Download PELVIC PAIN

PELVIC PAIN
Danielle Burkland, MD
Clinical Assistant Professor
Department of Obstetrics/Gynecology
OBJECTIVES
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
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Review differential diagnosis of pelvic pain
Review the pathogenesis, clinical
manifestation and management of
endometriosis
Define numerous etiologies for chronic
pelvic pain
Review diagnosis and therapeutic options
for chronic pelvic pain
CASE 1
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
18 y/o presents for annual visit
Reports painful cramping with menses,
not always relieved with motrin
Reports dull achy feeling LLQ
throughout the month

What follow-up questions do you want
to ask?
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When did this begin? Painful periods since onset of
menses? Only last few months?
Pain begins with menses or precedes menses?
Pain change with urination or defecation?
Where is the cramping pain located?
When did the dull achy LLQ pain begin?
How often/frequent- daily, a few times per week?
Relieved with medication?
Worsened with urination or bowel movements?
Painful intercourse, if sexually active?
HPI
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Onset/first occurrence
Quality
Location
Intensity
Duration
Radiation
Temporal pattern
Exacerbating Factors
Alleviating Factors
Association with urination/defecation
Associated Review of
Systems

Urinary
– Frequency, hesitancy, dysuria, hematuria

Gastrointestinal
– Frequency of bowel movements, nature of stool,
gas, bloating, nausea/vomiting

Musculoskeletal
– Back pain, radiation

Vaginal
– Discharge, irritation
CASE 1
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18 y/o presents for annual visit
Reports painful cramping with menses,
not always relieved with motrin
Reports dull achy feeling LLQ
throughout the month
Case 1
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
Dysmenorrhea present since 15 but
worsening over the last year
Dull LLQ achy pain present for the last
6 months
No urinary or GI complaints
Case 1
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OB History
–
Nulliparous
–
–
–
13 x 28 x 5 /No STDs/No previous pap smears
Sexually active for the last yr, one partner
+dysmenorrhea, no menorrhagia
–
none
–
Hip fracture after MVA
–
–
No tobacco/etoh/drugs
Lives at home, student
–
Mother and Aunt with endometriosis
–
None
–
None
GYN History
PMH
PSH
SOCHx
FamHx
Medications
ALL
What do you want to do
next?
Physical Exam
Physical Exam
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AFVSS
Abdomen
– Soft, BS+, nondistended, mild LLQ TTP

