Download Chronic Pelvic Pain - UNC School of Medicine

Chronic Pelvic Pain
UNC School of Medicine
Obstetrics and Gynecology Clerkship
Case 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
Definition
 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
Prevalence
 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
Common Etiologies





(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
Etiology: Gynecologic
 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: Non-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
Symptoms





Dysmenorrhea
Pain lasting > 6 months
Impaired lifestyle
Dyspareunia
Pain during daily activities
Patient Evaluation: History
 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: Psychological
 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?
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
Patient Evaluation: Physical Exam
 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?”
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.
Patient Evaluation: Physical Exam
 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: Further Studies
 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
Management
 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
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.