1. Chronic pelvic pain Karen C. Wang, MD
Department of Obstetrics and Gynecology
Director of Minimally Invasive Surgery
Beth Israel Medical Center
April 22, 2010

2. Objectives Define and review the impact of chronic pelvic pain (CPP)
Discuss the potential etiologies of CPP
Review current treatment modalities for common gynecologic causes of CPP
Emphasize the importance of a multidisciplinary approach to the management of CPP

3. Chronic Pelvic Pain (CPP)
Non-cyclic pain
Duration > 6 months
Localized to: anatomic pelvis, anterior abdominal wall, lumbrosacral back or buttocks
Sufficient severity to cause functional disability or lead to medical care
Anterior abdominal wall at or below umbilicus
American College of Obstetricians and Gynecologists Practice Bulletin No. 51, March 2004

4. Epidemiology
15-20% of women between the ages of years have pelvic pain lasting more than one year during their lifetime
Primary indication for:
10% outpatient gynecology visits
12% hysterectomy
40% diagnostic laparoscopy
Howard FM, Ob Gyn Surv 1993, Lee NC et al AJOG 1984, Zondervan K, et al Br J Gen Prac 2001, Tu FF, AJOG 2006

5. Social Impact of CPP Among women with CPP Use 3x more medications
Have 4x more GYN surgeries
Are 5x more likely to have a hysterectomy
58% reduce normal activity >1 day/month
26% stay in bed >1 day/month
15% report lost time from work
48% report reduced work productivity
Among those gallup poll participants, many of these women have milder impact on their daily life, fortunately, but in a significant fraction, QOL is clearly impaired both at work & at home
Mathias SD et al Obstet Gynecol 1996, Reiter R et al. Obstet Gynecol 1990

6. Economic impact of CPP
$ million/year in laparoscopic evaluations
$881 million/year in direct costs
$2 billion/year in indirect costs
Indirect costs include loss of work and productivity of individuals with CPP
The economic impact, based on our study of the NSAS, and an earlier estimate from a Gallup poll of 5325 US women, is in the billions
Tu FF & Beaumont, JL AJOG 2006, Mathias SD et al Ob/Gyn 1996

7. Important Considerations
Pain is subjective
A normal physical examination does not preclude the presence of pathology
Never expect only one diagnosis or etiology
Many people in my field, gynecology, equate pelvic pain with endometriosis (the ectopic presence of endometrial tissue in the peritoneal cavity and other sites).
Clinical experience and epidemiological studies suggest the pathophysiology is far more complicated than this one-to-one concordance.
Endometriotic implants is only one observation associated with symptoms of pain in the female pelvic/abdominal region.
This classic elephant and blind men metaphor is an appropriate metaphor for the patchwork approach to pelvic pain workup that results from our specialist dominated workup.
By the time painful stimuli from the periphery reach the thalamus, considerable integration of inputs (which may represent both somatic and visceral input) can occur. At the sensory cortex, even more integration can occur, which is how psychological state can further modulate the pain experience.
Unfortunately for the suffering patient, they don’t necessarily get a interdisciplinary evaluation at first. Urology, gynecology, neurology, PM&R-PT, GI, anesthesia, psychiatry-psychology all may lay claim to the patient who presents with persistent abdominal-pelvic pain symptoms.
Clinicians need to recognize when treatment isn’t effective that prompt initiation for multidisciplinary mgt is needed, with a humble understanding that our historical labels for pain disorders (endometriosis, interstitial cystitis, or adhesions) are inadequate.

