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

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 - 16-18%
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 2000.
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.