Chronic Pelvic Pain Pelvic Congestion Syndrome

1. Chronic Pelvic PainPelvic Congestion Syndrome 부산백병원 산부인과 이 경 복

2. CPP Is a Significant and Common Disorder in Women • Magnitude of CPP - >9 million women in the United States - 20% of women had pelvic pain >1 year in duration • CPP accounts for - 10% of referrals for OB/Gyn visits - over 40% of laparoscopies - 18% of hysterectomies • Patients with CPP have significantly lower general health scores compared with patients without CPP • CPP is associated with painful intercourse (dyspareunia)

3. Definition of Chronic Pelvic Pain • Duration - six or more months • Location - anatomic pelvis - abdominal wall below the umbilicus - lower back • Non-cyclic - ± Dysmenorrhea -± Dyspareunia • Severity - Medical or surgical therapy required - Functional impairment

4. Causes of Chronic Pelvic Pain

5. Neuropathology of Chronic Pelvic Pain Visceral Silent Afferent • Thinly or unmyelinated – easily damaged locally • All can transmit pain - yet most are silent : 10% afferent are silent in skin : 30-80% visceral afferents are silent • Silent afferent become active with prolonged stimulation • Many more interneunical synapses • Silent afferents play major role in tissue sensitization • Barrage of nociceptive/painful stimuli to dorsal horn • ; metabolic, biochemical, & electrophysiological • change • Prolonged release of glutamate and substance P in • DH • Decrease threshold or loss of inhibition = Allodynia • NMDA receptor activation & increased excitability of • large pool of internuncial neurons = Expansion of • receptive fields • Based on duration and severity, these biochemical • changes can become permanent = Centralization • ; exaggerated reflex output with end organ • dysfunction and spontaneous firing of DH neurons • Centralization • Despite removal of original “insult” pain • persists. The dorsal horn is still • hyperexcitable with spontaneous activity. • Example: Phantom limb • Spinal memory

6. Neuropathic responses • Visceral Hyperalgesia - visceral sensitization : IBS, IC • Viscerovisceral Hyperalgesia - cross-talk - referral sensitization to second viscera : IC with IBS, Endometriosis with IC • Viscerosomatic hyperalgesia - referral neurogenic inflammation : IC with vulvodynia/ CPP with TP • Visceromuscular reflex : pelvic floor tension syndrome • Viscerocutaneous reflex

7. History taking

8. Physical Examination • standing examination • sitting examination • supine examination • lithotomy examination

9. Laboratory Evaluation • The use of routine tests in women with CPP is discouraged. • Lab tests should be obtained - the results will change the diagnosis - the result will change the further evaluation - the result will change the treatment • blood testing • urine testing • stool testing • STD testing • hormonal assays • tumor marker

10. Imaging Evaluation

11. Endoscopic Evaluation • routine part of evaluation of CPP • The decision of endoscopic procedure patient’s history & physical examination findings avoid unnecessary risks, expense, & false expectations

12. Laparoscopy • CPP as the indication for diagnostic laparoscopy ; over 40% • Laparoscopic findings of CPP ; no visible pathology- 35% ; Occult somatic pathology - 47% in CPP and negative laparoscopic finding endometriosis- 33% pelvic adhesion-24% chronic PID-5% ovarian cyst-3% pelvic varicosities-<1% myomas-<1% others-4%

13. Laparoscopy • Predominant role of laparoscopy in CPP ; diagnosis or R/O endometriosis and adhesions • Advantages of laparoscopy in the evaluation of CPP - patient reassurance - differentiation between gyn and non-gyn etiology - R/o serious or malignant disease - increased accuracy of diagnosis - immediate surgical treatment is often possible.

14. Hysteroscopy • Hysteroscopic findings at the time of combined laproscopic and hysteroscopic evaluation in women with CPP ; 32%(significant abnormalities laparoscopically in almost all of these patients) ; submucosal myoma-8.9% intrauterine polyp-6.9% cervical stenosis-9.2% intrauterine scarring-0.5% hyperplasia-1.4% uterine septum-1.1% others-4.1% • Role of hysteroscopy in the evaluation of CPP

15. Medical therapy • tricyclic antidepressants • improved pain tolerance • restore normal sleep • reduced depressive symptoms • *** for patients with • sleep disturbance • mild to moderate mood • disturbance • Anxiolytics • anticonvusants Oral analgesics • initial treatment option ; begin with less expensive PG synthetase inhibitor • scheduled rather than PRN basis; ; ‘‘As needed dosing” may increase pain due to ‘‘attention-driven phenomenon” • Narcotics are not recommended for CPP ; increased dysmortility disorder due to potent SM relaxing effect increased sedation and altered cognition increased abuse and addiciton potential

