Chronic Pelvic Pain

1. Chronic Pelvic Pain Leslie Ablard M.D.

2. Chronic Pelvic Pain • There is no generally accepted definition of chronic pelvic pain • Many authors have used duration of at least 6 months that occurs below the umbilicus and is severe enough to cause functional disability or require treatment (some prefer non-cyclic)

3. Chronic Pelvic Pain • Approx 15-20% of women ages 18-50 yrs have chronic pelvic pain greater than 1 yrs duration • 20% of all hysterectomies performed for benign disease • 40 % of all gynecological laparoscopies performed annually in the United States

4. Population at Increased Risk • Demographic profiles of large surveys suggest that women with chronic pelvic pain are no different in terms of age, race and ethnicity, education, socioeconomic status, or employment status • May be slightly more likely to be separated or divorced • Tend to be of reproductive age • Age is not a specific risk factor

5. Physical and Sexual Abuse • Significant association of physical and sexual abuse with various chronic pain disorders • 40-50% have a history of abuse • May decrease threshold for pain • Important to ensure they are not currently being abused or in danger

6. Gynecologic Causes of Pelvic Pain • Endometriosis • Adhesions (chronic PID) • Leiomyomata • Adenomyosis • Pelvic congestion syndrome • Mittelschmerz • Adnexal masses

7. Non-gynecologic Causes of Pelvic Pain • Gastrointestinal • Urologic • Musculoskeletal • Psychologic

8. Gynevision

9. Etiology • Study from UK • Urinary Causes – 30.8% • GI Causes- 37.7% • Gynecologic- 20.2% • Many women with chronic pelvic pain have more than 1 disease that may lead to pain • 25-50% women who received medical care in primary care practices have more than 1 diagnosis along with chronic pelvic pain • IBS, endometriosis, IC • Women with more than 1 organ system diagnosis have greater pain

10. History

11. Physical Exam

12. “Compartmentalized” Pelvic Exam • Perineum • Pelvic floor • Urethra / bladder • Cervix • Uterus / adnexa

13. Lab Tests • Laboratory  • Laboratory testing is of limited value in evaluating women with CPP • Baseline tests are obtained to screen for a chronic infectious or inflammatory process, and to exclude pregnancy • CBC with diff • UA • G/C • Pregnancy test • Further laboratory testing is based on the clinical impression that emerges after a complete history and physical examination

14. Imaging • Pelvic US • Highly sensitive for identifying pelvic masses/cysts and determining the origin of the mass (ovary, uterus, fallopian tube) • Less reliable for distinguishing between benign and malignant neoplasms and diagnosing adenomyosis • Particularly useful for detecting small pelvic masses (less than 4 cm in diameter), which often cannot be palpated on bimanual examination • Useful for detecting hydrosalpinges, which point to pelvic inflammatory disease as the cause of CPP • MRI • Used to better define an abnormality suspected by sonography  and for diagnosis of adenomyosis

16. Gastrointestinal Causes of Pelvic Pain • Irritable bowel syndrome • Chronic appendicitis • Inflammatory bowel disease (Crohn’s) • Diverticulitis • Diverticulosis • Meckel’s diverticulum

17. Urologic Causes of Pelvic Pain • Unstable bladder (detrusor instability) • Urethral syndrome (chronic urethritis) • Interstitial cystitis

18. Musculoskeletal/Myofascial Causes of Pelvic Pain • Fibromyalgia • Hernias (inquinal, femoral, umbilical, incisional, spigelian) • Nerve entrapment (neuritis) • Fasciitis • Scoliosis • Disc disease • Spondylolisthesis • Osteitis pubis

19. “Top of the list” Etiologies • Gynecologic • PID • Endometriosis • Prior surgery? Pelvic Adhesions • Non-gynecologic • IC • IBS • Musculoskeletal Disorders • Psychiatric

20. PID • 18-35% of acute PID develop chronic pelvic pain • Actual mechanism not well known • Inpatient or outpatient treatment does not reduce the odds of developing subsequent chronic pelvic pain

21. PID

22. Endometriosis • Diagnosed laparoscopically in approx 33% of women with chronic pelvic pain • 24% adhesive disease • 35% no visible pathology • More than 50% with abnormal laparoscopic findings have normal pre-op exam

23. Endometriosis

24. Endometriosis • Treatment • Medical management • GnRH agonists – Lupron most commonly used • May be used for a “suggestive “diagnosis or treatment • 6-12 months with add-back norethindrone 5mg for bone protection and symptom relief • Continuous OCPs or higher dose progestins • Depo Provera • Surgical Management • Hysterectomy • Laparoscopy with ablation for mild to mod disease

25. Treatment • Surgical excision or destruction of endometriotic tissue • Significant pain relief for 1 yr in 45-85% of women • Recurrence range from 15-100% • Avg time to recurrence is 40-50 months • Most effective in early disease (not stage IV endometriosis) • Hysterectomy (not just dx of endometriosis) • Several prospective cohort studies • 90% of women had relief of pain at 1 and 2 yrs post hysterectomy • 1 yr after hysterectomy for chronic pelvic pain, 74% had complete resolution of pain and 21% had decreased pain • Retrospective study of hysterectomy with no path found that 78% were pain free after 1 yr

26. Past Surgery • History of abdominopelvic surgery associated with chronic pelvic pain • Women without preoperative pain • 3-9% develop pelvic pain or back pain in the 2 yrs after a hysterectomy • Cesarean delivery also may be a risk factor for chronic pelvic pain (OR of 3.7)

