Chronic Pelvic Pain (CPP)

Chronic Pelvic Pain (CPP)

• CPP is considered a prevalent and challenging disorder.
• CPP is defined as noncyclic pain lasting 6 or more months.
• Pain localizes to the anatomic pelvic region, anterior abdominal wall (at or below the umbilicus), lumbosacral back, or buttocks.
• The severity of CPP leads to functional disability or the need for medical care.
• Approximately 38 out of 1,000 primary care visits among women aged 15 to 73 are for CPP.
• This rate is comparable to the incidence of asthma visits.
• CPP accounts for 20% of all referrals to gynecology clinics.
• In one-third to one-half of CPP cases, the underlying pathology cannot be identified.
• CPP may occur in 50% of patients with a history of physical or sexual abuse, which makes treatment more challenging.

Common Causes of CPP

• If the diagnosis of CPP is known, the pain generator has been identified.
• If the diagnosis is unknown, it is important to determine if the pain is visceral, somatic, neuropathic, or a combination.

Visceral Pelvic Pain

• Originates from organs such as the bladder, rectum, uterus, ovaries, or fallopian tubes.
• Pain is often elicited by distension, compression, or torsion of an organ.
• Pain is not well localized and is often described as dull and achy.
• A small number of visceral afferent nerves cover a large area, making it difficult to pinpoint the exact location of the pain.

Somatic Pelvic Pain

• Originates from support structures of the pelvic cavity, including fascia, muscles, and the pelvic floor.
• Pain is often well localized and is typically described as sharp and focal.

Neuropathic Pelvic Pain

• Nerves send sensory impulses to the brain.
• Impulses travel along a nerve axon in a regular pattern when the nervous system is working correctly.
• When a nerve is injured, the transmission of impulses fails, causing the nerve to fire aberrantly.
• Injured nerves develop pathologic activity, manifesting as abnormal excitability.
• Elevated sensitivity to normal chemical, thermal, and mechanical stimuli is characteristic.
• Aberrant nerve firing is interpreted by the brain as neuropathic pain.
• Nerves can be damaged mechanically, via infection, or from metabolic conditions, toxins, radiation, or idiopathically.
• Neuropathic pain is reported as electric, shooting, or burning, rather than achy or dull.

Evaluation of Pain History

• The goal is to understand the parameters of the pain.
• Evaluating the specific details surrounding the pain is necessary.
• A commonly used mnemonic is PQRST.
• PQRST refers to:
  • P: Palliative or Provoking factors.
  • Q: Qualities (burning, electric, sharp, dull).
  • R: Radiation.
  • S: Severity (usually done on a visual analog scale of 0 to 10).
  • T: Temporal events associated with the pain (is the pain constant or does it come and go?)

Common High-Yield Causes of CPP

• Postoperative pelvic adhesions
• Endometriosis
• Pelvic congestion syndrome (pelvic varices)
• Leiomyoma (fibroids)
• Interstitial cystitis (IC)
• Chronic prostatitis
• Irritable bowel syndrome
• Extra-pelvic referred pain

Postoperative Pelvic Adhesions

• Abnormal bands of scar tissue are present, but may show no symptoms.
• This may cause visceral pain by impairing organ mobility.
• Open gynecologic procedures, especially ovarian surgery, carry a higher risk of readmissions directly related to adhesions.
• Symptomatic adhesions can present as deep, dull, achy pain.
• Adhesions involving the vagina or uterus may cause pain during intercourse.
• Treatment is commonly done via laparoscopy due to the elective nature of the procedure and shorter recovery time.

Endometriosis

• Collection of endometrial cells develops remote from the uterus
• Hormonal stimulation triggers an inflammatory response in endometrial tissue.
• Diagnosis is confirmed surgically with pathology.
• Increased pain usually occurs a few days before menses and begins to resolve 1-2 days into the menses.
• Pain during or after sex is common and usually predictive of deep retrovaginal endometriosis.
• Sonographic findings may include cysts in the ovaries, referred to as endometriomas.
• There may be difficulty becoming pregnant.
• Treatments include:
  • Oral contraceptives to reduce menstrual pain.
  • Progesterone, which counteracts estrogen and inhibits the endometrium growth.
  • NSAIDs.
  • Surgery for pain.

