CHRONIC PELVIC PAIN

1
CHRONIC PELVIC PAIN
Bruce G. Bateman, MD
2
Chronic Pelvic Pain

• Scope and Cost
• Back pain 4.1
• Chronic pelvic pain 3.8
• Asthma 3.7
• Migraine 2.1
• Direct and Indirect Costs to U.S.
• Healthcare system 2 billion/year
• Organ System Distribution
• Gastrointestinal 38
• Urinary 31
• Gynecologic 20

3
CPPGeneral Associations/Demographics

• No association with race, ethnicity,
  socioeconomic status
• Tends to occur with higher frequency in
  reproductive age women
• Higher prevalence in separated or divorced women

Obstet Gynecol 1996
4
The Importance of Placebo Effect in Pain
Treatment/Research

• Review of placebo effect studies
• Placebo effect frequency varies and is often gt30
• Placebo effect occurs with surgical and medical
  therapy
• A placebo effect prone personality was not
  identified

Turner Et Al Jama, 1994
5
Echelons of Data

• Randomized controlled trials
• Controlled trials without randomization, case
  controlled, multiple series
• Opinions of authorities or expert committees

US Preventative Services
6
Experience is simply the name we give our
mistakes
Oscar Wilde
7
Scope of Pelvic Pain Differential Diagnosis

• ACOG practice bulletin 2004 lists 68 diagnoses
• Diagnoses are organized based data levels
• I, II, III
• There are 28 level I disorders

8
GYN
9
CPP GYN Differential Diagnosis Level I Data

• Endometriosis
• GYN Malignancy
• Pelvic Congestion Syndrome
• Ovarian Remnant Syndrome
• Pelvic Inflammatory Disease
• TB Salpingitis

ACOG Practice Bulletin 2004
10
(No Transcript)
11
Endometriosis
12
Does Response to Hormonal Therapy Predict
Presence or Absence of Endometriosis?
Jenkins Human Reprod 2008

• 104 patients treated for 3 months of hormonal
  therapy for pelvic pain
• 57 failed to respond. 47 responded.
• Laparoscopy findings
• 67 of responders had endo
• 68 of non-responders had endo

13
(No Transcript)
14
(No Transcript)
15
Visible and Non-Visible Endometriosis and
Laparoscopy in Fertile and Infertile Women and
Patients with Pelvic Pain
Balasch Human Reprod 1996

• N100
• Endometriosis present
• 50 - Infertility
• 44 - Pelvic Pain
• 43 - Normal Fertile
• Normal appearing uterosacral ligament
• Biopsy
• in 11 visible endometriosis group
• in 6 no visible endometriosis

16
Surgical Treatment of Endometriosis

• Pain relief after conservative surgery widely
  variable approximately 50 ¹
• Recurrent pain after conservative surgery tends
  to be refractory to further surgery ¹
• Uterosacral and presacral nerve ablation
  procedures lack level I data to support
  usefulness ²
• Hysterectomy for pain/endometriosis has 15
  incidence of recurrent pain within one year ³

¹ Olive 2002 ² Vercellini 1991
³ Vercellini 2000
17
Cost of Treatment 6 Month Course

• Lupron 4000
• Mirena IUD 700
• Oral Contraceptives 500
• Depo Provera 348

18
Randomized Trial of Levonorgestrel IUD and GnRH
Analogue ForEndometriosis and Pelvic Pain
Petta Hum Reprod 2005

• 82 patients
• Daily pain diary
• 6 month treatment
• 85 IUD group pain relief
• 83 GnRH analogue pain relief
• Trend to faster pain relief in Stage III and IV
  disease

19
Aromatase Inhibitors for Treatment of
Endometriosis

• Endometriosis implants grow in response to
  estrogen
• Endometriosis implants have significant aromatase
  activity ¹
• Aromatase acts at the last step in estrogen
  synthesis
• Type II aromatase inhibitors cause competitive
  inhibition
• Anastrozole
• Letrozole

¹Simpson 1993
20
No previous surgery
Endo present
No Endo
Want pregnancy
Not want pregnancy
No response
No response
21
gt 1 yr
lt 1 yr
Pain not resolved
Pain resolved
Negative
Positive
22
Endometriosis Summary Points

• Perform laparoscopy early
• Recognize endometriomas on ultrasound
• Consider Mirena IUD for medical therapy
• Aromatase inhibitors/oral contraceptives for pain
• When doing extrapative surgery - remember the
  source of estrogen

