Chronic Pelvic Pain

1. Chronic Pelvic Pain Marvin L. Stancil, M.D. Associate Professor Obstetrics and Gynecology University of Nebraska Medical Center

2. Medical Student Objectives • Define chronic pelvic pain. • Cite the prevalence and common etiologies of chronic pelvic pain. • Describe the symptoms & physical exam findings associated with chronic pelvic pain. • Discuss the steps in the evaluation & management options for chronic pelvic pain. • Discuss the psychosocial issues associated with chronic pelvic pain.

3. Chronic Pelvic Pain Definition Chronic Pelvic Pain (CPP) is pain of apparent pelvic origin that has been present most of the time for the past six months and is affecting the patient’s quality of life

4. Chronic Pelvic Pain Definition • Difficult to diagnose Frustration for patient and physician • Difficult to treat • Difficult to cure

5. Chronic Pelvic Pain Incidence • Affects 15-20% of women of reproductive age • Accounts for 20% of all laparoscopies • Accounts for 12-16% of all hysterectomies • Associated medical costs of $3 billion annually

6. Psychological Gastrointestinal Etiology Urological Gynecological Musculoskeletal

7. Chronic Pelvic Pain Demographics • Demographics of age, race, ethnicity, education, and socioeconomic status do not differ between those with and without chronic pelvic pain • Higher incidence in single, separated or divorced women • 40-50% of women have a history of abuse

8. Chronic Pelvic Pain Etiology: United Kingdom Primary Care Database • 25-50% of women had more than one diagnosis • Severity and consistency of pain increased with multisystem symptoms • Most common diagnoses: • endometriosis • adhesive disease • irritable bowel syndrome • interstitial cystitis Diagnosis Distribution Gastrointestinal Urinary Gynecological 37.7% 30.8% 20.2%

9. Chronic Pelvic Pain Diagnosis Obtaining a COMPLETE and DETAILED HISTORY is the most important key to formulating a diagnosis

10. Chronic Pelvic Pain Diagnosis: Obtaining the History • Duration of Pain • Nature of the Pain • Sharp, stabbing, throbbing, aching, dull? • Specific Location of Pain • Associated with radiation to other areas? • Modifying Factors • Things that make worse or better? • Timing of the Pain • Intermittent or constant? • Temporal relationship with menses? • Temporal relationship with intercourse? • Predictable or spontaneous onset? • Detailed medical and surgical history • Specifically abdominal, pelvic, back surgery

11. Chronic Pelvic Pain Diagnosis: Obtaining the History • Use the REVIEW OF SYSTEMS • to obtain focused, detailed history of organ systems involved in the differential diagnosis

12. Chronic Pelvic Pain Diagnosis: Obtaining the History Gynecological Review of Systems • Associated with menses? • Association with sexual activity? (Be specific) • New sexual partner and/or practices? • Symptoms of vaginal dryness or atrophy? • Other changes with menses? • Use of contraception? • Detailed childbirth history? • History of pelvic infections? • History of gynecological surgeries or other problems?

13. Chronic Pelvic Pain Diagnosis: Obtaining the History Gastrointestinal Review of Systems • Regularity of bowel movements? • Diarrhea/ constipation/ flatus? • Relief with defecation? • History of hemorrhoids/ fissures/ polyps? • Blood in stools, melena, mucous? • Nausea, emesis or change in appetite? • Abdominal bloating? • Weight loss?

14. Chronic Pelvic Pain Diagnosis: Obtaining the History Urological Review of Systems • Pain with urination? • History of frequent or recurrent urinary tract infection? • Hematuria? • Symptoms of urgency or urinary incontinence? • Difficulty voiding? • History of nephrolithiasis?

15. Chronic Pelvic Pain Diagnosis: Obtaining the History Musculoskeletal Review of Systems • History of trauma? • Association with back pain? • Other chronic pain problems? • Association with position or activity? • Any abdominal wall complaints or surgery?

16. Chronic Pelvic Pain Diagnosis: Obtaining the History Psychological Review of Systems • History of verbal, physical or sexual abuse? • Diagnosis of psychiatric disease? • Onset associated with life stressors? • Exacerbation associated with life stressors? • Familial or spousal support?

