3RationaleEvery physician should understand that chronic pelvic pain (CPP) might be the manifestation of a variety of problems.
4Objectives The student will be able to: Define chronic pelvic pain Cite the incidence and etiologiesCite clinical manifestationsCite diagnostic proceduresList management options
5Definition Lower abdominal pain At least six months duration Alters quality of a woman’s lifeMay or may not have gynecologic cause
6Epidemiology and etiologies Overall %10-30% of gyn visits12-19% of hysterectomies (~ 80,000/yr.)30% of laparoscopy indicationsEtiologiesIrritable bowel %Abdominal cutaneous nerve - 70%Atypical menstrual pain - ~20%Urologic - < 5%Infectious - < 2%
7Clinical Manifestations SubjectiveDysmenorrhea most commonLong-term debilitating pain > 6 mo.Impaired life styleIncomplete relief with attempted therapiesDyspareuniaDepression common
8Clinical Manifestations PsychosocialAge yr.Pain poorly localizedMultiple somatic complaintsPrior surgeriesHistory of depression and/or abuse (sexual or physical)
9Etiology: Gyn diseaseEndometriosis-presence of functional endometrial tissues outside uterus20% of CPP30-40% with infertilitySequelae of PID (25% CPP)Chronic endometritisPelvic fibrosisInfertilityNeoplasiaUterineOvarianPelvic support defect/congestionPostoperative adhesionOvarian remnant syndromeBowel/omentum
15Diagnosis Complete history Pelvic pain questionnaire Characteristics of pain - location, radiationOnsetCyclic vs. non-cyclic painImpact on lifestyleRelation to mensesChanges in menstrual patternAggravating/alleviating factor
16Diagnosis Complete history (con’t) Dyspareunia + History of pelvic infectionDietary and bowel habitsUrinary symptomsSurgeriesPelvic inflammatory diseaseDepression/mood disordersHistory of abuse (physical or sexual)
17Complete physical examination SkinOld scarNeedle marks or “tracks” (substance abuse)NeuromuscularLow back tendernessMusculoskeletal pain
19Complete physical examination PelvisUterine mobility/fixationTendernessCervical/uterineAdnexalRectal and/or vaginal examMassesSize and shape of uterusAdnexaUterosacralOvarian cystEnlarged, tender, boggy uterus - adenomyosisUterosacral tenderness or nodularity - endometriosis
20Complete physical examination Psychological/personality evaluationSomatic complaintsSexual orientationHistory of substance abuseHistory of physical and/or sexual abuseSelf-image (high or low self-esteem)Past mental health
28Therapeutic trial Multidisciplinary approaches most successful Physical modalitiesPhysical therapyExercise Diet (functional bowel)MassageTranscutaneous electrical nerve stimulationNerve blocks/trigger point injections
29Therapeutic trial Multidisciplinary approaches most successful Pharmacologic therapiesRegular dosing schedule superior to “prn”NSAIDsAnalgesics - use least potent which will control painNonnarcotic (ASA, acetaminophen, propoxyphene)Narcotic - use cautiously (tolerance, dependence)Serotonin uptake inhibitorsTricyclic antidepressantsOral contraceptives (endometriosis, menstrual pain)Danocrine, Depo-Provera (endometriosis)GnRH agonists
30Therapeutic trial Multidisciplinary approaches most successful Surgical therapiesTailored to suspected physical pathologyOffered if other approaches failMay be unsuccessful, lead to complications, high recurrence ratesLaparoscopic uterosacral nerve ablation (LUNA)Presacral neurectomyConscious pain mappingFulguration/resection of endometriosisLysis of pelvic adhesionsHysterectomy + oophorectomy
31Therapeutic trial Re-evaluation (2-6 mo.) Improvement Therapeutic failureConsideration of fertility
32Therapeutic trial Laparoscopy Endometriosis - 16-18% Staging (American Fertility Society)Immediate treatment (ablation or excision and adhesiolysis)Definitive (ablation)Conservative - excision and adhesiolysisPelvic adhesions - 20%SeverityLyse adhesionsNormal pelvis - 36%Non-gyn disease %
33Follow-up visitsInitial history and physical with labLabPain diary
34Follow-up visits Second visit Review lab finding Initiate therapy (empiric or specificAdditional diagnosticsRecommend counseling
35Follow-up visits Third visit Review pain diary Discuss results of therapyScheduling laparoscopy
36Postop management Definitive Rx for objective physical disease Hysterectomy with bilateral salpingo-oophorectomyContinued medical therapyAnalgesicsHormonalPain clinicAntidepressants
37ReferencesAssociation of Professors of Gynecology and Obstetrics, Chronic Pelvic Pain: An Integrated Approach. APGO Educational Series on Women’s Heath Issues, APGO, Washington, DC, January 2000.Adapted from Association of Professors of Gynecology and Obstetrics Medical Student Educational Objectives, 7th edition, copyright 1997
39Patient PresentationA 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.
40Patient PresentationShe 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.
41Patient PresentationShe 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.
42Patient PresentationShe 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.
43Patient 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.
44Differential diagnosis of chronic pelvic pain Gynecologic originGastrointestinal disordersUrinary problemsMusculoskeletal diseasePain processing disordersPsychiatric and psychological
45Management PlanThe 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.
46Teaching pointsChronic 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.
47Teaching pointsChronic 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.
48Teaching pointsPatients 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.
49Teaching pointsPossible 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.
50Teaching pointsEven 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.