1. Chronic pelvic pain Mr MK Oak MBBS, ChM, MPH, MSc (Med Sci), Expert Witness Certificate (Civil), Diploma Gynaecological Endoscopy, FRCOG, MEWI Consultant Obstetrician and Gynaecologist

2. Pain is, a sensory and emotional experience associated with actual or potential tissue damage. What is pain

3. Highly unpleasant physical sensation caused by injury or illness On the spectrum of sensation extreme end of sensation. Range from dull ache to agonizing continuous sharp pain or colicky pain and variations in-between. Effect may vary from being aware to inability to function. Pain

4. Nociceptive- stimulation of peripheral nerve ending – Visceral- difficult to locate and often referred to different parts. – Deep somatic. Due to stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fasciae and muscles. It is dull aching and poorly localized. – Superficial somatic due to activation of nociceptors. Usually sharp, well defined and located due minor injuries and burns. Types of pain

5. Nociceptive- stimulation of peripheral nerve ending – Visceral usually Fallopian tube – Deep somatic. Vague history may suggest gynaecological cause but may not be so – Superficial somatic due to activation of nociceptors. ?CPSP Nociceptive pain ? relevance to gynaecology

6. Causes Categories – Thermal often superficial – Mechanical superficial as well as deep – Chemical Causes of nociceptive pain

7. Neuropathic due to damage to nerve ending Typical description is – Burning – Stabbing – Aching – Shooting ?Relevance to gynaecology Types of pain cont

8. Phantom pain Psychogenic pain Types of pain cont

9. Intermittent or constant pain in a woman for six or more months Pain in lower part of the abdomen or pelvis Not exclusively associated with menses or sex Affects woman’s ability to function Heavy economic, family and social burden Definition of chronic pelvic pain

10. Genesis of chronic pelvic pain Poorly understood and not exclusively due to gynaecological pathology. Consider other causes such as – Hernias – Retro-peritoneal tumours – Musculo-skeletal

11. Incidence similar to low back pain Or Migraine Incidence

12. Age greoup almost exclusively 15-50 years Parous Demographics

13. Pattern of pain Nature of pain Aggravating and relieving factors Associated symptoms Bladder, bowel symptoms Psychological factors Pain diary Effect on ADL Management History

14. Onset-trigger Duration Relation to – Bowel movement – Micturition – Menses – Sexual intercourse – Physical activity History cont

15. Obvious but often not mentioned TOP Puerperal sepsis Infected episiotomy/tear Obstetrics history

16. Previous abdominal surgery including caesarean section Puerperal infection Intrauterine contraceptive device Pelvic inflammatory disease STI Medical and surgical history

17. Occupation and how the symptoms impact occupation Impact on sex life Life style – Smoking – Drug/substance abuse – Alcohol An opportunity to explore family/social support Family and social history

18. General Abdominal – Abdominal- masses e.g. fibroids Perineum: local scarring, granulation tissue, tethring Pelvic – Lower genital tract – Virginal discharge – Cervix – Size and position of the uterus – Any pelvic masses Examination

19. Often at this stage, it may become evident that the pain is non-gynaecological Examination

20. ?FBC Inflammatory markets HVS and Cervical swab (chlamydia) MSSU STI Screen ?? CA125 Investigations

21. Ultrasound scan – Abdominal – Pelvic – Trans-vaginal ??? CT/MRI Investigations

22. Laparoscopy Micro-laparoscopy or conscious pain mapping Investigations cont

23. Endometriosis/adenomyosis ?? Adhesions Pelvic congestion Pelvic vericose Veins – Ovarian – Pelvic Causes/contributory factors gynaecological

24. IBS Interestitial cystitis Musculoskeletal Nerve entrapment CPSP Psychological and social issues Causes/contributory factors non- gynaecological

25. Simple analgesics ?? Value NSAID Hormonal Oral Hormonal ?? Mirena Hormonal Injectable – Depo-provera – GnRHa with add back Treatment

26. Anti-spasmodics Antibiotics Amitriotyline Gabapentin More appropriate-multi-disciplinary approach Treatment cont

27. Surgical treatment of endometriosis Adhesiolysis Treatment