Presentation on theme: "Chronic Pelvic Pain Marvin L. Stancil, M.D. Associate Professor"— Presentation transcript:
1Chronic Pelvic Pain Marvin L. Stancil, M.D. Associate Professor Obstetrics and GynecologyUniversity of Nebraska Medical Center
2Medical Student Objectives Define chronic pelvic pain.Cite the prevalence and common etiologies of chronic pelvic pain.Describe the symptoms & physical exam findings associated with chronic pelvic pain.Discuss the steps in the evaluation & management options for chronic pelvic pain.Discuss the psychosocial issues associated with chronic pelvic pain.
3past six months and is affecting the patient’s quality of life Chronic Pelvic PainDefinitionChronic Pelvic Pain (CPP) is pain of apparent pelvic origin that has been present most of the time for thepast six months and is affecting the patient’s quality of life
4Chronic Pelvic Pain Definition Difficult to diagnose Frustration for patient andphysicianDifficult to treatDifficult to cure
5Chronic Pelvic Pain Incidence Accounts for 20% of all laparoscopies Affects 15-20% of women of reproductive ageAccounts for 20% of all laparoscopiesAccounts for 12-16% of all hysterectomiesAssociated medical costs of $3 billion annually
7Chronic Pelvic Pain Demographics Demographics of age, race, ethnicity, education, and socioeconomic status do not differ between those with and without chronic pelvic painHigher incidence in single, separated or divorced women40-50% of women have a history of abuse
8Chronic Pelvic Pain Etiology: United Kingdom Primary Care Database 25-50% of women had more than one diagnosisSeverity and consistency of pain increased with multisystem symptomsMost common diagnoses:endometriosisadhesive diseaseirritable bowel syndromeinterstitial cystitisGastrointestinalUrinaryGynecological37.7%30.8%20.2%Diagnosis DistributionFound that diagnoses related to the urinary and GI tracts were more common than gynecological diagnoses.For example, 43% of women with CPP without GI or urologic symptoms had moderate to severe pain; whereas 71% of women with both GI and urological symptoms had moderate to severe pain.
9Chronic Pelvic Pain Diagnosis Obtaining a COMPLETE and DETAILED HISTORYis the most important key toformulating a diagnosis
10Diagnosis: Obtaining the History Chronic Pelvic PainDiagnosis: Obtaining the HistoryDuration of PainNature of the PainSharp, stabbing, throbbing, aching, dull?Specific Location of PainAssociated with radiation to other areas?Modifying FactorsThings that make worse or better?Timing of the PainIntermittent or constant?Temporal relationship with menses?Temporal relationship with intercourse?Predictable or spontaneous onset?Detailed medical and surgical historySpecifically abdominal, pelvic, back surgery
11Chronic Pelvic Pain Use the REVIEW OF SYSTEMS Diagnosis: Obtaining the HistoryUse the REVIEW OF SYSTEMSto obtain focused, detailed history of organ systems involved in the differential diagnosis
12Gynecological Review of Systems Chronic Pelvic PainDiagnosis: Obtaining the HistoryGynecological Review of SystemsAssociated with menses?Association with sexual activity? (Be specific)New sexual partner and/or practices?Symptoms of vaginal dryness or atrophy?Other changes with menses?Use of contraception?Detailed childbirth history?History of pelvic infections?History of gynecological surgeries or other problems?
13Gastrointestinal Review of Systems Chronic Pelvic PainDiagnosis: Obtaining the HistoryGastrointestinal Review of SystemsRegularity of bowel movements?Diarrhea/ constipation/ flatus?Relief with defecation?History of hemorrhoids/ fissures/ polyps?Blood in stools, melena, mucous?Nausea, emesis or change in appetite?Abdominal bloating?Weight loss?
14Urological Review of Systems Chronic Pelvic PainDiagnosis: Obtaining the HistoryUrological Review of SystemsPain with urination?History of frequent or recurrent urinary tract infection?Hematuria?Symptoms of urgency or urinary incontinence?Difficulty voiding?History of nephrolithiasis?