Pelvic Congestion Syndrome (Pelvic Varices)

• Overfilling of the pelvic venous system occurs.
• This can result from pregnancy or be of unknown origin.
• The pain is not related to the menstrual cycle.
• Pain is constant and worsens with standing.
• Patients get some relief when they lie down.
• Pain worsens as the day goes on.
• Patients often complain of postcoital ache and may have heavy vaginal discharge.
• Treatments include:
  • Estrogen management because it is a venous dilator.
  • Correction of a hipoestrogenic state.
  • Interventional radiologic techniques where a percutaneous catheter is placed into the vein and the vein is embolized, which can provide relief of pain in 50-60% of patients.

Leiomyoma (Fibroids)

• A benign tumor occurs within the uterus.
• The pathogenesis of pain associated with these lesions is unclear.
• They are more common in African-Americans than Whites.
• Increased menstrual bleeding (menorrhagia) occurs.
• Pain can be spontaneous or induced by tactile pressure.
• Symptoms often become worse during pregnancy.
• Treatments include:
  • Medications help to regulate the menstrual cycle or create a hypogonadal state.
  • Myomectomy to remove the fibroid while leaving the uterus in place.
  • Removal of the uterus is permanent solution.

Interstitial Cystitis (IC)

• Inflammation of the bladder wall occurs.
• The cause is unknown.
• IC is more common in women.
• There are no radiographic, lab, or serologic findings.
• No biopsy patterns are pathognomonic for IC.
• Daytime and nighttime urinary frequency, urgency, and pelvic pain for at least 6 weeks are characteristic.
• Cystitis may be worse around the menstrual cycle.
• The is an absence of proven urinary infection.
• There are intermittant periods of exacerbations and remissions.
• Approximately 90% of cases are female.
• Treatments include:
  • Elmiron. -Low-molecular weight heparins.
  • Amitriptyline.

Chronic Prostatitis

• In males, this term is a misnomer as there is no evidence it is associated with infection.
• Nonetheless, it is usually treated with oral antibiotics.
• This condition involves intermittant dysuria and pelvic pain or discomfort for >3 of the previous 6 months without documented urinary tract infections.
• Patients may have ejaculatory pain and erectile disfunction.
• Treatmenet: - Antibiotics

Irritable Bowel Syndrome (IBS)

• It is a functional GI disorder characterized by abdominal pain and altered bowel habits with no unique pathology.
• Includes spasmodic pelvic and abdominal cramping that varies in location.
• There is pain relief with defecation.
• It may be associated with constipation, diarrhea or mixed picture.
• Symptoms may increase with menses.
• Treatments include:
  • Fiber supplementation may improve symptoms of constipation or diarrhea.
  • Reassurance can be beneficial.

Extra-Pelvic Referred Pain

• Causes can include thoracic-lumbar spine pathology.
• Symptoms vary.
• Treatment is determined by the cause.

CPP Medications

• Medications are used to combat the symptoms of CPP.
• If the pain is thought to be somatic or visceral in nature, NSAIDs are a first-line option.
• If the pain has a neuropathic quality-described as electric or burning-a neuropathic medication is used.
• If there is pelvic pain described as squeezing and spasmodic, a muscle relaxant is appropriate.
• If conservative medical management options fail, opioid medications are the next option.
• Opioid therapy may allow the return of normal function

CPP Injections

• Minimally invasive procedures can be used to help control pelvic pain.
• The superior hypogastric plexus is the relay station for sending pelvic pain to the brain, where as the ganglion impar is for sending perineal pain to the brain.
• The superior hypogastric plexus lies at the interspace between the fifth lumbar vertebra and the sacrum.
• The ganglion impar (Ganglion of Walther) is located at the junction of the sacrum and the соссух
• A needle can be advanced under fluoroscopic guidance to the plexus and the impar.
• There is evidence to support the use of performing blocks using a local anesthetic rather than a neurolytic substance (generally reserved for cancer pain), to help relieve nononcologic pelvic and perineal pain.
• Pelvic wall injections can be beneficial for suspected pelvic wall pain, somatic pain, of unclear etiology or pelvic wall pain from a neuroma.
• An injection into the area using a local anesthetic coupled with a steroid can be effective.
• This type of injection may provide long-term pain relief.
• The theory is that the anesthetic breaks a chronic pain cycle and the steroids enhance the anesthetic effect by leading to neuronal membrane stabilization.

CPP 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.
• A small percentage (3% to 5%) will experience worsening of pain or will develop new symptoms after surgery.
• Another surgical procedure presacral neurectomy has been shown to decrease midline pelvic pain.
• Presacral neurectomy is performed on the anterior aspects of vertebral body L5 and the sacrum.
• The procedure can be done via laparoscopy or laparotomy.