Pelvic
–
–
–
–
–
NEFG
Vagina: no discharge, no lesions
Cervix: nulliparous
Uterus: normal size, retroverted
Adnexa: nonmobile, left adnexal mass and TTP
Assessment
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18 y/o G0 with dysmenorrhea that is
worsening as well as chronic LLQ pain
Differential Diagnosis
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Primary Dysmenorrhea
Ovarian cyst
– Hemorrhagic, teratoma
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Constipation
Endometriosis
PID
Pregnancy
Dysmenorrhea
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Dysmenorrhea – severe, painful cramping
sensation in the lower abdomen often
accompanied by other symptoms –
sweating, tachycardia, headaches, n/v,
diarrhea, tremulousness, all occurring just
before or during menses
- Primary: no obvious pathologic condition,
onset < 20 years old
- Secondary: associated with pelvic
conditions or pathology
Dysmenorrhea
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Pathogenesis: elevated PG F2α in
secretory endometrium (increased
uterine contractility)
Treatment: NSAIDs – PG synthetase
inhibitors – 1st line treatment of choice
Other treatment options: OCPs, other
analgesics
Secondary Dysmenorrhea
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Etiologies
- Cervical Stenosis
- Endometriosis and Adenomyosis
- Pelvic Infection
- Adhesions
- Pelvic Congestion Syndrome ?
Plan
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GC/CT cultures
Urine HCG
CBC
UA/urinalysis
What do you want to do
next?
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Pelvic Ultrasound
Pelvic Ultrasound
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7 cm thick walled cystic mass with
homogenous low to medium level
echoes consistent with endometrioma
Endometriosis - Diagnosis
2 or more of the following histologic features are criteria for Dx:
1.
2.
3.
4.
Endometrial epithelium
Endometrial glands
Endometrial stroma
Hemosiderin-laden macrophages
Endometriosis
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Presence of endometrial glands and stroma outside of the
endometrial cavity
– Ovaries, anterior/posterior cds, posterior broad ligaments, uterosacral
ligaments, uterus, fallopian tubes, sigmoid, appendix, round ligaments
– Less commonly: vagina, cervix, RV septum, cecum, ileum, abdominal
scars, ureters, bladder
– Exceptional cases: breast, lung, CNS
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Incidence: 6-10% of reproductive age women
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Prevalence
–
–
–
–
1-7% of women undergoing Lsc BTL
71-87% % of women undergoing Dx LSC for chronic pelvic pain
20-50 % of women undergoing LSC for infertility
50% of teenagers undergoing LSC for pain/dysmenorrhea
Pathogenesis
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Pathogenesis
– Implantation Theory: retrograde menstruation
 Increased incidence in women with genital tract
obstruction
– Lymphatic/Vessel spread
– Coelomic Metaplasia Theory
– Altered Immunity: deficient cellular immunity, reduced NK
cell activity, increased leukocytes/macrophages in
peritoneal cavity
Genetic
 FDR have 7 % incidence of endo v 1% in an unrelated
person
 Strong concordance in monozygotic twins
 Polygenic-multifactorial mechanism
Pathogenesis
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Aberrant expression of endometrial genes +
altered hormonal response predisposes to
the development of lesions
Local overproduction of prostaglandins
– Increase in COX-2
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Local overproduction of estrogen by
increased aromatase activity
Progesterone resistance dampens
antiestrogenic effect of progesterone and
amplifies local estrogenic effect
Clinical Presentation
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Symptoms not specific
– Similar symptoms seen in patients with PID, IBS, IC and chronic
adhesive disease
– Variable and unpredictable
– Significant number will be asymptomatic
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Clinical Features
–
–
–
–
Pelvic pain and dysmenorrhea
Deep dyspareunia
Cyclical bowel or bladder symptoms
Subfertility
–
–
–
–
–
–
Most commonly- no abnormal findings
Localized tenderness in cds/usl
Palpable tender nodules in cds/usl, rvs
Pain with uterine movement
Tender, enlarged adnexal masses
Fixation of adnexa/uterus in retroverted position
Physical Findings
Clinical Manifestations
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Pain, pain, pain
Chronic inflammatory disorder
– Increase numbers of activated macrophages and
proinflammatory cytokines in the peritoneal fluid
– TNF-αand IL-1, 6 and 8
 Induction of prostaglandins
 Increased expression of nerve growth factor
 Increased density of nerve fibers
Clinical Manifestations
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Infertility/Subfertility
– Mechanism is not well understood especially in mild stage
disease
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Abnormal peritoneal environment
– Oxidative stress
– Higher concentrations of inflammatory cytokines
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may affect sperm function
Promote abnormal oocyte cytoskeletal function
Advance endometriosis can result in abnormal tubal
function
Diagnosis
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Diagnosis
– Laparoscopic visualization
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Superficial powder-burn lesions
Black, dark-brown, bluish puckered lesions representing hemorrhage,
varying degree of fibrosis
Variety of colors/shapes
– Accuracy of dx depends on location and type of lesion, experience of
surgeon, and extent of disease
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Imaging Studies
– Pelvic u/s not so useful except for “omas”
– Consider MRI, BE for concern for bowel involvement
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Laboratory
– Elevated CA125 levels
– Extent of elevation parallels extent of disease
– Not sensitive nor specific
Treatment Options
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Recommend laparoscopic excision
given it’s size and symptoms
Long term treatment plan as well
Laparoscopy
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Characterized by
chocolate filled cysts
composed of old blood
products
Usually accompanied
by other endometriotic
implants or lesions
Treatment
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No evidence to support one medical
treatment more superior to another for
management of pelvic pain nor that
treatment affects future fertility
Laparoscopy affords opportunity for
conservative surgical management
– Avoids expense and SE of medical Rx
– Risk of damage to adjacent organs, infections,
trauma and adhesion formation
Endometriosis
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NSAIDs
– No RCT demonstrating efficacy
– Effective for minimal pain symptoms
– Variable response in individuals to different NSAIDS
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OCPs
– Induce decidualization and atrophy of endometrial tissue
– Conflicting evidence of whether this treatment limits
progression of disease
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GnRH agonists
– Mimic menopause which is assc with reduction of sx
(pregnancy as well)
– RCTs demonstrating relief of pain and reducing size of
implants; no effect on future fertility
Endometriosis
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Progestins
– Initially cause decidualization and then atrophy of endometriotic
tissue
– Also inhibit pituitary LH/FSH and ovarian hormone production
– RCT demonstrating efficacy
– SE: wt gain, irregular bleeding, mood changes
– Options
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Oral mpa 10 qd, NE 5- 15 qd
DMPA (bone density)
LNG-IUC
Implanon
Progesterone antagonists/Selective progesterone receptor
modulators (SPRM)
– Mifepristone, asoprisnil
– Phase III clinical trials
Endometriosis
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Danazol (androgens)
– RCT demonstrating efficacy
– 19 nortestosterone derivative with progestin like effects
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Inhibits LH/FSH, inhibit implant growth and inhibit ovarian
enzymes resp. for estrogen production
– SE include wt gain, acne, hirsuitism, LFT, hot flashes,
depression
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Aromatase inhibitors
– Not approved, novel promising approach
– Inhibit local estrogen production by implants and inhibit
estrogen production in ovary, brain, adipose tissue
Endometriosis
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Surgery
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–
–
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–
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Severe, incapacitating symptoms
Acute
Failed or worsened with medical mgmt
Presence of advanced disease
Patient reluctance to use hormones
Conservative versus Definitive
Laparoscopy preferred
Recurrence
– 40 % at ten yrs
– 20% have additional surgery w/n 2 yrs
Surgical therapy
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Surgical management does seem to improve
pregnancy rates but the magnitude of effect is
unknown
2 RCTs for mild disease had conflicting results
No RCTs for advanced disease
Removal of endometriomas can improve pregnancy
rates
Althought, surgery may damage ovary and reduce
ovarian reserve
Repetitive ovarian surgery can negatively impact
IVF outcomes
Progession of Disease
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No systematic research about natural
history of disease
Second look laparoscopy of those in
control group
– 29% disease progression
– 29% disease regression
– 42% static disease
Case 2
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35 y/o who presents with two year
history of severe pelvic pain requiring
narcotic use
What’s the next step?
HPI
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Onset/first occurrence
Quality
Location
Intensity
Duration
Radiation
Temporal pattern
Exacerbating Factors
Alleviating Factors
Association with urination/defecation
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Reports
– chronic pain, everyday that is burning and
throbbing in lower abdomen
– intermittent sharp stabbing pain that also
happens everyday; wakes her from sleep
– severe debilitating cramping with menses
– menorrhagia for 6-8 days per month
– symptoms prevent her from working, taking care
of her children
– chronic constipation
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OBHX: G2P2
– FTCS c/b necrotizing fasciitis; required multiple
debridements with chronic scarring
– FT VBAC
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GYNHX
– History of multiple episodes of PID as a teenager
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PMH
– Bipolar disorder, obesity
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PSH
– C/S, BTL/LOA, multiple fascial debridements,
appendectomy
What stands out to you?
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OBHX: G2P2
– FTCS c/b necrotizing fasciitis; required multiple
debridements with chronic scarring
– FT VBAC
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GYNHX
– History of multiple episodes of PID as a teenager
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PMH
– Bipolar disorder, obesity
PSH
– C/S, BTL/LOA, multiple fascial debridements,
appendectomy
History - continued
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SOCHX
– Smoker, Denies ETOH/Drug use
– Lives with boyfriend and second child
– Does not have custody of first child and has strained
relationship
– History of sexual abuse as a teenager
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FAMHX
– noncontributory
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ALL
– Zantac, betadine, eggs, penicillin, erythromycin
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Meds
– Seroquel, xanax, dilaudid, fioricet
What stands out to you?
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SOCHX
– Smoker, Denies ETOH/Drug use
– Lives with boyfriend and second child
– Does not have custody of first child and has strained
relationship
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– History of sexual abuse as a teenager
FAMHX
– noncontributory
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ALL
– Zantac, betadine, eggs, penicillin, erythromycin
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Meds
– Seroquel, xanax, dilaudid, fioricet
What’s the next step?
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Physical Exam
– Abdomen- obese, scarred below pannus
– Pelvic: uterine and bilateral adnexal TTP
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Assessment
– 37 y/o with history of PID, sexual abuse, prior surgery c/b
fasciitis with menorrhagia, dysmenorrhea and chronic
pelvic pain
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Plan
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Exclude current infection
Bowel regimen for constipation
Pain Center Evaluation for chronic opiod use
Psychiatric referral to optimize treatment and counseling
Pelvic Imaging
Differential Diagnosis
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Chronic Pelvic Pain
–
–
Adhesive disease secondary to prior PID, prior surgery
hydrosalpinx
–
Long standing sexual abuse as a teenager
–
PID and prior surgery
–
Obesity, poor abdominal wall musculature
–
Chronic constipation, IBS
–
Has worsening of painful symptoms with menses and menorrhagia
–
Menorrhagia
Somatization
Depression
Opiod dependence
Adhesive Disease
Endometriosis
Musculoskeletal
Gastrointestinal
Adenomyosis
Endometritis/Chronic PID
Imaging
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Pelvic MRI: Diffuse adenomyosis and
endometrioma
Adenomyosis:
thickening
of junctional
zone
Management
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Does evidence of endometriosis and
adenomyosis account for all of patient’s
symptoms?
Therapeutic options
– OCPs, Depo-Provera, Danazol, GnRH agonist
– Surgery
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What are the potential complications?
What type of surgery?
What else?
– Pain management
Chronic Pelvic Pain
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Definition:
– at least 6 months
– Below umbilicus
– Functional disability and require treatment
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Prevalence: 4-25%
10% of ambulatory visits
– Indication for hysterectomy in 20% of all cases for benign
disease
– Indication in 40% of all gyn lsc

