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PELVIC PAIN Danielle Burkland, MD Clinical Assistant Professor Department of Obstetrics/Gynecology OBJECTIVES 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 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? 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 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 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 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 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 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 18 y/o G0 with dysmenorrhea that is worsening as well as chronic LLQ pain Differential Diagnosis Primary Dysmenorrhea Ovarian cyst – Hemorrhagic, teratoma Constipation Endometriosis PID Pregnancy Dysmenorrhea 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 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 Etiologies - Cervical Stenosis - Endometriosis and Adenomyosis - Pelvic Infection - Adhesions - Pelvic Congestion Syndrome ? Plan GC/CT cultures Urine HCG CBC UA/urinalysis What do you want to do next? Pelvic Ultrasound Pelvic Ultrasound 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 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 Incidence: 6-10% of reproductive age women 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 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 Aberrant expression of endometrial genes + altered hormonal response predisposes to the development of lesions Local overproduction of prostaglandins – Increase in COX-2 Local overproduction of estrogen by increased aromatase activity Progesterone resistance dampens antiestrogenic effect of progesterone and amplifies local estrogenic effect Clinical Presentation Symptoms not specific – Similar symptoms seen in patients with PID, IBS, IC and chronic adhesive disease – Variable and unpredictable – Significant number will be asymptomatic 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 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 Infertility/Subfertility – Mechanism is not well understood especially in mild stage disease Abnormal peritoneal environment – Oxidative stress – Higher concentrations of inflammatory cytokines may affect sperm function Promote abnormal oocyte cytoskeletal function Advance endometriosis can result in abnormal tubal function Diagnosis Diagnosis – Laparoscopic visualization 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 Imaging Studies – Pelvic u/s not so useful except for “omas” – Consider MRI, BE for concern for bowel involvement Laboratory – Elevated CA125 levels – Extent of elevation parallels extent of disease – Not sensitive nor specific Treatment Options Recommend laparoscopic excision given it’s size and symptoms Long term treatment plan as well Laparoscopy Characterized by chocolate filled cysts composed of old blood products Usually accompanied by other endometriotic implants or lesions Treatment 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 NSAIDs – No RCT demonstrating efficacy – Effective for minimal pain symptoms – Variable response in individuals to different NSAIDS OCPs – Induce decidualization and atrophy of endometrial tissue – Conflicting evidence of whether this treatment limits progression of disease 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 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 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 Danazol (androgens) – RCT demonstrating efficacy – 19 nortestosterone derivative with progestin like effects Inhibits LH/FSH, inhibit implant growth and inhibit ovarian enzymes resp. for estrogen production – SE include wt gain, acne, hirsuitism, LFT, hot flashes, depression Aromatase inhibitors – Not approved, novel promising approach – Inhibit local estrogen production by implants and inhibit estrogen production in ovary, brain, adipose tissue Endometriosis Surgery – – – – – 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 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 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 35 y/o who presents with two year history of severe pelvic pain requiring narcotic use What’s the next step? HPI Onset/first occurrence Quality Location Intensity Duration Radiation Temporal pattern Exacerbating Factors Alleviating Factors Association with urination/defecation 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 OBHX: G2P2 – FTCS c/b necrotizing fasciitis; required multiple debridements with chronic scarring – FT VBAC GYNHX – History of multiple episodes of PID as a teenager PMH – Bipolar disorder, obesity PSH – C/S, BTL/LOA, multiple fascial debridements, appendectomy What stands out to you? OBHX: G2P2 – FTCS c/b necrotizing fasciitis; required multiple debridements with chronic scarring – FT VBAC GYNHX – History of multiple episodes of PID as a teenager PMH – Bipolar disorder, obesity PSH – C/S, BTL/LOA, multiple fascial debridements, appendectomy History - continued 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 FAMHX – noncontributory ALL – Zantac, betadine, eggs, penicillin, erythromycin Meds – Seroquel, xanax, dilaudid, fioricet What stands out to you? 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 FAMHX – noncontributory ALL – Zantac, betadine, eggs, penicillin, erythromycin Meds – Seroquel, xanax, dilaudid, fioricet What’s the next step? Physical Exam – Abdomen- obese, scarred below pannus – Pelvic: uterine and bilateral adnexal TTP Assessment – 37 y/o with history of PID, sexual abuse, prior surgery c/b fasciitis with menorrhagia, dysmenorrhea and chronic pelvic pain Plan – – – – – 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 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 Pelvic MRI: Diffuse adenomyosis and endometrioma Adenomyosis: thickening of junctional zone Management Does evidence of endometriosis and adenomyosis account for all of patient’s symptoms? Therapeutic options – OCPs, Depo-Provera, Danazol, GnRH agonist – Surgery What are the potential complications? What type of surgery? What else? – Pain management 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 Irritable Bowel Syndrome – Chronic relapsing pattern of abdomino-pelvic pain and bowel dysfunction with constipation or diarrhea Inflammatory Bowel Disease Diverticulitis Celiac Disease Fibromyalgia Chronic Pelvic Pain Myofascial pain Syndrome – Ilioinguinal nerve entrapment after pfannensteil Somatization Disorder Opiate Disorder Physical and Sexual Abuse – 47 % of women with CPP disclose a history of abuse Depression Sleep Disorders Chronic Pelvic Pain Patients disappointed – – – – – – 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 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 Laboratory tests – – – – CBC Urinalysis GC/CT HCG Imaging options – Pelvic ultrasound – MRI Laparoscopy Empiric treatment Chronic Pelvic Pain Treatment Empiric treatment – Treatment effects are not specific Intensive diagnostic evaluation – Costly, invasive, surgery, complications Analgesia Chronic Pelvic Pain Treatment 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 42 y/o presents with LLQ pain What’s next? HPI 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 Irritable Bowel Syndrome – Chronic relapsing pattern of abdomino-pelvic pain and bowel dysfunction with constipation or diarrhea Inflammatory Bowel Disease Diverticulitis Celiac Disease Fibromyalgia Chronic Pelvic Pain Myofascial pain Syndrome – Ilioinguinal nerve entrapment after pfannensteil Somatization Disorder Opiate Disorder Physical and Sexual Abuse – 47 % of women with CPP disclose a history of abuse Depression Sleep Disorders Chronic Pelvic Pain Patients disappointed – – – – – – 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 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 Laboratory tests – – – – CBC Urinalysis GC/CT HCG Imaging options – Pelvic ultrasound – MRI Laparoscopy Empiric treatment Chronic Pelvic Pain Treatment Empiric treatment – Treatment effects are not specific Intensive diagnostic evaluation – Costly, invasive, surgery, complications Analgesia Chronic Pelvic Pain Treatment 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