15Musculoskeletal Review of Systems Chronic Pelvic PainDiagnosis: Obtaining the HistoryMusculoskeletal Review of SystemsHistory of trauma?Association with back pain?Other chronic pain problems?Association with position or activity?Any abdominal wall complaints or surgery?
16Psychological Review of Systems Chronic Pelvic PainDiagnosis: Obtaining the HistoryPsychological Review of SystemsHistory of verbal, physical or sexual abuse?Diagnosis of psychiatric disease?Onset associated with life stressors?Exacerbation associated with life stressors?Familial or spousal support?
17A bimanual exam alone is NOT sufficient for evaluation Chronic Pelvic PainDiagnosis: The Physical ExamEvaluate each area individuallyAbdomenAnterior abdominal wallPelvic Floor MusclesVulvaVaginaUrethraCervixViscera – uterus, adnexa, bladderRectumRectovaginal septumCoccyxLower Back/SpinePosture and gaitA bimanual exam alone isNOT sufficient for evaluation
18Diagnosis: Objective Evaluative Tools Chronic Pelvic PainDiagnosis: Objective Evaluative ToolsBasic TestingPap SmearGonorrhea and ChlamydiaWet MountUrinalysisUrine CulturePregnancy TestCBC with DifferentialESR or CRPSpecialized TestingMRI or CT ScanEndometrial BiopsyLaparoscopyCystoscopyUrodynamic TestingUrine CytologyColonoscopyElectrophysiologic studiesPELVIC ULTRASOUNDReferral to Specialist
19Differential Diagnosis Chronic Pelvic PainDifferential DiagnosisThe differential diagnosis for Chronic Pelvic Pain is extensiveChallenges the gynecologist to “think outside the uterus”Diagnosis, evaluation and treatment plans:Should align with pertinent positives and negatives from the History and PhysicalOften requires an interdisciplinary approach
20Differential Diagnosis: Chronic Pelvic PainDifferential Diagnosis:Gynecological Conditions that may Cause or Exacerbate Chronic Pelvic PainLevel AEndometriosisGynecologic malignanciesOvarian Retention SyndromeOvarian Remnant SyndromePelvic Congestion SyndromePelvic Inflammatory SyndromeTuberculosis SalpingitisLevel BAdhesionsBenign Cystic MesotheliomaLiomyomataPostoperative Peritoneal CystsLevel CAdenomyosisDysmenorrhea/ Ovulatory PainNonendometriotic Adnexal CystsCervical StenosisChronic Ectopic PregnancyChronic EndometritisEndometrial or Cervical PolypsEndosalpingiosisIntrauterine Contraceptive DeviceOvarian Ovulatory PainResidual accessory ovarySymptomatic Pelvic ProlapseSource: ACOG Practice Bulletin #51, March 2004
22Chronic Pelvic Pain Endometriosis Presence of endometrial tissue outside of uterine cavityUsually found in dependent areas of the pelvisMost commonly in ovaries, posterior cul-de-sac, uterosacral ligamentsEndometrial glands and stroma on biopsyMay be at distant sites such as bowel, bladder, lung, skin, pluraeEtiology not well understoodRetrograde menstruationLymphatic and hematologic spread of menstrual tissueMetaplasia of coelomic epitheliumImmunologic dysfunction
23Endometriosis: Prevalence Chronic Pelvic PainEndometriosis: PrevalenceTypically diagnosed in women years of ageDiagnosed in approximately 45% of women undergoing laparoscopy for any indicationDiagnosed in approximately 30% of women undergoing laparoscopy with primary complaint of chronic pelvic painFound in 38% of women with infertilityFamily history increases risk ten-foldSignificant cause of morbidity
