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

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Presentation on theme: "Karen C. Wang, MD Department of Obstetrics and Gynecology Director of Minimally Invasive Surgery Beth Israel Medical Center April 22, 2010."— Presentation transcript:

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

2  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  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 American College of Obstetricians and Gynecologists Practice Bulletin No. 51, March 2004

4  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  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 Mathias SD et al Obstet Gynecol 1996, Reiter R et al. Obstet Gynecol 1990

6  $ million/year in laparoscopic evaluations  $881 million/year in direct costs  $2 billion/year in indirect costs Tu FF & Beaumont, JL AJOG 2006, Mathias SD et al Ob/Gyn 1996

7  Pain is subjective  A normal physical examination does not preclude the presence of pathology  Never expect only one diagnosis or etiology

8  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 GYN GU PM&R GI Neurology/pain med

9 Gynecologic Urologic Gastrointestinal Musculoskeletal/ Neurologic 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 Gynecologic Urologic Gastrointestinal Musculoskeletal/ Neurologic 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

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

15 Normal Pelvis

16 Uterus Ovary endometriosis adhesions

17  Defined by the presence of endometrial glands and stroma outside of the uterus  Histological diagnosis that requires surgical evaluation

18  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

19 -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.

20  Histological confirmation after surgical exploration  Ultrasound  Adnexal mass  MRI  Adnexal mass  Adenomyosis  Infiltrating endometriosis of uterosacrals or cul de sac  CA-125  Nonspecific. May be elevated with benign or malignant disease

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

22 1999 Joan Beck Posterior cul-de-sac 69% Ovaries 33% Fossa ovarica 45% Anterior cul-de-sac 24% Bowel/appendix 5%

23 Surgical Medical

24  MEDICAL  NSAIDs  Combination OCP  Progestins  Oral  Depo-Provera  Mirena IUD  GnRH agonist (> 18 y.o.)  Danazol  Aromatase inhibitor

25 TreatmentRoute Cost/ 6 mo. Adverse Effects Estrogen & progesterone Pills, patch, ring $240Breast tenderness, spotting, headaches ProgesteroneOral, injectable $60-400Weight gain, mood swings, breast tenderness, edema DanazolOral$350Hirsutism, acne, voice change, vaginal atrophy GnRH agonistsIM, nasal spray $ Hot flushes, vaginal atrophy, bone loss

26  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) Petta, Hum Rep 2005; Lockhat F et al, Hum Rep 2005

27  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 Petta, Hum Rep 2005; Lockhat F et al, Hum Rep 2005

28  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  SURGICAL  Conservative  Laparoscopy*  Excision/ablation  LUNA/presacral neurectomy  Adnexal mass  Oophorectomy  Hysterectomy + BSO  Resection of lesions (rectovaginal, small bowel, extrapelvic) * Sutton CJ et al, Fertil Steril 1997

30  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  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

32  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) Sutton et al. Fertil Steril 1994; 62(4): * p=0.01, laser vs. expectant VAS pain score (0-10) *

33  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 Namnoun et al. Fertil Steril 1995; Matorras et al. Fertil Steril Recurrent painReoperation for recurrent pain Namnoun 1995 Hysterectomy 62%31% Hysterectomy +BSO 10%3.7% Matorras 2002 Hysterectomy +BSO 0% Hysterectomy +BSO +HRT 2.5%3.7%

35  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  Other sources of pain have been excluded and/or maximally treated!!! Interstitial cystitisFibromyalgia Urerthral syndromeIrritable bowel syndrome Pudendal neuralgiaLevator ani myalgia Piriformis syndrome

37  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  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

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40  % 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  ~ 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 Howard F, Ob Gyn Surv 1993; Sulaiman et al. Ann Surg 2002

42  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  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 Swank D et al. Lancet 2003 Pain scores hrQOL scores

44 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 One Year Follow-up

46  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

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48  Involuntary spasm of the pelvic floor muscles  Etiology  Inflammation  Childbirth  Pelvic surgery  Trauma

49  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 Hetrick DC et al Neurourol Urodyn 2006

50  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 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  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 Tu FF et al Ob Gyn Surv 2005

52 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 Must refer to physical therapist with expertise in pelvic pain and intravaginal pelvic floor modalities!

53  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  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  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

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57  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  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  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  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  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)

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