16. Pelvic Congestion Syndrome • Introduction CPP; 10% of all gynecological referrals Pelvic migraine is associated with presence of ovarian and pelvic varicose veins. Up to 15% of women between the age of 20-50 years have varicose veins in the pelvis, although not all experience symptoms( up to 60%; PCS) Protean manifestation & limited appreciation by both clinician & radiologists –underdaignosed cause of CPP

17. Pelvic Congestion Syndrome • Anatomy Complex networkof venous structure Plexuses surround rectum, bladder, vagina, uterus, & ovaries : All interconnected by anastomosis : Essentially valveless Major drainage into internal iliac system Ovarian vein left into left renal vein right into ven cava 13-15% of women lack valves in Lt ovarian vein(6% in Rt ovarian vein) Normal caliber of ovarian vein: < 5 mm

18. Etiology • Hypotheses - Anatomic dysfunction ; venous overload and valvular incompetence - Hormonal dysfunction ; relaxation of SM in the walls of pelvic veins ; ovarian hormones, possibly estrogen - Orgasmic dysfunction ; visceral vasocongestion caused by sexual stimulation(If no orgasm)- pelvic discomfort & psychic irritaion-permanent pathologic changes in the pelvic organ(debatable) - Psychosomatic dysfunction ; chicken-or-egg question chronic pelvic pain-or-psychopathology dilemma Stress actually led to chronic vascular congestion & subsequent PCS. Absence of pain after TAH with BSO in PSC patients with psychosocial disturbance ; report return to normla lifestyles. - Iatrogenically induced dysfunction ; interruption of the utero-ovarian circulation with functional & anatomical changes including PCS

19. Symptoms • Pain - dull, aching pain in the pelvis ; chronic recurring or constant pain aching but episodes of sharp stabbing pain worsened or brought on by lifting, walking, sitting on chair, prolonged standing or  intra—abdominal pressure predominantly one side, occasionally on other side - low back ache(sacrodynia) - sexually related pain ; post coital aching lasting hours or 1-2 days deep thrust dyspareunia - menstrually related pain ; congestive dysmenorrhea

20. Symptoms • Menstrual disorders ; Menorrhagia and Polymenorrhea • May have associated symptoms similar to IBS, Interstitial Cystitis, Frequency-Urgency Syndrome • Psychiatirc and emotional disturbances ; simple anxiety to depression with attempted suicide ; psychological evaluation & consultation

21. Physical Examination • Ovarian point tenderness with history of postcoital ache ; 94% sensitive and 77% specific for pelvic congestion • abdominal Exam • tenderness with reproduction of pain with • deep palpation over ovarian point • Pelvic examination • - cervical motion tenderness • - retrocervical and paracervical tenderness • - marked ovarian tenderness with • gentle compression • - uterine Tenderness

22. Diagnostic Testing • USG • Laparoscopy • CT, MRI, or MRA • Venography

23. Diagnostic TestingUSG(standing or valsalva maneuver) • Tortuous pelvic veins with a diameter of greater than 6 mm. • Slow blood flow(about 3 cm/sec) or reversed caudal flow • Dilated arcuate veins in the myometrium that communicate between bilateral pelvic varicose veins • Sonographic appearances of polycystic changes of the ovaries. • Various change of doppler wave forms Left ovarian vein; 100% aorta-ov. vein- renal vein Right ovarian vein; 50% ov. vein-IVC-aorta

24. Diagnostic Testinglaparoscopy

25. Diagnostic Testingvenography- selective ovarian venography • ovarian vein diameter of >10 mm(at least more than 5 mm) • congestion of the ovarian plexus • uterine venous engorgement • filling of the pelvic veins across the midline/or filling of vulvovaginal and thigh varicosities

26. Treatment • Medical treatment NSAID Oral pill Provera ; 30-50 mg daily reduction of pain in 80% pain recurs upon discontinuation GnRH agonist ; more significant improvement compared to MPA with longer benefit

27. Treatment • Surgical treatment TAH with BSO symptomatic improvement in 2/3 not as effective as ovarian vein ligation Ovarian vein ligation 73% to 78% cure or symptomatic improvement estabilishment of collateral channel & recurrence of symptoms

28. Treatment • endovascular treatment 73% to 78% cure or symptomatic improvement