Chronic pelvic pain Gynecologists perspective A. El-Dabh, FRCOG, FACOG Fairview Hospital Cleveland Clinic Objectives Gynecologists work-up for CPP Common gynecological etiologies When Gynecologists refer patients to pain management CHRONIC pelvic pain Gynecological literature No universally accepted definition. 3 months duration 6 months duration 6 months cyclic or 3 months non cyclic Chronic pelvic pain in Pain Management literature Incomplete relief by previous treatments Pain out of proportion to tissue damage Loss of physical function Vegetative signs of depression Altered family dynamics NB: This is best known by GYNs as CPP SYNDROME Pathophysiology of pain In acute pain, a peripheral painful stimulus from damaged or irritated tissue is centrally perceived. This pain is proportional to the damage or stimulus In CPPS, it is often difficult to find enough pathology to explain the pain The pain stimulus-perception system is often obscured by complicating emotional factors Scope of the problem of CPP from a gynecological perspective 10% of gynecologists visits 40% of laparoscopies Howard FM Obstet Gynecol Surv 1993 Jun;48(6):357-87 20% of hysterectomies done for benign diseases Farquhar CM; Steiner CA Obstet Gynecol 2002 Feb;99(2):229-34 Gynecologists role in CPP 1- Ruling out the coexistence of an acute etiology for pain (eg strangulated hernia, ruptured ovarian cyst) 2- Diagnosing and treating the underlying condition that resulted in CPP (eg endometriosis, IBS) 3- Diagnosing and referring patients with genuine CPP syndrome Scope of CPP Gynecological disorders. GI. Urinary. Musculoskeletal Psychiatric and Psychological disorders. Pain processing disorders. How do Gynecologists work up patients with CPP? History taking Pain description by the patient; Duration Intensity Frequency Aggravating factors Relieving factors Relationship to BM, urination or SI Relationship to menses History taking Review of symptoms: Particular attention to be paid to GI, GU, reproductive, musculoskeletal or psychoneuronal systems History of Previous treatment especially surgeries Drug or alcohol abuse Sexual, physical or psychological abuse Screening for depression/ abuse Many screening methods Three simple questions: During the past month, have you felt down, depressed or hopeless? During the past month, have you felt little interest or pleasure in doing things? Have you ever been touched against your will? Whooley MA; Avins AL; Miranda J; Browner WS J Gen Intern Med 1997 Jul;12(7):439-45 Clues, pointers in pain description Dull diffuse pain is usually visceral as the bowel is symmetrically innervated Abdominal visceral sensation in man. Ann Surg 1947; 126:709 Surg Gynecol Obstet 1949; 89:573 Somatic pain is localized Cyclical pain related to menses is often caused by endometriosis or adenomyosis Pain that started with pregnancy or shortly thereafter is often musculoskeletal Dysmenorrhea and dyspareunia are often signs of endometriosis Clues, pointers Referred pain is usually aching and superficial Nerve entrapment pain is usually described as hot, cold or as an electric shock Pain associated by urge to void is often caused by interstitial cystitis Pain associated by weight loss can be associated with malignancy Abdominal exam Guarding , rigidity Ascites, organomegaly Palpation starting from the quadrant that is least tender Particular attention to hernia sites, inguinal, femoral, periumbulical and incisional Carnett’s sign While supine, the patient is asked to raise her head or raise both legs while the examining finger is on the tender point Increased tenderness with the rectus abdominus muscle tightened is an indication for myofascial pain; hernia, entrapped nerve or trigger point Visceral pain should diminish with tightening of the rectus muscle Carnett, JB. Intercostal neuralgia as a cause of abdominal pain and tenderness. Surgery, Gynecology & Obstetrics 1926; 42:625 Pelvic