

We made a number of statements regarding management of endometriosis and CPP patients for which participants were asked to rate their agreement. Most of the participants felt that managing CPP is difficult (81%; 29/36), requires more time (81%; 29/36), is poorly compensated (77%; 28/36), and is associated with patient frustration (89%; 32/36). We are also listed a number of feelings that could be elicited by these patients and asked the participants to rate their agreement. Forty-four percent of respondents (16/36) had feelings of frustration, while many respondents found patients to be challenging (69%; 25/36) and intellectually stimulating (47%; 17/36).

Resources

The responses indicated a need for clearer guidelines for CPP diagnosis and management (Table 2). Few respondents had a good comfort level with pain management of CPP patients (23%; 8/35), and there was also a strong desire for patient education (Table 2).

Table 2: Guidelines and resources for CPP.

The resources used most often by physicians for information about CPP were conferences/courses, online resources, colleagues, and clinical practice guidelines (Table 3). There was high interest in a website with a dedicated section on CPP (71%; 25/35), and also interest in a British Columbia wide pain hotline (43%; 15/35) and phone support from a CPP clinic (40%; 14/35). A third of respondents was interested in a preceptorship in a CPP clinic (37%; 13/35), and a quarter (26%; 9/35) were interested in a preceptorship in their clinic setting.

Table 3: How do you currently access information and resources on CPP?

There was a very high interest in using all the resources offered at the British Columbia Women’s Centre for Pelvic Pain and Endometriosis (Table 4). For those few respondents that would not refer to the clinic, distance was the most commonly mentioned issue (11%; 4/35) and one mentioned long waitlists. When asked about the preferred follow-up plan for the CPP patients after coming to the clinic, the majority of responders (60%; 21/35) wanted to continue caring for these patients along with the GP.

Table 4: BC Women’s Hospital & Health Centre has a Centre for Pelvic Pain and Endometriosis. Would you (or have you) consider contacting or referring your patients with CPP to this centre for any of the following services?

A needs assessment is a systematic process for determining gaps between current conditions and desired conditions. The need can be a desire to improve current performance or to correct a deficiency. By clearly identifying a problem, resources can be directed towards implementing a feasible and applicable solution [11]. The ultimate goal of this needs assessment is to improve the care of CPP patients across British Columbia. Most of our questions had defined choices but there were also many open-ended questions as well to help capture ideas or suggestions that may not have been represented otherwise.

There have been a few published needs assessments in the field of pelvic pain but they were conducted in other countries with different health-care systems and results may not be applicable to Canada [7-10]. There was also a needs assessment survey on the management of CPP conducted in 2002 by the Society of Obstetricians and Gynaecologists of Canada (SOGC). These survey results revealed a desire for more training in the recognition and management of CPP, and were mentioned in the SOGC Guidelines on chronic pelvic pain, but to our knowledge were never published independently [12,13]. It is not surprising that respondents desired more training, as chronic pelvic pain is difficult to treat [14]. Although there is a wide range of medical and surgical treatments, there are controversies in management and more research required, in particular the need for more randomized trials [14].

In our study, the overall impression of clinical burden by responders was that CPP patients require a lot of office visits and extra time from them and their support staff. They felt that this time was poorly compensated. It is important that alternative payment schemes be developed to allow for OB-GYNs and other specialists to provide the time and care required for patients with chronic pain.

The practice pattern that emerged from our survey was that of a thorough evaluation with a frequent use of laparoscopy. The most common diagnosis made was endometriosis, which is consistent with the literature [3]. However, only 5% of respondents were able to make a diagnosis for the cause of CPP in >70% of their patients. This is a common problem in this patient population and we have identified it as a potential knowledge gap. Laparoscopic recognition of subtle atypical appearances of endometriosis lesions is important to make the diagnosis in some women with endometriosis, especially in younger women. There are also a variety of urologic, gastrointestinal, and musculoskeletal causes of CPP that can be diagnosed by the OB-GYN [12,13]. The majority of participants felt that less than 50% of their patients had a good response to treatment, and they usually referred non-responders to other healthcare providers.

The physician experiences with CPP patients were split. About one third of responders found these patient encounters satisfying and twothirds found them difficult. However, the majority of responders was intellectually stimulated and felt challenged by these patients, indicating openness to learning more and providing improved management. There was discomfort with the pain management of CPP patients, including use of narcotic medications, which is another knowledge gap. It is notable that there was much more comfort with the management of endometriosis than CPP.

Resource needs identified by this survey were that of better clinical guidelines for diagnosis and management of CPP. The SOGC did publish CPP guidelines in 2005 [12,13]. While 63% of respondents accessed CPP guidelines, only 34% were clear about the diagnosis or management of CPP. Follow-up of this issue is a priority for our Centre.

Another resource need identified by the survey was a dedicated website with information about CPP. Responders were also very interested in patient support materials and patient support groups. We have recently launched our British Columbia Women’s Centre for Pelvic Pain and Endometriosis website (www.bcwomens.ca/pelvicpainendo) which has many useful patient and physician resources. Another online resource has been developed through the PainBC society (www.painbc.ca).

A pain specialist hot-line and phone support were also of interest to responders. A pain specialist hot-line has been available since 2012 through the St. Paul’s Hospital in Vancouver as part of their chronic disease support hotline initiative. Phone support for physicians is currently being implemented through our Centre. There were a select number of OB-GYNs who expressed an interest in preceptorships or mini-fellowships in CPP, either at our Centre or in their office. The goal of such preceptorships is to develop satellite centres of expertise in other areas of British Columbia to minimize travel for patients, as distance was identified as a barrier to care for some CPP patients.

Limitations of this study include a low response rate (21%), although it is within expectations for this type of survey, which limits the generalizability of our results. Most respondents were in solo practice and 40% had over 20 years in practice, which might contribute to some bias compared to OB-GYNs in group practice or who recently completed post-graduate training. Strengths of the study include its thorough investigation of OB-GYN current practice and needs for CPP, and its use of both quantitative and qualitative questions.

In conclusion, this is the first published Canadian needs assessment of Obstetrician- Gynaecologists on the topic of chronic pelvic pain. The needs gaps in caring for CPP patients identified by this survey were: time constraints, remuneration, achieving a diagnosis, pain management, clinical guidelines, online resources and patient support material, phone support, and distance from a centre of expertise. There was a high rate of support from respondents for an interdisciplinary centre for CPP and also a high rate of referral or desire to refer to interdisciplinary services. This survey will allow our Centre to better focus on the identified gaps and strive to bridge those in a timely fashion. These findings will also be useful to the ongoing initiatives in British Columbia and other provinces to train physicians in chronic pain and to institute changes in the health care system to optimize the care of patients with chronic pain.