Chronic Pelvic Pain (CPP) Overview

• Chronic Pelvic Pain (CPP) is a common and complex disorder.
• CPP is noncyclic pain lasting 6 months or more, located in the pelvic region, lower abdominal wall, lower back, or buttocks.
• CPP is severe enough to cause functional disability.
• About 38 out of 1,000 primary care visits by women aged 15-73 are for CPP.
• CPP accounts for 20% of gynecology clinic referrals.
• The underlying cause of CPP cannot be identified in one-third to one-half of cases.
• CPP may occur in 50% of patients with a history of physical or sexual abuse.

Common Causes of Chronic Pelvic Pain

• When the diagnosis is known, the pain generator is identified.
• If the diagnosis is unknown, determining the pain type (visceral, somatic, neuropathic, or combination) is crucial.

Visceral Pelvic Pain

• Visceral pain originates from organs like the bladder, rectum, uterus, ovaries, or fallopian tubes.
• Visceral pain is caused by distension, compression, or torsion of an organ.
• Visceral pain is often poorly localized, described as dull and achy.
• A small number of visceral afferent nerves cover a large area, making it difficult to pinpoint the exact pain location.

Somatic Pelvic Pain

• Somatic structures include fascia, muscles, and the pelvic floor.
• Somatic pain is often well localized and described as sharp and focal.

Neuropathic Pelvic Pain

• Nerves transmit sensory impulses to the brain for interpretation.
• Impulses travel along a nerve axon in a regular pattern in a healthy nervous system.
• Injured nerves may fire abnormally due to a failure in regular impulse transmission.
• Injured nerves develop abnormal excitability.
• Injured nerves have increased sensitivity to chemical, thermal, and mechanical stimuli.
• Aberrant nerve firing is interpreted by the brain as neuropathic pain.
• Nerve damage can stem from mechanical issues, infection, metabolic conditions, toxins, radiation, or idiopathic causes.
• Neuropathic pain is often described as electric, shooting, or burning.

Evaluation of Pain History

• The goal of taking a pain history is to understand the parameters of the pain.
• A commonly used mnemonic is PQRST:
  • P: Palliative or Provoking factors
  • Q: Qualities (burning, electric, sharp, dull)
  • R: Radiation
  • S: Severity (visual analog scale 0 to 10)
  • T: Temporal events (constant or intermittent)

Common Causes of CPP: Postoperative Pelvic Adhesions

• Postoperative pelvic adhesions are abnormal bands of scar tissue and often asymptomatic.
• Adhesions may cause visceral pain by impairing organ mobility.
• Open gynecologic, ovarian surgery has a higher risk of readmissions from adhesions.
• Symptomatic adhesions present as deep, dull, achy pain.
• Adhesions involving the vagina or uterus may cause pain during intercourse.
• Laparoscopy is a common treatment for postoperative pelvic adhesions because of the elective nature of the procedure and shorter recovery time.

Common Causes of CPP: Endometriosis

• Endometriosis involves the collection of endometrial cells that develop outside the uterus.
• Hormonal stimulation can cause endometrial tissue to trigger an inflammatory response.
• A surgical diagnosis confirms endometriosis through pathology.
• Increased pain linked with endometriosis often occurs a few days before menstruation and resolves 1-2 days into menstruation.
• Pain during or after sex may be present.
• Sonographic findings may include cysts in the ovaries.
• Endometriosis may cause issues with becoming pregnant.
• Treatment includes oral contraceptives to reduce menstrual pain and Progesterone which counteracts estrogen and inhibits the growth of the endometrium.
• NSAIDs can also be very helpful
• Surgery for endometriosis-associated pain is an option for both diagnosis and treatment.

Common Causes of CPP: Pelvic Congestion Syndrome (Pelvic Varices)

• Pelvic congestion syndrome involves the overfilling of the pelvic venous system.
• It may result from pregnancy or unknown causes.
• Pain is unrelated to the menstrual cycle.
• Pain is constant and worsens with standing, improves when lying down, and gets worse as the day progresses.
• Patients complain of postcoital ache and heavy vaginal discharge.
• Estrogen leads to the vein vasodilation or venous.
• Treatment includes interventional radiologic techniques using a catheter to embolize the vein for pain relief in 50-60% of patients

Common Causes of CPP: Leiomyoma (Fibroids)

• Leiomyomas are benign tumors in the uterus.
• The origin of pain associated with leiomyomas is unclear.
• They occur more commonly in African-Americans than in Whites.
• Increased menstrual bleeding (menorrhagia) may occur.
• Pain can be spontaneous or induced by tactile pressure.
• Symptoms often worsen during pregnancy.
• Medications to regulate menstruation as well hypogonadal state can yield benefit.
• Fibroid removal can be achieved with Myomectomy, which leaves the uterus in place.
• Removal of the uterus is a permanent solution for uterine fibroids.

