Chronic pelvic pain

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Chronic pelvic pain

• Dr. Mridula A. Benjamin.
• Dept of Obs and Gyn
• RIPAS Hospital, Brunei

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• An unpleasant sensory and emotional experience
  associated with actual or potential tissue damage
  
• Why is Chronic Pelvic Pain so Different?
• Difficult / Unsatisfactory

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• Acute pelvic pain symptom of underlying tissue
  injury.
• Chronic pelvic pain pain becomes the disease
• Recurrent, unrelated to menses, intercourse,
  pregnancy
• Chronic pain pain lasting 6 months or
  longer.
• Chronic pelvic pain syndrome chronic pelvic pain
  causing emotional and behavioral changes.

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Type of pain

• Visceral pain
• Referred Pain
• Somatic Pain
• Myalgia
• Hyperalgesia
• Neuroinflammation 

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Sources of chronic pelvic pain 

• Gynecological
• Urological
• Gastrointestinal
• Musculoskeletal
• Neuropathic
• Other

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Incidence

• 14 24 of women b/w 18 and 50 years.
• 1/3 do not consult doctor.
• 60 who consult are not referred to tertiary
  centre.
• Population studies GI (37), Urinary (31),
  Gynae (20).
• Laparoscopic findings No pathology (35),
  Endometriosis (33), Adhesions (24).

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Differential Diagnosis for Chronic Pelvic Pain

• Gynecologic Gastrointestinal
• Endometriosis syndrome Irritable bowel
• Adhesions (chronic pelvic Chronic Appendicitis
  inflammatory disease)
• Leiomyomata Inflammatory bowel disease
• Adenomyosis Diverticulosis
• Pelvic congestion syndrome Diverticulitis
• Meckels diverticulum

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Differential Diagnosis

• Urologic Psychological
• Abnormal bladder function Depression (detrusor
  instability)
• Urethral syndrome Somatization (chronic
  urethritis)
• Interstitial cystitis
• Psychosexual dysfunction/ Personality disorder
  abuse

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Differential Diagnosis

• Musculoskeletal Surgical
• Nerve entrapment (neuritis)
  Chronic appendicitis
• Fasciitis
  Hernia
• Scoliosis
  Bowel disease
• Disc disease
  Adhesive disease
• Spondylolisthesis
• Osteitis pubis

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MOST FREQUENTLY MISSED COMPONENTS OF CPP

• Abdominal trigger points
• Vestibulitis
• Pelvic floor myalgia
• Hernias
• Pelvic congestion
• Interstitial cystitis

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History questionnaires

• A. Who have you consulted about your current
  medical complaint? What did they tell you?
• B. How are you currently coping with your pain?
• C. Do you have any history of a major episode of
  depression?
• D. Do you feel you are experiencing symptoms of
  depression? Yes NoCheck those that
  apply Mood disturbances Feelings of
  hopelessness Low energy Sleep disturbance Loss
  of pleasure in activities Feelings of
  worthlessness Loss of appetite Thoughts or
  plans of suicide

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History questionnaires

• E. Has anyone ever abused you sexually?(40 vs
  17) If yes, at what age?By whom?
• F. Has anyone ever touched you in any way that
  made you feel uncomfortable?If yes, at what
  age?By Whom?
• Has anyone ever asked you to touch them when you
  did not want to?If yes, at what age?By whom?
• Vaginal discharge, Dyspareunia(41vs 14),
  Dysmenorrhoea(81vs 58).

Adapted from Carter JE. Chronic Pelvic Pain
Diagnosis and Management
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History activities