8. Important Considerations
Neurology/pain med
Simultaneously evaluate and treat all contributing factors (collaboration)
Treatment is challenging due to the lack of effective durable treatments
Economic pressures often hinder extensive workup GI
GYN
Need collaboration
Patients with this disorder face significant hurdles in disease mgt.
Clinicians are often limited in ability to distinguish the relative contribution of somatic structures (pelvic girdle, back and abdomen musculature, joints, tendons, ligaments) and internal visceral structures (bladder, bowel, reproductive structures)
Insurance coverage and willingness of primary practitioners and access may limit actual interdisciplinary evaluation. Also consistent universal algorithms for when to perform lsc, imaging studies, Gi endoscopy, or fluoroscopy are lacking.
Selfe and colleagues in the UK have identified that economic pressure may limit practitioner’s enthusiasm for engaging these patients, who can consume excessive time for busy clinicians already being pinched by insurers.
Limited training in pain mgt and the neurobiology of pain plagues practitioners who typically would encounter these patients, particularly gyne and urology.
Finally, the ideal treatments, which would be mechanism based, have not been developed
amongst multiple providers.
PM&R GU

9. Common etiologies of CPP*
Musculoskeletal/Neurologic
Gynecologic
Urologic
Gastrointestinal
Endometriosis
Adenomyosis
Adhesions
Chronic PID
Uterine fibroids
Pelvic congestion
Ovarian remnant
Residual ovarian
syndrome
Vaginal apex pain
Vestibulodynia
Interstitial Cystitis
Urethral syndrome
Chronic UTI
Bladder stones
IBS
Functional Bowel
disorders
Chronic appendicitis
Inflammatory bowel
disease
Hernias
Diverticular disease
Intermittent bowel
Obstruction
Pelvic floor myalgia
Trigger points
Idiopathic low back
pain
Disc disease
SI joint disease
Coccydynia
Nerve entrapment
syndromes
*excludes carcinomas

10. Common etiologies of CPP*
Gynecologic
Urologic
Musculoskeletal/Neurologic
Gastrointestinal
Endometriosis
Adenomyosis
Adhesions
Chronic PID
Uterine fibroids
Pelvic congestion
Ovarian remnant
Residual ovarian
syndrome
Vaginal apex pain
Interstitial Cystitis
Urethral syndrome
Chronic UTI
Bladder stones
IBS
Functional Bowel
disorders
Chronic appendicitis
Inflammatory bowel
disease
Hernias
Diverticular disease
Intermittent bowel
Obstruction
Pelvic floor myalgia
Trigger points
Idiopathic low back
pain
Disc disease
SI joint disease
Coccydynia
Nerve entrapment
syndromes
*excludes carcinomas

11. Endometriosis

12. Case Study 1
26 year-old G0 presents with complaints of crampy intermittent shooting pelvic pain for the past four years. +dysmenorrhea since menarche, previously controlled with NSAIDs. Now with daily pelvic pain worse shortly before and during menses. +deep dyspareunia and +dyschezia. Never been on oral contraceptives.

13. Case Study 1 Examination Abdomen diffusely tender
Cervix deviated to the left on speculum examination
Uterus retroverted and minimally mobile
Thickening and tenderness of the left uterosacral ligament
Fullness and tenderness of the right adnexa

14. Case Study 1
Pelvic ultrasound shows a complex 5 cm right adnexal mass that is persistent on serial ultrasounds over 4 months.

15. Normal Pelvis

16. Endometriosis
adhesions
endometriosis
Uterus
Ovary

17. Endometriosis
Defined by the presence of endometrial glands and stroma outside of the uterus
Histological diagnosis that requires surgical evaluation
PPV of visual inspection of implants with histological confirmation is 50-80% according to various studies.

18. Etiology of Endometriosis
Implantation Theory
Retrograde menstruation
Direct transplantation Theory
Post-surgical (cesarean section, myomectomy, episiotomy)
Lymphatic or vascular dissemination
Coelomic metaplasia
Peritoneal cavity has cells that can de-differentiate into endometrial tissue
Implantation theory
girls with genital tract obstructions (mullerian malformations) have higher incidence of endometriosis
Coelomic metaplasiasome endometriosis found in adolescents before menarche

19. Symptoms of Endometriosis
-None -Chronic non-menstrual pelvic pain -Dysmenorrhea -Dyspareunia
-Pelvic mass
-Dyschezia
-Decreased quality of life
-Infertility
Severity of symptoms do not correlate with severity of anatomic disease except for depth of infiltration
Co-occurrence with: interstitial cystitis, irritable bowel syndrome, temperomandibular disorder, migraine, fibromyalgia, vulvodynia.
Susceptibility to endometriosis is though to depend on the complex interatin of genetic, immunologic, hormonal and environmental factors. 19 19

