Download Managing Chronic Pelvic Pain Patients

Priscilla Abercrombie, RN, NP, PhD, AHN-BC
HS Clinical Professor
Obstetrics, Gynecology & Reproductive Sciences
UCSF Community Health Systems
UCSF Chronic Pelvic Pain Clinic
UCSF Osher Center for Integrative Medicine
SFGH Women’s Health Center
Founder, Women’s Health & Healing
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 Define
chronic pelvic pain (CPP) and
identify the most common causes of CPP.
 Identify myofascial sources of pain that are
rarely recognized and treated in patients
with CPP.
 Explore the many different treatment
modalities that are available for patients
with CPP.
 Provide a systematic approach for the
successful assessment and management of
CPP.
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I
have no affiliation with any
pharmaceutical companies, etc.
 I will discuss off-label use of drugs.
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“Continuous or episodic pain in the lower
abdomen or pelvis lasting >=6 months and
associated with a negative impact on qualityof-life” (Williams, et al., 2004)
Definitions vary greatly throughout the clinical and
research literature.
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 Prevalence 12-39%
 Medical Care
• 20% of all referrals to gynecologists
• >40% of all laparoscopies
• 12% of all hysterectomies
 Costs
•
•
•
•
to Society
$882 million in outpatient visits alone
15% time lost from work
45% reduced productivity
Total costs estimated at > $2 billion / yr
Howard FM. Obstetrical and Gynecological Survey 1993;48:357-87.
Mathias SD, Kuppermann M, et al. Obstetrics & Gynecology 1996;87:321-7.
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 Rarely
caused by a single condition
 Usually multifactorial (Howard, 2003)
 Involves both physiological and
psychological conditions
 Can be classified as cyclic or noncyclic
• Seldom fits into those categories clinically
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
39 yo with crampy lower abdominal pain x 3 years

Daily pain 3/10, worsens to 8/10 twice a week

Limits activities (including sex), enjoyment of life

Worse with her period

Pain with intercourse

Has constipation with bloating

Urinary frequency
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No standard diagnostic criteria
No standard method of evaluating patients
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 ACOG
 Society
of obstetricians and
gynecologists of Canada
 European Association of Urology
Review articles:
 Howard
 Learman
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 Listen
to her story about living with CPP
 Discuss concerns, fears and insights
 Reflect back what you have heard
 Build trust and rapport
• Distrust health care providers
• Endured multiple diagnostic tests
• No cause for pain found
• Have not been heard/believed
• Must be psychological
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 Pain
history: quality,
location, timing with
cycle, contributing or
relieving factors,
body map
 Medical/surgical
history including Rxs
 Ob/Gyn: menstrual
history
 GI
symptoms/pain
 Urinary symptoms, IC
screening
 Quality of life
 Health habits: ETOH,
substance abuse
 Review records
See International Pelvic Pain Society Website for history and PE forms:
English, Spanish, French
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 Assess
impact on functioning and quality of life
• “What things would you like to be able to do
that you can’t do because of the pain?”
• “How are things at home? At work?”
 Elicit patient’s view of illness, fears and concerns
• Do you have any thoughts or concerns about
what might be causing the pain?
 Screen for current or prior physical or sexual
violence, including events in childhood
 Screen for depression
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Test
Rationale
Urinalysis and culture
Bladder symptoms suggestive of UTI
Wet mount, STI screening
Signs or risk factors for genital tract infection
ALT and creatinine
Taking multiple medications or concern for liver
or kidney disease
Depressive or constitutional symptoms
TSH, CBC, FBS, Vitamin D OH
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Pelvic sonogram
CT and MRI
Laproscopy
Bimanual exam limited or abnormal
Other diagnostic studies are abnormal or
inadequate
Persistent symptoms, infertility, large ovarian
cysts, treatment of endometriosis or adhesions
Cystoscopy
Concern for IC or other bladder abnormalities
FOBT x 3 or referral for
colonoscopy
GI symptoms or concern for colon cancer
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Identify underlying pathology
Reproduce pain
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 Observe
gait, posture, balance
 Examine hip flexibility and symmetry
 Test for weakness, tenderness or sensory
disturbances in the back, buttocks, legs,
and pelvis
 Palpate the abdomen for masses, muscle
tension, tenderness and trigger points
Don’t confine your exam to the gyn table
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 Differentiates
pain originating from the
abdominal wall versus peritoneal cavity
(Suleiman et al., 2001)
 The patient raises her head and
shoulders from the examination table
while the provider palpates the tender
area on the abdomen.
 Positive Carnett’s sign: pain remains
unchanged or increases when the
abdominal muscles are tensed.
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Trigger points are hyperirritable
palpable nodules that are taut bands of
muscle fibers (Tough et al., 2007)
 When palpated the pain usually radiates
to another location
 Found in abdominal wall and pelvic floor
locations
 Major contributor to CPP