Endometriosis: most common diagnosis at time of
LSC for CPP; 30%
Chronic Pelvic Pain
Gynecologic:
Endometriosis
Gastrointestinal:
Chronic PID
IBS GU:
Pelvic Adhesions
IBD Interstitial Cystitis
Pelvic Congestion Musculoskeletal:
Diverticulitis
Recurrent
Utifloor myalgia
Pelvic
Adenomyosis
Neurological:
Chronic
intermittent
bowel
obstruction
Urethral
diverticulum
Myofascial
pain
Ovarian remnant syndrome Neuralgia
Neoplasia
Neoplasia
Mental
Fibromyalgia
Fibroids
Herniated
disc Health:
Chronic
Constipation
RadiationCysts
cystitis
Somatization
Peritoneal Inclusion
Abdominal
epilepsy
Celiac
Sprue
Endosalpingiossi, neoplasia, fallopian tube prolapse, tuberculosis salpingitis,
Substance
abuse
Abdominal
migraine
Physical and sexual abuse
Depression
Sleep Disorders
Chronic Pelvic Pain
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PID: up to 30 % of women with PID develop CPP
Pelvic Congestion Syndrome
– controversial entity
– Shifting location of pain, deep dyspareunia, post-coital
pain, exacerbations after prolonged standing
– Radiologic findings of pelvic varicosities with reduced
blood flow (pelvic venography)

