Chronic Pelvic Pain PDF

Chronic Pelvic Pain Actually two quite different kinds of pain exist: The first is termed nociceptive. This pain is nociceptive associated with tissue damage or inflammation, so it is also called ‘inflammatory pain’. The second is termed neuropathic and results from...

Chronic Pelvic Pain Actually two quite different kinds of pain exist: The first is termed nociceptive. This pain is nociceptive associated with tissue damage or inflammation, so it is also called ‘inflammatory pain’. The second is termed neuropathic and results from a lesion to the peripheral or central nervous systems. Many pains will have a mixed neuropathic and nociceptive aetiology.  ACOG Definition of CPP “Non-cyclic pain of 6 or more months duration that localizes to the anatomic pelvis, abdominal wall at or below the umbilicus, lumbosacral back or the buttocks and is of sufficient severity to cause functional disability or lead to medical care.” ACOG Practice Bulletin No. 51. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2004;103:589-605.  Definition of Chronic Pelvic Pain Duration Non-cyclic ± Dysmenorrhea 3months if continues ± Dyspareunia Severity 6 months if cyclic Medical or Location surgical therapy Anatomic pelvis required Abdominal wall Functional below the umbilicus impairment Lower back ACUTE vs CHRONIC PAIN ACUTE PELVIC PAIN: PAIN symptom of underlying tissue injury and disease CHRONIC PELVIC PAIN: pain becomes the disease (etiology not found or treatment of presumed etiology fails)  CPP Syndrome Is the occurrence of persistent or recurrent episodic pelvic pain associated with symptoms suggestive of lower urinary tract, sexual, bowel or gynaecological dysfunction. dysfunction There is no proven infection or other obvious pathology. (adopted from ICS 2002)  CPP Syndrome Bladder pain syndrome Generalized vulvar pain Urethral pain syndrome syndrome Endometriosis associated pain Localized vulvar pain syndrome syndrome Vestibular pain syndrome Vaginal pain syndrome Clitorial pain syndrome Vulvar pain syndrome Anorectal pain syndrome Anismus pain syndrome Pudendal pain syndrome Perineal pain syndrome Pelvic floor muscle pain syndrome  CPP Is a Significant and Common Disorder in Women Magnitude of CPP >9 million women in the United States1 20% of women had pelvic pain >1 year in duration2 CPP accounts for 10% of referrals for OB/Gyn visits3 Over 20% of laparoscopies4 12 -18 % of hysterectomies5 Patients with CPP have significantly lower general health scores compared with patients without CPP1 1. Mathias SD et al. Obstet Gynecol. 1996;87:321- 327. 4. Howard FM. Obstet Gynecol Surv. 2. Jamieson DJ, Steege JF. Obstet Gynecol. 1993;48:357-387. 1996;87:55-58. 5. Carlson KJ et al. Obstet Gynecol. 1994;83:556- 3. Reiter RC. Clin Obstet Gynecol. 1990;33:130-136. 565.  Prevalence of CPP is Comparable to Other Common Medical Problems N=24,053 CPP Migraine Asthma Back Pain Cross-sectional analysis by UK Mediplus Primary Care database. ondervan KT et al. Br J Obstet Gynaecol. 1999:106;1149-1155.  ACOG Practice Bulletin Number 51; March 2004 CPP is common in women and presents a diagnostic challenge Most common disorders that cause CPP are endometriosis, interstitial cystitis and irritable bowel syndrome 38-85% of women presenting to a gynecologist for CPP may have IC ACOG Practice Bulletin No. 51. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2004;103:589-605. Necessity of Multidisciplinary Approach International Pelvic Pain Society Assssment Form Chronic Pelvic Pain: History Pain duration > 6 months Incomplete relief by most previous treatments, including surgery and non-narcotic analgesics Significantly impaired functioning at home or work Signs of depression such as early morning awakening, weight loss, and anorexia  Pain out of proportion to pathology History of childhood abuse, incest, rape or other sexual trauma Current sexual dysfunction Previous consultation with one or more health care providers and dissatisfaction with their management of her condition Physical Examination General Examination Check Abdominal Wall Systematic physical exam of abdominal, pelvic, and rectal areas, focusing on the location and intensity of the pain. Check for Pelvic Floor Myalgia Single Digit Pelvic Exam Speculm exam Bimanual exam Rectovaginal exam Palpate the coccyx, coccyx both internally and externally  Patient Evaluation for Bladder Tenderness Suprapubic tenderness Anterior vaginal wall/ bladder base X tenderness Levator muscle spasm Rectal spasm Howard FM, Perry CP, Carter JE, El-Minawi AM. Pelvic Pain: Diagnosis and Management. Lippincott. 