Chronic Pelvic Pain

Jennifer Griffin, MD M3 Student Clerkship Lecture University of Nebraska Medical Center

Chronic Pelvic Pain

 Definition

= Pain of apparent pelvic origin that has been present most of the time for 6 months

Chronic Pelvic Pain

 Difficult

to diagnose.  Difficult to treat.  Difficult to cure.

 =Physician

and patient frustration.

Just because youre a hammer doesnt necessarily make every problem a nail.

Chronic Pelvic Pain

 Gynecologic  Gastrointestinal  Urologic  Musculoskeletal/  Psychological

Pelvic Floor

Chronic Pelvic Pain

 United
    

Kingdom data:

Urinary dx 30.8% GI dx 37.7% Gynecologic 20.2% 2525-50% have >1 dx MC Dx = endometriosis, adhesions, IBS, IC

Getting the History



Nature of the Pain:

 

Sharp, stabbing, colicky, burning? Where specifically is it located? Does it come and go or is it constant? Does it occur with certain activities? Is it related to menses? Is it consistent and predictable? Can you do anything to make it better/ worse?

Timing of the Pain:

   

Modifying factors:


Review of Systems


Gynecologic:
        

Association with menses? Association with sexual activity? (be specific) New sexual partners/ practices? Symptoms of vaginal dryness / atrophy? Other changes in menses? Use of contraceptives? Childbirth history and any associations? History of pelvic infections? History of other gyn problems/ surgeries?

Review of Systems
 Gastrointestinal:
      

Regularity of bowel movements? Diarrhea/ constipation/ flatus? Relief with defecation? History of hemorrhoids/ fissures/ polyps? Blood in stools, melena, or mucous? Nausea, vomiting, or appetite change? Weight loss?

Review of Systems
 Urologic:
    

Pain with urination? History of frequent / recurrent UTIs? Blood in urine? Symptoms of urgency or incontinence? Difficulty voiding?

Review of Systems
 Musculoskeletal:
   

History of trauma? Association with back pain? Other chronic pain problems? Association with position or activity?

Review of Systems
 Psychological:
    

History of abuse (verbal/ physical/ sexual)? Diagnosis of psychiatric disease? Association with life stressors? Exacerbated by life stressors? Family/ spousal support?

Chronic Pelvic Pain

 Diagnosis
 

   

History and Physical Targeted imaging studies (U/S best for gyn evaluation) EMB/D&C Laparoscopy Cystoscopy/ Colonoscopy Physical therapy evaluation

Chronic Pelvic Pain



Gynecologic Origin
         

Endometriosis Primary Dysmenorrhea Leiomyomas Dyspareunia Vaginismus Adenomyosis Infectious causes Pelvic congestion syndrome Pelvic organ immobility Cancer

ACOG Practice Bulletin #51, March 2004

Gyn Causes


Cyclic:
   

Primary dysmenorrhea Endometriosis Adenomyosis Mittleschmertz Pelvic masses Adhesions Infections NonNon-gyn causes Endometriosis Vaginismus Vaginal atrophy Musculoskeletal Any non-cyclic cause could be exacerbated. non-

NonNon-cyclic:
   

Related to intercourse:
    

Chronic Pelvic Pain: Cyclic

 Endometriosis


  

7-10% of women (up to 50% in premenopausal women) 33% of women undergoing laparoscopy for pelvic pain will be diagnosed with endometriosis Found in 38% of infertile women Family history increases risk 10x Significant cause of morbidity

Chronic Pelvic Pain: Cyclic

 Endometriosis:
   

Etiology

Retrograde menstruation Hematogenous/lymphatogenous Coelomic metaplasia Immunologic dysfunction

Chronic Pelvic Pain: Cyclic

 Endometriosis:
  

Classic Triad

Dysmenorrhea Dyspareunia Infertility

 But
 

may present with:

Chronic pelvic pain Adnexal mass

Chronic Pelvic Pain: Cyclic



Endometriosis: Diagnosis
 

  

Clinical suspicion Presence of endometrial glands in biopsy outside endometrial cavity Elevated CA-125 without evidence of other pathology CARelief of pain with empiric GnRH agonist Laparoscopy
Multiple appearances: red, brown, scar, white, puckering, powder burn, adhesions, endometriomas Multiple locations: ovary, uterosacral ligaments, cul-de-sac, cul-derectovaginal septum, and others

Chronic Pelvic Pain

 Endometriosis:
 

Classification ASRM 1996

Chronic Pelvic Pain: Cyclic



Endometriosis: Treatment
        

Laparoscopic removal/destruction NSAIDs OCPs Danazol GnRH analogs x 6-12 months 6LUNA TAHTAH-BSO Pain clinic/TENS units Presacral neurectomy

