Presentation on theme: "Chronic pelvic pain Karen C. Wang, MD"— Presentation transcript:
1Chronic pelvic pain Karen C. Wang, MD Department of Obstetrics and GynecologyDirector of Minimally Invasive SurgeryBeth Israel Medical CenterApril 22, 2010
2Objectives Define and review the impact of chronic pelvic pain (CPP) Discuss the potential etiologies of CPPReview current treatment modalities for common gynecologic causes of CPPEmphasize the importance of a multidisciplinary approach to the management of CPP
3Chronic Pelvic Pain (CPP) Non-cyclic painDuration > 6 monthsLocalized to: anatomic pelvis, anterior abdominal wall, lumbrosacral back or buttocksSufficient severity to cause functional disability or lead to medical careAnterior abdominal wall at or below umbilicusAmerican College of Obstetricians and Gynecologists Practice Bulletin No. 51, March 2004
4Epidemiology15-20% of women between the ages of years have pelvic pain lasting more than one year during their lifetimePrimary indication for:10% outpatient gynecology visits12% hysterectomy40% diagnostic laparoscopyHoward FM, Ob Gyn Surv 1993, Lee NC et al AJOG 1984, Zondervan K, et al Br J Gen Prac 2001, Tu FF, AJOG 2006
5Social Impact of CPP Among women with CPP Use 3x more medications Have 4x more GYN surgeriesAre 5x more likely to have a hysterectomy58% reduce normal activity >1 day/month26% stay in bed >1 day/month15% report lost time from work48% report reduced work productivityAmong 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 homeMathias SD et al Obstet Gynecol 1996, Reiter R et al. Obstet Gynecol 1990
6Economic impact of CPP$ million/year in laparoscopic evaluations$881 million/year in direct costs$2 billion/year in indirect costsIndirect costs include loss of work and productivity of individuals with CPPThe economic impact, based on our study of the NSAS, and an earlier estimate from a Gallup poll of 5325 US women, is in the billionsTu FF & Beaumont, JL AJOG 2006, Mathias SD et al Ob/Gyn 1996
7Important Considerations Pain is subjectiveA normal physical examination does not preclude the presence of pathologyNever expect only one diagnosis or etiologyMany 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.
8Important Considerations Neurology/pain medSimultaneously evaluate and treat all contributing factors (collaboration)Treatment is challenging due to the lack of effective durable treatmentsEconomic pressures often hinder extensive workupGIGYNNeed collaborationPatients 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 developedamongst multiple providers.PM&RGU
12Case Study 126 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.
13Case Study 1 Examination Abdomen diffusely tender Cervix deviated to the left on speculum examinationUterus retroverted and minimally mobileThickening and tenderness of the left uterosacral ligamentFullness and tenderness of the right adnexa
14Case Study 1Pelvic ultrasound shows a complex 5 cm right adnexal mass that is persistent on serial ultrasounds over 4 months.
17EndometriosisDefined by the presence of endometrial glands and stroma outside of the uterusHistological diagnosis that requires surgical evaluationPPV of visual inspection of implants with histological confirmation is 50-80% according to various studies.