20. Diagnosis of Endometriosis
Histological confirmation after surgical exploration
Ultrasound
Adnexal mass
MRI
Adenomyosis
Infiltrating endometriosis of uterosacrals or cul de sac
CA-125
Nonspecific. May be elevated with benign or malignant disease
Histological confirmation requires at least two of the following:
Endometrial epithelium
Endoemtrial glands
Endometrial stroma
Hemosiderin laden macrophages

21. Prevalence of Endometriosis2%
asymptomatic
10%
reproductive aged women
30%
subfertile
60%
chronic pelvic pain
50%
adolescent with chronic pelvic pain
Found in 2% of asymptomatic women. 0%
100%
ACOG practice bulletin 2000

22. Location of endometriosis
Posterior cul-de-sac 69%
Ovaries %
Fossa ovarica %
Anterior cul-de-sac 24%
Bowel/appendix %
1999 Joan Beck

23. trEATment options
Medical
Surgical

24. Treatment for Endometriosis
MEDICAL
NSAIDs
Combination OCP
Progestins
Oral
Depo-Provera
Mirena IUD
GnRH agonist (> 18 y.o.)
Danazol
Aromatase inhibitor
OCPs bring relief by creating a “pseudopregnancy” state and suppresses menstruation.
induce atrophy of eutopic and ectopic endometrial tissue; decrease PG production, reduce inflammation NOT cytoreductive.
Progestin-only mixed results. As effective as danazol and GnRH agonsist//side effects include irregular bleeding and weight gain. Limit Depo to 2 years due to association with decreased bone mineral density.
Danazolandrogen/ antiestrogen mg daily x 6 months then continuous ocp. Not well tolerated
GnRH agonistdownregulates HPO axis. Hypoestrogenic state. Limit to 6 months without add back therapy. In adolescents, associated with 5% loss in trabecular bone density and 2% in femoral neck

25. Hormonal Treatments Treatment Route Adverse Effects Cost/ 6 mo.
Estrogen & progesterone
Pills, patch, ring
$240
Breast tenderness, spotting, headaches
Progesterone
Oral, injectable
$60-400
Weight gain, mood swings, breast tenderness, edema
Danazol
Oral
$350
Hirsutism, acne, voice change, vaginal atrophy
GnRH agonists
IM, nasal spray $
Hot flushes, vaginal atrophy, bone loss

26. Levonorgestrel-IUD for endometriosis
Advantage – low maintenance, minimal side effects
5 year lifespan
Systemic and local effects
RCT LNG-IUD vs. Lupron
6 month follow-up
Significant improvement from baseline in both groups
No difference between groups
3 year follow-up data in observational series (n=34)
56% continuation rate at end
VAS dropped from 7.7 -> 2.7
(average pain, previous month)
To try and decrease systemic effects from progestins, some clinicians have used the recently introduced progestin-containing intrauterine device.
The compound it contains is LNG, found in many OCPs.
These have long been used for contraception, and have quite high effectiveness, also decreasing the volume of menstrual shedding.
Insertion of these devices is quite straightforward and has been effectively done by trained laypersons in areas underserved by physicians globally.
They can be left in for 5 years.
Similar to oral progestins, there is a combination of systemic and local effects, but systemic suppression of ovulation only for 1st 3 mo – afterwards LNG levels below 200 pg/cc.
Local effect on macrophage concentrations, inflammation in peritoneum.
In an uncontrolled study, typical IUD continuation rates were found in endometriosis patients, and those that stayed on it had fairly impressive decreases in average pain. However, controls needed, and being done presently
Equivalent to GnRH in RCT in decreasing lesion size and pain, recurrence of pain after surgery for endo
No hypoestrogenic state
Petta, Hum Rep 2005; Lockhat F et al, Hum Rep 2005