Adenomyosis
– Presents ages 40-50
– Pain due to bleeding/swelling in endometrial glands w/n
myometrium
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Ovarian Remnant Syndrome
Fibroids
Chronic Pelvic Pain
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Ovarian Cancer
– Lower abdominal
pain/discomfort/pressure/bloating
– Increased abdominal size
– Constipation
– Lack of appetite/nausea/indigestion
– Low back pain
– fatigue
Chronic Pelvic Pain
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Interstitial Cystitis (IC/PBS)
– Chronic inflammatory condition
– Irritable bladder dysfunction with exaggerated urge to
void
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Irritable Bowel Syndrome
– Chronic relapsing pattern of abdomino-pelvic pain and
bowel dysfunction with constipation or diarrhea
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Inflammatory Bowel Disease
Diverticulitis
Celiac Disease
Fibromyalgia
Chronic Pelvic Pain
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Myofascial pain Syndrome
– Ilioinguinal nerve entrapment after pfannensteil
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Somatization Disorder
Opiate Disorder
Physical and Sexual Abuse
– 47 % of women with CPP disclose a history of
abuse
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Depression
Sleep Disorders
Chronic Pelvic Pain
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Patients disappointed
–
–
–
–
–
–
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Provide personalized care; earn trust and confidence
Empathic, listening
Validation: take sx seriously
Provide explanation of pain syndrome
Reassurance
TIME
TIME
TIME
International Pelvic Pain Society (www.pelvicpain.org)
– Detailed approach to obtaining history, pain quantification and mapping,
with extensive ROS
– Monthly pain calendar
– Effect on QOL
– Screen for depression and abuse
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During the past month, have you felt down, depressed or hopeless?
During the past month, have you felt little interest or pleasure in doing things?
Have you ever been touched against your will?
Chronic Pelvic Pain
Diagnosis
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Laboratory tests
–
–
–
–
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CBC
Urinalysis
GC/CT
HCG
Imaging options
– Pelvic ultrasound
– MRI
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Laparoscopy
Empiric treatment
Chronic Pelvic Pain
Treatment