Common Causes of CPP: Interstitial Cystitis (IC)

• Interstitial cystitis involves inflammation of the bladder wall.
• The cause of interstitial cystitis is unknown.
• It is more common in women than in men.
• No pathognomonic radiographic, lab, or serologic findings exist.
• Daytime and nighttime urinary frequency, urgency, and pelvic pain for at least 6 weeks are characteristic.
• Cystitis may worsen around the menstrual cycle.
• There is an absence of proven urinary infection.
• Intermittent periods of exacerbations and remissions may occur.
• Approximately 90% of cases involve females.
• Elmiron is specifically approved for IC which is taken orally
• Although the cause of interstitial cystitis is not known, Amitriptyline can lead to improvement of symptoms in about two-thirds of subjects treated

Common Causes of CPP: Chronic Prostatitis

• Chronic prostatitis, found in males, has no evidence of being associated with infection.
• Treatable with oral antibiotics.
• It involves intermittent dysuria and pelvic pain or discomfort for at least 3 of the previous 6 months without documented urinary tract infections.
• Patients may experience ejaculatory pain and erectile dysfunction.
• Treated with antibiotics even if it has no association with infection

Common Causes of CPP: Irritable Bowel Syndrome (IBS)

• IBS is a functional GI disorder characterized by abdominal pain and altered bowel habits without specific organic pathology.
• Patients may experience spasmodic pelvic and abdominal cramping that varies in location.
• IBS is associated with pain relief with defecation.
• It may be associated with constipation, diarrhea, or a mixed picture.
• Symptoms may increase with menses.
• Treatments involve fiber supplementation and reassurance, as theres no specific regiment

Common Causes of CPP: Extra-Pelvic Referred Pain

• Extra-pelvic referred pain may originate from thoracic-lumbar spine pathology.
• Symptoms vary based on specific issue
• Treatment is dependent on the cause

CPP Treatment: Medications

• Medications can be used to combat CPP symptoms.
• NSAIDs are a first-line option for somatic or visceral pain.
• Neuropathic medications are recommended for neuropathic pain (electric or burning quality).
• Muscle relaxants are appropriate for pelvic pain described as squeezing and spasmodic.
• Opioid medications are an option if conservative medical management options fail, allow the return of normal function.

CPP Treatment: Injections

• Minimally invasive procedures can help control pelvic pain.
• The superior hypogastric plexus is the relay station for sending pelvic pain to the brain.
• The ganglion impar is the relay station for sending perineal pain to the brain.
• The superior hypogastric plexus lies at the interspace between the fifth lumbar vertebra and the sacrum.
• Ganglion impar (Ganglion of Walther) is located at the junction of the sacrum and the coccyx.
• A needle can be advanced under fluoroscopic guidance to both of these locations.
• The use of a local anesthetic rather than a neurolytic substance is effective.
• Pelvic wall injections can be beneficial for somatic pain, and pelvic wall pain.
• An injection into the area using a local anesthetic coupled with a steroid can be effective.
• The anesthetic breaks a chronic pain cycle and the steroids enhance the anesthetic effect by leading to neuronal membrane stabilization.

CPP Treatment: Surgery

• For pain thought to be visceral in nature, removing the offending agent has been explored as a treatment modality.
• Removing the pelvic organs that may be the pain generators remains a very controversial topic in obstetrics and gynecology.
• Some 10% to 19% of hysterectomies and 40% of laparoscopies are done for nononcologic CPP.
• The most common findings after hysterectomy and bilateral salpingo-oophorectomy are adhesions, endometriosis, and adnexal remnants.
• Presacral neurectomy has been shown to decrease midline pelvic pain, the procedure is performed on the anterior aspects of vertebral body L5 and the sacrum.
• A needle can be advanced under fluoroscopic guidance to both of these locations and performed via laparoscopy or laparotomy.