18Etiology of Endometriosis Implantation TheoryRetrograde menstruationDirect transplantation TheoryPost-surgical (cesarean section, myomectomy, episiotomy)Lymphatic or vascular disseminationCoelomic metaplasiaPeritoneal cavity has cells that can de-differentiate into endometrial tissueImplantation theorygirls with genital tract obstructions (mullerian malformations) have higher incidence of endometriosisCoelomic metaplasiasome endometriosis found in adolescents before menarche
19Symptoms of Endometriosis -None -Chronic non-menstrual pelvic pain -Dysmenorrhea -Dyspareunia-Pelvic mass-Dyschezia-Decreased quality of life-InfertilitySeverity of symptoms do not correlate with severity of anatomic disease except for depth of infiltrationCo-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.1919
20Diagnosis of Endometriosis Histological confirmation after surgical explorationUltrasoundAdnexal massMRIAdenomyosisInfiltrating endometriosis of uterosacrals or cul de sacCA-125Nonspecific. May be elevated with benign or malignant diseaseHistological confirmation requires at least two of the following:Endometrial epitheliumEndoemtrial glandsEndometrial stromaHemosiderin laden macrophages
21Prevalence of Endometriosis 2%asymptomatic10%reproductive aged women30%subfertile60%chronic pelvic pain50%adolescent with chronic pelvic painFound in 2% of asymptomatic women.0%100%ACOG practice bulletin 2000
22Location of endometriosis Posterior cul-de-sac 69%Ovaries %Fossa ovarica %Anterior cul-de-sac 24%Bowel/appendix %1999 Joan Beck
24Treatment for Endometriosis MEDICALNSAIDsCombination OCPProgestinsOralDepo-ProveraMirena IUDGnRH agonist (> 18 y.o.)DanazolAromatase inhibitorOCPs 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.Danazolandrogen/ antiestrogen mg daily x 6 months then continuous ocp. Not well toleratedGnRH agonistdownregulates 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
25Hormonal Treatments Treatment Route Adverse Effects Cost/ 6 mo. Estrogen & progesteronePills, patch, ring$240Breast tenderness, spotting, headachesProgesteroneOral, injectable$60-400Weight gain, mood swings, breast tenderness, edemaDanazolOral$350Hirsutism, acne, voice change, vaginal atrophyGnRH agonistsIM, nasal spray$Hot flushes, vaginal atrophy, bone loss
26Levonorgestrel-IUD for endometriosis Advantage – low maintenance, minimal side effects5 year lifespanSystemic and local effectsRCT LNG-IUD vs. Lupron6 month follow-upSignificant improvement from baseline in both groupsNo difference between groups3 year follow-up data in observational series (n=34)56% continuation rate at endVAS 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 presentlyEquivalent to GnRH in RCT in decreasing lesion size and pain, recurrence of pain after surgery for endoNo hypoestrogenic statePetta, Hum Rep 2005; Lockhat F et al, Hum Rep 2005
27Levonorgestrel-IUD for endometriosis Decrease lesion size and pain symptoms in rectovaginal nodulesEquivalent to GnRH agonist (Lupron) in randomized controlled trialDecrease in recurrence of pain after surgery for endometriosisOver 50% of women choose to retain IUD after 3 yearsTo 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 presentlyPetta, Hum Rep 2005; Lockhat F et al, Hum Rep 2005
28Efficacy of medical therapy Most treatment decrease symptoms in 70-85% of usersChoose treatment based on patient preference, cost, and side-effectsRecurrence is common after discontinuation of medical therapy
29Treatment for Endometriosis SURGICALConservativeLaparoscopy*Excision/ablationLUNA/presacral neurectomyAdnexal massOophorectomyHysterectomy + BSOResection 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 yearDouble 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
30Indications for surgery To establish a diagnosisTo improve or relieve symptomsTo normalize anatomy for sub-fertilityTo investigate a massTo evaluate pain that is refractory to other treatments
31Conservative Surgical Management Recurrence rate is correlated with disease severity37% mild disease74% severe disease67% within two years of surgeryUse of GnRH agonist for 3 months delays recurrenceRecurrence rate in 7 years.
32Laparoscopy for pelvic pain associated with endometriosis (RCT) Sutton et alStudy designRCT, double blindedN=63 ♀ stage I-III endometriosis[Laparoscopic laser ablation + LUNA] vs. expectant managementResultsNo 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)4.563% 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
33Hysterectomy ± BSO Touted as “definitive treatment” No RCTs to evaluate efficacyEndometriosis &/or pelvic pain may recur, even if BSO performedIncidence unknown, estimates vary widely ~2-60%
34Reoperation for recurrent pain Hysterectomy is not definitive for all endometriosis or chronic pelvic painRecurrent painReoperation for recurrent painNamnoun 1995Hysterectomy62%31%Hysterectomy +BSO10%3.7%Matorras 20020%Hysterectomy +BSO +HRT2.5%Namnoun 1995138 women underwent TAH +/- BSO for endometriosisJohn’s Hopkins Hospital109 BSO 10% recurrence; 3.7% needed re-op29 no BSO 62% recurrence pain ; 31 % re-opif retain ovaries, RR for pain recurrence is 6.1; 8.1 for re-opMatorras 2002looked at recurrence of pain with use of HRTNamnoun et al. Fertil Steril 1995; Matorras et al. Fertil Steril 2002.
