Chronic Pelvic Pain
CPP refers to pelvic pain of more than 6
months’ duration that has a significant effect on
daily function and quality of life. CPP includes
reproductive and nonreproductive organ–related
pain.
NERVES CARRYING PAINFUL IMPULSES FROM
THE PELVIC ORGANS
Perineum, vulva, lower vagina
*
*
*
S2-4 (Pudendal, inguinal, genitofemoral,
posterofemoral cutaneous)
*** Upper vagina, cervix, lower uterine segment,
posterior urethra, bladder trigone, uterosacral
and cardinal ligaments, rectosigmoid, lower
ureters
S2-4 Pelvic parasympathetics
***Uterine fundus, proximal fallopian tubes,
broad ligament, upper bladder, cecum,
appendix, terminal large bowel
T11-12, L1 Sympathetics via hypogastric plexus
Outer two-thirds of fallopian tubes, upper
ureter
*
*
*
T9-10 Sympathetics via aortic and superior
mesenteric plexus
*** Ovaries
T9-10 Sympathetics via renal and aortic plexus and
celiac and mesenteric ganglia
Abdominal wall
*
*
*
T12-L1 Sympathetics via renal and aortic plexus
and celiac and mesenteric ganglia T12-L1
Iliohypogastric T12-L1 Ilioinguinal L1-2
Genitofemoral
Visceral pain is therefore usually referred to the
skin, which is supplied by the corresponding spinal
cord segment (referred pain).
The structures of the female genital tract vary in
their sensitivity to pain. The skin of the external
genitalia is exquisitely sensitive. Pain sensation is
variable in the vagina, and the upper vagina is
somewhat less sensitive than the lower. The cervix
is relatively insensitive to small biopsies but is
sensitive to deep incision or to dilation. The
uterus is quite sensitive. The ovaries are insensitive
to many stimuli, but they are sensitive to rapid
distention of the ovarian capsule or compression
during physical examination
Patient Evaluation
HISTORY
PHYSICAL EXAMINATION
The abdomen should be examined initially, and
the patient should be asked to point to the exact
location of the pain and its radiation. The
abdominal wall should be examined for
evidence of myofascial trigger points and for
iliohypogastric (T12, L1), ilioinguinal (T12, L1),
or genitofemoral (L1, L2) nerve entrapment.
Each dermatome of the abdominal wall and back
should be palpated with a fingertip and points of
severe tenderness should be marked with a pen.
Points that are more tender or that reproduce the
patient’s pain suggest nerve entrapment. These
points should be injected with 2 to 3 mL of 0.25%
bupivacaine. Chronic abdominal wall pain is
confirmed if the pain level is reduced by at least
50%
A thorough pelvic examination should be per
formed, with an attempt made localize the
patient’s pain.
FURTHER INVESTIGATIONS
Laboratory studies are of limited value in the
diagnosis of CPP, although a complete blood
count, erythrocyte sedimentation rate (ESR), and
urinalysis are indicated. pregnancy test in
reproductive age is mandatory.
Pelvic ultrasonography should be performed. If
bowel or urinary symptoms are present, an
abdominal and pelvic computed tomographic (CT)
scan, endoscopy, cystoscopy, or CT urogram may
be useful.
Laparoscopy should only be performed if no
etiology for the pain can be identified, or when
indicated to treat specific pathology.
CAUSES OF CHRONIC PELVIC PAIN
* GYNECOLOGIC Endometriosis ,Salpingo-
oophoritis (pelvic inflammatory disease), Ovarian
remnant syndrome, Pelvic congestion syndrome
,Cyclic pelvic (uterine) pain ,Myomata uteri
(degenerating) Adenomyosis, Adhesions
Gastrointestinal Pain
*
*Neuromuscular Pain
PSYCHOLOGIC FACTORS
*
Urinary pain
*
Management
**THE MULTIDISCIPLINARY TEAM
The personnel should include a gynecologist, a
psychologist, a physical therapist with pelvic
floor muscle expertise, and for more complex cases
requiring diagnostic or therapeutic nerve blocks, an
anesthesiologist. An acupuncturist may also be a
useful
**MEDICAL AND SURGICAL MANAGEMENT
In the initial stages of therapy, a trial of
ovulation and or menstrual suppression with
combined
hormonal
contraception
(pills,
patches, rings; cyclic or continuous), high-dose
or intrauterine progestins or a gonadotropin-
releasing hormone analogue (GnRH-a) may be
helpful. Ovulation and/or menstrual suppression is
especially helpful in patients who have midcycle,
premenstrual, or menstrual exacerbation of pain, or
in those who have ovarian pathology, such as
periovarian adhesions or recurrent functional cyst
formation. NSAIDs are also useful.
Pharmacologic approaches are frequently used in
the form of tricyclic antidepressants, selective
serotonin
reuptake
inhibitors
(SSRIs),
anticonvulsants or other GABA-ergic agents, and
topical or injectable local anesthetics.
**INJECTION THERAPIES
Acupuncture, nerve blocks, and trigger-point
injections of local anesthetics may provide
prolonged pain relief. Acupuncture has been used
successfully for dysmenorrhea. Acupuncture
probably increases spinal cord endorphins. A
significant percentage of patients with pelvic
pain have abdominal wall trigger points or nerve
entrapments that respond to weekly or biweekly
injections of a local anesthetic (usually up to
five injections is sufficient).
Vulval pain
:causes
• Infections (candida)
• Bartholin gland infection
• Skin conditions (e.g. lichen sclerosis, eczema,
VIN
• vulvodynia
Vulvodynia
Vulvodynia describes a group of women with vulval
discomfort, most often described as a burning pain,
occurring in the absence of skin disease or
infection.
Patients can be further classified by the anatomical
site of the pain (e.g. generalized, localized and
clitoral) and also by whether pain is provoked or
unprovoked.
Clinical examination is normal, although some
patient have touch sensitivity – so-called allodynia.
This is the phenomenon when there is
reprogramming of the nerve endings from touch to
pain. The diagnosis is clinical and treatments can
vary. Patients with sexual pain may require
psychosexual
counselling
and
vulval
desensitization(massage), whereas patients with
unprovoked pain may benefit from drugs, such as
the tricyclic antidepressants or the anticonvulsants,
dysparunia
Definition: pain during or after sexual intercourse,
which can be classified as superficial affecting the
vagina, clitoris or labia, or deep with pain
experienced within the pelvis.
Risk factors include female genital mutilation
(FGM), suspected PID and endometriosis,
peri/postmenopausal status, depression or anxiety
states and history of sexual assault.
An evaluation should include a psychosexual
history;
abdominal and pelvic examination should
look for lower genital tract lesions (e.g. skin
disorder, scarring, anatomical abnormality),
vaginismus (involuntary contraction of vaginal
muscles during vaginal examination), areas of
tenderness within the lower and upper genital tract
and evidence of pelvic disease (masses,
tenderness, fixity of organs).
•
Investigations:
•
superficial dyspareunia: consider a biopsy of lower
genital tract lesions and swabs;
•
deep dyspareunia: consider transvaginal
ultrasound scan (TVUSS), swabs and laparoscopy.
•
Treatment:
•
superficial dyspareunia: treat any identifiable
cause;
•
deep dyspareunia: treat as for chronic pelvic pain.