27. Levonorgestrel-IUD for endometriosis
Decrease lesion size and pain symptoms in rectovaginal nodules
Equivalent to GnRH agonist (Lupron) in randomized controlled trial
Decrease in recurrence of pain after surgery for endometriosis
Over 50% of women choose to retain IUD after 3 years
To try and decrease systemic effects from progestins, some clinicians have used the recently introduced progestin-containing intrauterine device.
The compound it contains is LNG, found in many OCPs.
These have long been used for contraception, and have quite high effectiveness, also decreasing the volume of menstrual shedding.
Insertion of these devices is quite straightforward and has been effectively done by trained laypersons in areas underserved by physicians globally.
They can be left in for 5 years.
Similar to oral progestins, there is a combination of systemic and local effects, but systemic suppression of ovulation only for 1st 3 mo – afterwards LNG levels below 200 pg/cc.
Local effect on macrophage concentrations, inflammation in peritoneum.
In an uncontrolled study, typical IUD continuation rates were found in endometriosis patients, and those that stayed on it had fairly impressive decreases in average pain. However, controls needed, and being done presently
Petta, Hum Rep 2005; Lockhat F et al, Hum Rep 2005

28. Efficacy of medical therapy
Most treatment decrease symptoms in 70-85% of users
Choose treatment based on patient preference, cost, and side-effects
Recurrence is common after discontinuation of medical therapy

29. Treatment for Endometriosis
SURGICAL
Conservative
Laparoscopy*
Excision/ablation
LUNA/presacral neurectomy
Adnexal mass
Oophorectomy
Hysterectomy + BSO
Resection of lesions (rectovaginal, small bowel, extrapelvic)
Surgical therapy is associated with a significant reduction in pain during the first 6 months of therapy. But 44% develop recurrence of symptoms within 1 year
Double blinded RCT comparing laser vaporization and LUNA to control in 63 adults with proven endo. At 6 month followup, 63% had pain relief. 23% of controls had pain relief. At 1 year, 90% of treatment group had continued relief.
*Sutton CJ et al, Fertil Steril 1997

30. Indications for surgery
To establish a diagnosis
To improve or relieve symptoms
To normalize anatomy for sub-fertility
To investigate a mass
To evaluate pain that is refractory to other treatments

31. Conservative Surgical Management
Recurrence rate is correlated with disease severity
37% mild disease
74% severe disease
67% within two years of surgery
Use of GnRH agonist for 3 months delays recurrence
Recurrence rate in 7 years.

32. Laparoscopy for pelvic pain associated with endometriosis (RCT)
Sutton et al
Study design
RCT, double blinded
N=63 ♀ stage I-III endometriosis
[Laparoscopic laser ablation + LUNA] vs. expectant management
Results
No difference at 3 months (48% of expectant group with improved pain)
Significant improvement with laser ablation at 6 months (63% vs. 23%, p<0.01)
8.5 *
VAS pain score (0-10)
4.5
63% of the intervention group compared to 23% of the expectant management group had pain improvement.
Sutton et al. Fertil Steril 1994; 62(4):
* p=0.01, laser vs. expectant

33. Hysterectomy ± BSO Touted as “definitive treatment”
No RCTs to evaluate efficacy
Endometriosis &/or pelvic pain may recur, even if BSO performed
Incidence unknown, estimates vary widely ~2-60%

34. Reoperation for recurrent pain
Hysterectomy is not definitive for all endometriosis or chronic pelvic pain
Recurrent pain
Reoperation for recurrent pain
Namnoun 1995
Hysterectomy
62%
31%
Hysterectomy +BSO
10%
3.7%
Matorras 2002 0%
Hysterectomy +BSO +HRT
2.5%
Namnoun 1995
138 women underwent TAH +/- BSO for endometriosis
John’s Hopkins Hospital
109 BSO 10% recurrence; 3.7% needed re-op
29 no BSO 62% recurrence pain ; 31 % re-op
if retain ovaries, RR for pain recurrence is 6.1; 8.1 for re-op
Matorras 2002
looked at recurrence of pain with use of HRT
Namnoun et al. Fertil Steril 1995; Matorras et al. Fertil Steril 2002.