35Indications for hysterectomy in women with endometriosis Chronic pelvic pain with significant reduction in quality of lifeDoes not desire fertilityUnresponsive to medical therapy and prior conservative surgical therapyIf undergoing BSO, understands and accepts negative impact of castration on other health parametersOsteoporosis, cardiovascular disease, sexual dysfunction, menopausal symptoms, long-term risk/benefits of HRT, etc.AND….
36Indications for hysterectomy in women with endometriosis Other sources of pain have been excluded and/or maximally treated!!!Interstitial cystitisFibromyalgiaUrerthral syndromeIrritable bowel syndromePudendal neuralgiaLevator ani myalgiaPiriformis syndrome
37Challenges 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.
38Evidence that endometriosis-associated CPP may be a central pain syndrome High co-prevalence with other central pain disordersNerve fiber proliferation in endometriosis lesionsNerve fiber proliferation in endometrial lining and myometrium in women with endometriosis and women with chronic pelvic painIncreased generalized pain sensitivity in women with endometriosisIn 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.
40Pelvic Adhesions: Incidence 55-100% incidence at second look laparoscopy (average 85%)>90% incidence following major abdominal surgeryFollowing myomectomy, adnexal adhesions occur:94% with posterior uterine incisions56% with anterior/fundal uterine incisionsLau, Tulandi in Peritoneal Surgery 1999; Diamond, Fertil Steril 1987; Tulandi, et al. Obstet Gynecol 1993
41Pelvic & Abdominal Adhesions ~ 25% prevalence among CPP patients80% of patients undergoing pain mapping reported pain when adhesions palpatedNerves, sensory neuron markers found in adhesions of both pain & pain-free patientsAdhesions have been targeted for treatment of CPP particularly since the advent of laparoscopy.*need SulaimanOne 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 movementOthers 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
42Complications Associated with Pelvic Adhesions Infertility (40%)Chronic pelvic pain (50%)Small bowel obstruction (49-74%)20% within 1 month40% within 1 yearReoperationLiakakos Dig Surg, 2001; Monk et al.AmJ Obstet Gynecol 1994El-Mowafi Prog Obstet Gynecol 2000
43Is Adhesiolysis Effective? RCT of laparoscopic lysis of adhesions vs. diagnostic laparoscopy100 participants with chronic abdominal pain (> 6 months)Participants, assessors maskedOutcome: overall improvement in pain, functionNo difference in groups at one yearPain scoresThere 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 BUTHowever, there was no difference in one year outcome compared to the control group of women who only underwent diagnostic laparoscopy.MOS 34 at baselinehrQOL scoresSwank D et al. Lancet 2003
44Adhesions & CPPSensory nerve fibers are present in human peritoneal adhesionsNerve fibers were present in all the peritoneal adhesions examinedNerve fibers expressing substance P were present in all adhesions irrespective of chronic pelvic painNerves were often associated with blood vesselsSulaiman H, Annals of Surgery, 2001
45Pain Relief After Adhesiolysis 65204242One Year Follow-up
46Is Adhesiolysis Effective? Several observational studies suggest adhesiolysis may be of some benefit for women with CPPPatients most likely to benefit:Severe, stage IV adhesionsNo endometriosisPatients with limited psychological distress and/or comorbiditiesSteege 1991, Malik 2000
48Pelvic Floor Myalgia Involuntary spasm of the pelvic floor muscles EtiologyInflammationChildbirthPelvic surgeryTrauma
49Pelvic Floor myofascial syndrome History“heavy aching pelvic pressure, falling-out sensation,” often later in the day after prolonged sittingdyspareuniaDiagnostic tests (unvalidated)Contracted, painful muscles on intravaginal examEMG or vaginal manometry– elevated baseline tone, muscle instability, and decreased endurance contractile capacityThiele describes it as television bottomSlocumb’s vaginal trigger points?InnervationViscero-somatic convergenceEfficacy 25%-80% (Morris & Newton vs. Cooper)Hetrick DC et al Neurourol Urodyn 2006
