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Pelvic Pain
Tracy Irwin, MD, MPH
Assistant Professor
University of Illinois at Chicago
Definition
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Pain of apparent pelvic origin that has
been present most of the time for at
least six months and severe enough to
cause functional disability or require
medical or surgical treatment
Obstet Gynecol Sur 1993;48:357-87
Prevalence
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3.8% of women 15-73
39% complain of it in primary care
settings
10% of referrals to gynecologists
$880 million in direct health care costs
Over $2 billion in indirect costs
Br J Obstet Gynaecol 1999;106:1149-55
Obstet Gynecol 1996;87:55-7
Obstet Gynecol 1996;87:321-7
Taking a History
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Age, Gravity, Parity
Location, Duration, Timing, Quality,
Character, Alleviating and Aggravating
Factors
Relation to menses, Cyclic pattern
Dyspareunia or Dyschezia
Medications, Prior Tx, Prior Surgery
Depression, Abuse
Focused Physical
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Standing Exam
– Gait, Posture, Symmetry, Trigger Points
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Sitting Exam
– Posture, Palpation, Sensory Testing, Strength
Testing
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Supine Exam
– Leg Flexion and Raise, Abdominal Palpation,
Trigger Points, Pubic Symphsis
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Lithotomy Exam
– Inspection, Sensory Testing, Palpation of Pelvic
Floor Muscles and Coccyx, Bimanual Exam,
Rectovaginal Exam
Systems
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Gynecologic
Gastrointestinal
Bladder
Neurogenic
Psychological
Musculoskeletal
Gynecologic
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Endometriosis
Dysmenorrhea
Leiomyomas
Dyspareunia
Vaginismus
Adenomyosis
Infectious causes
Pelvic congestion syndrome
Pelvic organ immobility
Cancer
ACOG Bulletin #51
March 2004
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Level A
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Endometriosis
Malignancy
Ovarian Remnant
Pelvic Congestion Syndrome
PID
Tuberculous Salpingitis
Level B
– Adhesions, benign cysts, fibroids, post op peritoneal cysts
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Level C
– Adenomyosis, Dysmenorrhea, benign cysts, cervical
stenosis, chronic ectopic, chronic endometritis, polyps,
endosalpingiosis, IUD, mittleschmerz, prolpase
Endometriosis
– 7-10% of women (up to 50% in
premenopausal women)
– 33% of women undergoing Laparoscopy
for pelvic pain will be diagnosed with
endometriosis
– Found in 38% of infertile women
– Familial history increases risk 10x
– Significant cause of morbidity
Endometriosis
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Etiology
– Retrograde menstruation
– Hematogenous/lymphatogenous
– Coelomic metaplasia
– Immunologic dysfunction
Endometriosis
Laparoscopic Appearance of Endometriosis, Martin et al.1990
Endometriosis
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Characterisitcs
– Dysmenorrhea, Dyschezia, Dyspareunia,
Uterosacral Nodularity, Adnexal Mass
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Diagnosis
– Clinical suspicion
– Presence of endometrial glands in biopsy outside
endometrial cavity
– Relief of pain with empiric GnRH agonist
– Laparoscopy
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Multiple appearances: red, brown, scar, white,
puckering, powder burn
Endometriosis
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Treatment
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NSAID’s
OCP’s
Danazol
GnRH analogs x 6-12 months
Laparoscopic removal/destruction
LUNA
TAH-BSO
Pain clinic/TENS units
Presacral neurectomy
Endometriosis
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GnRH Agonists
– Ling et al. After 3 months of treatment pain
relief seen in 81% of those treated vs. 39% of
the placebo group
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Laparscopic Surgical Treatment
– RCT 6 months 63% of treated vs. 23% of
controls had a statistically significant relief of
pain
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Presacral Neurectomy
– RCTs statistically significant improvement in
midline dysmenorrhea
Dyspareunia
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Endometriosis
Adnexal masses
Vulvovaginitis/STIs
Chronic endometritis
Vaginal dryness
Vaginal atrophy
Obstetrical trauma
Surgical scars
Vaginismus
Dyspareunia
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Vaginismus
– Definition – involuntary spasm of the muscles
around the vagina
– Potential Causes- abuse, trauma, psychological
issues, painful intercourse in the past
– Treatment
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Physical Therapy
Biofeedback
Partner Communication
Anxiolyitics
Pelvic Floor Anatomy
Pelvic Floor Spasm/Strain
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Anatomy
– Piriformis
– Coccygeus
– Levator ani
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Treatment
– Muscle Relaxers
– Physical Therapy/Biofeedback/TENS
– Communication with Partner
Dysmenorrhea
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Definition – painful periods
Primary – starts within first 2-3 years of
menstruation
Secondary – due to underlying cause
(endometriosis, PID)
Treatment
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NSAID’s
OCP’s
Treat underlying cause (i.e. endometriosis)
Fibroids
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Benign tumors of uterine smooth muscle
Symptoms
– Pressure, Pain, Degeneration
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Treatment
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NSAID’s
OCP’s
Lupron
Uterine Artery Embolization
Exablation MRI guided U/S ablation
Myomectomy
Hysterectomy
Fibroids
Infections
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PID
Recurrent UTI
Chronic Endometritis
Tuberculous Salpingitis
Gynecologic Cancer
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Cervix
Uterine
Ovarian
Psychologic
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40-50% have history or sexual abuse
Domestic Violence
Relationship/Communication Issues
Treatment
– Counseling (Individual +/- couples)
– TCA
– SSRIs
Psychologic Causes
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Somatization Disorder
– Complaints begin before 30 y/o, occur over
several years, seek treatment or impair social,
occupational, or other functions.
