An Integrative Approach to the Management of Chronic Pelvic Pain

1. An Integrative Approach to the Management of Chronic Pelvic Pain Priscilla Abercrombie, RN, NP, PhD, AHN-BC HS Clinical Professor Obstetrics, Gynecology & Reproductive Sciences UCSF Community Health Systems UCSF Chronic Pelvic Pain Clinic UCSF Osher Center for Integrative Medicine SFGH Women’s Health Center Founder, Women’s Health & Healing

2. Objectives Define chronic pelvic pain (CPP) and identify the most common causes of CPP. Identify myofascial sources of pain that are rarely recognized and treated in patients with CPP. Explore the many different treatment modalities that are available for patients with CPP. Provide a systematic approach for the successful assessment and management of CPP.

3. Disclosures I have no affiliation with any pharmaceutical companies, etc. I will discuss off-label use of drugs.

4. Most Common Definition “Continuous or episodic pain in the lower abdomen or pelvis lasting >=6 months and associated with a negative impact on quality-of-life” (Williams, et al., 2004) Definitions vary greatly throughout the clinical and research literature.

5. Chronic Pelvic Pain • Howard FM. Obstetrical and Gynecological Survey 1993;48:357-87. • Mathias SD, Kuppermann M, et al. Obstetrics & Gynecology 1996;87:321-7. • Prevalence 12-39% • Medical Care • 20% of all referrals to gynecologists • >40% of all laparoscopies • 12% of all hysterectomies • Costs to Society • $882 million in outpatient visits alone • 15% time lost from work • 45% reduced productivity • Total costs estimated at > $2 billion / yr

6. Overview of CPP • Rarely caused by a single condition • Usually multifactorial (Howard, 2003) • Involves both physiological and psychological conditions • Can be classified as cyclic or noncyclic • Seldom fits into those categories clinically

7. One Patient’s Story 39 yo with crampy lower abdominal pain x 3 years Daily pain 3/10, worsens to 8/10 twice a week Limits activities (including sex), enjoyment of life Worse with her period Pain with intercourse Has constipation with bloating Urinary frequency

8. Assessment No standard diagnostic criteria No standard method of evaluating patients

9. Clinical Guidelines ACOG Society of obstetricians and gynecologists of Canada European Association of Urology Review articles: Howard Learman

10. Obtaining History • Listen to her story about living with CPP • Discuss concerns, fears and insights • Reflect back what you have heard • Build trust and rapport • Distrust health care providers • Endured multiple diagnostic tests • No cause for pain found • Have not been heard/believed • Must be psychological

11. Components of the CPP History • Pain history: quality, location, timing with cycle, contributing or relieving factors, body map • Medical/surgical history including Rxs • Ob/Gyn: menstrual history • GI symptoms/pain • Urinary symptoms, IC screening • Quality of life • Health habits: ETOH, substance abuse • Review records See International Pelvic Pain Society Website for history and PE forms: English, Spanish, French

12. Emotional Health • Assess impact on functioning and quality of life • “What things would you like to be able to do that you can’t do because of the pain?” • “How are things at home? At work?” • Elicit patient’s view of illness, fears and concerns • Do you have any thoughts or concerns about what might be causing the pain? • Screen for current or prior physical or sexual violence, including events in childhood • Screen for depression

13. CPP Diagnostic Tests

14. Physical Exam Identify underlying pathology Reproduce pain

15. Musculoskeletal exam Observe gait, posture, balance Examine hip flexibility and symmetry Test for weakness, tenderness or sensory disturbances in the back, buttocks, legs, and pelvis Palpate the abdomen for masses, muscle tension, tenderness and trigger points Don’t confine your exam to the gyn table

16. Carnett’s Sign Differentiates pain originating from the abdominal wall versus peritoneal cavity (Suleiman et al., 2001) The patient raises her head and shoulders from the examination table while the provider palpates the tender area on the abdomen. Positive Carnett’ssign: pain remains unchanged or increases when the abdominal muscles are tensed.

17. Trigger points are hyperirritable palpable nodules that are taut bands of muscle fibers (Tough et al., 2007) When palpated the pain usually radiates to another location Found in abdominal wall and pelvic floor locations Major contributor to CPP Myofascial Trigger Points See also: Lavelle, E., Lavelle, W., & Smith, H. (2007). Myofascial trigger points. Anesthesiology Clinics, 25, 841-51.

19. CPP Pelvic Exam • External genitalia: vulvar / vestibular lesions and tenderness (Q tip test) • Urethra and bladder: mass or tenderness, prolapse • Vagina, cervix: • inspection (lesion, trauma, infection, prolapse) • 12-point unimanual exam • Wet mount/STI screening if clinical suspicion • Uterus, adnexae – bimanual • Size, shape, consistency, mobility, mass, tenderness • Rectal or rectovaginal • Lesion, rectocele, uterine retroflexion, uterosacral nodules

20. Q Tip Test From National Vulvodynia Association CME Course 2010

21. Q Tip Test Purpose: identify and map changes in sensation including allodynia Gently touch with a q-tip Start at the thigh and work down to perineum bilaterally Include clitoris and perianal areas Proceed from labia majora to labia minora then the vestibule Record findings

22. Diagnosis of Vulvodynia Incidence: 3-5% of reproductive age women

23. Examining Pelvic Floor Muscles

24. 12-point Unimanual Vaginal Exam • Palpate in 4 quadrants x 3 depths • NO abdominal palpation • Just beyond hymen • 12:00 urethra, 6:00 rectum • 3:00/9:00 obturatorinternus • Mid-vagina • 12:00 bladder base, 6:00 rectum • 3:00/9:00 puborectalis • Just before cervix • 12:00 bladder, 6:00 rectum/cul-de-sac • 3:00/9:00 pubo/iliococcygeus