• Sports/exercise
• Patient deems important

• Work
• School
• Social activities
• Childcare

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Pain Questionnaire
Date Name Age G
P LMP Cycle day A. Fill in the
following chart on pain location Pain site
Date pain
first noticed Describe events preceding pain
(and indicate cycle day) Describe pain using
adjectives (and indicate cycle day) Rate pain
intensity from 0 (no pain) to 10 (most
severe) List additional pain sites on back of
form B. Rate the overall interference of pain
from 0 (low) to 10 (high) for each of the
following Work School
Social activities Childcare
Sports and exercise Relationships
Other C. Check or list things that Increase
pain Decrease pain Intercourse
Lying down Bowel movement
Heating pad Urination Hot
bath Physical activities Medication Other D. List
prior treatments or tests Surgeries GI
studies Type Type Date Date Diagnosis
Diagnosis E. List medications, dates used, and
effectiveness using the 0 to 10
scale Drug Dates Used Rating F. Check off
symptoms you are experiencing other than
pain Bleeding Bowel problems Nausea
Headache Fatigue Other
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• General Examination Gait- Musculoskeletal
• Check  Abdominal Wall Point trigger, Ovarian
  point tenderness
• Inspection of Vulva introitus- Vestibulitis
• Q-tip test for vestibulitis
• Check for Pelvic Floor Myalgia
• Single Digit Pelvic Exam
• Bimanual exam
• Rectovaginal exam

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Investigations

• WCC, ESR
• CA 125
• HVS / Endocervical swabs
• USS
• Laparoscopy.

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Pelvic congestion syndrome

• Equal in parous nulliparous
• ??? Underlying endocrine disorder
• Peripheral hormone levels normal
• Prolonged standing, dysparuenia, postcoital
  aching
• Stress m/g
• Hormonal- MPA/ GnRH agonists
• Hyst BSO
• Vein occlusion- Intervention radiology

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• Endometriosis- Laparoscopic ablation
• LUNA- unclear
• PSN- Positive
• Adhesions- Often coincidental
• Adhesiolysis effective
  only in dense
• Chronic PID- Salpingectomy/ BSO
• Nerve entrapment- LA/ Release
• Neuropathic post surgical- gabapentin/
  Behavioural

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Non-gynecologic Causes

• Non-gyn causes account for significant CPP
• Complete history and physical essential
• Pain, symptoms checklist and history
  questionnaire is helpful

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Non-gynecologic Causes

• Irritable bowel syndrome is most common
• Urethral synd / IC common- often missed
• Tenderness specific to abdominal wall- consider
  nerve entrapment
• Myalgia, disc disease and referred pain must be
  ruled out
• Abdominal wall, umbilical and spigelian hernias
• Psychological factors
• 
  

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IBS

• Cramping, colicky pain ( lower abd )
• Worsens 1 to 1.5 hrs after meal
• Abdominal distention
• Relief of pain with bm
• Freq/loose bm with onset pain
• Palpable, tender sigmoid colon
• Hard pellet-like stool

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• Urethral syndrome
• Dysuria, Urgency and Frequency
• Without nocturia
• Treatment Responds-- long term antibiotic (3
  mos )
• Responds-- urethral dilation

• Interstitial cystitis
• Dysuria, Urgency, Frequency
• With nocturia ( 2 to 3x /night)
• Treatment
• Correct hypoestrogen
• Bladder drills/training
• Amitryptiline

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Musculoskeletal

• Ergonomic impairments
• Exaggeration lumbar lordotic curve
• Anterior pelvic tilt
• Scoliosis
• Poor posture

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Musculoskeletal

• Nerve entrapment
• Ilioinguinal/iliohypogastric-- L1 abdominal wall
• Lateral femoral cutaneous -- L2-3 meralgia
  parasthetica
• Genitofemoral -- muscle entrapment bifurcates at
  iliacus

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Psychological

• Depression
• Sexual abuse
• Anxiety disorder
• Personality disorder

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Medical Management

• Multi disciplinary approach Gynae, pain
  specialist, psychologist, anaesthetist, surgeon,
  physiotherapist, nurse, proper FU.
• Analgesics.
• Anxiolytics and antidepressants.
• Medroxyprogesterone acetate.
• Antibiotics.
• Gabapentin Post hysterectomy pain.

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Surgical management

• Adhesion release RCTs dense
• LUNA beware of prolapse and bladder dysfx
• Presacral neurectomy beware of vessel injury,
  bladder/bowel dysfx.
• Hysterectomy with BSO
• Surgical mx of non gynae causes.

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Non conventional therapy

• Static magnetic therapy RCTs showed use after 4
  week treatment.
• Cognitive and behavioral therapy.
• TENS formal trials are lacking
• Photographic reassurance??!!
• Writing therapy??!!

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Summary

• Thoroughness, continuity, multidisciplinary
  approach and compassion are central themes of
  successful management

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• THANK YOU