24Endometriosis: Signs and Symptoms Chronic Pelvic PainEndometriosis: Signs and SymptomsSymptomsPhysical ExamVisible lesions on cervix or vaginaTender nodules in the cul-de-sac, uterosacral ligaments or rectovaginal septumPain with uterine movementTender adnexal masses (endometriomas)Fixation (retroversion) of uterusRectal massNormal findingsDysmenorrheaDyspareuniaInfertilityIntermenstrual SpottingPainful DefecationPelvic HeavinessAsymptomaticSymptoms are not well correlated with extent of disease – pain is out of proportion to the physical exam findings or radiologic findings or laparoscopic findings.Dyspareunia is usally with deep (rather than superficial) penetration.Symptoms usually regress with pregnancy and menopause
25Endometriosis: Diagnosis Chronic Pelvic PainEndometriosis: DiagnosisDiagnosis can be made on clinical history and examSerum CA125 may be elevated but lacks sufficient specificity and sensitivity to be usefulImaging studies lack sufficient resolution to detect small endometrial implantsLaparoscopy is gold standard for diagnosisMultiple appearances: red, brown, scar, white, powder burn, vesicular lesions, adhesions, defects in peritoneum, endometriomasAllows diagnosis and treatment
26Laparoscopic Appearance of Endometriosis Chronic Pelvic PainLaparoscopic Appearance of Endometriosis
27Endometriosis: Diagnosis Chronic Pelvic PainEndometriosis: DiagnosisRevised classification system by the ASRM (1996)Poor correlation between symptoms and extent of diseaseClassification system has been revised three times – last time in 1986.Useful for comparing patients to themselves and for comparing research.However, there is no correlation between stage of endometriosis and extent of disease. Some people can be found to have minimal disease but have excruiating pain whereas others can have extensive disease but have no pain at all.
29Endometriosis: Medical Treatment Chronic Pelvic PainEndometriosis: Medical TreatmentNSAIDS for mild diseaseFirst Line: Oral contraceptivesSuppress ovulation and menstruationCyclic or continuous therapyImproves symptoms in up to 70-80%Second Line: Progestins, GnRH agonists, DanazolLupron Depot (x 6-12 months)Improves symptoms in up to 80-85%Side effects: hot flashes, vaginal dryness, insomnia, bone loss irritability“Add back” estrogen +/- progestin
30Endometriosis: Surgical Treatment Chronic Pelvic PainEndometriosis: Surgical TreatmentLaparoscopic Removal or DestructionTreatment at time of diagnosisUsed in conjunction with medical therapyImproves pain in up to 80-90% of patientsLaparotomy (TAH/BSO)Inadequate response to medical treatment or conservative surgical treatment with no desire for future fertilityMay preserve ovaries in young women, but 30% with recurrent symptomsLUNALaparoscopic Uterosacral Nerve Ablation (LUNA), Presacral neurectomyInvolves transecting the nerve plexus at the base of the cervical-uterosacral ligament junction or retroperitoneum
31Chronic Pelvic Pain Adenomyosis Description: Presence of endometrial glands and stroma within the myometriumSymptoms: Dysmenorrhea; Menorrhagia; Enlarged boggy uterus; typically affects women age 30-40’sDiagnosis: Pathology, MRI (ultrasound limited usefulness)Treatment: Hysterectomy; usually when diagnosis is made
32Chronic Pelvic Pain Primary Dysmenorrhea Description: Pain associated with menses that usually begins 1-3 days prior to the onset of menses; last 1-3 daysRisk Factors: Nulliparity, Young Age, Heavy menses, Cigarette SmokingSymptoms: Crampy lower abdominal pain; +/- nausea, emesis, diarrhea or headache, normal physical examTreatment: NSAIDS, Multivits with B-complex, Hormonal Therapy (OCPs, OrthoEvra, Nuvaring, Mirena IUD, Depo-Provera. Usual improvement after childbirth.
