1. Chronic pelvic pain Presented by: DR Afsar tabatabai

2. Definition Nonmenstrual pain of 6 months duration or greater, localized to the pelvis, anterior abdominal wall below the pelvis, or lower back, severe enough to result in functional disability or require medical or surgical treatment.

3. Putative Pelvic Pain States Adhesions Pelvic inflammatory disease (PID), endometriosis inflammatory bowel disease prior surgery Painful bladders syndrome Uterian originated pains Psychological problems

4. Adhesions Pelvic inflammatory disease (PID), endometriosis, inflammatory bowel disease, or prior surgery may cause adhesions; yet, in up to 50% of cases, there may be no significant antecedent event while some case series have shown benefit to adhesiolysis, others have shown no treatment benefit;

5. Endometriosis little correlation between the extent of disease present and the degree of pain several appearances ranging from the more typical powder burn,blue-gray lesions to atypical lesions that may be clear, red, or white. Associated Symptoms : cyclic pelvic pain dysmenorrhea. Tenesmus involving the rectosigmoid colon. dyspareunia or ovarian mass (endometrioma). Pain may precede the menses, occur with menses, and continue after menses

6. Endometriosis Treatment: First line NSAIDs,OCP Danazol,GnRH agonists No response to conservative treatment surgery

7. Pelvic Inflammatory Disease can be a cause of acute pain, or even asymptomatic.  mechanisms for pain: inflammation and distension of the fallopian tubes. hydrosalpinx will sometimes persist for months or years and may cause CPP.

8. Myofascial Pain(MFPS) common in patients with a history of trauma or multiple surgeries and is often overlooked as a cause for CPP.  Patterns of pain: localized, reproducible, hyperirritable trigger points within a muscle  Treatment: icing, stretching exercises, and injection with local anesthesia,physical therapy

9. Pelvic Varicosity Pain Syndrome worsen throughout the day Dyspareunia Post coital pain  Mechanism: Increasing in vein diameters substance P and calcitonin gene-related peptide  Treatment: GnRH agonists Medroxiprogesteron acetate surgery

10. Painful Bladder Syndrome characterized by urgency, frequency, or pain in the absence of a urinary tract infection or malignancy.  Diagnosis: distending the bladder cystoscopically under anesthesia  Treatment: diet, exercise, smoking cessation, transcutaneous electrical nerve stimulation, bladder training, medications, bladder distention, or bladder instillation.

11. Irritable Bowel Syndrome  (Rome III criteria): - recurrent abdominal pain or discomfort that is present for at least 3 months - with onset at least 6 months previous and at least two of the following clinical features: (a) improvement with defecation (b) onset associated with a change in frequency of stool (c) onset associated with a change in the form (appearance) of stools.

12. Irritable bowel syndrome  Mechanism: visceral hyperalgesia infection imbalance of neurotransmitters psychologic factors  Treatment: Treating symptoms In pain prodominance: tricyclic antidepressants, NSAIDs, anticholinergics, calcium channel blockers, and in some cases opioids.

13. Ovarian Remnant Syndrome a history of extensive endometriosis or pelvic inflammatory processes resulting in a technically difficult oophorectomy DX: FSH,LH are at normal range. Ultrasonography Treatment: Surgery(removing all ovarian tissue….)

14. Residual Ovary Syndrome  Mechanism: cyclical expansion of the ovary encased in adhesions chronic lower abdominal pain, dyspareunia, and radiation of pain to the back or anterior thigh A tender mass may be palpated on bimanual exam  Treatment: Bilateral oophorectomy

15. Pain of Uterine Origin Adenomyosis Chronic endometritis Degenerating leiomyomata PVPS Cervical stenosis Intrauterine contraceptive device Hysterectomy may be indicated in the absence of pathology in patients who have concluded childbearing and who have not responded to conservative therapy

16. Psychological problems  Consider: Depression Panic attack Anxiety

17. History and Physical Exam Characterists:What does the pain feels like? (sharp, dull, crampy, etc.) Onset: Was the pain onset sudden or gradual? Is it cyclic or constant? Location:Is the pain localized or diffuse? Duration:How long has the pain been present, and how has it changed over time? Exacerbation:What activities or movements make the pain worse? Relief:What medication, activities, and positions make the pain better? Radiation:Does the pain radiate anywhere (back, groin, flank, etc.)?

18. Cyclic Causes for Chronic Pelvic Pain Adenomyosis Endometriosis IBS Mittelschmerz Ovarian remnant syndrome PVPS

19. Gastrointestinal Causes for Chronic Pelvic Pain. Cholecystitis Chronic appendicitis Constipation Diverticulitis IBS Inflammatory bowel disease Intermittent bowel obstruction Neoplasm Pseudomembranous enterocolitis Ulcer (duodenal, gastric)

20. Urologic Causes for Chronic Pelvic Pain Bacterial cystitis Detrusor dyssynergia Neoplasm PBS (interstitial cystitis) Radiation cystitis Urethral caruncle Urethral diverticulum Urethral syndrome Urolithiasis

21. treatment NSAID Anti convalsants Anti depressents Narcotics

22. thank you