23
Treating adhesions and fallopian tube occlusion
with manual pelvic physical therapy

Altern Med Health 2008
24
Pelvic Vascular Congestion Syndrome

• First described 1949 H.C. Taylor in Amer J
  Ob/Gyn attributed to stress
• Symptoms
• Pelvic pain
• Shifting location
• Deep dyspareunia
• PC pain
• ? pain by standing
• Normal peripheral hormone levels ¹
• Findings
• Dilated uterine and ovarian veins ¹

¹ Beard 1984
25
(No Transcript)
26
Incompetent Ovarian VeinsCommon CT Findings
Rozenblit 2001

• 34 female renal donors
• CT scans
• Dilated, incompetent veins present in 47 of
  asymptomatic women

27
Ovarian Veins MRI Findings in Asymptomatic
Population
Nascimento 2001

• 22 female renal donors
• Asymptomatic
• 38 had passive reflux from left renal vein into
  gonadal vein with significant dilation

28
Ovarian Vein Embolization for Treatment of Pelvic
Congestion
Maleux 2000

• 41 women, mean age 38 years
• 32 underwent unilateral ovarian vein embolization
• 9 bilateral embolization
• Results (mean follow up 20 months)
• 9 variable pain relief
• 58 total pain relief

29
Treatment of Pelvic Congestion

• 47 patients with pure pelvic congestion
  syndrome
• Randomized to 6 months treatment
• Goserelin 3.75 mgm/m
• v
• Medroxyprogesterone 30 mgm/d
• Follow up at 12 months
• Significant improvement in Goserelin group pain
  and venography scores

Soysal 2001
30
Gastrointestinal
31
CPP Gastrointestinal Differential Diagnosis

• Colon cancer
• Constipation
• Inflammatory bowel disease
• Irritable bowel syndrome

ACOG Practice Bulletin 2004
32
Irritable Bowel Syndrome

• 12 weeks of 2 of 3 of these pain associations
  (within 12 months)
• Relieved by defecation
• Onset associated with change in frequency of
  stool
• Onset associated with change in stool form

Rome II Criteria
33
IBS

• Prevalence greater in women
• First presentation to physician gt between ages
  30-50
• Prevalence is similar in whites and blacks may
  be lower in hispanics

AGA Technical Review 2002
34
What Do Patients with Irritable Bowel Disease
Dream About?

• Significantly more patients with irritable bowel
  syndrome (18) and inflammatory bowel disease
  (22) vs controls (3) dreamt their bowels

Dig. Liver. DIS 2002
35
Pathophsysiocology IBS

• Motility although transit is accelerated in
  diarrhea and slowed in constipation there is no
  consensus on motility abnormalities in patients
  with IBS
• Viseral Hypersensitivity IBS patients have pain
  at lower lumenal bowel volumes and pressures
  than uneffect patients
• Inflammation varied gut immune response
• CNS Modulation CNS modulates motility,
  secretion, immune function, and blood flow

AGA Technical Review 2002
36
IBS Pathophysiology

• Psychogenic stress exacerbates GI symptoms
• Psychiatric comorbidity is common among IBS
  patients
• Psychosocial factors affect clinical outcome
• Psychosocial factors affect which patients
  consult physicians

AGA Technical Review 2002
37
GI Evaluation

• If alarm signs are absent, evaluation may
  include physical exam only with a trial of
  treatment
• Signs that drive testing
• Short symptom duration with rapid progression
• Demographics age gt 50
• Family history positive for cancer or
  inflammatory bowel disease
• Absence of clear psychosocial issues
• Other evaluation possibilities
• CBC, Chemistries, Sed Rate, TSH
• Stool for ova and parasites
• Colonoscopy
• Bowel biopsy
• Bowel radiographics

AGA Technical Bulletin 2002
38
IBS - Treatment

• Diet
• Patients often attribute symptoms to specific
  foods
• However, there are no food types that uniformly
  cause symptoms in IBS
• Drug therapy for symptoms
• Pain
• antispasodics (smooth muscle relaxants)
  dicyclomine
• peppermint oil
• Psychological treatment useful if
• Awareness that stress increased symptoms at least
  mild anxiety/ depression
• Main symptom is pain/diarrhea

39
IBS Treatment - Reviews

• Bulking agents, antispasmodics and
  antidepressants for treatment of IBS
• 16 studies reviewed
• Conclusions
• Antispasmodics may be effective to decrease pain
  from IBS
• No evidence bulking agents are effective
  treatment
• No evidence antidepressants are effective
  treatment

Cochran Review Quartero 2005
40
Herbal Medications for Treatment of IBS

• Studies are of generally poor quality
• Herbal medications are promising
• It is premature to recommend herbal treatment
  for IBS

