Acute Pelvic Pain: Causes and Diagnosis

• Pelvic pain is reviewed by Col. Trimble Spitzer

Acute Pelvic Pain

• Definition: pain lasting less than 6 months
• Gynecologic causes include ovarian torsion, ectopic pregnancy, ovarian cyst (ruptured or hemorrhagic), and infection
• Non-gynecologic GI causes include appendicitis, diverticulitis, ischemic bowel, and bowel obstruction
• Urinary causes include urinary tract infection and kidney stone

Acute Pelvic Pain: Ovarian Torsion

• Characterized by sudden, severe, unilateral pain, and may include nausea
• Examination findings include tenderness
• Labs will show a negative HCG
• Imaging with Pelvic US reveals enlarged adnexa, possibly with Doppler
• Treatment involves emergent surgery

Acute Pelvic Pain: Ectopic Pregnancy

• May present with spotting or pain
• Can cause a dull ache to severe pain with rebound/guarding
• Exam findings include unilateral tenderness and "fullness"
• Labs will show a positive HCG, but no appropriate rise after 48 hours, doubling HCG at 33%-50% rise
• Imaging with Pelvic US reveals an adnexal mass
• Treatment options include MTX or surgery

Acute Pelvic Pain: Ovarian Cyst

• Characterized by variable onset and positional discomfort
• Imaging with Pelvic US reveals a unilateral ovarian cyst
• Treatment involves observation and consideration of OCPs for prevention

Acute Pelvic Pain: Infection (PID)

• Symptoms include fever/chills, malaise, and pain
• Labs will show STI Cx and increased WBC
• Imaging with Pelvic US reveals bilateral enlargement/dilation
• Treatment involves admission and IV antibiotics
• 18-35% of women with PID will develop chronic pelvic pain (CPP)
• Outpatient treatment vs. inpatient regimens don't seem to impact risk of developing CPP
• Outpatient 34% vs. inpatient 30%

Chronic Pelvic Pain (CPP)

• Definition: noncyclical pain lasting more than 6 months
• Can lead to a chronic stress phenotype characterized by a vicious cycle of physical and psychological consequences
• Prolonged activity restriction can lead to physical deconditioning
• Continued fear, anxiety, and distress can lead to long-term deterioration in mood and social isolation
• 12-33% of women with CPP also meet criteria for Major Depressive Disorder
• Source cannot always be reproductive tract: 30.8% GU, 37.7% GI, 20.2% GYN
• Women with CPP more likely than the gen population to have: dysmenorrhea (81% vs 58%) and dyspareunia (41% vs 14%)

Prevalence & Common non-GYN Contributors to CPP

• Estimates range from 5.7% to 26.6%
• Common contributors to CPP, unrelated to the female reproductive system include:
  • Irritable bowel syndrome where IBS symptoms are found in 50-80% of women with CPP
  • Interstitial cystitis/painful bladder syndrome: clinically characterized by irritative voiding (urgency/frequency) in absence of disease, up to 70% of IC have pelvic pain complaints
  • Pelvic floor muscle tenderness, including Fibromyalgia, and Depression

Initial Evaluation for CPP

• Take a pain history including location, severity, quality, and timing
• Detail a chronology of symptoms including triggers and associations
• Review previous treatments and identify pain aggravators/alleviators
• Obtain a detailed medical, surgical, and GYN history
• Perform a thorough physical examination, paying attention to underlying myofascial structures in addition to the viscera and genitalia

Common (GYN) Etiologies of CPP

• Endometriosis
• Adenomyosis
• Fibroids
• Adhesions/Sequelae of PID
• Adnexal mass
• Chronic infection
• Vestibulitis/vulvodynia

Endometriosis

• History includes primary or secondary dysmenorrhea with pain before/during the menstrual cycle
• Physical examination reveals a normal or non-mobile uterus ± adnexal mass, rectovaginal nodularity
• Labs show none abnormal
• Pelvic US may find endometriomas but may be normal
• Treatment includes NSAIDs, OCPs, Levonorgestrel-IUD, and GnRH analogs
• Up to 80% of CPP is reported related to endo
• Pain associated with viscero-visceral interactions, even after endo has been ablated
• Laparoscopy diagnoses Endo in 33% of CPP patients
• Degree of pain is NOT associated with ASRM staging
• 20% of students miss school for pelvic pain
• Abnormal exam findings correlate with 70-90% of abnormal findings on laparoscopy, but >50% abnml laps have nml exams preop

Adenomyosis

• History includes progressive secondary dysmenorrhea with increased menstrual bleeding
• Physical examination reveals an enlarged "boggy" uterus and generalized tenderness
• Labs may show anemia
• Imaging can be conducted with Pelvic MRI
• Treatment includes hysterectomy (only definitive treatment), NSAIDs, OCPs, and Levonorgestrel-IUD

Leiomyoma/Uterine Fibroids

• History includes ↑ menstrual flow/heavy cycles with clots, worsening dysmenorrhea, +FHx fibroids, highest prevalence among African Americans
• Physical examination reveals an enlarged uterus, irregular mass, ± tenderness
• Labs may show anemia
• Imaging via Pelvic US
• Treatment involves NSAIDS, OCPs, myomectomy, uterine artery embolization, and hysterectomy

