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Chronic Pelvic Pain

Chronic Pelvic Pain. Fawaz Edris MD, RDMS, FRCSC, FACOG, AAACS. Introduction. Non cyclical uterine or non-uterine pelvic pain > 6/12 Gynecological GIT Urological Orthopedic Musculoskeletal “superficial” (nerve entrapment, hernia, referred) Psychological (by exclusion). Introduction.

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Chronic Pelvic Pain

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  1. Chronic Pelvic Pain Fawaz Edris MD, RDMS, FRCSC, FACOG, AAACS

  2. Introduction • Non cyclical uterine or non-uterine pelvic pain > 6/12 • Gynecological • GIT • Urological • Orthopedic • Musculoskeletal • “superficial” (nerve entrapment, hernia, referred) • Psychological (by exclusion)

  3. Introduction • Somatic pain • Visceral pain • Diffusely spread • Lack of well defined areas in the sensory cortex • Viscerosomatic convergence • No neurons in the spinal cord receives only visceral pain • Viscerosomatic neurons • Larger receptive field than somatic • Less numbers than somatic

  4. History • Pain history and its components • Relationship to period, bowel movement, urination, intercourse and activity • Previous episodes • Other symptoms (GIT, urological, weight loss, etc) • Effect on life (social, work, family) • Relationship of onset to events (newly married, rape, lifting, chest infection, etc) • Hx of sexual, physical, or emotional abuse • What medication used • What investigations done • Other stress or psychological symptoms (depression, anxiety, etc) BUT! • Secondary gain (off work, husband to stay, attention, etc) BUT! • Full GynHx(STD, PID, Infertility, dysparunia, surgeries including D&C, etc.) • Full surgical Hx • Medical Hx(IBS, IC, IBD)

  5. Examination • Abdominal (point, superficial, deep) • Pelvic (tenderness, mobility, nodularity) • Nerve entrapment • Dermatomes • Head raising

  6. Investigations • Limited use • Scopes: if symptoms suggest (GIT, Urological) • Imaging: if symptoms suggest musculoskeletal • U/S: although of limited use • Laparoscopy the ultimate but last method • Psychological evaluation

  7. Gynecological • Endometriosis (30%) • Pathogenesis • 20-30% missed on laparoscopy • Treatment is medical (may start before Dx) • Cont. OCP • Depot Provera • Danzol • GnRH analouge + add back therapy • If no response, surgical (TAH / TAH+BSO) • Size and location doesn’t correlate with pain • Path0physiology of pain not well understood • Infertility • Chronic PID(25%) • Recurrent exacerbations • Hydrosalpinges • Adhesions !!

  8. Gynecological • Ovarian • Cysts are ASYMPTOMATIC, unless • Rapid distention • Bleeding • Torsion • Special cysts (Endometrioma, Dermoid) • Ovarian remnants retroperitonealy (with cyst) • Uterine • Adenomyosis (rarely CPP) • Fibroid are ASYMPTOMATIC, unless • Degeneration • Torsion • Prolapsed submucus fibroid • Retroverted uterus DOSE NOT cause CPP. Maybe dysparunia!

  9. Gynecological • Pelvic Congestion Syndrome • Myth! • Non specific symptoms • No agreed upon diagnostic measures • No agreed upon therapeutic measures

  10. Non-Gynecological • G.U.T • Multiple examples, the most common: • Urethral syndrome • IC • Common: 1 in 5 women • Urgency, frequency, nocturia, CPP • Diagnosis & treatment • G.I.T • Multiple examples, the most common: • IBS, IBD, Hernias. • Innervation of the lower intestinal tract, same as uterus and fallopian tubes  pelvic pain

  11. Psychological • 30% of CPP remains undiagnosed even after laparoscopy • Is this a primary or secondary thing!

  12. Pain Perception • Every pain is a result of stimulus and response, however: Chronic pain ≠Acute pain. • Acute pain: response is appropriate to stimulus. • Chronic pain is affected additionally by: • Patient’s reaction to pain • Family’s reaction to the patient and her pain (reinforce or persistence) • So: Response to a stimulus is inappropriate, exaggerated, inaccurate, and may persist even after the stimulus is gone

  13. Management • Therapeutic, supportive, and sympathetic physician-patient relationship should be established (only few can do it!) • Regular F/U rather than “come back when pain persist” • The latter reinforces pain behavior • If no pathology is found, patient should NOT be ignored! • Reassurance + symptomatic treatment • Multidisciplinary pain clinic

  14. Management • Multidisciplinary pain clinic • GYN, Psychologist, Anesthetist, others • If no team is in place, use referrals. • Psychologist • Techniques for stress reduction, adaptive strategies • Marital, sexual, and social counseling

  15. Management • Treat underlying cause if found! • If none is found: • Multidisciplinary team • NSAIDs • Ovulatory/menstrual suppression • Cont. OCP, Depot Provera, Danzol, GnRHanalouge + add back therapy • May work for those with pain related to the period (mid-cycle, premenstrual or menstrual) or those with ovarian causes (ovarian remnant) • Low dose TCA (increase inhibitory neuromodulators)

  16. Management • Surgeries • If no pathology  NOT effective • If no strong evidence of pathology  thorough psychological evaluation before any surgery • Lysis of adhesions: • NOT effective unless the site of adhesions = site of pain. • Vicious cycle

  17. Thank you

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