exam Vulva Urethra Vagina and muscles Uterus Adnexae US ligaments Vulvar examination Particularly important in patients presenting with vulvar pain or vulvodynia This pain may be described as burning, mild or severe sensitivity, generalized or localized on the vulva, provoked or unprovoked Pain is much exacerbated by touching the vulva or vaginal entry The only physical sign often seen is sensitivity to touch with a q tip Urethra examination Palpation of the urethra can often uncover a diverticulum This may be the source of chronic pain due to recurrent UTIs Rarely urethral diverticula harbor a stone Palpation of the uterus ADENOMYOSIS: enlarged, soft and tender uterus exam particularly helpful if before menses FIBROIDS: enlarged, irregular, firm and nodular uterus Both conditions result in pelvic pain before and with menses as well as heavy painful periods Adnexal exam The adnexae (ovaries and tubes) are palpated to check for: 1- Enlargement; ovarian cysts or solid tumors, benign or malignant 2- Tenderness, may be a sign of chronic PID, endometriosis or pelvic adhesions NB Pelvic congestion syndrome is a controversial entity Wadsworth J Br J Obstet Gynaecol. 1988 Feb;95(2):153-61 Uterine prolapse check Most patients will complain of pain at the end of the day or after prolonged standing Pain may be accompanied by low backache Traction on the protruding cervix will duplicate the pain On asking the patient to strain; the cervix, bladder or the rectal wall will be seen protruding down to or beyond the hymenal ring Wearing a pessary will provide relief Pelvic neuropathies Iliohypogastric (T12, L1) and ilioinguinal (L1)nerves are the most commonly affected Genitofemoral Nerve disorders (L1, 2) Patients will present with lower abd pain descending into the genital area Pudendal neuropathy (S1,2,3): Patients will present with dyspareunia, bladder pain, rectal pain and sitting pain Weiss JM J Urol 2001 Dec;166(6):2226-31 IH GF P II Pelvic muscle palpation Pyriformis/ Levator ani syndrome is not a rare form of chronic pelvic pain Digital palpation of these muscles using a single digit will feel these muscles contracted and tender The anal wink reflex is often absent in these patients. Brief Orthopedic exam Exaggerated lumbar lordosis Pelvic tilt; distance between ASIS and lateral malleolus bilaterally Tender joints particularly the symphysis pubis, sacro-iliac joints and the hip joints Tender vertebrae indicating osteoarthritis or prolapsed discs Common etiologies for CPP Endometriosis and CPP Definition: The presence of endometrial glands and stroma outside the endometrial cavity and uterine musculature Symptoms Can be associated with many distressing and debilitating symptoms, such as pelvic pain, severe dysmenorrhea, and dyspareunia, or it may be asymptomatic Endometriosis and CPP Prevelance; In general population is not known 12 to 32 % of patients undergoing laparoscopy for CPP 50% of teenagers with CPP 9 to 50% of patients undergoing laparoscopy for infertility Sangi-Haghpeykar H; Poindexter AN 3rd Obstet Gynecol 1995 Jun;85(6):98392 Chatman DL; Ward AB J Reprod Med 1982 Mar;27(3):156-60 Missmer et alAm J Epidemiol 2004 Oct 15;160(8):784-96 Endometriosis and CPP Accurate diagnosis is made by laparoscopy Different often very subtle findings: Typically powder burns or gunshot lesions Can often have a variety of shapes and colors, including clear, pink, brown, white or yellow May be only seen as areas of scarring on the peritoneal surface Stegman et alFertil Steril. 