27. Pelvic adhesions

28. Treatment • Laparoscopic Adhesiolysis

29. Interstitial Cystitis • Clinically characterized by irritative voiding symptoms of urgency and frequency in the absence of objective evidence of other disease • 70% of women with IC report pelvic pain • Suggested that 38-85% of women presenting to the gynecologist with chronic pelvic pain may have IC • Difficult to diagnose- no true gold standard • Intravesical K instillition of 40ml of KCL • Cystoscopy with Hunners ulcers (petechiae or glomerulations) • Decreased bladder capacity (less than 350cc) without anesthesia

30. IC

31. Interstitial Cystitis - Treatment • Hydrodistention • Dimethyl sulfoxide (DMSO) 50% • 50cc periodically • Bladder retraining • Biofeedback • Antidepressant (e.g., Elavil, Tofranil) • Antihistamines • SSRIs • Pentosan polysulfate (Elmiron)

32. IBS • Characterized by chronic, relapsing pattern of abdominopelvic pain and bowel dysfunction with constipation or diarrhea • Symptoms consistent with 50-80% of women with chronic pelvic pain • Current diagnosis is the Rome II Criteria • At least 12 wks (not consecutive) in the preceding 12 mo with 2 of 3 features • 1. Relieved by defecation • 2. Onset associated with change in frequency of stool • 3. Onset associated with a change in stool form or appearance

33. Medical Treatment of IBS

34. Musculoskeletal Disorders • Trigger points • Fibromyalgia • Myofacial pain • Lumbar vertebral disorders • Pelvic floor myalgia • Faulty posture • Exaggerated lumbar lordosis and thoracic kyphosis • May contribute to up to 75% of chronic pelvic pain

36. Musculoskeletal Screening Examination for Patients Presenting with Chronic Pelvic Pain - History • Normal laparoscopy • History of trauma to low back or lower extremities, including motor vehicle accident or fall • Pain is altered by positional changes, particularly prolonged standing or sitting • Lack or response to previous gynecologic intervention • Exacerbation with stress

37. Muscle Relaxants for Patients Presenting with Chronic Pelvic Pain

38. What do you do if your work-up doesn’t point you to any etiology of the pain?

39. Laparoscopy • When do you do one? • Suspicious of pathology based on imaging or PE • Failed medical management • When endometriosis is suspected on visual findings- biopsies and histological confirmation is important • Adolescents should not be excluded from the rest of the population for laparoscopic evaluation

40. Treatment • Antidepressants • TCAs- imipramine, amitryptyline, desipramine, and doxepin, have been shown in placebo controlled studies to improve pain levels and pain tolerance in those with chronic pain syndromes • Not clear if others such as SSRIs are as effective • “Evidence is insufficient to substantiate efficacy of antidepressants although the efficacy of TCAs for other chronic pain syndromes suggest they also might be efficacious for chronic pelvic pain”

41. Response Following Administration of Three Major Antidepressants

42. The Pelvic Witch Hunt

43. Be wary of claims for: • Presacral neurectomy • Uterine suspension • LUNA (lap US nerve ablation) • Surgery for pelvic congestion • Lysis of adhesions • Hysterectomy

44. Treatment • Analgesics • NSAIDS including COX-2 inhibitors relieve various pain • No clinical trials have addressed chronic pelvic pain • Opioids are increasingly used but randomized trials suggest no improvement in functional or psychological status with increased risk in addiction

45. Treatment • Combined OCPs • Provide significant relief • Suppress ovulation • Reduce spontaneous uterine activity • Stabilize estrogen and progesterone levels • Abrogate menstrual increases in prostaglandin levels • Reduce the amt of pain and symptoms associated with menses • Recommended for endometriosis-associated chronic pelvic pain • One study showed OCPs comparable to GnRH agonist goserelin in relieving chronic pelvic pain and dysparenia but less effective in relieving dysmenorrhea in women with endometriosis • OCPs do not significantly affect long-term recurrence of endometriosis • Continuous OCPs may be superior- no good data

46. Treatment • GnRH Agonists • “down-regulate” Hypothalamic-pituitary gland production and release of LH and FSH to reduce estradiol levels significantly • Nafarenlin, Goserelin, Leuprolide • Emperic treatment with GnRH agonists have the same efficacy in women with symptoms consistent with endometriosis, whether or not they actually have endometriosis • Strongly suggests the response does not depend on surgical confirmation • Other pain from IBS, IC also vary with the menstrual cycle and respond to GnRH agonist treatment • Good evidence supports add-back therapy with estrogen, progesterone, or both can decrease side effects without loss of efficacy

47. Treatment • Progestins • MPA • 30-100mg po per day effectively decreases pain from endometriosis and pelvic congestion syndromes • Depo Provera may also be effective but no good studies

48. Treatment • Exercise • Most studies suggest dysmenorrhea is decreased by exercise but not definitive data on chronic pelvic pain • PT • Electrotherapy, fast and slow twitch exercises of the striated muscles of the pelvic floor, manual therapy of myofascial trigger points shown improvement of pain in 65-70% of patients

49. Treatment • Psychotherapy • Many suggest various modes of psychotherapy including cognitive therapy, operant conditioning, and behavioral modification appear to be helpful • Up to 50% of women with chronic pelvic pain have a history of physical or sexual abuse

50. Treatment • Herbal and Nutritional Therapies • Many clinical trials of mag, B6, B1, omega 3s, Japanese herbal combinations have been studies with no conclusive data • Magnestic Field Therapy • Application of magnets to trigger paints may improve symptoms • Only one clinical trial has evaluated their use and had significant methodologic flaws • Acupuncture • Acupuncture, acupressure, and transcutaneous nerve stimulation therapies have shown better than placebo in the treatment of dysmenorrhea • Only case reports for nonmenstrual chronic pelvic pain