35. Indications for hysterectomy in women with endometriosis
Chronic pelvic pain with significant reduction in quality of life
Does not desire fertility
Unresponsive to medical therapy and prior conservative surgical therapy
If undergoing BSO, understands and accepts negative impact of castration on other health parameters
Osteoporosis, cardiovascular disease, sexual dysfunction, menopausal symptoms, long-term risk/benefits of HRT, etc.
AND….

36. Indications for hysterectomy in women with endometriosis
Other sources of pain have been excluded and/or maximally treated!!!
Interstitial cystitis
Fibromyalgia
Urerthral syndrome
Irritable bowel syndrome
Pudendal neuralgia
Levator ani myalgia
Piriformis syndrome

37. Challenges of endometriosis
Little, if any, correlation between extent of disease and severity of pain.
Medical and surgical therapies are non-specific.
ex. Lupron is an effective therapy for cyclic-IBS.
Medical and surgical therapies are inadequate for many patients.
ex. Hysterectomy/BSO is not curative for all patients, 5-10% report persistent/recurrent pain.
Frequency of recurrent pain is high following medical and surgical therapies.
Pain recurs often in the absence of recurrent endometriotic disease.

38. Evidence that endometriosis-associated CPP may be a central pain syndrome
High co-prevalence with other central pain disorders
Nerve fiber proliferation in endometriosis lesions
Nerve fiber proliferation in endometrial lining and myometrium in women with endometriosis and women with chronic pelvic pain
Increased generalized pain sensitivity in women with endometriosis
In the last decade (or so), the scientific community has begun to question whether nociceptive input by endometriosis implants is the only source of pain in women with this condition. Despite our inclination as gynecologists to view endometriosis as a disease that needs to be cut out, there are 2 lines of evidence that have forced us to look at other potential mechanisms of pain in this condition.
First, numerous studies have failed to find a correlation among clinical pain scores, types of pain, and various aspects of the anatomy of the endometriosis implants. For example, there is little if any evidence that the degree of pain is correlated with the stage of anatomic disease.
Second, although removal or destruction of endometriosis implants alleviates pain symptoms in many women, surgery (including total hysterectomy and BSO) does not provide relief to all women and pain may often recur even without evidence of residual or recurrent disease.
For these two reasons, among others, researchers have begun to evaluate the possibility that there are neural mechanisms involved in the development and maintenance of endometriosis-related pelvic pain.

39. Adhesions

40. Pelvic Adhesions: Incidence
55-100% incidence at second look laparoscopy (average 85%)
>90% incidence following major abdominal surgery
Following myomectomy, adnexal adhesions occur:
94% with posterior uterine incisions
56% with anterior/fundal uterine incisions
Lau, Tulandi in Peritoneal Surgery 1999; Diamond, Fertil Steril 1987; Tulandi, et al. Obstet Gynecol 1993

41. Pelvic & Abdominal Adhesions
~ 25% prevalence among CPP patients
80% of patients undergoing pain mapping reported pain when adhesions palpated
Nerves, sensory neuron markers found in adhesions of both pain & pain-free patients
Adhesions have been targeted for treatment of CPP particularly since the advent of laparoscopy.
*need Sulaiman
One review has suggested that 25% of CPP patients have adhesions, but this is likely a function of previous surgical history selection into practices (Howard F Ob Gyn Surv 1993)
How adhesions might cause pain is unclear, short of overt intestinal obstruction.
Some believe symptoms result from restriction of organ movement
Others have argued that because sensory nerves are found in adhesions, there may be intrinsic nociception from irritation of adhesions directly.
Observational studies have suggested that 2/3 of patients would respond to adhesiolysis.
Howard F, Ob Gyn Surv 1993; Sulaiman et al. Ann Surg 2002

42. Complications Associated with Pelvic Adhesions
Infertility (40%)
Chronic pelvic pain (50%)
Small bowel obstruction (49-74%)
20% within 1 month
40% within 1 year
Reoperation
Liakakos Dig Surg, 2001; Monk et al.AmJ Obstet Gynecol 1994
El-Mowafi Prog Obstet Gynecol 2000

