Chronic Pelvic PainUNC School of Medicine

Obstetrics and Gynecology ClerkshipCase Based Seminar Series

Objectives for Chronic Pelvic Pain

Define chronic pelvic pain Cite the prevalence and common etiologies of chronic

pelvic pain Describe the symptoms and physical exam findings

associated with chronic pelvic pain Discuss the psychosocial issues associated with

chronic pelvic pain Discuss the steps in the evaluation and management

options for chronic pelvic pain

Pelvic pain of more than 6 months duration that has a significant effect on daily function and quality of life

Includes reproductive and non-reproductive related pelvic pain that is primarily acyclic

Definition

Overall 15-20% of women aged 18 to 50 yrs have chronic pelvic pain that lasts > 1 year

10-30% of gynecologic visits 12-19% of hysterectomies (~ 80,000/yr.) 30% of laparoscopy indications

Prevalence

(Percentages vary widely depending on practice setting No apparent pathology ~ 33% Endometriosis ~ 33% Adhesions or Chronic PID ~ 25% Other causes ~ 9%

Gynecologic Genitourinary Gastrointestinal Neuromuscular Psychological

Common Etiologies

Gynecologic Endometriosis Adhesions Chronic PID Ovarian remnant syndrome Pelvic congestion syndrome Recurrent hemorrhagic ovarian cysts Myomata uteri (degenerating) Uterine retroversion Adenomyosis Pelvic floor and hip muscle pain Visceral hyperalgesia

Etiology: Gynecologic

Genitourinary Urinary retention Urethral syndrome Interstitial cystitis

Gastrointestinal Penetrating neoplasms Irritable bowel syndrome Irritable bowel disease Partial small bowel obstruction Diverticulitis Hernia

Etiology: Non-Gynecologic

Neuromuscular Nerve entrapment syndrome Generalized myofascial pain syndrome Fibromyalgia

Psychological Depression PTSD (history of abuse/trauma) Anxiety disorders Personality disorder

Etiology: Non-Gynecologic

Dysmenorrhea Pain lasting > 6 months Impaired lifestyle Dyspareunia Pain during daily activities

Symptoms

Characteristics of the pain: Onset Location Duration Radiation Severity Alleviating/aggravating factors Relation to menstrual cycle Cyclic vs. non-cyclic Evolution over time Responses to treatments

Patient Evaluation: History

Psychological Evaluation Use good clinical judgment in deciding when/if to ask about

this! History of traumatic event History of abuse (emotional/physical/sexual) Depression Anxiety Hypochondriasis Secondary gain Therapy/counseling about these events? How much do they enter the patient’s thoughts on a daily

basis?

Patient Evaluation: Psychological

Physical exam

• Observe patient’s mobility as she gets up on the table.

• Palpate the entire back, but especially the paraspinous and SI joint areas– Referred pain?

• Then palpate abdomen

Abdominal exam Listen for bowel sounds Ask patient to point to exact location of pain, radiation, and

grade its severity (scale of 0 to 10) Ask the patient to map and demonstrate her tender area(s)

by palpating with and without abdominal wall flexion Palpate entire abdomen with a single digit, with and w/o

abdominal wall flexion (Carnett sign) Palpate from least painful area to most painful area Referred pain?

Patient Evaluation: Physical Exam

Evaluate for nerve entrapment Trigger points Ilioinguinal, iliohypogastric, and genitofemoral nerves Abdominal wall and back dermatomes Mark “jump signs” (points of motion tenderness ) Straight leg raise

Patient Evaluation: Physical Exam

Pelvic Exam: ask one question at a time Vulva General anatomy; educational exam as needed Retract labia; walk posterior vestibule with cotton-tipped applicator in

cases of dyspareunia or constant vulvar pain. Vagina

Discharge Epithelial quality, lesions Cervix: Pap, cultures if indicated; Q-tip walk to evaluate sensitivity

Single digit exam: what hurts? (Order determined by history) Cervix; motion tenderness Bladder and urethra Uterus, esp lower uterine segment Adnexa Levators, obturators, piriformi Referral of pain? Similarity to chief complaint?: “Does this hurt? Is it like the pain you

get? Does it travel anywhere?”

