Protocols for post-op pain management standards

Dr. Steve Vasilev, MD, Gynecologist, Endometriosis Surgeon:*
 
This is a phenomenally great question and points to the extreme importance of making sure pain management is fully integrated into the plan, as opposed to being an afterthought. Ideally, any pain that is already present should be controlled as best as possible BEFORE surgery, and then additional measures are taken to anticipate that the pain may get worse for a while before getting better. This spike in pain may be due to the inflammation from surgery and very complex neurologic feedback loops that have to be kept in mind, involving both peripheral and central sensitization. After the pain from the endo is gone and the postoperative inflammatory pain is gone then life can get back to normal in most cases. But this requires active individualized management to get you through it and not just some standard postoperative pain meds.
There are “standards” that exist to enhance recovery from surgery but everyone is different. So, someone who has pelvic floor spasms may be managed differently perioperatively than someone who has likely central sensitization. It is not an exact science and often there can be multiple causes but the very best efforts should be made to determine what the main origins of pain are before surgery.
After a thorough assessment, a program should be started which may include pelvic floor physical therapy, mainstream pain management optimization, and possibly integrative measures such as acupuncture, natural anti-inflammatories, and things like that. Everyone is different and the time to find out what may be the main pain drivers is before, not after, surgery.
While some surgeons try to be pain management specialists the truth is that those docs who are in the fields of neurology, anesthesia or some internal medicine doctors who specialize in pain, study pain management in far greater depth than surgeons. This is why a multidisciplinary team of a surgeon, pelvic floor therapist and pain management specialist usually gets better results. Everyone stays in their lane in helping synergize and get you the best result. Add on top of that an integrative holistic specialist who understands what a natural component or two can add and you have the dream team.
Also, as noted, everyone is different. If someone is already regularly taking opioids for pain management this is totally different from a patient who is able to control pain with non-steroidal anti-inflammatory medications or similar. Management of these two situations after surgery is very different. Again, addressing the baseline before surgery is critical.
For any surgery, it is becoming standard of practice to follow something called the ERAS protocol. This stands for “enhanced recovery after surgery” and, among a lot of other healing measures, involves use of multiple medications designed to try to minimize pain while avoiding opioids as much as possible. Opioids can not only become addictive but also can cause much slower recovery from surgery and complications. Of course, they are used where necessary, but an expert guiding hand is crucial for optimal results. Many of the medications used in the ERAS protocol as commonly used to help alleviate endometriosis pain, started well before surgery and then adjusted to get someone through recovery as smoothly as possible and then, ideally, tapered off.  Parenthetically, there is much more to ERAS than pain management and includes nutritional modifications to help surgical healing.
This is just a brief summary of what should be considered to not have bad experiences after surgery. Beyond the perioperative period of a few weeks, the treatment strategy should continue, including pelvic floor therapy. In particular, someone who has central sensitization may have a longer route to recovery. Simplistically put, central sensitization is when your central nervous system has learned that pain is there and even when the stimulus (the endo) is gone or minimized, the pain remains. Treatment plans can get very complex in this case but can be anticipated based on the individual situation.
I hope this helps emphasize that in most cases, thinking of excision surgery in isolation and not as part of a bigger treatment plan can lead to very subpar results.
 
*This is not medical advice and is aimed for informational use only. Please contact the doctor’s office or consult with your doctor for any medical questions.