Chronic Pelvic Pain: Cyclic

 Dysmenorrhea
    

NSAIDs OCPs Vitamins: B6, B1 Mg++ OmegaOmega-3-Fatty acids

Chronic Pelvic Pain: Cyclic

 Leiomyomas
   

Pressure Pain Degeneration Treatment:

NSAIDs OCPs Lupron Myomectomy Hysterectomy

Chronic Pelvic Pain: Cyclic

 Adenomyosis

=endometrial glands within the myometrium  Rarely diagnosed via ultrasound  May be inferred with laparoscopy  Will have complaints related to bleeding and pain.  May be anemic.  Definitive Dx and Tx: hysterectomy/pathology

Chronic Pelvic Pain



Dyspareunia
        

Endometriosis Adnexal masses Vulvovaginitis Chronic endometritis Vaginal dryness Vaginal atrophy Obstetrical trauma Surgical scars Vaginismus

Chronic Pelvic Pain: Dyspareunia

 Vaginismus
  

Primary Secondary Treatment:

Biofeedback Partner involvement, patient in control Valium

Chronic Pelvic Pain: Dyspareunia

 Pelvic
    

Floor Muscle Spasm and Strain

Piriformis m. Coccygeus m. Levator ani m. Peripartum pelvic pain syndrome Treatment:

Biofeedback TENS units Valium Cooperation with sexual partner

Chronic Pelvic Pain: Non-cyclic Non Pelvic

    

congestion syndrome

Varicosities in the pelvis. ?Etiology Dx: laparoscopy, ultrasound Progesterones are tried, but of limited benefit. Only cure is hysterectomy

Chronic Pelvic Pain: Non-cyclic Non Pelvic



organ immobility

Secondary to Endometriosis, PID, Previous surgery, cancer Evaluate thoroughly to identify source if unknown. Treatment depends on reproductive desires/quality of life issues
Hysterectomy +/- BSO +/-

Chronic Pelvic Pain: Non-cyclic Non PID



Be specific: Endomyometritis, Salpingitis, Salpingooophoritis, TOA MCC:

Chlamydia and Gonorrhea, USA Tuberculosis, Developing countries

 

1818-35% women develop CPP No difference whether treated as in- or outin- outpatient

Chronic Pelvic Pain

 Infectious
   

causes

Chronic endometritis PID Tuberculous salpingitis Recurrent UTIs

Chronic Pelvic Pain: Non-cyclic Non Gynecologic

   

malignancies

Ovarian Cervical Uterine Vulvar

Chronic Pelvic Pain

 Other
      

Gynecologic origin:

IUD IntraIntra-uterine, cervical polyps Ovulatory pain (Mittelschmerz) Ovarian retention/remnant syndrome Adhesions Adnexal cysts Pelvic relaxation

Chronic Pelvic Pain



Treatment of Gynecologic Problems

       

     

Empathic listening Analgesics (preferably NSAIDs, avoid opioids) OTC products (Astroglide, Replens, KY) OCPs Antibiotics Removal of IUD, polyps GnRH analogs Surgery (Destruction/removal lesions, adhesiolysis, LUNA, hysterectomy, presacral neurectomy etc) Biofeedback/PT Antidepressants and Psychotherapy Marital/partner counseling Massage Acupuncture Exercise

Chronic Pelvic Pain

 Urologic
   

Origin, Level A:

Bladder malignancy Interstitial Cystitis Radiation Cystitis Urethral Syndrome

Chronic Pelvic Pain

 Bladder


origin, Level B:

Uninhibited Bladder Contractions (Detrusor dyssynergia) Urethral diverticulum

Chronic Pelvic Pain

 Urologic
   

origin, Level C:

Chronic UTI Recurrent, acute UTI Urolithiasis Urethral caruncle

Chronic Pelvic Pain

 Urologic


origin

Urologic evaluation:
Urinalysis Urine culture Urine cytology Cystourethroscopy +/- hydrodistension +/IVP

Chronic Pelvic Pain



Urologic origin: Interstitial Cystitis

       

Urinary urgency/frequency Glomerulations Potassium chloride test Emuron Antihistamines Tricyclic antidepressants (Imipramine 25-50mg @ hs) 25Intravesical treatments: DMSO, BCG Avoidance of acidic foods

Chronic Pelvic Pain

 Gastrointestinal
   

Origin, Level A:

Carcinoma of colon Constipation Inflammatory bowel disease Irritable Bowel Syndrome

Chronic Pelvic Pain

 IBS

Chronic Pelvic Pain



Irritable Bowel Syndrome

Etiology and pathophysiology unknown (no biochemical, inflammatory or mechanical reason found)  12% U.S. population  2:1 women:men  Peak age 30-40s 30 Rare >50 y.o.  Associated with stress  Increased gut motility and sensitivity to stimulants H. Mertz, NEJM 2003


