Presentation on theme: "Obstetrics and Gynecology Clerkship Case Based Seminar Series"— Presentation transcript:
1Obstetrics and Gynecology Clerkship Case Based Seminar Series Chronic Pelvic PainUNC School of MedicineObstetrics and Gynecology ClerkshipCase Based Seminar Series
2Objectives for Chronic Pelvic Pain Define chronic pelvic painCite the prevalence and common etiologies of chronic pelvic painDescribe the symptoms and physical exam findings associated with chronic pelvic painDiscuss the psychosocial issues associated with chronic pelvic painDiscuss the steps in the evaluation and management options for chronic pelvic pain
3DefinitionPelvic pain of more than 6 months duration that has a significant effect on daily function and quality of lifeIncludes reproductive and non-reproductive related pelvic pain that is primarily acyclic
4PrevalenceOverall 15-20% of women aged 18 to 50 yrs have chronic pelvic pain that lasts > 1 year10-30% of gynecologic visits12-19% of hysterectomies (~ 80,000/yr.)30% of laparoscopy indications
5Common Etiologies(Percentages vary widely depending on practice settingNo apparent pathology ~ 33%Endometriosis ~ 33%Adhesions or Chronic PID ~ 25%Other causes ~ 9%GynecologicGenitourinaryGastrointestinalNeuromuscularPsychological
6Etiology: Gynecologic EndometriosisAdhesionsChronic PIDOvarian remnant syndromePelvic congestion syndromeRecurrent hemorrhagic ovarian cystsMyomata uteri (degenerating)Uterine retroversionAdenomyosisPelvic floor and hip muscle painVisceral hyperalgesia
10Patient Evaluation: History Characteristics of the pain:OnsetLocationDurationRadiationSeverityAlleviating/aggravating factorsRelation to menstrual cycleCyclic vs. non-cyclicEvolution over timeResponses to treatments
11Patient Evaluation: Psychological Psychological EvaluationUse good clinical judgment in deciding when/if to ask about this!History of traumatic eventHistory of abuse (emotional/physical/sexual)DepressionAnxietyHypochondriasisSecondary gainTherapy/counseling about these events?How much do they enter the patient’s thoughts on a daily basis?
12Physical exam Observe patient’s mobility as she gets up on the table. Palpate the entire back, but especially the paraspinous and SI joint areasReferred pain?Then palpate abdomen
13Patient Evaluation: Physical Exam Abdominal examListen for bowel soundsAsk patient to point to exact location of pain, radiation, and grade its severity (scale of 0 to 10)Ask the patient to map and demonstrate her tender area(s) by palpating with and without abdominal wall flexionPalpate entire abdomen with a single digit, with and w/o abdominal wall flexion (Carnett sign)Palpate from least painful area to most painful areaReferred pain?Carnet sign?
14Patient Evaluation: Physical Exam Evaluate for nerve entrapmentTrigger pointsIlioinguinal, iliohypogastric, and genitofemoral nervesAbdominal wall and back dermatomesMark “jump signs” (points of motion tenderness )Straight leg raise
15Patient Evaluation: Physical Exam Pelvic Exam: ask one question at a timeVulvaGeneral anatomy; educational exam as neededRetract labia; walk posterior vestibule with cotton-tipped applicator in cases of dyspareunia or constant vulvar pain.VaginaDischargeEpithelial quality, lesionsCervix: Pap, cultures if indicated; Q-tip walk to evaluate sensitivitySingle digit exam: what hurts? (Order determined by history)Cervix; motion tendernessBladder and urethraUterus, esp lower uterine segmentAdnexaLevators, obturators, piriformiReferral of pain? Similarity to chief complaint?: “Does this hurt? Is it like the pain you get? Does it travel anywhere?”Single digit exam, obturator
16Physical exam, continued Bimanual exam: size, shape, and mobility?Start with non-tender areas firstMake two hands almost meet, sweep caudadCommunicate with patient throughoutDescribe limits of exam due to habitus, guardingExamine to “count of 3” if patient is too uncomfortable.
