Chronic pelvic pain

Chronic pelvic pain

Dr. Ahmed jasim Ass.Prof. MBChB-DOG-FICMS COSULTANT OF GYN. & OBST.

Def.

Chronic pelvic pain refers to pain in the region between the hips, below the bellybutton. In order to be considered chronic, the pain must last for at least six months or longer. Chronic pelvic pain syndrome: chronic pelvic pain causing emotional and behavioral changes.

Type of pain

Visceral pain Referred Pain Somatic Pain Myalgia Hyperalgesia Neuroinflammation

Difficult to diagnose

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

Gynecological Urological Gastrointestinal Musculoskeletal Neuropathic Other

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

Gastrointestinal
Musculoskeletal
Urological
Psychological

Differential Diagnosis for Chronic Pelvic Pain

GynecologicGastrointestinalEndometriosis syndrome Irritable bowelAdhesions (chronic pelvic Chronic Appendicitis inflammatory disease)Leiomyomata Inflammatory bowel diseaseAdenomyosisDiverticulosisPelvic congestion syndromeDiverticulitisMeckel’s diverticulum

Differential Diagnosis

Urologic Psychological Abnormal bladder function Depression (detrusor instability) Urethral syndrome Somatization (chronic urethritis) Interstitial cystitis Psychosexual dysfunction/ Personality disorder abuse

Differential Diagnosis

Musculoskeletal Surgical Nerve entrapment (neuritis) Chronic appendicitis Fasciitis Hernia Scoliosis Bowel disease Disc disease Adhesive disease Spondylolisthesis Osteitis pubis


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

Signs and Symptoms

Pain during intercourse Cramping or sharp pains Heaviness or a feeling of pressure inside the pelvis Extreme and constant pain Intermittent pain A dull ache Pain during bowel movements

General Examination: Gait- Musculoskeletal Check Abdominal Wall – Point trigger, Ovarian point tendernessInspection of Vulva & introitus- VestibulitisCheck for Pelvic Floor Myalgia Single Digit Pelvic Exam Bimanual exam Rectovaginal exam

Investigations

WCC, ESRCA – 125HVS / Endocervical swabsUSSLaparoscopy.

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



Treatment:
Possible treatments for chronic pelvic pain include:Birth control pills to stop menstruation Progestogen (medroxy progesterone acetate (MPA)) waseffective after 4 months’ treatmentOver the counter pain relief medications, such as ibuprofen or aspirin Relaxation exercises, massage or physical therapy Antibiotics Psychological counseling Surgery to correct pelvic abnormalities Antibiotics if infection is the source of the pain Antidepressants Trigger point injections

Surgical management

Adhesion release. beware of prolapse and bladder. Presacral neurectomy: beware of vessel injury, bladder/bowel. Hysterectomy with BSO Surgical mx of non gynae causes.

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