17. Chronic Pelvic Pain Diagnosis: The Physical Exam Evaluate each area individually • Abdomen • Anterior abdominal wall • Pelvic Floor Muscles • Vulva • Vagina • Urethra • Cervix • Viscera – uterus, adnexa, bladder • Rectum • Rectovaginal septum • Coccyx • Lower Back/Spine • Posture and gait A bimanual exam alone is NOT sufficient for evaluation

18. Chronic Pelvic Pain Diagnosis: Objective Evaluative Tools Basic Testing Specialized Testing • Pap Smear • Gonorrhea and Chlamydia • Wet Mount • Urinalysis • Urine Culture • Pregnancy Test • CBC with Differential • ESR or CRP • MRI or CT Scan • Endometrial Biopsy • Laparoscopy • Cystoscopy • Urodynamic Testing • Urine Cytology • Colonoscopy • Electrophysiologic studies • PELVIC ULTRASOUND • Referral to Specialist

19. Chronic Pelvic Pain Differential Diagnosis • The differential diagnosis for Chronic Pelvic Pain is extensive • Challenges the gynecologist to “think outside the uterus” • Diagnosis, evaluation and treatment plans: • Should align with pertinent positives and negatives from the History and Physical • Often requires an interdisciplinary approach

20. Chronic Pelvic Pain Differential Diagnosis: Gynecological Conditions that may Cause or Exacerbate Chronic Pelvic Pain Level A Level C Level B • Endometriosis • Gynecologic malignancies • Ovarian Retention Syndrome • Ovarian Remnant Syndrome • Pelvic Congestion Syndrome • Pelvic Inflammatory Syndrome • Tuberculosis Salpingitis • Adhesions • Benign Cystic Mesothelioma • Liomyomata • Postoperative Peritoneal Cysts • Adenomyosis • Dysmenorrhea/ Ovulatory Pain • Nonendometriotic Adnexal Cysts • Cervical Stenosis • Chronic Ectopic Pregnancy • Chronic Endometritis • Endometrial or Cervical Polyps • Endosalpingiosis • Intrauterine Contraceptive Device • Ovarian Ovulatory Pain • Residual accessory ovary • Symptomatic Pelvic Prolapse Source: ACOG Practice Bulletin #51, March 2004

21. Chronic Pelvic Pain Differential Diagnosis: Gynecological Conditions Cyclical Non-cyclical • Endometriosis • Adenomyosis • Primary Dysmenorrhea • Ovulation Pain/ Mittleschmertz • Cervical Stenosis • Ovarian Remnant Syndrome • Pelvic Masses • Adhesive Disease • Pelvic Inflammatory Disease • Tuberculosis Salpingitis • Pelvic Congestion Syndrome • Symptomatic Pelvic Organ Prolapse • Vaginismus • Pelvic Floor Pain Syndrome

22. Chronic Pelvic Pain Endometriosis • Presence of endometrial tissue outside of uterine cavity • Usually found in dependent areas of the pelvis • Most commonly in ovaries, posterior cul-de-sac, uterosacral ligaments • Endometrial glands and stroma on biopsy • May be at distant sites such as bowel, bladder, lung, skin, plurae • Etiology not well understood • Retrograde menstruation • Lymphatic and hematologic spread of menstrual tissue • Metaplasia of coelomic epithelium • Immunologic dysfunction

23. Chronic Pelvic Pain Endometriosis: Prevalence • Typically diagnosed in women 25 -35 years of age • Diagnosed in approximately 45% of women undergoing laparoscopy for any indication • Diagnosed in approximately 30% of women undergoing laparoscopy with primary complaint of chronic pelvic pain • Found in 38% of women with infertility • Family history increases risk ten-fold • Significant cause of morbidity

24. Chronic Pelvic Pain Endometriosis: Signs and Symptoms Physical Exam Symptoms • Visible lesions on cervix or vagina • Tender nodules in the cul-de-sac, uterosacral ligaments or rectovaginal septum • Pain with uterine movement • Tender adnexal masses (endometriomas) • Fixation (retroversion) of uterus • Rectal mass • Normal findings • Dysmenorrhea • Dyspareunia • Infertility • Intermenstrual Spotting • Painful Defecation • Pelvic Heaviness • Asymptomatic

25. Chronic Pelvic Pain Endometriosis: Diagnosis • Diagnosis can be made on clinical history and exam • Serum CA125 may be elevated but lacks sufficient specificity and sensitivity to be useful • Imaging studies lack sufficient resolution to detect small endometrial implants • Laparoscopy is gold standard for diagnosis • Multiple appearances: red, brown, scar, white, powder burn, vesicular lesions, adhesions, defects in peritoneum, endometriomas • Allows diagnosis and treatment

26. Chronic Pelvic Pain Laparoscopic Appearance of Endometriosis

27. Chronic Pelvic Pain Endometriosis: Diagnosis • Revised classification system by the ASRM (1996) • Poor correlation between symptoms and extent of disease

28. Chronic Pelvic Pain Staging of Endometriosis

29. Chronic Pelvic Pain Endometriosis: Medical Treatment • NSAIDS for mild disease • First Line: Oral contraceptives • Suppress ovulation and menstruation • Cyclic or continuous therapy • Improves symptoms in up to 70-80% • Second Line: Progestins, GnRH agonists, Danazol • Lupron Depot (x 6-12 months) • Improves symptoms in up to 80-85% • Side effects: hot flashes, vaginal dryness, insomnia, bone loss irritability • “Add back” estrogen +/- progestin

