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8th Edition APGO Objectives for Medical Students Chronic Pelvic Pain.

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Presentation on theme: "8th Edition APGO Objectives for Medical Students Chronic Pelvic Pain."— Presentation transcript:

1 8th Edition APGO Objectives for Medical Students Chronic Pelvic Pain

2

3 Rationale Every physician should understand that chronic pelvic pain (CPP) might be the manifestation of a variety of problems.

4 Objectives The student will be able to: Define chronic pelvic pain Cite the incidence and etiologies Cite clinical manifestations Cite diagnostic procedures List management options

5 Definition Lower abdominal pain At least six months duration Alters quality of a woman’s life May or may not have gynecologic cause

6 Epidemiology and etiologies Overall % 10-30% of gyn visits 12-19% of hysterectomies (~ 80,000/yr.) 30% of laparoscopy indications Etiologies Irritable bowel % Abdominal cutaneous nerve - 70% Atypical menstrual pain - ~20% Urologic - < 5% Infectious - < 2%

7 Clinical Manifestations Subjective Dysmenorrhea most common Long-term debilitating pain > 6 mo. Impaired life style Incomplete relief with attempted therapies Dyspareunia Depression common

8 Clinical Manifestations Psychosocial Age yr. Pain poorly localized Multiple somatic complaints Prior surgeries History of depression and/or abuse (sexual or physical)

9 Etiology: Gyn disease Endometriosis-presence of functional endometrial tissues outside uterus 20% of CPP 30-40% with infertility Sequelae of PID (25% CPP) Chronic endometritis Pelvic fibrosis Infertility Neoplasia Uterine Ovarian Pelvic support defect/congestion Postoperative adhesion Ovarian remnant syndrome Bowel/omentum

10 Etiology: Non-gyn disease Urology Chronic UTI Interstitial cystitis Bladder/ureteral/kidney stone Urethral diverticulum Urethral syndrome

11 Etiology: Non-gyn disease Gastrointestinal Gall bladder disease (cholelithiasis) Chronic appendicitis/post appendectomy with peritonitis Constipation Diverticulitis Irritable Bowel Syndrome Peptic ulcer Inflammatory bowel disease Neoplastic disease

12 Etiology: Non-gyn disease Musculoskeletal Herniated disc Arthritis of spine Fibromyositis Hernia Nerve entrapment syndrome post-operative Osteoporosis (fractures) Trauma/sprains Spinal deformities Fibromyalgia

13 Etiology: Non-gyn disease Psychosocial Abuse (physical/sexual) Depression Personality disorder Relationship dysfunction Somatoform disorders/confusion with identity Substance abuse

14 Etiology: Non-gyn disease Others Heavy metal poisoning Porphyria Sickle disease (hemolytic crises) Tertiary syphilis (tabes dorsalis)

15 Diagnosis Complete history Pelvic pain questionnaire Characteristics of pain - location, radiation Onset Cyclic vs. non-cyclic pain Impact on lifestyle Relation to menses Changes in menstrual pattern Aggravating/alleviating factor

16 Diagnosis Complete history (con’t) Dyspareunia + History of pelvic infection Dietary and bowel habits Urinary symptoms Surgeries Pelvic inflammatory disease Depression/mood disorders History of abuse (physical or sexual)

17 Complete physical examination Skin Old scar Needle marks or “tracks” (substance abuse) Neuromuscular Low back tenderness Musculoskeletal pain

18 Complete physical examination Abdomen Hernias Distension Bowel sounds Tenderness Trigger points

19 Complete physical examination Pelvis Uterine mobility/fixation Tenderness Cervical/uterine Adnexal Rectal and/or vaginal exam Masses Size and shape of uterus Adnexa Uterosacral Ovarian cyst Enlarged, tender, boggy uterus - adenomyosis Uterosacral tenderness or nodularity - endometriosis

20 Complete physical examination Psychological/personality evaluation Somatic complaints Sexual orientation History of substance abuse History of physical and/or sexual abuse Self-image (high or low self-esteem) Past mental health

21 Complete physical examination Laboratory Complete blood count and sedimentation rate Leukocytosis Elevated sedimentation rate Cervical culture Gonorrhea Chlamydia

22 Complete physical examination Sonography Neoplasm/uterine enlargement or irregularity Adnexal mass (cyst or tumor)

23 Therapeutic trial Therapy tailored to likely etiology

24 Therapeutic trial Antibiotics

25 Therapeutic trial Hormonal manipulation Cyclic therapy/regulation of menses Suppress ovulation (OCP, DMPA and Lupron) Suppress menses (Lupron, DMPA)

26 Therapeutic trial Therapy tailored to likely etiology

27 Therapeutic trial Multidisciplinary approaches most successful Psychosocial support Treat depression Address sleep disorders Biofeedback Counseling

28 Therapeutic trial Multidisciplinary approaches most successful Physical modalities Physical therapy Exercise Diet (functional bowel) Massage Transcutaneous electrical nerve stimulation Nerve blocks/trigger point injections

29 Therapeutic trial Multidisciplinary approaches most successful Pharmacologic therapies Regular dosing schedule superior to “prn” NSAIDs Analgesics - use least potent which will control pain Nonnarcotic (ASA, acetaminophen, propoxyphene) Narcotic - use cautiously (tolerance, dependence) Serotonin uptake inhibitors Tricyclic antidepressants Oral contraceptives (endometriosis, menstrual pain) Danocrine, Depo-Provera (endometriosis) GnRH agonists

30 Therapeutic trial Multidisciplinary approaches most successful Surgical therapies Tailored to suspected physical pathology Offered if other approaches fail May be unsuccessful, lead to complications, high recurrence rates Laparoscopic uterosacral nerve ablation (LUNA) Presacral neurectomy Conscious pain mapping Fulguration/resection of endometriosis Lysis of pelvic adhesions Hysterectomy + oophorectomy