2008 Jun;89(6):1632-6. Epub 2007 Jul 26 Challenges in diagnosing endometriosis Accurate diagnosis is dependant on the size and location of the lesion and the experience of the operator In one study comparing surgeons who did less than 5 laparoscopies a year to others who did between 27 and 99, the correct diagnosis was made in 54% for the first group versus and 99% for the second Endometriosis and CPP Treatment: Mainstay of treatment is surgical excision of the implants TAH +/- BSO is reserved for older patients with extensive disease Medical therapy for patients with mild or recurrent disease. This includes BCP, progestogens, GR analogs and off label use of aromatase inhibitors Pelvic congestion and CPP Old diagnosis that has attracted new interest. Proponents believe that ovarian or broad ligaments veins dilatation can cause pain and that embolizing these vessels relieves pain. Beard et al Lancet 1984 Oct 27;2(8409):946-9 These reports are limited, lack control and are not universally accepted. The role of pelvic congestion in CPP is currently questionable J Lancet 1987 Aug 15;2(8555):351-3 Urological causes of CPP Chronic UTI Urinary calculi Interstitial cystitis Urethral syndrome Interstitial cystitis or PBS Painful bladder syndrome is the complaint of suprapubic pain related to bladder filling, accompanied by other symptoms such as increased daytime and night-time frequency, in the absence of proven urinary infection or other obvious pathology Report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 2002; 21:167 Prevalence of IC or PBS Because of the lack of clear definition, prevalence varies widely between reports In patients with CPP, the prevalence was quoted between 12 and 75% Parsons CL; Bullen M; Kahn BS; Stanford EJ; Willems JJ Obstet Gynecol. 2001 Jul;98(1):127-32 Sant GR Urology. 2007 Apr;69(4 Suppl):S5-8 ISC/PBS Etiology Not exactly understood Thought to be caused by a defect in the GAG layer lining the bladder This layer makes the bladder wall impermeable to bladder irritants Irritants penetrating the urothelium irritate the nerves and muscles of the bladder wall resulting in tissue damage, pain and hypersensitivity The role of the urinary epithelium in the pathogenesis of interstitial cystitis/prostatitis/urethritis. Parsons CL Urology. 2007 Apr;69(4 Suppl):S9-S16 Diagnosis of ISC/PBS On examination, tenderness over the bladder base, pelvic floor or urethra Cystoscopy to rule out bladder pathology Hydrodistention with characteristic glomerulations and Hunner’s ulcers Potassium challenge test Bogart LM; Berry SH; Clemens JQ J Urol. 2007 Feb;177(2):450-6 Teichman JM; Parsons CL Urology. 2007 Apr;69(4Suppl):S41Int Urogynecol J Pelvic Floor Dysfunct 2005; 16:430 GI causes of CPP The intestines and the reproductive organs share the same innervations. Common causes of GI CPP are: IBS Inflammatory Bowel disease Diverticular disease Colon cancer IBS Usually presents as abdominal pain or chronic pelvic pain relieved by a BM with altered bowel habits Etiology is unknown May be present in 50 to 80% of CPP pt J Psychosom Obstet Gynaecol 1996 Mar;17(1):39-46 Rome criteria for IBS 12 wks in last 12 months of abdominal pain +2/3: relieved by defecation change in frequency of defecation change in stool form or appearance Symptoms that increase diagnostic accuracy -abnormal stool frequency >3/d or <3/wk , -mucus -bloating Rome III diagnostic criteria* for irritable bowel syndrome. Longstreth, GF,et alGastroenterology 2006; 130:1480 Inflammatory bowel disease Pain, distention and gas as in IBS Diarrhea and fever are often present. - Diverticulitis: more common above 40 with LLQ pain -Crohn’s disease: more common in younger patients with RLQ pain -Chronic appendicitis: controversial; if present is rare Hernias Most common in CPP 2 3 1 Inguinal hernias Most common types of abdominal hernia Indirect inguinal hernias: -Develop at the internal Inguinal ring -Are congenital but become obvious later -Defect in closure of processus vaginalis Direct inguinal hernias Congenital or acquired weakness of muscle on the posterior wall of the inguinal canal Pelvic adhesions and CPP The relationship between CPP and the presence of pelvic adhesions is poorly defined Dense adhesions may limit organ mobility resulting in visceral pain This has been shown in conscious laparoscopic pain mapping pain Howard FM, El-Minawi AM, Sanchez RA Obstet Gynecol. 