43. Is Adhesiolysis Effective?
RCT of laparoscopic lysis of adhesions vs. diagnostic laparoscopy
100 participants with chronic abdominal pain (> 6 months)
Participants, assessors masked
Outcome: overall improvement in pain, function
No difference in groups at one year
Pain scores
There has been a recent RCT for adhesiolysis which hopefully you have all seen.
A team of Dutch surgeons showed in a well designed study that adhesiolysis improves both pain and quality of life in chronic abdominal pain patients.
They randomized 100 subjects (all with adhesions and pain with other pathology excluded), ~90% female, to either lsc adhesiolysis 52 or dx lsc 48 only.
Both groups had substantial pain relief and significant improved QOL BUT
However, there was no difference in one year outcome compared to the control group of women who only underwent diagnostic laparoscopy.
MOS 34 at baseline
hrQOL scores
Swank D et al. Lancet 2003

44. Adhesions & CPP
Sensory nerve fibers are present in human peritoneal adhesions
Nerve fibers were present in all the peritoneal adhesions examined
Nerve fibers expressing substance P were present in all adhesions irrespective of chronic pelvic pain
Nerves were often associated with blood vessels
Sulaiman H, Annals of Surgery, 2001

45. Pain Relief After Adhesiolysis65 20 42 42
One Year Follow-up

46. Is Adhesiolysis Effective?
Several observational studies suggest adhesiolysis may be of some benefit for women with CPP
Patients most likely to benefit:
Severe, stage IV adhesions
No endometriosis
Patients with limited psychological distress and/or comorbidities
Steege 1991, Malik 2000

47. Pelvic Floor Myaglia

48. Pelvic Floor Myalgia Involuntary spasm of the pelvic floor muscles
Etiology
Inflammation
Childbirth
Pelvic surgery
Trauma

49. Pelvic Floor myofascial syndrome
History
“heavy aching pelvic pressure, falling-out sensation,” often later in the day after prolonged sitting
dyspareunia
Diagnostic tests (unvalidated)
Contracted, painful muscles on intravaginal exam
EMG or vaginal manometry– elevated baseline tone, muscle instability, and decreased endurance contractile capacity
Thiele describes it as television bottom
Slocumb’s vaginal trigger points?
Innervation
Viscero-somatic convergence
Efficacy 25%-80% (Morris & Newton vs. Cooper)
Hetrick DC et al Neurourol Urodyn 2006

50. Pelvic floor myofascial syndrome
Identified in over 20% of women in CPP referral clinics
Associations with IC, vulvodynia, endometriosis
Treatment includes pelvic floor physical therapy and other adjuvant therapies
While the distinctions remain unclear vs. TPs, regional ms pain syndromes can also be identified in PP pts.
We commonly look for generalized hypertonus, tenderness in x muscles.
These have been most widely accepted as potentially contributing to IC & vulvodynia.
Moreover, some recent studies have suggested that pelvic floor therapy alone may improve bladder irritative symptoms in IC, suggesting that somato-visceral convergence may underlie some IC cases.
These syndromes may be more common than once thought, as in a recently published study, we retrospectively reviewed initial intakes on over 900 women at the UNC pelvic pain referral clinic, and found over 20% had either pelvic floor or piriformis tenderness.
The gyne exam can be quite subjective, and there are no published validated or reproducible methods of measuring spasm/hypertonus.
Weiss JM et al J Urol 2001, Glazer HI et al JRM 1998,Tu FF et al. JRM 2006, Tu et al OGS 2005

51. Treatments Only 2 RCTs identified in systematic review
extremely limited focus (pregnancy-related pelvic pain and botulinum toxin for myofascial pain)
Small n (44, 30 respectively)
Methodological issues: no power analysis and mixture of myofascial pain conditions in botulinum toxin study
For now: individualized therapeutic approach – goal is desensitization
AHRQ Evidence base III
Tu FF et al Ob Gyn Surv 2005

52. Treatments - physical therapy
Manual therapy
muscle core strengthening (pelvic/lumbar stabilization)
muscle re-education
joint mobilization
myofascial release
Modalities
Biofeedback
electrical stimulation (TENS)
Orthotic devices
pelvic stability belt
gait assistance
vaginal cones
Summary of treatments 4-5 slides
Botox A (ANZOG)
Biofeedback in men
Weiss
PT experience in children
Comprehensive experience (RIC)
Must refer to physical therapist with expertise in pelvic pain and intravaginal pelvic floor modalities!