31 Therapeutic trial Re-evaluation (2-6 mo.) Improvement Therapeutic failure Consideration of fertility

32 Therapeutic trial Laparoscopy Endometriosis % Staging (American Fertility Society) Immediate treatment (ablation or excision and adhesiolysis) Definitive (ablation) Conservative - excision and adhesiolysis Pelvic adhesions - 20% Severity Lyse adhesions Normal pelvis - 36% Non-gyn disease %

33 Follow-up visits Initial history and physical with lab Lab Pain diary

34 Follow-up visits Second visit Review lab finding Initiate therapy (empiric or specific Additional diagnostics Recommend counseling

35 Follow-up visits Third visit Review pain diary Discuss results of therapy Scheduling laparoscopy

36 Postop management Definitive Rx for objective physical disease Hysterectomy with bilateral salpingo- oophorectomy Continued medical therapy Analgesics Hormonal Pain clinic Antidepressants

37 References Association of Professors of Gynecology and Obstetrics, Chronic Pelvic Pain: An Integrated Approach. APGO Educational Series on Women’s Heath Issues, APGO, Washington, DC, January Adapted from Association of Professors of Gynecology and Obstetrics Medical Student Educational Objectives, 7th edition, copyright 1997

38 Clinical Case Chronic Pelvic Pain

39 Patient Presentation A 24-year old woman presents to you as a self-referral for pelvic pain. She describes a four-year history of intermittent lower abdominal and pelvic pain that is now constant in nature. The pain is always present, sometimes sharper in the left lower quadrant and not related to menses.

40 Patient Presentation She has occasional nausea and is sometimes constipated. Nothing makes the pain better or worse. Over the years, she has used acetaminophen and ibuprofen, and has not found any relief. She began her menses at age 13 and they have come on a regular monthly basis. She experiences some premenstrual bloating and has cramps with her periods, and reports discomfort at other times of the month.

41 Patient Presentation She had a trial of oral contraceptives and then a subsequent laparoscopy by a prior gynecologist. She was told that everything looked normal. She is otherwise a healthy non-smoker, but reports that this pain is making her life miserable.

42 Patient Presentation She has a bachelor’s degree from a local college, works as computer processor and lives at home with her parents. She has never been sexually active. Upon further questioning, she reports that her oldest brother sexually abused her as a child.

43 Patient Presentation Physical exam Somewhat flattened affect, but smiles occasionally. 5 feet 4 inches; 142 pounds. Trapezius and paraspinous muscles tender on palpation. No costovertebral angle tenderness. Abdomen is soft with 2 well-healed pelviscopy incisions. There is no rebound or guarding or mass. Tenderness is elicited with deep palpation of the lower quadrants. External genitalia, vagina and cervix are normal. Uterus is mid-position, mobile and the adnexa are mildly tender. The rectal vault is palpably normal with soft stool that is heme negative.

44 Differential diagnosis of chronic pelvic pain Gynecologic origin Gastrointestinal disorders Urinary problems Musculoskeletal disease Pain processing disorders Psychiatric and psychological

45 Management Plan The patient was counseled about the multiple possible causes of chronic pelvic pain. The provider was empathic and sensitive in regards to this challenging problem. A plan of care was devised jointly and she was scheduled for a follow-up. The patient’s previous records and operative report was obtained and reviewed. On a subsequent visit, the patient did note that the pain worsens when her older brother returns home for family holidays. She reports that she has never mentioned this to the therapist that she has recently started seeing. A trial of low dose tricyclic antidepressants was initiated which helped the patient with sleeping, but did not make the pain go away. The patient continued to follow up at regularly scheduled intervals with her gynecologist and therapist, and had less emergency room visits.

46 Teaching points Chronic pelvic pain can be defined as cyclic pain of 6 months duration or non-cyclic pain of 3 months duration and the pain interferes with normal activities. The problem of chronic pelvic pain is under-recognized. It may affect 15% to 24% of American women and accounts for a large proportion of office visit time and many invasive surgical procedures.

47 Teaching points Chronic pelvic pain can be derived from a variety of sources, including gynecologic, gastrointestinal, rheumatologic, musculoskeletal, urologic or psychiatric. It can be difficult to diagnose the etiology and can be challenging to treat. The health care provider must perform a thorough history and physical exam, which are often much more valuable in making a diagnosis than any laboratory or radiologic tests.

48 Teaching points Patients present to different specialists based on their belief of what is causing the pain. Gastrointestinal diseases may cause symptoms such as nausea, vomiting, bloating or changes in bowel habits. Urinary tract disorders my cause dysuria, urgency or vague pelvic discomfort. Patients need to be asked about fatigue, sleep disturbances, or mood disorders and fibromyalgia and depression considered. Patients also need to be queried about physical and sexual abuse, or any history of substance abuse. Musculoskeletal disorders can be determined by a thorough motor and sensory examination, with attention to the back, hips and legs.

49 Teaching points Possible gynecologic causes of chronic pelvic pain include endometriosis, adenomyosis, chronic pelvic infection or adhesions. A normal laparoscopy does not completely rule out endometriosis, as the changes can be subtle and occasionally missed. Providers can consider an empiric trial of oral contraceptives or GnRH agonists after non-gynecologic causes have been ruled out. Some providers recommend a trial of antibiotics or non- steroidal anti-inflammatories for potential infectious causes. In the case of depression, whether overt or covert, antidepressants should be initiated.

50 Teaching points Even when the etiology is determined, chronic pelvic pain can be difficult to treat. The patient may need to be seen regularly and provided with much support. Co-management with a psychologist, social worker or therapist may be helpful.


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