30. Chronic Pelvic Pain Endometriosis: Surgical Treatment • Laparoscopic Removal or Destruction • Treatment at time of diagnosis • Used in conjunction with medical therapy • Improves pain in up to 80-90% of patients • Laparotomy (TAH/BSO) • Inadequate response to medical treatment or conservative surgical treatment with no desire for future fertility • May preserve ovaries in young women, but 30% with recurrent symptoms • Laparoscopic Uterosacral Nerve Ablation (LUNA), Presacral neurectomy • Involves transecting the nerve plexus at the base of the cervical-uterosacral ligament junction or retroperitoneum

31. Chronic Pelvic Pain Adenomyosis • Description:Presence of endometrial glands and stroma within the myometrium • Symptoms: Dysmenorrhea; Menorrhagia; Enlarged boggy uterus; typically affects women age 30-40’s • Diagnosis: Pathology, MRI (ultrasound limited usefulness) • Treatment: Hysterectomy; usually when diagnosis is made

32. Chronic Pelvic Pain Primary Dysmenorrhea • Description:Pain associated with menses that usually begins 1-3 days prior to the onset of menses; last 1-3 days • Risk Factors: Nulliparity, Young Age, Heavy menses, Cigarette Smoking • Symptoms: Crampy lower abdominal pain; +/- nausea, emesis, diarrhea or headache, normal physical exam • Treatment: NSAIDS, Multivits with B-complex, Hormonal Therapy (OCPs, OrthoEvra, Nuvaring, Mirena IUD, Depo-Provera. Usual improvement after childbirth.

33. Chronic Pelvic Pain Pelvic Inflammatory Disease • Description:Spectrum of inflammation and infection in the upper female genital tract • Endometritis/ endomyometritis • Salpingitis/ salpingo-oophritis • Tubo-ovarian Abscess • Pelvic Peritonitis • Pathophysiology: Ascending infection of vaginal and cervical microorganisms • Chlamydia ,Gonorrhea (developed countries) • Tuberculosis (developing countries) • Acute PID usually polymicrobial infection

34. Chronic Pelvic Pain Pelvic Inflammatory Disease • Risk Factors • Adolescent • Multiple sexual partners • Greater than 2 sexual partners in past 4 weeks • New partner in the past 4 weeks • Prior history of PID • Prior history of gonorrhea or chlamydia • Smoking • None or inconsistent condom use • Instrumentation of the cervix and lower reproductive tract

35. Chronic Pelvic Pain Pelvic Inflammatory Disease: CDC Diagnostic Guidelines (2006) • Minimum Criteria (one required): • Uterine Tenderness • Adnexal Tenderness • Cervical Motion Tenderness • No other identifiable causes • Specific criteria for dx: • Pathologic evidence of endometritis • US or MRI showing hydrosalpinx, TOA • Laparosopic findings consistent with PID • Additional criteria for dx: • Oral temperature greater than 101F • Abnormal cervical or vaginal discharge • Presence of increased WBC in vaginal secretions • Elevated ESR or C-reactive protein • Documented of GC or CT

36. Chronic Pelvic Pain Pelvic Inflammatory Disease • Treatment: Outpatient and Inpatient Abx dosing regimens; Total therapy for 14 days, maybe longer if TOA • Sequelae • Infertility • Ectopic Pregnancy • Chronic Pelvic Pain • Occurs in 18-35% of women who develop PID • May be due to inflammatory process with development of pelvic adhesions • Refer to www.CDC.gov/std; revised 2010, • updated Aug. 2012 for outpt. GC treatment

37. Chronic Pelvic Pain Pelvic Congestion Syndrome • Description:Retrograde flow through incompetent valves venous valves can cause tortuous and congested pelvic and ovarian varicosities; Etiology unknown. • Symptoms:Pelvic ache or heaviness that may worsen premenstrually, after prolonged sitting or standing, or following intercourse • Diagnosis:Pelvic venogrpahy, CT, MRI, ultrasound, laparoscopy • Treatment:Progestins, GnRH agonists, ovarian vein embolization or ligation, and hysterectomy with bilateral salpingo-oophorectomy (BSO)

38. Chronic Pelvic Pain Pelvic Floor Pain Syndrome • Description:Spasm and strain of pelvic floor muscles • Levator Ani Muscles • Coccygeus Muscle • Piriformis Muscle • Symptoms:Chronic pelvic pain symptoms; pain in buttocks and down back of leg, dyspareunia • Treatment:Biofeedback, Pelvic Floor Physical Therapy, TENS (Transcutaneous Electrical Nerve Stimulation) units, antianxiolytic therapy, cooperation from sexual partner