– Need 4 Pain Symptoms, 2 GI symptoms, 1
sexual symptom, 1 pseudoneurological symptom
– Treatment
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Counseling
Treatment of underlying mood disorder
SSRIs
Urologic Causes
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Level A
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Interstitial Cystitis
Bladder Malignancy
Radiation Cystitis
Urethral Syndrome
Level B
– Detrusor Dysynergy
– Urethral Diverticulum
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Level C
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Chronic UTI
Recurrent, Acute UTI
Urolithiasis
Urologic Causes
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Evaluation
„ Urinalysis
„ Urine
culture
„ Urine cytology
„ Cystourethroscopy +/- hydrodistension
„ IVP
Urologic Causes
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Interstitial Cystitis
– Sx – Urgency, Frequency, Constant
Suprapubic Pain
– Dx – Cystoscopy – Hydrodistension,
decreased bladder capacity
– Tx – Avoid Acidic Foods, Antihistamines,
TCA, Intravesicular DMSO, Capsaicin or
BCG, Elmiron
Interstitial Cystitis
Gastrointestinal Causes
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Level A
– Irritable Bowel Syndrome
– Constipation
– Inflammatory Bowel Disease
„ Ulcerative
Colitis or Crohn’s Disease
– Colon Cancer
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Level C
– Colitis
– Chronic Intermittent Bowel Obstruction
– Diverticular Disease
Gastrointestinal Causes
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Irritable Bowel Syndrome
– No biochemical, inflammatory or
mechanical reason
– 12% U.S. population
– 2:1 women : men
– Peak age 30-40’s
– Rare >50 y/o
– Associated with stress
– Increased gut motility and sensitivity to
stimulants
Gastrointestinal Causes
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Irritable Bowel Syndrome Treatment
– Dietary changes (decreased caffeine, fat,
eliminate lactose, sorbitol and fructose,
increased fiber)
– Decrease stress
– Cognitive psychotherapy
– Medications:
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Antidiarrheals (e.g. Loperamide)
Antispasmodics (e.g. Bentyl, Belladona)
Anti-Gas (e.g. Beano, Simethicone)
Peppermint Oil
TCA’s
Serotonin receptors 3 or 4 agonists (e.g. Lotronex (3),
Zelnorm (4))
Gastrointestinal Causes
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Constipation – Medical Causes
– Neurological Disorders
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Multiple Sclerosis
Parkinson's disease
Chronic Idiopathic Intestinal Pseudo-obstruction
Stroke
Spinal Cord Injuries
– Metabolic and Endocrine Disorders
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Diabetes
Uremia
Hypercalcemia
Hypothyroidism
– Systemic Disorders
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Amyloidosis
Lupus
Scleroderma
Gastrointestinal Causes
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Constipation – Other Causes
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Lack of dietary fiber
Lack of physical activity (especially in the elderly)
Medications (narcotics)
Milk
Changes in life or routine such as pregnancy, aging, and
travel
Abuse of laxatives
Ignoring the urge to have a bowel movement
Dehydration
Problems with the colon and rectum
Problems with intestinal function (chronic idiopathic
constipation)
Gastrointestinal Causes
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Constipation – Treatment
– Adequate Water Intake
– Adequate Fiber Intake
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Diet – ADA recommends 20-35 grams/day
Supplements – Fibercon, Benefiber, Metamucil
– Stool Softeners - Colace
– Laxatives
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Stimulants – Dulcolax, Senokot
Osmotics – Miralax
– Lubricants – Fleets Enema
– Serotonin Agonist – Zelnorm
– Biofeedback
Musculoskeletal Causes
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Level A
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Abdominal wall myofascial pain (trigger points)
Chronic coccygeal or back pain
Faulty or poor posture
Fibromyalgia
Neuralgia of iliohypogastric, ilioinguinal, and/or
genitofemoral nerves
– Pelvic floor myalgia (levator ani or piriformis syndrome)
– Peripartum pelvic pain syndrome
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Level B
– Herniated nucleus pulposus, Neoplasia of spinal cord or
sacral nerve
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Level C
– Compression of lumbar vertebrae, Degenerative joint
disease, Hernias, Strains and Sprains, Spondylosis
Musculoskeletal Causes
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Fibromyalgia
– Long term widespread pain in muscles,
tendons and ligaments without weakness
– Linked to fatigue, headache, morning
stiffness, sleep disturbance, anxiety,
depression
– Associated with trigger points
– Dx – 3 months of pain and pain in 11/18
trigger points
Musculoskeletal Causes
Fibromyalgia Trigger Points
Musculoskeletal Causes
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Fibromyalgia – Treatment
– Lifestyle Changes (exercise)
– NSAIDs
– Anti-Depressants (tricyclics
– Physical Therapy
– Neurontin
– Cognitive Behavioral Therapy
Chronic Pelvic Pain
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Conclusion
– Diverse causes in many different organ
systems
– May treat underlying disease, or may just
treat pain itself as a diagnosis
– Clinicians need to be patient and
empathetic