1. Chronic Pelvic Pain in Primary Care
GGPET March 2015
Mr Philip Kaloo
Consultant Gynaecologist and Laparoscopic Surgeon
Endometriosis and Pelvic Pain Clinic, CGH
Interactive session, almost no neuroanatomy
Cpp – many underlying causes, affecting all the pelvic organs.
Major negative factors affecting qol of pt

2. Outline Definitions Importance Causes History – Including Red flags
Examination / Investigations
Initial management in primary care
Quiz

3. Definition - Chronic Pelvic Pain
Intermittent or constant pelvic pain of at least 6 months duration
Not a disease, but a complex multifactorial syndrome i.e. cognitive, behavioural and physical consequences
In the lower abdomen or pelvis.
Not occurring exclusively with menstruation or intercourse
• duration of 6 months or longer;
• incomplete relief with most treatments;
• significantly impaired function at home or work;
• signs of depression, such as early awakening, weight
loss, or anorexia; and
• altered family roles.

4. Importance
Prevalence rate: 38/1000 = similar to asthma, migraine and back pain in primary care
20% GOPD Consultations
Cognitive consequences
Physical consequences
Behavioural consequences
And therefore social consequences, sexual consequences
Cognitive consequences – depression
Behavioural consequences –
Physical consequences – fatigue
30% of patients never have a definable cause for their pain
Economic costs of lost earnings/ time off work. Repeat consultations and repeat investigations

5. Chronic Pelvic Pain Syndrome
Gynae GI
Musculoskeletal
Urological
Chronic Pelvic Pain Syndrome
1/3 of cpp = cpps
Up to 60 % of cpp is gynae

6. Just a few more definitions!
Chronic pelvic pain syndrome - Is the occurrence of chronic pelvic pain where there is no proven infection or other obvious local pathology that may account for the pain
Neuropathic pain – Pain caused by a primary lesion or dysfunction of the nervous system – peripheral or central,..
Myofascial trigger point – localised areas of deep tenderness in muscles
Nerve entrapment – Pain from a nerve within scar tissue, fascia or narrow foramen
Visceral hyperalgesia – Increased pain from a stimulus that normally provokes pain
Allodynia – Pain from a stimulus that does not normally provoke pain
Opioid-induced hyperalgesia – paradoxical increased sensitivity to nerve stimulation following opioid use
no proven infection or other obvious local pathology that may account for the pain
Allodynia – no change in the quality of a sensation but the response is altered.
Hyperaesthesia – increased sensitivity to stimulation , hyperalgesia related to cutaneous sensations
Trigger points – may be secondary to repeat chronic contraction

7. Aetiological – infection, trauma surgery inflammation
Causes:
Anatomical
Aetiological – infection,
trauma
surgery
inflammation
Functional bowel disease
Commonly seen in patients with CPP. Multiple studies demonstrate visceral
hyperalgesia (e.g. exaggerated hyperalgesia (e.g. exaggerated
response to distension, Shared nerve supply Shared nerve supply – S2, S , S3, S , S4
Supra Supra-sacral effects commonly seen sacral effects commonly seen
(e.g. stress, diet) (e.g. stress, diet)
OVARIAN PATOHOLGY – CYSTS, RESIDUAL OVARY, OVARIAN REMNANT
Anatomical
Aetiological – infection,
trauma
surgery

8. GYNAECOLOGICAL Endometriosis Adenomyosis Adhesions Ovarian pathology
PID
Fibroids?
Hypo-oestrogenism
Endometriosis is the most common cause of cpp, 70% of women with CPP have endo.
Significantly more nerve fibres in endometriotic peritoneum than in normal.
Dyspareunia - Hypo-oestrogenism secondary to childbirth
Vulvodynia (6 months)– generalised (Pain at different places at different times)
vulvar vestibulitis (only at entrance to vagina), only comes on after touch/pressure, burning
Vestibultis is initiated by touch not generalised vulvodynia
Causes: hx chronic antibiotic use, hypersensitivity to yeast infection, hormonal changes, nerve or muscle injury
Adhesions – including residual ovarian syndrome and ovarian remnant syndrome
Pid – 25% develop cpp

9. MUSCULOSKELETAL Myofascial dysfunction
Nerve entrapment (Inc. Pudendal nerve, post surgery)
Herniae
Sacroiliac
Levator ani and pirformis pain
Pelvic floor – non-contracting muscles, non-relaxing muscles and non-contracting and non-relaxing
overactive causes dysfunctional voiding, overactive bladder, constipation and dyspareunia
underactive causes
Dysfunction of pelvic floor affects pelvic viscera and vice versa.
Treatment – physiotherapy, biofeedback and
Myofascial trigger point – repeated or chronic muscle overuse can activate trigger points in muscle = hyperirritable spots within a tight band.
The affected muscle is shortened therefore limiting function. Pain aggravated by pressure
Myofascial trigger point treatment:
Manual therapy – pressure and release, compression etc
Dry needling
Wet needling – local /botulinum a toxin(inhibits acetylcholine release at the nm junction
Nerve entrapment – highly localised , sharp stabbing pain. 3.7% after pfanenstiel