2000;96(6):934 Pelvic myofascial pain AKA pelvic floor dysfunction, Levator myalgia, Pelvic floor spasm, Myofascial pelvic pain syndrome Prevalent but commonly overlooked cause of CPP; 78% of CPP in one study * Symptoms are vague Flares are unexpected Manifestations are inconsistent * Bassaly R et al, Int Urogynecol J. 2011:22(4):413-418 Pelvic myofascial pain Diagnosis; Tight often band-like pelvic muscles felt on exam Palpating these muscles will reproduce the pain Treatment Pelvic massage Trigger point injection Neuromodulation Treatment of PMP syndrome Therapeutic massage: Consists of vaginal manipulation of the trigger-point muscle bundle In a study of 47 patients randomized between vaginal myofascial vs general massage, both given weekly for an hour for 10 weeks, the improvement rate was 57% vs 21% J Urology. 2009;182(2):570-580 Treatment of PMP syndrome Trigger point injections: Aim is to relax or anesthetize the tender points in the muscles involved Mechanism of action is not known Ideal agent is not known Bupivacaine + Lidocaine + Triamcinolone resulted in 72.2% improvement and 36% cure. Langford et al Neurourol. 2007 (1):59-62 Botoxin A was found to be equally successful as placebo in small series with significant improvement in both groups. Abbott et al Obstet Gynecol. 2006;108(4):915-923 Treatment of PMP syndrome Neuromodulation: Direct conduction from a lead in the sacrum Retrograde using percutaneous TNS 42% of patients reported at least 50% decrease in pain after 12 weeks of weekly 30 min sessions. Van Balken et al Eur Urol. 2003:43(2):158-163 No placebo controlled studies No FDA approval Sacral neuromodulation PTNS Psychiatric and Psychological causes of CPP Depression Physical and sexual abuse Somatization Hypochondriasis Opioid seeking Facticious and malingering Am J Psychiatry 1988 Jan;145(1):75-80 Diagnostic and Statistical manual of Mental Disorders. Primary Care Version. Fourth Edition ed. Washington DC 1995 Bapkin et al 1995Obstet Gynecol 1990 Jul;76(1):92-6 Investigations for patients with CPP Complete blood count with differential Urinalysis Testing for Chlamydia and Gonorrhea infection Pregnancy test Gambone JC; Mittman BS; Munro MG; Scialli AR; Winkel CA Fertil Steril 2002 Nov;78(5):961-72 Imaging for CPP Ultrasound useful for diagnosis of Ovarian cysts, and endometriomas Ovarian masses/ cysts smaller than 4 cms in diameter Small fibroids and adenomyosis Hydrosalpinx diagnosis that could have resulted from chronic PID MRI rarely useful to diagnose adenomyosis Best Pract Res Clin Obstet Gynaecol 2000 Jun;14(3):433-66 Laparoscopy in CPP 1/3 of laparoscopies are done for CPP Findings are: No visible pathology 35% Endometriosis 33% Pelvic adhesions 24% PID 5% Ovarian cyst 3% Other diagnoses 5% Tu FF; Beaumont JL Am J Obstet Gynecol. 2006 Mar;194(3):699- 703 Howard, FM. The role of laparoscopy in the chronic pelvic pain patient. Clin Obstet Gynecol 2003; 46:749 Treatment of CPP Treatment of pathology found Depression : cognitive-behavioral therapy antidepressants Somatization: Psychotherapy IBS: antidpressants, fiber, antispasmodics IC: bladder distension, antidepressants, Pentosan polysulphate (Elmiron) When do Gynecologists refer to pain management When the diagnosis of CPP syndrome is made: 1- No etiology for pain is found in spite of a comprehensive work-up 2- Treatment is completed but the patient is still symptomatic 3- The severity or location of pain does not match the pathology. CONCLUSIONS CPP is a symptom of many possible conditions; work-up of the reproductive, GU, GI and musculoskeletal systems may be needed to reach a diagnosis. Check the patient’s previous w/up particularly her previous surgeries KNOW your referring Gynecologist Beware of missing endometriosis, pelvic adhesions IC and hernias!!
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