See also: Lavelle, E., Lavelle, W., & Smith, H. (2007). Myofascial trigger points.
Anesthesiology Clinics, 25, 841-51.
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




External genitalia: vulvar / vestibular lesions and
tenderness (Q tip test)
Urethra and bladder: mass or tenderness, prolapse
Vagina, cervix:
 inspection (lesion, trauma, infection, prolapse)
 12-point unimanual exam
 Wet mount/STI screening if clinical suspicion
Uterus, adnexae – bimanual
 Size, shape, consistency, mobility, mass, tenderness
Rectal or rectovaginal
 Lesion, rectocele, uterine retroflexion, uterosacral
nodules
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From National Vulvodynia Association CME Course 2010
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 Purpose: identify
and map changes in
sensation including allodynia
 Gently touch with a q-tip
 Start at the thigh and work down to
perineum bilaterally
 Include clitoris and perianal areas
 Proceed from labia majora to labia
minora then the vestibule
 Record findings
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Vulvodynia
PE
Chronic
Vulvar
Pain
No visible
findings
Erythema
Hyperalgesia
Allodynia
Generalized pain
Burning, stabbing,
stinging, etc.
Vestibulodynia
Pain at vestibule only
Provoked
Burning
R/O
Infectious,
inflammatory,
neoplastic and
neurologic cause
Treat
accordingly
Incidence: 3-5% of reproductive age women
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 Palpate in 4 quadrants x 3
 NO abdominal palpation
 Just beyond hymen
depths
• 12:00 urethra, 6:00 rectum
• 3:00/9:00 obturator internus
 Mid-vagina
• 12:00 bladder base, 6:00 rectum
• 3:00/9:00 puborectalis
 Just
before cervix
• 12:00 bladder, 6:00 rectum/cul-de-sac
• 3:00/9:00 pubo/iliococcygeus
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Improve functional status
Improve quality of life
Decrease pain
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Gynecologic
Gastrointestinal
Urinary
tract
Musculoskeletal
Psychological
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







Endometriosis
Adenomyosis
Adhesions entrap ovaries, tether
pelvic organs
Vulvodynia, vulvar vestibulitis
Prolapse of the uterus
Ovarian dystrophy: ischemia
Ovarian vein congestion: edema
Pain during ovulation
(“mittelschmerz”)
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



Irritable bowel syndrome
Inflammatory bowel disease, diverticular
disease
Hernias
Cancer (rarely)
Urinary Tract Conditions
•
•
•
•
Interstitial cystitis: painful bladder syndrome
Infection: usually acute symptoms
Kidney stones: usually acute symptoms
Cancer (rarely)
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Low back, abdominal wall, and
pelvic floor muscle dysfunction
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Inciting Pain Event: uterus, ovary, bowel, bladder, muscles,
nerves
Local Muscle Tension
Secondary Muscle “Adaptations”:
Lower back, buttocks, hips, pelvic floor
Initial Event
Resolves (naturally
or with treatment)
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 Hypertonus
and tenderness are common
 Refer patients to physical therapists
specializing in pelvic floor muscle work
(advanced training)
• Myofascial release
• Biofeedback
• Abdominal breathing, rescue poses,
stretching exercises
• Home exercise program
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