Pelvic Adhesive Disease

• History includes previous abdominal/pelvic surgery, infections, ± dyspareunia, pain following a large meal
• Physical examination shows nonspecific pain and a “fixed pelvis"
• Labs will be normal
• Imaging with Pelvic US may show normal or fluid collections/abnormal lie of pelvic structures
• Treatment includes laparoscopic lysis of adhesions

Other CPP related conditions

• Vestibulitis/vulvodynia
• Uterine Pathology, such as chronic endometritis
• Pelvic Congestion Syndrome
• Gynecologic malignancies, especially if in a late stage
• Psychosomatic issues such as sexual assault

Diagnostic Studies

• Take a detailed history and focus a physical exam including location, severity, quality, and timing
• Imaging with Pelvic US is your mainstay, with the possibility of MRI
• 2/3 of women NEVER undergo testing, never get a diagnosis, and are never referred to a specialist or treatment

Treating Chronic Pelvic Pain

• Schedule a longer visit time with a continuity provider
• Obtain a thorough history and physical exam
• Consider the whole patient with a broad differential
• Refer to appropriate specialists such as GI, Urology, or Urogyn
• Avoid opioids

Medical Treatments

• Hormonal treatments include OCPs and Medroxyprogesterone acetate
  • P4 and estrogen components play a rold
  • MPA decreases the frequency of GnRH release, blunting the midcycle LH surge, which prevents follicular maturation/ovulation
  • GnRH agonist (Lupron)
• Analgesics such as NSAIDS and COX-2 inhibitors
  • Opioids are not recommended for the treatment of CPP but can be used acuutely with pain
• Psychosomatic/neuropathic pain etiology
  • +/-Tricyclics/ Serotonin-norepinephrine reuptake inhibitors (SNRIs) can be used, although evidence of their efficacy is weak
  • Gabapentin works by showing a high affinity for binding sites throughout the brain corresponding to voltage-gated calcium channels and inhibiting the release of excitatory neurotransmitters

Surgical Therapies

• Diagnosis only: 20% of women were shown to have improvement after Dx scope only
• Lyse Adhesions: most improvement with adhesiolysis of dense adhesions involving bowel
• Excision/Ablation of Lesions: Op Laps can provide 45-85% women improvement x1yr (study included mostly stage 1/2 endometriosis)

• 40% of all GYN laparoscopies are done for CPP as at least one indication

• Endometriosis & Adhesions account for 90% of abnormal findings in surgery
• The routine use of laparoscopic adhesiolysis is not recommended for the management of CPP
• Repeat laparoscopies to treat pain typically have decreasing efficacy and are not recommended

Other Surgical Therapies

• Presacral Neurectomy helps by affecting the presacral nerve plexus which supplies the cervix, uteus, prox tubes with afferent pain sensory and for central dysmenorrhea unresponsive to other therapies
• Uterine nerve ablation involves transecting uterosacral ligaments but has not been shown to be helpful

Other Therapies

• Exercise
• Pelvic Floor PT
• Acupuncture
• Trigger point injections
• Counseling
• Psychotherapy such as Cognitive Behavioral Therapy(CBT)
• Herbal therapies such as Vit B1 (100mg) +Mg
• Magnetic field/ultrasound waves
• Pain Clinic to treat neuropathic pain

Pelvic Floor PT

• CPP is commonly associated with pelvic floor muscle tenderness
• PTs use a wide range of modalities & tools tailored to each patient's specific symptoms and clinical findings
• Modalities include:
  • External and internal tissue mobilization
  • Myofascial release
  • Manipulative therapies to mobilize visceral, urogenital, and joint structures
  • Electrical stimulation
  • Active pelvic floor retraining
  • Biofeedback
  • Bladder and bowel retraining
  • Pelvic floor muscle stretching
• Even if it does not improve with Pelvic PT, may help identify a treatable musculoskeletal disorder

Cognitive Behavioral Therapy (CBT)

• Helps counteract CPP which predisposes patients to depression, anxiety, and social isolation
• Goal-oriented therapy should be used in conjunction with medical and physical therapies
• Patients learn to modulate their thoughts and manipulate their environment to lessen their pain perception and improve coping skills
• It is critical that the patient understands that referral does not mean that the pain is psychosomatic or any less real

Trigger Point Injections & Botox

• Injections include saline, anesthetic, steroids, or opioids
• Performed by appropriately trained OBGYNs
• Safe; can provide immediate relief (nerve entrapment or fascial trigger point)
• May require repeated doses
• There is varying e evidence to support the use botox (+) / (-) in the treatment of myofascial pelvic pain refractory to physical therapy

Interprofessional Team Approach

• Use Symptom questionnaires can be completed before or during the visit to assist in screening
• Depression patients with complex mood symptoms, suicidal thoughts, or other risk factors may benefit from evaluation by a mental health professional
• Interstitial cystitis patients with unexplained urinary symptoms (eg, frequency, urgency) and bladder pain may benefit from referral for additional evaluation
• Irritable bowel syndrome (IBS) patients with IBS sx & risk factors may warrant additional evaluation to rule out inflammatory bowel disease or colon cancer through appropriate referrals to primary care &/or gastroenterology

Advocacy as Interprofessional Team Member

• Consider involving a pain specialist
• Specialists certified by the American Board of Pain Medicine are trained to develop comprehensive treatment plans for pain