Chronic Pelvic Pain PDF

Chronic Pelvic Pain Dr. Iman Akef Khowailed WCS, DSC  Chronic Pelvic Pain Chronic pelvic Pain is often defined as pelvic pain that lasted longer than 3 months. Pelvic Pain > 3 months if continuous Pelvic Pain > 6 months if cyclic  Hypertonic dysfunction...

Chronic Pelvic Pain Dr. Iman Akef Khowailed WCS, DSC  Chronic Pelvic Pain Chronic pelvic Pain is often defined as pelvic pain that lasted longer than 3 months. Pelvic Pain > 3 months if continuous Pelvic Pain > 6 months if cyclic  Hypertonic dysfunction Hypertonic dysfunction often include diagnoses of pelvic tension, myalagia or pelvic floor spasm, incisional pain, vulvodynia, coccydynia, dyspareunia, and constipation. Any of the hypertonic dysfunction that reappear may then become a chronic pelvic pain syndrome. Conditions that may contribute to chronic pelvic pain Vulvodynia IC Levator Ani syndrome Pudendal neuralagia Dyspareunia Vaginismus Dysmenorrhea Vulvodynia/Vestibuldynia “Chronic Vulvar pain, most often described as burning pain, occur in the absence of relevant visible findings or clinically identifiable neurological disorder.”  Vulvodynia Is a syndrome of vulvar discomfort characterized by burning, itching, stinging or rawness. Vulvodynia- allodynia of the vulva Generalized (entire vulva) Provoked (sexual, non sexual or both) Unprovoked Mixed Localized (vestibule, clitoris) Provoked Unprovoked Mixed  Clinical signs and symptoms of vulvodynia and vestibulodynia Genital Symptoms Itching, burning, stabbing pain (hot poker feeling), severe pain with intercourse, inflammatory signs (redness & swelling). Urinary symptoms Urgency , frequency, burning pain during and after urination High resting SEMG levels Trigger points in the surrounding muscles such as STP, bulbocavernosus, levator ani and OI Other symptoms Generalized soreness in pelvic muscles, hips , gluteus Impaired ROM in hips & L/S region Hypersensitive to any touch Typical pelvic pain posture Vulvodynia is one of the leading cause of dyspareunia  Positive cotton swab test Gentle pressure of cotton swab around vulva/vestibule will produces patients symptoms For each site, the patient will Rates the pain severity Describe the pain character (burning )  Interstitial Cystitis/ Painful bladder Syndrome Inflammation of the bladder wall/lining. Chronic pelvic pain, pressure, or discomfort perceived to be related to the urinary bladder and accompanied by at least one other urinary system such as urge to void or urinary frequency. Suprapubic pain related to bladder filling accompanied by increased frequency in the absence of the proven other obvious pathology.  Clinical Signs and Symptoms of IC Urgency and frequency of urination. Pelvic Pain/ Pressure. Bladder spasms Dyspareunia Burning pain suprapubically and into groin General soreness in pelvic muscles , hips , gluteus Impaired ROM L/S, hips Poor sleep due to nocturnal and burning/ severe pain after urination Typical pelvic pain posture or flexed posture for splinting pelvic pain.  Associated symptoms Irritable bowel syndrome Urethral burning Genital pain(tip of the penis and testicles in the male patients Chronic constipation Slow urinary stream(inefficient void volume or pelvic floor muscle tension ) Food sensitivities that worsen the symptoms Pelvic Pain that intensifies 1 week before the menstrual period  Proposed Etiology Chronic or subclinical infection Neurogenic inflammation Autoimmune Genetic Environmental (smoking, diet, stress)  Dyspareunia Recurrent or persistent pain during intercourse or discomfort associated with attempted or complete vaginal penetration. Deep dyspareunia refers to pain with deep vaginal penetration (mid or upper vaginal) Superficial (introital) dyspareunia is pain with initial penetration of the vagina or at the vaginal introital Situational dyspareunia Generalized dyspareunia  Causes Vulvovaginitis or urethritis can result in skin irritation and pain with initial penetration or early dyspareunia. Vulvar vestibulitis & vulvodynia Atrophic vaginitis( thinning of the vaginal lining in post menauposal women) Endometriosis Psychological trauma Past history of sexual abuse Dyspareunia Questions and QOL Is pain superficial or deep ? Sense of friction or lack of lubrication ? Estrogen level post partum or peri menopausal Is scar present Duration of symptoms, onset  Vaginismus Involuntary reflex contraction and spasm of the perineal muscles, making vaginal penetration impossible or painful. This muscle spasm is a conditioned response to some sort of real or imagined painful stimulus. Primary : women who have never been able to have intercourse Secondary : secondary to dyspareunia Over activity of the superficial/ deep muscles Often the bulbocavernosus is in tension, closed very tightly Patient reports “something blocking the entrance” or tight spot”  Pudendal Neuralagia Alcock’s syndrome Painful neuropathic condition involving the dermatome of the pudendal nerve. Neuropathic pain in the distribution of the pudendal nerve Rectal, perineal, clitoral, penile branches Burning, numbing, tingling Hyperalgesia Allodynia Parathesia Pudendal Nerve  Functional Impact of Pudendal Neuralgia & Symptoms Significant pain with sitting Relieved with supine position Feeling of foreign body in the vagina or the rectum Scrotum/Testicular pain Bowel or bladder dysfunction Urgency/frequency of urination or pain with urination Rectal pain Constipation Sexual dysfunction Low libido Decreased arousal or hyper arousal (PGAD persistent genital hyperarousal) or pain with orgasm  Functional Impact of Pudendal Neuralgia & Symptoms After an extended bicycle ride, patient may experience a deprivation of physical sensation in the penis and scrotum. Pain during erection Difficulty sustaining erection or painful ejaculation Low back pain resulting from radiation of the pain  Levator Ani Syndrome Pelvic Floor Muscle Spasm Abnormally increased muscle activity in the pelvic floor muscles (levator ani complex) resulting in acute or chronic pain. Terms often associated with this dysfunction are levator spasm syndrome, and pelvic floor myalgia. Pain & spasm in the area of the coccyx, piriformis muscle, gluteal muscles, and posterior thigh.  Common Etiologies of Pelvic Floor Muscle Spasm Pain Physical or emotional trauma Poor posture Childbirth Pelvic surgery Low back pain Sexual abuse Poor voiding and defecating habits  Symptoms Low back pain (In a study of 94 patients with a diagnosis of chronic pelvic pain. Sinaki et al found that 82% of theses subjects complained of low back pain) Heaviness in the pelvic area Constipation Painful bowel movements Leg pain Coccyx pain Dyspareunia The quality of pain is describes as achy, heavy, throbbing.  Coccydynia Pain in & around the coccyx. Pain in and around the coccyx may be from direct trauma such a s fall resulting in dislocation, fracture, arthritis, or presumed injury during vaginal delivery.  Symptoms Pelvic Pain Pain in the lower back Sacroiliac Pain Painful bowel movement Dyspareunia Aching or grabbing pain that may be sharp and radiate to the buttocks Pelvic Pain exacerbated by sitting for long time and excessive hip extension during activities. Thank YOU