Ultrasound energy, manual therapy
Local anesthetic injection: 93% success
by 5th injection
•
Lidocaine 1% x 10-15cc, bupivicaine 0.25% 0.5% x 10-15cc
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Address anxiety, depression, and sexual dysfunction
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Patient A
Patient B
Depressed
Not Depressed
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 Pain
has impact on quality of life and functional
capacity
 Women become isolated and have difficulty
communicating needs
 Relationships become strained
 Pre-existing psych issues such as PTSD
exacerbated by pain
 Anxiety and depression common
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(Main, et al., BMJ, 2002)
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 Identify
and treat psychological
morbidity
 Assist in the development of:
• Positive coping techniques
• Communication strategies
• Problem solving skills
 Set
realistic treatment goals
 Acknowledge and support woman
 Provide medication management
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 Dyspareunia
is common
 Can lead to sexual dysfunction and
strained sexual relationships
 68% of women with CPP have sexual
dysfunction
• Hypoactive desire 54%
• Arousal disorder 33%
• Orgasmic disorder 22%
• Sexual pain 74%
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 Learn
about your body
• Explore your pleasure spots
• Educate your partner
 Connect
with your partner in sexual and
non-sexual ways
 Prepare for sex: relax the PF muscles, use
lubricants, take time for arousal
 Reinvent your sex life
 Avoid painful activities
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 Definition: “an
amplification of neural
signaling within the central nervous
system that elicits pain hypersensitivity”
(Woolf, 2011).
 Body continues to experience pain
despite healing from a precipitating
injury
 Pain in the setting of no known pathology
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 CNS
perpetuates pain by demonstrating
exaggerated or prolonged responses to
painful stimuli this is referred to as
“windup”
 Reduced capacity for inhibition
 Occurs in many CPP disorders such as
vulvodynia (Zhan, Z., 2011),
dysmenorrhea (Bajaj, P., 2002), and
endometriosis (He, W., 2010)
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 Analgesics:
• Opioids
• NSAIDS
• Topical anesthetics*
 Antidepressants
• Tricyclics*
• SSRI’s/SNRI’s*
 Muscle
relaxants
 Nerve blocks
 Neurologics:
pregabalin
 Neurotoxin:
OnabotulinumtoxinA*
 Anticonvulsants
*Off label use
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 Referral
to pain management specialist:
nerve blocks, medication consult
 Mind/body interventions: breathing
exercises, imagery, MBSR, laughter yoga, etc.
 Movement therapies: yoga, Tai Chi,
Feldenkrais, etc.
 Anti-inflammatory diet/herbs
 Support health: multivitamins, B complex,
fish oil, calcium/magnesium, herbal tonics
 Alternative providers: TCM, craniosacral,
chiropractic, energy medicine,
strain/counter strain, etc.
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Some Improvement
• Celebrate, adjust meds, encourage adherence,
focus on activity limitation endpoints
 No Improvement
• Optimize treatment of depression if present
• Facilitate pelvic floor PT if not yet done
• Consider empiric treatments vs. invasive
diagnostic studies (e.g., GnRHa vs. laparoscopy
for presumed endometriosis)
 Continues without Improvement
• Begin work-up anew
• Consider hysterectomy only if conditions are
met

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 Set
realistic goals with your patient:
improved function vs. complete remission
 Have a systematic approach to assessment
 Be wary of the assumption pain is linked to
pathology or obvious tissue damage
 Use medication contracts
 Work as an interdisciplinary team- Build a
community
 Have lots of tools in your tool kit
 Keep learning about innovative strategies
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
International Pelvic Pain Society: www.pelvicpain.org

National Vulvodynia Association: www.nva.org
Endometriosis treatment guidelines:
http://guidelines.endometriosis.org/

Interstitial Cystitis Association: www.icahelp.com
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

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Irritable Bowel Syndrome:
http://digestive.niddk.nih.gov/ddiseases/pubs/ibs_ez/inde
x.htm
American Physical Therapy Association:
http://www.apta.org//AM/Template.cfm?Section=Home
UCSF Chronic Pelvic Pain Clinic:
https://www.obgyn.medschool.ucsf.edu/gynecology/ccss/
pelvic_pain/index.aspx
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