10. GASTROINTESTINAL IBS Chronic appendicitis Constipation
Inflammatory bowel disease
IBS – 50% of patients presenting with pelvic pain to a gynae clinic have symptoms of IBS

11. UROLOGICAL Interstitial cystitis (Bladder pain syndrome)
Urethral pain syndrome
Chronic UTI
Calculi
Urothelium line bladder and urethra and so would be reasonable to assume pathology affecting the bladder can also affect the urethra
BPS – pain/pressure or discomfort associated with the bladder and urinary frequency. Having excluded all other causes.
aetiology : unidentified bladder insult to the bladder causing inflammation and neural changes. Defect in bladder wall causing increased sensitivity to urine.
Rx – Analgesia – respond poorly to nsaids
Anti-histamines
Amitryptyline >50mg/day

12. Points of referral Gynaecology Urology Gastroenterology Pain Medicine
Genitourinary Medicine
Dermatology
Rheumatology
Orthopaedics

13. Case study 1 44 year old business woman P1 (chronically ill)
Medically fit and well
12 months ago, antibiotics for chest infection
Severe thrush, initially responds
Then severe vulvodynia and dyspareunia and urinary urgency
Referred after 6 months. Examination – pain ++ , unable to do pv

14. Thoughts? Initial insult Peripheral nerve changes
Central sensitisation
Somato-viseral hyperalgesia
Vulvodynia
Neuroplasticity leading to allodynia (pain from stimuli that aren't normally painful) and hyperalgesia
Similar aetiology to cpp following PID, BPS and ? Functional bowel disorder

15. History Pattern of pain (Pain diaries)
Bladder, bowel, psychological symptoms
Menstrual cycle
Effects on lifestyle, family etc
Sexual function
“What do you think is causing the pain?”
*Time*
Site and Radiation
Exacerbations in symptoms during bladder filling
Intensity (Mild, Moderate, Severe) or 1-10
Duration (<I month, 1-6 month, >6 months)
VAS

16. “Red flag” signs and symptoms
PV bleeding – PCB, if >40yrs
Pelvic mass
New pelvic pain >50 yrs old
Bowel - PR bleeding
Urinary - Haematuria
Excessive weight loss
Suicidal ideation

17. Examination Abdomen – Carnetts' Test Vulva
Vaginal examination/bimanual
Speculum
Back/hips
*Time*
Examination is very different from a routine gynae examination
v.e single digit only, anterior tenderness - ?Bladder pain syndrome
Explain why not examining patient can be helpful

18. Investigation FBC, CRP Urinanalysis Vaginal and endocervical swabs
Imaging
(Laparoscopy - Grade A recommendation to rule out treatable cause,
a negative laparoscopy often helps)
Negative laparoscopy help in symptom relief because of effects on beliefs about pain and the exclusion of serious disease

19. Case study 2 32 year old nullip
3 year history of CPP and bowel symptoms
PMH: Myomectomy 4 yrs ago
Referred to gynae with pelvic pain/dyspareunia. Treated with COCP – unsuccessful. Normal TVS
Referred to pain clinic – amitryptyline, pregabalin and tramadol
Referred to Endometriosis/pelvic pain clinic

20. Initial Management Remove the original insult
Treat the pain i.e. NSAIDS, antispasmodics
Hormonal manipulation
Neuromodulators
TENS
Dietary modification
Complementary therapies
Psychological management

21. Medical management Regular review Oral imipramine or nortryptline
Analgesia
Simple analgesia
Tramadol mg 4 hourly
Neuromodulators
Amitryptyline 10-75mg/day
mg/day in 2 doses
Pregabalin
Other
Buscopan
Topical analgesics
Hormonal manipulation
Regular review
Oral imipramine or nortryptline
Gabapentin – side-effects; particularly drowsiness, peripheral oedema, dizziness
Others – Topical capsaican / lidocaine plasters
TCA’s i.e amitrypyline can be a problem in depressed patients because of problems re overdose
So SNRI’s can be more beneficial when an anti-depressant acitivity and anti-neuropathic pain is required
If little benefit with amitryptyline at 50-75mg/day, drop down slowly and then add a gabapentinoid

22. Referral criteria Consider referral at any stage
Severe pain having significant effect on daily activity
Deterioration in symptoms
Red flag symptoms

23. Quiz What is the prevalence of chronic pelvic pain?
What percentage of chronic pelvic pain (Excluding CPPS) is due to a gynaecological cause?
What does a positive Carnetts’ test suggest?
What could you use as a first line neuromodulator?
Can TENS machines be used in CPP?
In what type of CPP is this ‘helpful’?

24. Conclusion CPP is a very common condition in primary care
It is often a complex condition but a lot can be done without referral into secondary care
(chronic pelvic pain)
RCOG Guidelines
SOGC Guidelines
IASP