Cochran Reviews Liu 2006
41
COLONCLEANSEAUTHROITY.COM

• MYIRRITABLEBOWELSYNDROME.COM

42
(No Transcript)
43
Adhesions

• De Novo adhesion formation
• Laparotomy 50-60 1
• Laparoscopy 12-21 2
• Adhesion reformation
• Laparoscopy 3
• Dense ? 31
• Filmy ? 35
• Adhesion barrier use
• 5 of abdominal surgeries 4
• No comparative studies of available products

1 Menzies 92 2 Luciano 91 3
Luciano 08 4 diZerega 03
44
Adhesions and Abdominal Pain

• Restriction of tissue expansibility stimulating
  stretch receptors ¹
• Pain Mapping studies 80 of patients noted
  significant pain with probe of adhesions ²
• Sensory nerve fibers in adhesions
• 100 of adhesions sampled from 25 patients at
  laparotomy for CPP had sensory nerve fibers in
  all types of adhesions ³

¹ Williams 97 ² Steege 99 ³ Sulaiman 01
45
What do you get when you operate for pain?

• More pain

Meredith Aldrich MD 1971
46
Does Adhesiolysis Relieve Pain?
Wolter 2000

• 326 patients
• 45 mild
• 45 moderate
• 10 severe
• Complete resolution
• 70 pain free
• Incomplete resolution
• 57 pain free

47
Does Adhesiolysis Relieve Pain
Peters 92

• 48 patients
• Randomized laparotomy lysis
• 12 month follow up McGill Pain Score
• Conclusion
• No difference in pain resolution
• Trend to improvement in severe adhesions subgroup

48
Urologic
49
CPP Urologic Differential DiagnosisLevel 1

• Bladder malignancy
• Interstitial cystitis
• Urethral syndrome
• Radiation cystitis

50
(No Transcript)
51
Bladder Cancer

• Facts
• 8th most common cancer in women
• Incidence increases with age
• Risk factors
• Tobacco use
• Recurrent UTI
• Diet high fat
• Exposure to chemotherapy drugs and some hair
  dye products
• Symptoms
• Hematuria
• Frequency
• Dysuria

R. Levin 2008
52
Interstitial Cystitis (Syndrome)

• Defined by
• Urinary frequency and urgency
• Bladder pain
• Sterile urine
• Predominantly female 90
• Does not tend to be progressive
• No clear clinical marker for interstitial
  cystitis
• Potassium sensitivity test

Hanno 2002
53
(No Transcript)
54
Interstitial Cystitis
Inflammation Cytokine Release
Tissue Injury
Stress Depression
Bladder Spasm
Hyperalgesia
Shoskes 2008
55
Interstitial CystisisClinical Markers?

• 20 asymptomatic women undergoing tubal ligation
• Cystoscopy with hydrodistention of bladder
• Glomerulations noted in majority of subjects

Waxman 98
56
Interstitial Cystitis Factoids

• Interleukin 6 in bladder urine of IC patients
• 50 of IC patients have autoantibodies
• Estrogen receptors in mast cells of IC patients

Lotz 94
Keck 97
Letoureay 03
57
Persistent Sexual Arousal Syndrome Associated
with Increased Soy Intake
J. Sexual Medicine 2005
58
Treatment of Interstitial Cystitis

• Intravesical DMSO
• 50 response rate
• 50 relapse rate ¹
• Elmiron
• Oral agent
• 4-6 months treatment
• 42 response rate ²
• Elmiron Tricyclic antidepressant
• 80 response rate ²
• Amitriptyline
• 50 response rate ³

¹ Parkin 1997 ² Nickel 2001
³ Hanno 1994
59
CPP Musculoskeletal Differential Level I

• Abdominal wall trigger points
• Coccygeal or back pain
• Poor posture
• Fibromyalgia
• Neuralgias iliohypogastric
• ilioinguinal
• genitofemoral
• Pelvic floor myalgia
• Peripartum pelvic pain

ACOG Practice Bulletin 2004
60
CPP Other DiagnsosisLevel I

• Cutaneous nerve entrapment
• Depression
• Somatization disorder

ACOG Practice Bulletin 2004
61
Endometriosis
Interstitial Cystitis
IBS
Pain
Depression Somatization
62
Referral Centers for CPP

• Fred Howard, MD
• University of Rochester
• Phone [phone]
• John Steege, MD
• University of North Carolina
• Phone [phone]

63
CHRONIC PELVIC PAIN
Bruce G. Bateman, MD