Disease severity, pain, and patient perception: themes in clinical practice and research

Chapter 6 begins with a discussion of how to assess disease severity. It then moves on to the concepts of physical and emotional pain, which are particularly useful for understanding pelvic floor problems, infertility, pregnancy loss, and chronic pelvic pain. All of these have biological, psychological, and social features associated with their aetiopathogenesis, and presentations. To manage these conditions effectively, it is crucial to understand the patient's perception. First, pelvic/perineal dysfunction is addressed. This includes the loss of urinary and bowel continence, with deleterious effects on biopsychosocial health. The condition is common, and can cause severe morbidity following any delivery mode, including a planned caesarean. This is illustrated by an evaluation of biopsychosocial morbidity, quantified by categorising patient perceptions of severity of incontinence, and related sexual problems. The psychosomatic repercussions of infertility, miscarriage, stillbirth, and chronic pelvic pain are then appraised. Since physical and emotional pain can affect these conditions, timely recognition and biopsychosocial management helps promote positive physical, mental and social health. A special focus is given to endometrial implants outside the uterine cavity (endometriosis). These can cause chronic pelvic pain, infertility, and pregnancy loss, but may be symptomless. Their aetiology remains unclear. Ovulation suppression relieves pain and treatment is tentative, with removal of the affected pelvic organs being an extreme option. Even after this, however, symptoms may persist. A pathway using the tailored psychosomatic approach is advocated to provide patient-centred care where indicated.