Chronic Pelvic Pain



IBS Treatment


  

Dietary changes (decreased caffeine, fat, ?lactose intolerance, increased fiber) Decrease stress Cognitive psychotherapy Medications:
Antidiarrheals (e.g. Loperamide) Antispasmodics (e.g. Bentyl, Belladona) TCAs Serotonin receptors 3 or 4 agonists (e.g. Lotronex (3), Zelnorm (4))

Chronic Pelvic Pain

 Colon
 

carcinoma

Fecal occult blood testing Colonoscopy

Chronic Pelvic Pain

 Constipation
    

History and physical Bowel patterns Increased water and fiber Suppositories Oral Fiber pills, OTC preparations (avoid bowel stimulants)

Chronic Pelvic Pain

 Inflammatory
 

Bowel Disease

Crohns Disease Ulcerative Colitis

Chronic Pelvic Pain

 Gastrointestinal

origin, Level C (no Level

B):
  

Colitis Chronic intermittent bowel obstruction Diverticular disease

Chronic Pelvic Pain



Musculoskeletal, Level A:
    

Abdominal wall myofascial pain (trigger points) Chronic coccygeal or back pain Faulty or poor posture Fibromyalgia Neuralgia of iliohypogastric, ilioinguinal, and/or genitofemoral nerves Pelvic floor myalgia (levator ani or piriformis syndrome) Peripartum pelvic pain syndrome

Chronic Pelvic Pain

 Musculoskeletal
  

origin, Level B:

Herniated nucleus pulposus Low back pain Neoplasia of spinal cord or sacral nerve

Chronic Pelvic Pain

 Musculoskeletal
     

origin, Level C:

Compression of lumbar vertebrae Degenerative joint disease Hernias: ventral, inguinal, femoral, spigelian Muscular strains and sprains Rectus tendon strain Spondylosis

Chronic Pelvic Pain

 Other


NonNon-Gynecologic Origin, Level A:

 

Abdominal cutaneous nerve entrapment in surgical scar Depression Somatization disorder

Chronic Pelvic Pain

 Psychological
  

4040-50% women with CPP have a hx/o abuse Ask gently, non-judgementally nonTreatment:
TCAs SSRIs Counseling

Chronic Pelvic Pain

 Other
    

NonNon-Gynecologic origins, level B:

Celiac disease Neurologic dysfunction Porphyria Shingles Sleep disturbances

Chronic Pelvic Pain

 Other
   

NonNon-Gynecologic origin, Level C:

Abdominal epilepsy Abdominal migraine Bipolar personality disorders Familial Mediterranean fever

Clinical Pearl of Wisdom

 Evaluate

thoroughly based on history.  Provide treatment based on most likely diagnosis.

 If

pain improves, may step up to more aggressive treatment option if appropriate. pain is chronic and progressive, initiate treatment triad.

 If

Pelvic Pain Treatment Triad

 Medical

treatment of most likely diagnosis.  Psychiatric evaluation and treatment.  Pelvic physical therapy.

Case Studies

Case 1:
 26

year old female presents b/c of pain in her uterus.  Pain is worse with menses.  Used to be relieved with ibuprofen; now nothing makes it better.  Worse pain with deep penetration with intercourse.  New sexual partner over past 3 months.

Case 2
    

68 year old female presents b/c of pain in her uterus. Has noticed bloating and diarrhea more over past 3 months. Sexually active, only slightly exacerbated by intercourse. Has burning and discomfort with intercourse and urination after intercourse. Some night sweats, no significant hot flashes.

Case 3
 33

year old presents with pain around my ovary.  Pain is not chronic, but she has had several episodes of pain which have brought her to ER.  Last episode started during intercourse, and gradually improved over next two days.

Case 4
 24

year old medical student presents with pain around my ovaries.  History of ovarian cyst at age 16.  Seems to be worse during week of exam.  Admits to some increase in gas and diarrhea; feels better after BM.  Pain worse with sitting, studying for long periods of time.

Case 5
 47

year old female presents with pain with intercourse.  Seems to be worse with deep penetration, but also with entry.  Admits to recent marital problems (spouse had affair), though now this is resolved.  Also complains of irregular menses and occasional hot flashes.

Case 6
 47

year old female presents with pain with intercourse.  Pain described as a tight feeling with burning and irritation at the introitus.  Started over past year, worsening.  Reports good relationship with spouse, though she feels stressed due to negative sexual experiences.

Chronic Pelvic Pain

 Conclusions:
  

Thorough history and physical Imaging and lab studies Many treatment options available