53. Adjunctive treatments
Medications
analgesics/NSAIDs
tricyclic antidepressants and antiepileptic agents
muscle relaxants
topical analgesics (camphor, menthol, xylocaine, lidoderm patch)
trigger point injections (botulinum toxin, local anesthetics, steroids)
Psychotherapy, education, work evaluation

54. Pelvic Floor TP injections
Chronic pelvic pain:
89% of 122 women treated had significant symptom improvement (> 3 months follow-up)
Interstitial cystitis:
70% of 10 patients treated with both injections and manual therapy had >50% improvement on global symptom severity (mean follow-up 20 months)
Slocumb JC AJOG 1984 Weiss J, J Urol, 2001

55. Botulinum toxin injection for levator ani syndrome
Design
Double-blinded, RCT of botulinum toxin A 80U vs. placebo (30 per arm)
bilateral injections into puborectalis, pubococcygeus
Outcomes
26 month follow-up
no group differences in nonmenstrual pelvic pain (VAS 40 vs. 22)
Improvements from pretreatment in both groups
Botox (VAS 51 v. 22 p <0.01),
placebo (VAS 47 v. 40, p > 0.05)
Abbott JA et al Ob Gyn 2006

56. Things to Consider

57. Indications for laparoscopy as a diagnostic tool
Diagnose endometriosis and/or pelvic adhesions
Evaluate an adnexal mass
Keep in mind that:
30-50% of diagnostic laparoscopies for pelvic pain are negative
Initial multi-disciplinary therapy is superior to diagnostic laparoscopy and unidimensional therapy
Adhesion removal is no better than sham surgery

58. Diagnostic pearls
Chronic pelvic pain is generally multifactorial, often with multiple organ systems involved
expand differential diagnosis to include GI, GU, musculoskeletal, and central nervous system causes of pain

59. Treatment pearls
Begin with “gold-standard” therapies for contributing factors
Ex. Hormonal suppression for cyclic pain or chronic pain with cyclic exacerbation
Ex. Physical therapy for abdominal wall and pelvic floor myofascial pain
Ex. Laparoscopy for excision/ablation of endometriosis
When standard treatments fail, then reconsider the diagnosis, re-evaluate comorbid psychosocial variables

60. Treatment Pearls
Hysterectomy should be considered last resort for treatment of chronic pelvic pain
Depending on population surveyed and whether BSO performed, 3-62% of women will report persistent or recurrent pain
Women with pelvic pain and depression are more likely to report persistent pain and decreased QOL following hysterectomy than women with either condition alone
Patients & physicians should have reasonable expectations
Anecdotally, women with chronic daily pain, diffuse abdominal &/or pelvic floor pain are more likely to report recurrent or persistent pain following surgery
Namnoun et al. Fertil Steril Matorras et al. Fertil Steril Hartmann et al. Obstet Gynecol 2004.

61. Treatment pearls
Abnormalities in pain processing are a common mechanism in many chronic pain disorders (IBS, IC, fibromyalgia, etc.)
It is likely to be an underlying mechanism in at least some women with CPP
Consider adding centrally-acting medication when standard “gynecology” treatments fail
Antidepressants for pain
Antiepileptics for pain
Consider using centrally-acting medication as part of first-line therapy
Chronic pelvic pain with negative laparoscopy
Chronic pelvic pain with diffuse abdominal and pelvic floor tenderness with no or minimal endometriosis
Pelvic nerve entrapment syndromes (ex. Pudendal nueralgia)