33Pelvic Inflammatory Disease Chronic Pelvic PainPelvic Inflammatory DiseaseDescription: Spectrum of inflammation and infection in the upper female genital tractEndometritis/ endomyometritisSalpingitis/ salpingo-oophritisTubo-ovarian AbscessPelvic PeritonitisPathophysiology: Ascending infection of vaginal and cervical microorganismsChlamydia ,Gonorrhea (developed countries)Tuberculosis (developing countries)Acute PID usually polymicrobial infection
34Pelvic Inflammatory Disease Chronic Pelvic PainPelvic Inflammatory DiseaseRisk FactorsAdolescentMultiple sexual partnersGreater than 2 sexual partners in past 4 weeksNew partner in the past 4 weeksPrior history of PIDPrior history of gonorrhea or chlamydiaSmokingNone or inconsistent condom useInstrumentation of the cervix and lower reproductive tract
35Pelvic Inflammatory Disease: CDC Diagnostic Guidelines (2006) Chronic Pelvic PainPelvic Inflammatory Disease: CDC Diagnostic Guidelines (2006)Minimum Criteria (one required):Uterine TendernessAdnexal TendernessCervical Motion TendernessNo other identifiable causesSpecific criteria for dx:Pathologic evidence of endometritisUS or MRI showing hydrosalpinx, TOALaparosopic findings consistent with PIDAdditional criteria for dx:Oral temperature greater than 101FAbnormal cervical or vaginal dischargePresence of increased WBC in vaginal secretionsElevated ESR or C-reactive proteinDocumented of GC or CT
36Pelvic Inflammatory Disease Chronic Pelvic PainPelvic Inflammatory DiseaseTreatment: Outpatient and Inpatient Abx dosing regimens; Total therapy for 14 days, maybe longer if TOASequelaeInfertilityEctopic PregnancyChronic Pelvic PainOccurs in 18-35% of women who develop PIDMay be due to inflammatory process with development of pelvic adhesionsRefer to revised 2010,updated Aug for outpt. GC treatment
37Pelvic Congestion Syndrome Chronic Pelvic PainPelvic Congestion SyndromeDescription: Retrograde flow through incompetent valves venous valves can cause tortuous and congested pelvic and ovarian varicosities; Etiology unknown.Symptoms: Pelvic ache or heaviness that may worsen premenstrually, after prolonged sitting or standing, or following intercourseDiagnosis: Pelvic venogrpahy, CT, MRI, ultrasound, laparoscopyTreatment: Progestins, GnRH agonists, ovarian vein embolization or ligation, and hysterectomy with bilateral salpingo-oophorectomy (BSO)
38Pelvic Floor Pain Syndrome Chronic Pelvic PainPelvic Floor Pain SyndromeDescription: Spasm and strain of pelvic floor musclesLevator Ani MusclesCoccygeus MusclePiriformis MuscleSymptoms: Chronic pelvic pain symptoms; pain in buttocks and down back of leg, dyspareuniaLevator Ani Muscle: supports pelvic viscera, constricts lower end of rectum and vaginaCoccygeus muscle: aids in raising and supporting pelvic floorPiriformis: rotates thigh laterallyTreatment: Biofeedback, Pelvic Floor Physical Therapy, TENS (Transcutaneous Electrical Nerve Stimulation) units, antianxiolytic therapy, cooperation from sexual partner
39Chronic Pelvic Pain Differential Diagnosis: Urological Conditions that may Cause or Exacerbate Chronic Pelvic PainLevel ABladder CarcinomaInterstitial CystitisRadiation CystitisUrethral SyndromeLevel BDetrusor DyssynergiaUrethral DiverticulumLevel CChronic Urinary Tract InfectionRecurrent Acute CystitisRecurrent Acute UrethritisStone/urolithiasisUrethral CaruncleSource: ACOG Practice Bulletin #51, March 2004
40Interstitial Cystitis Chronic Pelvic PainInterstitial CystitisDescription: Chronic inflammatory condition of the bladderEtiology: Loss of mucosal surface protection of the bladder and thereby increased bladder permeabilityAlso called Painful Bladder SyndromeSymptoms:Urinary urgency and frequencyPain is worse with bladder filling; improved with urinationPain is worse with certain foodsPressure in the bladder and/or pelvisPelvic Pain in up to 70% of womenPresent in 38-85% presenting with chronic pelvic pain
41Interstitial Cystitis Chronic Pelvic PainInterstitial CystitisDiagnosis:Cystoscopy with bladder distensionIntravesicular Potassium Sensitivity TestPresence of glomerulations (Hunner Ulcers)Treatment:Avoidance of acidic foods and beveragesAntihistaminesTricyclic antidepressantsElmiron (pentosan polysulfate sodium)Intravesical therapy: DMSO (dimethyl sulfoxide)Elmiron: helps to prevent the formation of Hunner Ulcers by coating the bladder wall, thus making it harder for the acid in the urine to irritate the bladder wall lining which can lead to ulceration.