Patient Evaluation: Physical Exam

Physical exam, continued

• Bimanual exam: size, shape, and mobility?– Start with non-tender areas first– Make two hands almost meet, sweep caudad– Communicate with patient throughout– Describe limits of exam due to habitus, guarding– Examine to “count of 3” if patient is too

uncomfortable.

Pelvic Exam Fixed retroverted uterus & uterosacral tenderness/nodularity

Endometriosis Bilateral, tender, irregularly enlarged adnexal structures

Chronic salpingitis (PID) Enlarged, tender, boggy uterus Don’t forget the recto-vaginal examination!

Especially when history includes central pain, dyschezia, or dyspareunia.

To eliminate the recto-vaginal exam in such cases is malpractice.

Patient Evaluation: Physical Exam

Laboratory Complete blood count (CBC) Elevated sedimentation rate (ESR) - nonspecific Urinalysis (UA) Urine pregnancy test (UPT) Gonorrhea/Chlamydia

Testing Transvaginal ultrasound (adnexal mass, uterine irregularity) Abdominal and pelvic CT (bowel or urinary signs) Diagnostic laparoscopy

Ultimate method of diagnosis for CPP of undetermined etiology

Patient Evaluation: Further Studies

Laparoscopy (% vary widely in different practice settings) Normal pelvis Pelvic adhesions Non-gyn disease Endometriosis Fibroids Hernias

Patient Evaluation: Further Studies

Make a list of contributing factors; involve family member or S.O. when possible.

Treat any underlying pathology, but don’t flog it to death.

Include treatment of contributing factors as a package deal

Establish a therapeutic, supportive, and sympathetic (but structured) physician-patient relationship

Schedule regular follow-up appointments Patient should not be told to call ONLY if pain persists Deters pain behavior and secondary gain

Management

Educate, educate, educate Reassure patient of no serious underlying pathology Chronic v. acute pain Educate patient to likely mechanisms of pain production

Central nervous system: centralization Neuropathic Muscular Psychological (most often in reaction to pain events, not

the primary etiology)

Management

Treating multiple components of pain has been showed to be more effective than traditional gynecologic management.

This can be accomplished in a single clinic, or through collaboration among several specialists, such as

Gynecologist Physical therapist + Anesthesiologist + Acupuncturist Psychologist Sex therapist

Management

Pharmacologic therapies: Initial trial of hormonal manipulation

Cyclic therapy/regulation of menses Suppress ovulation (OCP, DMPA and Lupron) Suppress menses (DMPA, high dose intrauterine progestins)

NSAIDS Analgesics

Nonnarcotic (ASA, Acetominophen) Narcotic – use cautiously (tolerance, dependence)

SSRI’s or SNRI’s TCA’s, anti-epileptics

Especially for pain with neuropathic components

Management

Surgical therapies: Guarded prognosis in patients with multiple pain syndromes Degree of relief has uncertain relationship to amount of

pathology; most can be done laparoscopically Unilateral adnexectomy Hysterectomy + BSO Presacral neurectomy Uterine suspension Lysis of adhesions Resection/ablation of endometriosis

Anesthesia: Acupuncture Nerve blocks Trigger point injections

Management

Bottom Line Concepts Chronic pelvic pain is pelvic pain of more than 6 months duration that

has a significant effect on daily function and quality of life.

It affects 15-24% of American women in varying degrees of severity and accounts for a large portion of office visit and time.

Chronic pelvic pain is caused by a variety of factors including gynecologic, genitourinary, gastrointestinal, neuromuscular, and psychological.

Diagnostic laparoscopy is the ultimate method of diagnosis for patients with chronic pelvic pain of undetermined etiology.

Multidisciplinary approach has been shown to be more effective than pharmacologic or surgical therapy alone.

Even when etiology is determined, chronic pelvic pain can be difficult to treat and patients need to be seen regularly and provided much support.

References and Resources

APGO, Chronic Pelvic Pain: An Integrated Approach. APGO Educational Series on Women’s Heath Issues, APGO, Washington, DC, January 2000.

APGO Medical Student Educational Objectives, 9th edition, (2009), Educational Topic 39 (p82-83).

Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 30 (p279-282).

Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 21 (p259-264).

Katz: Comprehensive Gynecology, 5th edition, (2007), Vern Katz, Gretchen Lentz, Rogerio Lobo, David Gershenson. Chapter 8.