Empiric treatment
– Treatment effects are not specific
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Intensive diagnostic evaluation
– Costly, invasive, surgery, complications

Analgesia
Chronic Pelvic Pain
Treatment
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Endometriosis
IBS
– Diet, behavioral changes, medications, therapy

IC/PBS
– Diet, PT and medications

Adhesions
– Lack of evidence to support adhesiolysis for relieving
chronic pain
– Similar improvement at one yr mark
– ?reformation of adhesions v not the source of pain
– Adhesiolysis assc with significant complications
Chronic Pelvic Pain
Treatment

Myofascial pain syndrome
– Anecdotal, no rigorous clinical trials
– PT, trigger point injections, acupuncture

Depression
– Inconclusive if antidepressant treatment in and of itself improves
CPP


Chronic PID
Pelvic congestion syndrome
– RCTs for GnRH, progestins have shown improvement
– Hysterectomy, embolization

Adenomyosis
– Hysterectomy
– LNG-IUS, GnRH
Chronic Pelvic Pain
Treatment

Neuropathic pain
– TCA, gabapentin
Chronic Pelvic Pain
Treatment

Hysterectomy
– No RCT
– Cohort studies show significant relief/elimination for 7896%
– Factors associated with persistent pain symptoms include
young age (less than 30) and history of chronic PID

Laparoscopic Uterosacral nerve ablation (LUNA)
and presacral neurectomy (PSN)
– LUNA: studies show not useful
– PSN: technically more challenging/dangerous