50Pelvic floor myofascial syndrome Identified in over 20% of women in CPP referral clinicsAssociations with IC, vulvodynia, endometriosisTreatment includes pelvic floor physical therapy and other adjuvant therapiesWhile 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
51Treatments 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 studyFor now: individualized therapeutic approach – goal is desensitizationAHRQ Evidence base IIITu FF et al Ob Gyn Surv 2005
52Treatments - physical therapy Manual therapymuscle core strengthening (pelvic/lumbar stabilization)muscle re-educationjoint mobilizationmyofascial releaseModalitiesBiofeedbackelectrical stimulation (TENS)Orthotic devicespelvic stability beltgait assistancevaginal conesSummary of treatments 4-5 slidesBotox A (ANZOG)Biofeedback in menWeissPT experience in childrenComprehensive experience (RIC)Must refer to physical therapist with expertise in pelvic pain and intravaginal pelvic floor modalities!
53Adjunctive treatments Medicationsanalgesics/NSAIDstricyclic antidepressants and antiepileptic agentsmuscle relaxantstopical analgesics (camphor, menthol, xylocaine, lidoderm patch)trigger point injections (botulinum toxin, local anesthetics, steroids)Psychotherapy, education, work evaluation
54Pelvic 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
55Botulinum toxin injection for levator ani syndrome DesignDouble-blinded, RCT of botulinum toxin A 80U vs. placebo (30 per arm)bilateral injections into puborectalis, pubococcygeusOutcomes26 month follow-upno group differences in nonmenstrual pelvic pain (VAS 40 vs. 22)Improvements from pretreatment in both groupsBotox (VAS 51 v. 22 p <0.01),placebo (VAS 47 v. 40, p > 0.05)Abbott JA et al Ob Gyn 2006
57Indications for laparoscopy as a diagnostic tool Diagnose endometriosis and/or pelvic adhesionsEvaluate an adnexal massKeep in mind that:30-50% of diagnostic laparoscopies for pelvic pain are negativeInitial multi-disciplinary therapy is superior to diagnostic laparoscopy and unidimensional therapyAdhesion removal is no better than sham surgery
58Diagnostic pearlsChronic pelvic pain is generally multifactorial, often with multiple organ systems involvedexpand differential diagnosis to include GI, GU, musculoskeletal, and central nervous system causes of pain
59Treatment pearlsBegin with “gold-standard” therapies for contributing factorsEx. Hormonal suppression for cyclic pain or chronic pain with cyclic exacerbationEx. Physical therapy for abdominal wall and pelvic floor myofascial painEx. Laparoscopy for excision/ablation of endometriosisWhen standard treatments fail, then reconsider the diagnosis, re-evaluate comorbid psychosocial variables
60Treatment PearlsHysterectomy should be considered last resort for treatment of chronic pelvic painDepending on population surveyed and whether BSO performed, 3-62% of women will report persistent or recurrent painWomen with pelvic pain and depression are more likely to report persistent pain and decreased QOL following hysterectomy than women with either condition alonePatients & physicians should have reasonable expectationsAnecdotally, women with chronic daily pain, diffuse abdominal &/or pelvic floor pain are more likely to report recurrent or persistent pain following surgeryNamnoun et al. Fertil Steril Matorras et al. Fertil Steril Hartmann et al. Obstet Gynecol 2004.
61Treatment pearlsAbnormalities 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 CPPConsider adding centrally-acting medication when standard “gynecology” treatments failAntidepressants for painAntiepileptics for painConsider using centrally-acting medication as part of first-line therapyChronic pelvic pain with negative laparoscopyChronic pelvic pain with diffuse abdominal and pelvic floor tenderness with no or minimal endometriosisPelvic nerve entrapment syndromes (ex. Pudendal nueralgia)