17Patient Evaluation: Physical Exam Pelvic ExamFixed retroverted uterus & uterosacral tenderness/nodularityEndometriosisBilateral, tender, irregularly enlarged adnexal structuresChronic salpingitis (PID)Enlarged, tender, boggy uterusDon’t forget the recto-vaginal examination!Especially when history includes central pain, dyschezia, or dyspareunia.To eliminate the recto-vaginal exam in such cases is malpractice.
18Patient Evaluation: Further Studies LaboratoryComplete blood count (CBC)Elevated sedimentation rate (ESR) - nonspecificUrinalysis (UA)Urine pregnancy test (UPT)Gonorrhea/ChlamydiaTestingTransvaginal ultrasound (adnexal mass, uterine irregularity)Abdominal and pelvic CT (bowel or urinary signs)Diagnostic laparoscopyUltimate method of diagnosis for CPP of undetermined etiology
19Patient Evaluation: Further Studies Laparoscopy (% vary widely in different practice settings)Normal pelvisPelvic adhesionsNon-gyn diseaseEndometriosisFibroidsHernias
20ManagementMake a list of contributing factors; involve family member or S.O. when possible.Treat any underlying pathology, but don’t flog it to death.Include treatment of contributing factors as a package dealEstablish a therapeutic, supportive, and sympathetic (but structured) physician-patient relationshipSchedule regular follow-up appointmentsPatient should not be told to call ONLY if pain persistsDeters pain behavior and secondary gain
21Management Educate, educate, educate Reassure patient of no serious underlying pathologyChronic v. acute painEducate patient to likely mechanisms of pain productionCentral nervous system: centralizationNeuropathicMuscularPsychological (most often in reaction to pain events, not the primary etiology)
22ManagementTreating multiple components of pain has been showed to be more effective than traditional gynecologic management. This can be accomplished in a single clinic, or through collaboration among several specialists, such asGynecologistPhysical therapist+ Anesthesiologist+ AcupuncturistPsychologistSex therapist
23Management Pharmacologic therapies: Initial trial of hormonal manipulationCyclic therapy/regulation of mensesSuppress ovulation (OCP, DMPA and Lupron)Suppress menses (DMPA, high dose intrauterine progestins)NSAIDSAnalgesicsNonnarcotic (ASA, Acetominophen)Narcotic – use cautiously (tolerance, dependence)SSRI’s or SNRI’sTCA’s, anti-epilepticsEspecially for pain with neuropathic components
24Management Surgical therapies: Anesthesia: Guarded prognosis in patients with multiple pain syndromesDegree of relief has uncertain relationship to amount of pathology; most can be done laparoscopicallyUnilateral adnexectomyHysterectomy + BSOPresacral neurectomyUterine suspensionLysis of adhesionsResection/ablation of endometriosisAnesthesia:AcupunctureNerve blocksTrigger point injections
25Bottom Line ConceptsChronic pelvic pain is pelvic pain of more than 6 months duration that has a significant effect on daily function and quality of life.It affects 15-24% of American women in varying degrees of severity and accounts for a large portion of office visit and time.Chronic pelvic pain is caused by a variety of factors including gynecologic, genitourinary, gastrointestinal, neuromuscular, and psychological.Diagnostic laparoscopy is the ultimate method of diagnosis for patients with chronic pelvic pain of undetermined etiology.Multidisciplinary approach has been shown to be more effective than pharmacologic or surgical therapy alone.Even when etiology is determined, chronic pelvic pain can be difficult to treat and patients need to be seen regularly and provided much support.
26References and Resources APGO, Chronic Pelvic Pain: An Integrated Approach. APGO Educational Series on Women’s Heath Issues, APGO, Washington, DC, January 2000.APGO Medical Student Educational Objectives, 9th edition, (2009), Educational Topic 39 (p82-83).Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 30 (p ).Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 21 (p ).Katz: Comprehensive Gynecology, 5th edition, (2007), Vern Katz, Gretchen Lentz, Rogerio Lobo, David Gershenson. Chapter 8.