Relieves midline pain
Modest effectiveness
Case 3
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42 y/o presents with LLQ pain
What’s next?
HPI
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




Onset: for the last two years
Quality: sharp, pulling sensation; radiates to
the groin
Location: llq
Duration: every day, all day
Exacerbating Factors: standing for long
periods of time and menses
Relieving Factors: rest
Associated symptoms: no urinary or bowel
complaints
History




OB History: G0
GYN History: no abn paps, no stds
PMH: Allergies
PSH:
– Exlap for ruptured appendicitis
– Lsc removal of Fibroid
– Exlap to “remove ovary from back of uterus”




Sochx: neg
Meds: neg
All: neg
Famhx: noncontributory
What stands out to you?




OB History: G0
GYN History: no abn paps, no stds
PMH: Allergies
PSH:
– Exlap for ruptured appendicitis
– Lsc removal of Fibroid
– Exlap to “remove ovary from back of uterus”




Sochx: neg
Meds: neg
All: neg
Famhx: noncontributory
Physical Exam

Abdomen: Abdomen soft, non-tender. BS normal. No masses,
organomegaly, positive findings: rlq scar, pfannensteil, inc in
umbilicus
Pelvic:
External Genitalia:candidal rash externally, chronic skin
scarring of inner thighs c/w eczema
Vagina: Discharge: +white thick d/s, hyphae
Pelvic Supports: Normal
Cervix: nulliparous appearance
Uterus: anteverted and feels fixed to ant wall, also
with? Pedunculated fibroid or adnexal mass
Adnexa: right adnexa movable, left adnexa fullness
Anus and Perineum: Normal
Rectum: Deferred
Assessment

42 y/o with complicated surgical
history, chronic LLQ pain and exam
notable for fixed uterus and left
adnexal fullness
DDx






Chronic Adhesive Disease
Ovarian mass/cyst
Hydrosalpinx
Chronic PID
Fibroids
Diverticulitis
Plan

Pelvic ultrasound
– The right ovary measures 2.2 x 1.5 x 2.9 cm, and
demonstrates a normal follicular pattern. There's a
complex somewhat tubular structure in the left adnexa
likely representing a large, chronic, hydrosalpinx with a
maximum diameter of 1.6 cm. Several prominent
endosalpingeal folds are observed. There's no evidence of
internal debris or wall thickening to suggest an acute
salpingitis. What appears to the left ovary is identified
adjacent to this structure, measuring approximately 0.7x
0.7 x 1.9 cm. A small amount of free fluid seen in the left
adnexa.

Colonoscopy
Plan

Laparoscopic Salpingectomy/LOA
Chronic Pelvic Pain

Definition:
– at least 6 months
– Below umbilicus
– Functional disability and require treatment


Prevalence: 4-25%
10% of ambulatory visits
– Indication for hysterectomy in 20% of all cases for benign
disease
– Indication in 40% of all gyn lsc

Endometriosis: most common diagnosis at time of
LSC for CPP; 30%
Chronic Pelvic Pain
Gynecologic:
Endometriosis
Gastrointestinal:
Chronic PID
IBS GU:
Pelvic Adhesions
IBD Interstitial Cystitis
Pelvic Congestion Musculoskeletal:
Diverticulitis
Recurrent
Utifloor myalgia
Pelvic
Adenomyosis
Neurological:
Chronic
intermittent
bowel
obstruction
Urethral
diverticulum
Myofascial
pain
Ovarian remnant syndrome Neuralgia
Neoplasia
Neoplasia
Mental
Fibromyalgia
Fibroids
Herniated
disc Health:
Chronic
Constipation
RadiationCysts
cystitis
Somatization
Peritoneal Inclusion
Abdominal
epilepsy
Celiac
Sprue
Endosalpingiossi, neoplasia, fallopian tube prolapse, tuberculosis salpingitis,
Substance
abuse
Abdominal
migraine
Physical and sexual abuse
Depression
Sleep Disorders
Chronic Pelvic Pain


