Chronic Pelvic Pain-benjamin

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

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Why is Chronic Pelvic Pain so Different? Difficult / Unsatisfactory

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Acute pelvic pain: symptom of underlying tissue injury.

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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

Sources of chronic pelvic pain      

Gynecological Urological Gastrointestinal Musculoskeletal Neuropathic Other

Incidence   

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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%).

Differential Diagnosis for Chronic Pelvic Pain Gynecologic

Gastrointestinal

Endometriosis syndrome

Irritable bowel

Adhesions (chronic pelvic inflammatory disease)

Chronic Appendicitis

Leiomyomata

Inflammatory bowel disease

Adenomyosis

Diverticulosis

Pelvic congestion syndrome

Diverticulitis Meckel’s diverticulum

Differential Diagnosis Urologic

Psychological

Abnormal bladder function (detrusor instability)

Depression

Urethral syndrome (chronic urethritis)

Somatization

Interstitial cystitis Psychosexual dysfunction/ abuse

Personality disorder

Differential Diagnosis Musculoskeletal

Surgical

Nerve entrapment (neuritis) appendicitis

Chronic

Fasciitis

Hernia

Scoliosis

Bowel disease

Disc disease

Adhesive disease

Spondylolisthesis Osteitis pubis

MOST FREQUENTLY MISSED COMPONENTS OF CPP      

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

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 No Check 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

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?

n

Has anyone ever asked you to touch them when you did not want to? If yes, at what age? By whom?

n

Vaginal discharge, Dyspareunia(41%vs 14%), Dysmenorrhoea(81%vs 58%).

Adapted from Carter JE. “Chronic Pelvic Pain Diagnosis and Management”

History: activities    

Work School Social activities Childcare

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Sports/exercise Patient deems important

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

Investigations     

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

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

Non-gynecologic Causes 

Non-gyn causes account for significant CPP

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Complete history and physical essential

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Pain, symptoms checklist and history questionnaire is helpful

Non-gynecologic Causes   

Irritable bowel syndrome is most common Urethral synd / IC common- often missed Tenderness specific to abdominal wall- consider nerve entrapment

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Myalgia, disc disease and referred pain must be ruled out

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Abdominal wall, umbilical and spigelian hernias

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Psychological factors

IBS 

Cramping, colicky pain ( lower abd )

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Worsens 1 to 1.5 hrs after meal

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Abdominal distention

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Relief of pain with bm

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Freq/loose bm with onset pain

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Palpable, tender sigmoid colon

Urethral syndrome

Interstitial cystitis

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Dysuria, Urgency and Frequency

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Dysuria, Urgency, Frequency

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Without nocturia Treatment: Responds-- long term antibiotic (3 mos ) Responds-- urethral dilation

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With nocturia ( 2 to 3x /night)

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Treatment

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Correct hypoestrogen Bladder drills/training Amitryptiline

Musculoskeletal 

Ergonomic impairments

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Exaggeration lumbar lordotic curve

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Anterior pelvic tilt

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Scoliosis

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Poor posture

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

Psychological 

Depression

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Sexual abuse

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Anxiety disorder

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Personality disorder

Medical Management 

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

Surgical management  

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Adhesion release: RCT’s 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.

Non conventional therapy 

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

Summary 

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

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THANK YOU