2000:3 Physical Examination: Pelvic Traditional bimanual examination is the last portion of the pelvic examination Uterus Adnexa Anorectum Many layers palpated; non- specific findings likely  Investigations Should be selected discriminately as indicated by the findings of the history and physical exam Avoid unnecessary and repetitive diagnostic testing Vaginal smearing Cervical cultures HSG Stool analysis Ultrasound Diagnostic laparascopy Dysmenorrhoea Pain in association with menstruation may be primary or secondary. Primary dysmenorrhoea classically commences with the onset of ovulatory menstrual cycles and tends to decrease following childbirth to the use of non-steroidal anti-inflammatory drugs (NSAIDs), which are particularly helpful if they are started before the onset of menstruation. Dysmenorrhoea Suppression of ovulation using the oral contraceptive pill reduces dysmenorrhoea dramatically in most cases. Because of the chronic nature of the condition, potentially addictive analgesics should be avoided. Secondary dysmenorrhoea would suggest the development of a pathological process, and the exclusion of endometriosis and pelvic infection is essential Infection A history of possible exposure to infection should be sought and it is mandatory in all cases to obtain swabs to exclude chlamydia and gonorrhoea, as well as vaginal and genital tract pathogens. Patient’s sexual contacts will need to be traced in all cases with positive cultures. If there is doubt about the diagnosis then laparoscopy may be of great assistance. The treatment of infection depends on the causative organisms. Infection Subclinical chlamydial infection may lead to tubal pathology. Screening for this organism in sexually active young women may reduce the incidence of infertility. Chronic pelvic inflammatory disease is no longer common in developed countries, but still poses a significant problem with chronic pain in the Third World. Gynaecological malignancy The spread of gynaecological malignancy of the cervix, uterine body or ovary will lead to pelvic pain depending on the site of spread. Treatment is of the primary condition, but all physicians dealing with pelvic pain must be fully aware of the possibility of gynaecological malignancy. Injuries related to childbirth Tissue trauma and soft tissue injuries occurring at the time of childbirth may lead to chronic pelvic pain related to the site of injury. Dyspareunia is a common problem leading to long-term difficulties with intercourse and female sexual dysfunction. Denervation of the pelvic floor with re- innervation may also lead to dysfunction and pain.  PELVIC ADHESIONS If adhesions are found adhesiolysis is beneficial in only 40% (especially in patients with chronic pain syndromes) Steege, 1991 Endometriosis? characterized by the presence of endometrium- like tissue in ectopic sites outside the uterus, primarily on pelvic peritoneum and ovaries affects nearly 1 in 7 women of reproductive age third most common gynecologic disorder that requires hospitalization, and a leading cause of hysterectomy. Commonly affected organs and structures: Ovaries and the sacral ligament Endometriosis on bowel surfaces Endometriosis on appendix Endometriosis Symptoms Chronic pelvic pain Dysmenorrha Dyspareunia Infertility Endometriosis and Pain Chronic pelvic pain is the most consistent symptom with a prevalence of 30-70% in adults, and 45-58% in adolescents. Dysmenorrhea is associated with endometriosis in more than 50% of adults, and up to 75% of adolescents Dyspareunia is variable ranging from 4%-55% Endometriosis Treatment Medical Treatment Established Medical Treatments Experimental Treatments Surgical Treatment Conservative Coagulation/ablation Radical Excision  Role of laparoscopy Best evidence suggests that symptomatic relief can be achieved with either medical or surgical therapy for mild to moderate disease. For severe or nodular disease or for patients with endometriomas, surgical alternatives are most effective. ACOG technical bulletin Endometriosis & the endometrium Diamond & Osteen  Pain Control Restoration of Fertility Prevention of Recurrence Established Medical Treatments Oral Contraceptives Progestins Danazol NSAIDs GnRH analogues Suggested approach to endometriosis-associated pain 1st line: continuous low-dose monophasic oral contraceptive with NSAIDs as needed 2nd line: progestins (start with oral dosing, consider switching to levonorgestrel intrauterine device or depo if well tolerated) 3rd line: GnRH agonist with immediate add-back therapy 4th line: repeat surgery, followed by 1, 2, or 3 May consider low-dose (100–200 mg every day) danazol if other therapies poorly tolerated. Mahutte and Arici, 2003 Surgical Excision Aggressive Entire visible lesion should be removed. Any abnormal peritoneum is suspect (50% positive path) Conservative Uterus, tubes and ovaries most often can be conserved. Chronic Pelvic Pain Is Characterized by Overlapping Disease Conditions Interstitial Cystitis/PBS EndometriosisA Vulvodynia denomyosis Chronic Pelvic Pain Overlapping GI Disorders Disease Pelvic Infection IBS Conditions and Adhesions Recurrent UTI