42Differential Diagnosis: Chronic Pelvic PainDifferential Diagnosis:Gastrointestinal Conditions that may Cause or Exacerbate Chronic Pelvic PainLevel AColon CancerConstipationInflammatory Bowel DiseaseIrritable Bowel SyndromeLevel BNoneLevel CColitisChronic Intermittent Bowel ObstructionDiverticular DiseaseSource: ACOG Practice Bulletin #51, March 2004
43Irritable Bowel Syndrome (IBS) Chronic Pelvic PainIrritable Bowel Syndrome (IBS)Description: Chronic relapsing pattern of abdomino-pelvic pain and bowel dysfunction with diarrhea and/or constipationPrevalenceAffects 12% of the U.S. population2:1 prevalence in women: menPeak age of 30-40’sRare on women over 50Associated with elevated stress levelSymptomsDiarrhea, constipation, bloating, mucousy stoolsSymptoms of IBS found in 50-80% women with CPP
44Irritable Bowel Syndrome (IBS) Chronic Pelvic PainIrritable Bowel Syndrome (IBS)Diagnosis based on Rome II criteriaTreatmentDietary changesDecrease stressCognitive PsychotherapyMedicationsAntidiarrhealsAntispasmodicsTricyclic AntidepressantsSerotonin receptor (3, 4) antagonists
45Differential Diagnosis: Chronic Pelvic PainDifferential Diagnosis:Musculoskeletal Conditions that may Cause or Exacerbate Chronic Pelvic PainLevel AAbdominal Wall Myofascial Pain (Trigger Points)Chronic Back PainPoor PostureFibromyalgiaNeuralgia of pelvic nervesPelvic Floor MyalgiaPeripartum Pelvic Pain SyndromeLevel BHerniated DiskLow Back PainNeoplasia of spinal cord or sacral nerveLevel CLumbar Spine CompressionDegenerative Joint DiseaseHerniaMuscular Strains and SprainsRectus Tendon StrainsSpondylosisSource: ACOG Practice Bulletin #51, March 2004
46Differential Diagnosis: Chronic Pelvic PainDifferential Diagnosis:Psychological/Other Conditions that may Cause or Exacerbate Chronic Pelvic PainLevel AAbdominal cutaneous nerve entrapment in surgical scarDepressionSomatization DisorderLevel BCeliac DiseaseNeurologic DysfunctionPorphyriaShinglesSleep DisturbancesLevel CAbdominal EpilepsyAbdominal MigrainesBipolar Personality DisorderFamilial Mediterranean FeverSource: ACOG Practice Bulletin #51, March 2004
47Psychological Associations Chronic Pelvic PainPsychological Associations40 – 50% of women with CPP have a history of abuse (physical, verbal , sexual)Psychosomatic factors play a prominent role in CPPPsychotropic medications and various modes of psychotherapy appear to be helpful as both primary and adjunct therapy for treatment of CPP– Multidisciplinary pain clinicApproach patient in a gentle, non-judgmental mannerDo not want to imply that “pain is all in her head”
48Chronic Pelvic Pain Conclusions Chronic Pelvic Pain requires patience, understanding and collaboration from both patient and physicianObtaining a thorough history is key to accurate diagnosis and effective treatmentDiagnosis is often multifactorial – may affect more than one pelvic organTreatment options often multifactorial – medical, surgical, physical therapy, cognitive therapy