25. Treatment Goals Improve functional status Improve quality of life Decrease pain

26. Diagnostic Possibilities are Broad • Gynecologic • Gastrointestinal • Urinary tract • Musculoskeletal • Psychological

27. Gynecologic Causes • Endometriosis • Adenomyosis • Adhesions entrap ovaries, tether pelvic organs • Vulvodynia, vulvar vestibulitis • Prolapse of the uterus • Ovarian dystrophy: ischemia • Ovarian vein congestion: edema • Pain during ovulation (“mittelschmerz”)

28. Gastrointestinal Conditions Urinary Tract Conditions • Interstitial cystitis: painful bladder syndrome • Infection: usually acute symptoms • Kidney stones: usually acute symptoms • Cancer (rarely) • Irritable bowel syndrome • Inflammatory bowel disease, diverticular disease • Hernias • Cancer (rarely)

29. Musculoskeletal Maladaptations Low back, abdominal wall, and pelvic floor muscle dysfunction

30. Muscular Maladaptations Inciting Pain Event: uterus, ovary, bowel, bladder, muscles, nerves Local Muscle Tension Initial Event Resolves (naturally or with treatment) Secondary Muscle “Adaptations”: Lower back, buttocks, hips, pelvic floor

31. Myofascial pain • Hypertonus and tenderness are common • Refer patients to physical therapists specializing in pelvic floor muscle work (advanced training) • Myofascial release • Biofeedback • Abdominal breathing, rescue poses, stretching exercises • Home exercise program

32. Trigger Points • Ultrasound energy, manual therapy • Local anesthetic injection: 93% success by 5th injection • Lidocaine 1% x 10-15cc, bupivicaine 0.25% - 0.5% x 10-15cc

33. Emotional pain Address anxiety, depression, and sexual dysfunction

34. Which Patient Has More Pain? Patient A Depressed Patient B Not Depressed

35. Psychological morbidity Pain has impact on quality of life and functional capacity Women become isolated and have difficulty communicating needs Relationships become strained Pre-existing psych issues such as PTSD exacerbated by pain Anxiety and depression common

36. Fear Avoidance Model (Main, et al., BMJ, 2002)

37. Therapeutic goals • Identify and treat psychological morbidity • Assist in the development of: • Positive coping techniques • Communication strategies • Problem solving skills • Set realistic treatment goals • Acknowledge and support woman • Provide medication management

38. Sexuality Issues • Dyspareunia is common • Can lead to sexual dysfunction and strained sexual relationships • 68% of women with CPP have sexual dysfunction • Hypoactive desire 54% • Arousal disorder 33% • Orgasmic disorder 22% • Sexual pain 74%

39. Treating Sexual Pain • Learn about your body • Explore your pleasure spots • Educate your partner • Connect with your partner in sexual and non-sexual ways • Prepare for sex: relax the PF muscles, use lubricants, take time for arousal • Reinvent your sex life • Avoid painful activities

40. Central Sensitization Definition: “an amplification of neural signaling within the central nervous system that elicits pain hypersensitivity” (Woolf, 2011). Body continues to experience pain despite healing from a precipitating injury Pain in the setting of no known pathology

41. Central Sensitization CNS perpetuates pain by demonstrating exaggerated or prolonged responses to painful stimuli this is referred to as “windup” Reduced capacity for inhibition Occurs in many CPP disorders such as vulvodynia (Zhan, Z., 2011), dysmenorrhea (Bajaj, P., 2002), and endometriosis (He, W., 2010)

42. Pathways of Pain Perception

44. Treating Pain: Medications • Analgesics: • Opioids • NSAIDS • Topical anesthetics* • Antidepressants • Tricyclics* • SSRI’s/SNRI’s* • Anticonvulsants • Muscle relaxants • Nerve blocks • Neurologics: pregabalin • Neurotoxin: OnabotulinumtoxinA* *Off label use

45. More Treatments Referral to pain management specialist: nerve blocks, medication consult Mind/body interventions: breathing exercises, imagery, MBSR, laughter yoga, etc. Movement therapies: yoga, Tai Chi, Feldenkrais, etc. Anti-inflammatory diet/herbs Support health: multivitamins, B complex, fish oil, calcium/magnesium, herbal tonics Alternative providers: TCM, craniosacral, chiropractic, energy medicine, strain/counter strain, etc.

46. Some Improvement Celebrate, adjust meds, encourage adherence, focus on activity limitation endpoints No Improvement Optimize treatment of depression if present Facilitate pelvic floor PT if not yet done Consider empiric treatments vs. invasive diagnostic studies (e.g., GnRHa vs. laparoscopy for presumed endometriosis) Continues without Improvement Begin work-up anew Consider hysterectomy only if conditions are met CPP Treatments: Follow-up

47. Pearls Set realistic goals with your patient: improved function vs. complete remission Have a systematic approach to assessment Be wary of the assumption pain is linked to pathology or obvious tissue damage Use medication contracts Work as an interdisciplinary team- Build a community Have lots of tools in your tool kit Keep learning about innovative strategies

48. Patients don’t really come to us because they are in pain, they come to us because they are suffering.Ling, APS Conference 2010

49. Resources International Pelvic Pain Society: www.pelvicpain.org National Vulvodynia Association: www.nva.org Endometriosis treatment guidelines: http://guidelines.endometriosis.org/ Interstitial Cystitis Association: www.icahelp.com Irritable Bowel Syndrome: http://digestive.niddk.nih.gov/ddiseases/pubs/ibs_ez/index.htm American Physical Therapy Association: http://www.apta.org//AM/Template.cfm?Section=Home UCSF Chronic Pelvic Pain Clinic: https://www.obgyn.medschool.ucsf.edu/gynecology/ccss/pelvic_pain/index.aspx