Case Study in Chronic Pelvic Pain Jennifer McDonald DO F.A.C.O.G

61% of CPP will have no definitive diagnosis !!

Definition of Chronic Pelvic Pain (CPP) P Non-cyclic P 6 months or more in duration P Localized to pelvis, anterior abdominal wall below the umbilicus, lumbosacral area, or buttocks P Causes significant enough impairment to cause them to seek treatment

Case C.A. is a 26 year old white female who has been treated 12 times in the last two years for recurrent urinary tract infections. She presents with symptoms of urinary frequency, urgency, pelvic pain, and dyspaurenia. She also describes alternating diarrhea and constipation especially around the time of her menstrual cycle. She reports she is in a long term, monogamous relationship but is afraid to commit to marriage as her problem with painful intercourse is worsening. She admits that she voids times per day and awakens 3-5 times each night. She is a non-smoker and her menstrual cycles are painful but regular.

Important Questions for CPP patients P Where is your pain? P When did it start? P What makes it better? P What makes it worse? P Are your cycles painful? P Pain with urination? Frequency? P Is intercourse painful? P Do you have pain in other parts of your body? P What diagnostic studies have been done? P What were the results? P What treatments have been tried? How successfully? P How do you sleep? P How is your family life? Job? P Any bowel symptoms? P Have you seen other doctors?

Physical Exam P C.A. is a healthy appearing female who is height/weight appropriate P Supra-pubic and perineal tenderness as well as tenderness across the bladder base P No evidence of vaginitis or a sexually transmitted disease

Gynecologic - extra-uterine Gynecologic - uterine Urologic Gastrointestinal Musculoskeletal Neurologic Where do we look?

Pelvic Pain Assessment

Lab Evaluation Urinalysis Nitrite negative Leukocyte esterase negative Trace blood Bilirubin negative Urine Culture No organisms Cystoscopy/ Hydro-distension (Not always necessary)

C.A. has Interstitial Cystitis P CPP syndrome of bladder origin estimated to affect as many as 1 in 4.5 women P Often misdiagnosed as endometriosis, recurrent UTI’s, or overactive bladder P Typically white women of reproductive age (90%) P Symptoms first noticed in their 30s but usually a delay of 5-8 years before accurate diagnosis making average age P Women have consulted 5-8 healthcare professionals before receiving a correct diagnosis

Pathogenesis of IC GAG Layer Irritated Nerves K + and Urea

> 10 points 74% likelihood of IC 5-10 points 55% likelihood of IC Healthy women < 2 points PUF Screening C.A.’s PUF = 18

Potassium Sensitivity Test (PST) P 80% patients with IC have a +PST P Instillation of 40mL of room temperature sterile water. Pain rated 0-5 P Water removed after 5 minutes and replaced with 40 mL of KCl. Pain re-evaluated P Any increase of 2 or more points is a + result 91% patients with PUF > 20 will have + PST 76% patients with PUF % of patients with PUF 5-9 Allows us to reserve PST for women with suggestive symptoms but lower PUF scores

Obstacles to Diagnosis P IC relatively “new” or at least newly understood P Definition of IC not uniformly agreed upon P Lack of education in medical profession P No definitive test P Often misdiagnosed for long periods because of overlapping symptom complex P Variation in severity of symptoms

Treatments Elmiron  only drug FDA approved for treatment Resembles naturally occurring GAGs Reduces painful symptoms 2 to 4 months women with mild disease and 6-12 months in women with severe disease

Non-Pharmacologic Treatment Chiropractic care Biofeedback/Bladder training Pelvic floor relaxation exercises Dietary manipulation is mandatory AlcoholApplesBananas Citrus fruitsCoffeeCarbonated beverages ChocolateMayonnaiseMost nuts PineappleOnionsSoy sauce YogurtSour creamBeans

Keys to Treatment P Pain and its perception are located in the nervous system so its treatment must encompass a Mind and Body approach P Multiple interactive problems are most likely with CPP so it isn’t which treatment is best but which treatments P It usually took time for things to get to where they are so it will be take time to get them back to normal as well P Chronic pain affects a family not just an individual patient

The patient with CPP needs a multidisciplinary approach … are you ready?