39. Chronic Pelvic Pain Differential Diagnosis: Urological Conditions that may Cause or Exacerbate Chronic Pelvic Pain Level A Level C Level B • Bladder Carcinoma • Interstitial Cystitis • Radiation Cystitis • Urethral Syndrome • Detrusor Dyssynergia • Urethral Diverticulum • Chronic Urinary Tract Infection • Recurrent Acute Cystitis • Recurrent Acute Urethritis • Stone/urolithiasis • Urethral Caruncle Source: ACOG Practice Bulletin #51, March 2004

40. Chronic Pelvic Pain Interstitial Cystitis • Description:Chronic inflammatory condition of the bladder • Etiology: Loss of mucosal surface protection of the bladder and thereby increased bladder permeability • Symptoms: • Urinary urgency and frequency • Pain is worse with bladder filling; improved with urination • Pain is worse with certain foods • Pressure in the bladder and/or pelvis • Pelvic Pain in up to 70% of women • Present in 38-85% presenting with chronic pelvic pain

41. Chronic Pelvic Pain Interstitial Cystitis • Diagnosis: • Cystoscopy with bladder distension • Intravesicular Potassium Sensitivity Test • Presence of glomerulations (Hunner Ulcers) • Treatment: • Avoidance of acidic foods and beverages • Antihistamines • Tricyclic antidepressants • Elmiron (pentosan polysulfate sodium) • Intravesical therapy: DMSO (dimethyl sulfoxide)

42. Chronic Pelvic Pain Differential Diagnosis: Gastrointestinal Conditions that may Cause or Exacerbate Chronic Pelvic Pain Level A Level C Level B • Colon Cancer • Constipation • Inflammatory Bowel Disease • Irritable Bowel Syndrome None • Colitis • Chronic Intermittent Bowel Obstruction • Diverticular Disease Source: ACOG Practice Bulletin #51, March 2004

43. Chronic Pelvic Pain Irritable Bowel Syndrome (IBS) • Description:Chronic relapsing pattern of abdomino-pelvic pain and bowel dysfunction with diarrhea and/or constipation • Prevalence • Affects 12% of the U.S. population • 2:1 prevalence in women: men • Peak age of 30-40’s • Rare on women over 50 • Associated with elevated stress level • Symptoms • Diarrhea, constipation, bloating, mucousy stools • Symptoms of IBS found in 50-80% women with CPP

44. Chronic Pelvic Pain Irritable Bowel Syndrome (IBS) • Diagnosis based on Rome II criteria • Treatment • Dietary changes • Decrease stress • Cognitive Psychotherapy • Medications • Antidiarrheals • Antispasmodics • Tricyclic Antidepressants • Serotonin receptor (3, 4) antagonists

45. Chronic Pelvic Pain Differential Diagnosis: Musculoskeletal Conditions that may Cause or Exacerbate Chronic Pelvic Pain Level A Level C Level B • Abdominal Wall Myofascial Pain (Trigger Points) • Chronic Back Pain • Poor Posture • Fibromyalgia • Neuralgia of pelvic nerves • Pelvic Floor Myalgia • Peripartum Pelvic Pain Syndrome • Herniated Disk • Low Back Pain • Neoplasia of spinal cord or sacral nerve • Lumbar Spine Compression • Degenerative Joint Disease • Hernia • Muscular Strains and Sprains • Rectus Tendon Strains • Spondylosis Source: ACOG Practice Bulletin #51, March 2004

46. Chronic Pelvic Pain Differential Diagnosis: Psychological/Other Conditions that may Cause or Exacerbate Chronic Pelvic Pain Level A Level C Level B • Abdominal cutaneous nerve entrapment in surgical scar • Depression • Somatization Disorder • Celiac Disease • Neurologic Dysfunction • Porphyria • Shingles • Sleep Disturbances • Abdominal Epilepsy • Abdominal Migraines • Bipolar Personality Disorder • Familial Mediterranean Fever Source: ACOG Practice Bulletin #51, March 2004

47. Chronic Pelvic Pain Psychological Associations • 40 – 50% of women with CPP have a history of abuse (physical, verbal , sexual) • Psychosomatic factors play a prominent role in CPP • Psychotropic medications and various modes of psychotherapy appear to be helpful as both primary and adjunct therapy for treatment of CPP– Multidisciplinary pain clinic • Approach patient in a gentle, non-judgmental manner • Do not want to imply that “pain is all in her head”

48. Chronic Pelvic Pain Conclusions • Chronic Pelvic Pain requires patience, understanding and collaboration from both patient and physician • Obtaining a thorough history is key to accurate diagnosis and effective treatment • Diagnosis is often multifactorial – may affect more than one pelvic organ • Treatment options often multifactorial – medical, surgical, physical therapy, cognitive therapy