Women's Health: Chronic Pelvic Pain PDF

Women’s Health Chapter 140 Chronic Pelvic Pain  Definition (1 of 4)  A continuous or episodic, nonmenstrual pain of at least 6 months’ duration affecting both men and women  May be sudden or gradual in onset  Occurs at or below the umbilicus  Seve...

Women’s Health Chapter 140 Chronic Pelvic Pain  Definition (1 of 4)  A continuous or episodic, nonmenstrual pain of at least 6 months’ duration affecting both men and women  May be sudden or gradual in onset  Occurs at or below the umbilicus  Severe enough to interrupt normal activities of daily life  Chronic pelvic pain is the diagnosis itself  Four times more likely to have history of PID, constipation, IBD, depression/anxiety  May involve gastroenterologic, urologic, gynecologic, oncologic, musculoskeletal, and psychosocial systems  Considered the principle indication for 40% gynecologic laparoscopies and 12% hysterectomies performed for benign disease  The cause is often multifactorial, making it challenging  Definition continued.  Subset of the population who are at increased risk for CPP are patients with history of:  Physical and sexual abuse Survivors can develop long term medical condition associated with abuse and trauma such as cardiovascular problems i.e.. Hypertension, diabetes, malnourishment, STDs, chronic pain and incontinence. Mental health issues include psychiatric disorders, i.e.. Educational difficulties, low self-esteem, trouble forming and maintaining relationships  Pelvic inflammatory disease (PID) PID can lead to chronic pain around your pelvis and lower abdomen, causing depression and insomnia. Ectopic pregnancy occurs in approximately 9% of women with PID experiencing chronic pelvic pain. Symptoms of chronic PID are lower abdominal pain, fever, unusual discharge with foul odor from vagina,, pain or bleeding when having sex, burning upon urination, bleeding between periods  Definitions continued. Endometriosis- one of the leading causes of CPP and most common diagnosis made at the time of the gynecological laparoscopy for the evaluation of CPP  Endometriosis often causes severe pain in the pelvis during menstrual periods. Endometriosis is observed in 71 to 87% women with chronic pelvic pain. Infertility is a common problem that results.  CPP from endometriosis is a nulliparous, 20-30 year old female  Diagnosed by imaging of lesions in laparoscopy  No treatment can prevent endometriosis from occurring but a combination of hormonal treatment and/or surgery can control the disease.  Hormonal suppression medication include: Oral contraceptive pill, implanon Anti-inflammatory medications NSAIDS, Ibuprofen, Ponstan, Voltaren Mirena IUD Hormonal suppression treatment- Zoladex.  Definition continued.  Interstitial cystitis (IC)- chronic bladder imflammation People with IC have repeat discomfort, pressure, tenderness, or pain in the bladder, lower abdomen and pelvic area. Varies diagnostic tests used to diagnose. Drug of choice for IC is polysulfate sodium (Elmiron) Newer drug Dimethylsulfoxide is liquid instilled 20 minutes through temporary catheter.  Irritable bowel syndrome (IBS) 1/3 if women with IBS report chronic pelvic pain, migraine headaches, bladder discomfort, dyspareunia. Common GI disorders include constipation or IBS. Pelvic pain generally occurs under the naval, or low back pain. Also can occur as rectal, vaginal, or perineal. It is not related to pregnancy or menstruation  Definition continued.  Musculoskeletal D/O Pain and discomfort around the pelvic area. Common condition that lead to chronic pelvic pain are sacroiliac joint dysfunction, symphysis pubis dysfunction, weak pelvic floor muscles, joint immobility. Physical therapy is helpful  Postsurgical pain May develop after any surgical procedure and is common after abdominal and pelvic surgery with a prevalence between 10 and 40% (cholecystectomy, groin hernia repair, C section, pelvic fx) Pelvic nerves may be stretched during surgery or compressed afterwards. Postsurgical pain lasting more than 3 to 6 months after surgery  Clinical Presentation  May require multiple visits before the chief presentation is defined  Obtain a thorough med/surg history with the PQRST of pain.  Assess the relationship of the pain to each organ system.  Identify associated events, including complaints of fever, sweats, fatigue, anorexia, nausea, vomiting, and constipation.  Physical Exam and Diagnostics  Perform a detailed abdominal, pelvic, and back exam.  GOLD STANDARD OF INVESTIGATION OF CHRONIC PELVIC PAIN: Diagnostic laparoscopy  Diagnostics  Evaluation should include vaginal and cervical cultures for STDs, urinalysis, urine culture, complete blood count (CBC), pregnancy test, and erythrocyte sedimentation rate (ESR).  A transvaginal/renal ultrasound if bimanual exam was difficult, and/or laparoscopy, CT scan, or MRI may be indicated if endometriosis, adhesions, or chronic PID.  Differential Diagnosis  Musculoskeletal  Herniated disk disease, chronic pelvic tilt, degenerative joint disease, and myofascial trigger points  Gastrointestinal  IBS accounts for a large percentage of CPP.  Urologic  Urethral syndrome, chronic urethritis, interstitial cystitis, urethral diverticulum, and bladder spasms  Gynecologic  Endometriosis (one of most leading causes of CPP), adhesions  Psychological  Depression  Management  Supportive care  Counseling, positive reinforcement  Pharmacologic  NSAIDs (first line), tricyclic antidepressants, anticonvulsants (gabapentin)  Interventional  Neurostimulation, laparoscopy  Complementary and alternative medicine  Cognitive behavioral therapy (CBT)  Acupuncture biofeedback  Cannabis for medical purposes  Heat or cold  Guided imagery  Hypnosis, relaxation, massage, spinal manipulation