Chronic Pelvic Pain

Dr. Huda Adnan Sahib C.A.B.O.G.

Chronic Pelvic Pain (CPP) is pain of apparent pelvic origin that has been present most of the time for the past six months
Definition

Difficult to diagnose

Difficult to treat
Difficult to cure
Frustration for patient and physician
Definition

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
Incidence

Gynecological 20%

Gastrointestinal 37%
Musculoskeletal
Urological 30%
Psychological


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


Obtaining a COMPLETE and DETAILED HISTORY is the most important key to formulating a diagnosis
Diagnosis

Diagnosis: Obtaining the History

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?
Gynecological Review of Systems

Diagnosis: Obtaining the History

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?
Gastrointestinal Review of Systems

Diagnosis: Obtaining the History

Pain with urination? History of frequent or recurrent urinary tract infxn? Hematuria? Symptoms of urgency or urinary incontinence? Difficulty voiding? History of nephrolithiasis?
Urological Review of Systems

Diagnosis: Obtaining the History

History of trauma? Association with back pain? Other chronic pain problems? Association with position or activity?
Musculoskeletal Review of Systems

Diagnosis: Obtaining the History

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?
Psychological Review of Systems

Diagnosis: The Physical Exam

Evaluate each area individually
AbdomenAnterior abdominal wallPelvic Floor MusclesVulvaVaginaUrethraCervixViscera – uterus, adnexa, bladderRectumRectovaginal septumCoccyxLower Back/SpinePosture and gait A bimanual exam alone is NOT sufficient for evaluation



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

Differential Diagnosis: Gynecological Conditions

Cyclical
Endometriosis Adenomyosis Primary Dysmenorrhea Ovulation Pain/ Mittleschmertz Ovarian Remnant Syndrome
Non-cyclical
Pelvic Masses Adhesive Disease Pelvic Inflammatory Disease Pelvic Congestion Syndrome Symptomatic Pelvic Organ Prolaps Pelvic Floor Pain Syndrome

Pelvic Inflammatory Disease

Description: Spectrum of inflammation and infection in the upper female genital tract Endometritis/ endomyometritis Salpingitis/ salpingoophritis Tubo-ovarian Abscess Pelvic Peritonitis
Pathophysiology: Ascending infection of vaginal and cervical microorganisms Chlamydia and Gonorrhea (developed countries) Tuberculosis (developing countries) Acute PID usually polymicrobial infection



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 chlaymdia Smoking None or inconsistent condom use Instrumentation of the cervix

Pelvic Inflammatory Disease

Minimum Criteria (one required): Uterine Tenderness Adnexal Tenderness Cervical Motion Tenderness No other identifiable causes
Additional criteria for dx: Oral temperature greater than 101 Abnormal cervical or vaginal discharge Presence of increased WBC in vaginal secretions Elevated ESR or C-reactive protein Documented of CT
Specific criteria for dx: Pathologic evidence of endometritis US or MRI showing hydrosalpinx, Laparosopic findings consistent with PID

Pelvic Inflammatory Disease

Treatment: Multiple outpatient antibiotic regimens; total therapy for 14 days. A)CEFTERIAXON 500 mg im single dose and doxycycline 100 mg twice daily plus metronidazole 400 mg twice daily. B )ofloxacin 400 mg twice daily plus metronidazole twice daily. Inpatient regimens in form of i.v. cefteriaxon 2g daily plus i.v. or oral doxycycline 100 mg BD followed by oral doxycycline 100 mg BD plus metronidazole 400 mg BD.

*laparoscopy to confirm the diagnosis *drainage of abscess *treatement of concomitent diseases.
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

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

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)

Pelvic Floor Pain Syndrome

Description: Spasm and strain of pelvic floor muscles Levator Ani Muscles Coccygeus Muscle Piriformis Miscle
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


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

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

Interstitial Cystitis

Diagnosis: Cystoscopy with bladder distension Presence of glomerulations (Hunner Ulcers)
Treatment: Avoidance of acidic foods and beverages Antihistamines Tricyclic antidepressants Elmiron (pentosan polysulphate) Intravesical therapy: DMSO (dimethyl sulfoxide)



Differential Diagnosis: Gastrointestinal Conditions that may Cause or Exacerbate Chronic Pelvic Pain
Colon Cancer Constipation Inflammatory Bowel Disease
Colitis Chronic Intermittent Bowel Obstruction Diverticular Disease
Source: ACOG Practice Bulletin #51, March 2004
Irritable Bowel Syndrome

Irritable Bowel Syndrome (IBS)

Description: Chronic relapsing pattern of abdominopelvic pain and bowel dysfunction with diarrhea and constipation
PrevalenceAffects 12% of the U.S. population2:1 prevalence in women: menPeak age of 30-40’sRare on women over 50Associated with elevated stress level Symptoms Diarrhea, constipation, bloating, mucousy stools Symptoms of IBS found in 50-80% women with CPP

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

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



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 Conclusions