PID: up to 30 % of women with PID develop CPP
Pelvic Congestion Syndrome
– controversial entity
– Shifting location of pain, deep dyspareunia, post-coital
pain, exacerbations after prolonged standing
– Radiologic findings of pelvic varicosities with reduced
blood flow (pelvic venography)

Adenomyosis
– Presents ages 40-50
– Pain due to bleeding/swelling in endometrial glands w/n
myometrium


Ovarian Remnant Syndrome
Fibroids
Chronic Pelvic Pain

Ovarian Cancer
– Lower abdominal
pain/discomfort/pressure/bloating
– Increased abdominal size
– Constipation
– Lack of appetite/nausea/indigestion
– Low back pain
– fatigue
Chronic Pelvic Pain

Interstitial Cystitis (IC/PBS)
– Chronic inflammatory condition
– Irritable bladder dysfunction with exaggerated urge to
void
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Irritable Bowel Syndrome
– Chronic relapsing pattern of abdomino-pelvic pain and
bowel dysfunction with constipation or diarrhea
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Inflammatory Bowel Disease
Diverticulitis
Celiac Disease
Fibromyalgia
Chronic Pelvic Pain
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Myofascial pain Syndrome
– Ilioinguinal nerve entrapment after pfannensteil
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Somatization Disorder
Opiate Disorder
Physical and Sexual Abuse
– 47 % of women with CPP disclose a history of
abuse
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Depression
Sleep Disorders
Chronic Pelvic Pain
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Patients disappointed
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Provide personalized care; earn trust and confidence
Empathic, listening
Validation: take sx seriously
Provide explanation of pain syndrome
Reassurance
TIME
TIME
TIME
International Pelvic Pain Society (www.pelvicpain.org)
– Detailed approach to obtaining history, pain quantification and mapping,
with extensive ROS
– Monthly pain calendar
– Effect on QOL
– Screen for depression and abuse
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During the past month, have you felt down, depressed or hopeless?
During the past month, have you felt little interest or pleasure in doing things?
Have you ever been touched against your will?
Chronic Pelvic Pain
Diagnosis
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Laboratory tests
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CBC
Urinalysis
GC/CT
HCG
Imaging options
– Pelvic ultrasound
– MRI
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Laparoscopy
Empiric treatment
Chronic Pelvic Pain
Treatment
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Empiric treatment
– Treatment effects are not specific
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Intensive diagnostic evaluation
– Costly, invasive, surgery, complications
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Analgesia
Chronic Pelvic Pain
Treatment
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Endometriosis
IBS
– Diet, behavioral changes, medications, therapy
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IC/PBS
– Diet, PT and medications
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Adhesions
– Lack of evidence to support adhesiolysis for relieving
chronic pain
– Similar improvement at one yr mark
– ?reformation of adhesions v not the source of pain
– Adhesiolysis assc with significant complications
Chronic Pelvic Pain
Treatment
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Myofascial pain syndrome
– Anecdotal, no rigorous clinical trials
– PT, trigger point injections, acupuncture
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Depression
– Inconclusive if antidepressant treatment in and of itself improves
CPP
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Chronic PID
Pelvic congestion syndrome
– RCTs for GnRH, progestins have shown improvement
– Hysterectomy, embolization
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Adenomyosis
– Hysterectomy
– LNG-IUS, GnRH
Chronic Pelvic Pain
Treatment
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Neuropathic pain
– TCA, gabapentin
Chronic Pelvic Pain
Treatment
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Hysterectomy
– No RCT
– Cohort studies show significant relief/elimination for 7896%
– Factors associated with persistent pain symptoms include
young age (less than 30) and history of chronic PID
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Laparoscopic Uterosacral nerve ablation (LUNA)
and presacral neurectomy (PSN)
– LUNA: studies show not useful
– PSN: technically more challenging/dangerous
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Relieves midline pain
Modest effectiveness