Chronic Pelvic Pain
Dr. Huda Adnan SahibC.A.B.O.G.
Chronic Pelvic Pain (CPP) is pain of apparent pelvic origin that has been present most of the time for the
past six months
Chronic Pelvic Pain
• Definition
• Affects 15-20% of women of reproductive age
• Accounts for 20% of all laparoscopies• Accounts for 12-16% of all hysterectomies
Chronic Pelvic Pain
• Incidence
Etiology
Gynecological 20%
Gastrointestinal 37%
Musculoskeletal
Urological 30%
Psychological
• 25-50% of women had more than one diagnosis• Severity and consistency of pain increased with multisystem symptoms
• Most common diagnoses:
• endometriosis
• adhesive disease
• irritable bowel syndrome
• interstitial cystitis
• 1. History
• Obtaining a complete and detailed history is the most important key to formulating a diagnosis including gynecological, urological, gastrointestinal,muscluskeletal and psychological symptoms.
• Diagnosis
• 2. Physical Exam• Evaluate each area individually
• Abdomen
• Anterior abdominal wall
• Pelvic Floor Muscles
• Vulva
• Vagina
• Urethra
• Cervix
• Viscera – uterus, adnexa, bladder
• Rectum
• Rectovaginal septum
• Coccyx
• Lower Back/Spine
• Posture and gait
• A bimanual exam alone is
• NOT sufficient for evaluation
• 3. investigations
• Basic Testing
• Pap Smear
• Gonorrhea and Chlamydia
• Wet Mount
• Urinalysis
• Urine Culture
• Pregnancy Test
• CBC with Differential
• ESR
• PELVIC ULTRASOUND
• Specialized Testing
• MRI or CT Scan
• Endometrial Biopsy
• Laparoscopy
• Cystoscopy
• Urodynamic Testing
• Urine Cytology
• Colonoscopy
• Electrophysiologic studies
• Referral to Specialist
• Differential Diagnosis:
• Gynecological Conditions
• Cyclical
• Endometriosis
• Adenomyosis
• Primary Dysmenorrhea
• Ovulation Pain/ Mittleschmertz
• Ovarian Remnant Syndrome
• Non-cyclical
• Pelvic Masses
• Adhesive Disease
• Pelvic Inflammatory Disease
• Pelvic Congestion Syndrome
• Symptomatic Pelvic Organ Prolaps
• Pelvic Floor Pain Syndrome
• Pelvic Congestion Syndrome
• Description: Retrograde flow through incompetent venous valves can cause tortuous and congested pelvic and ovarian varicosities; Etiology unknown.• Symptoms: Pelvic ache or heaviness that may worsen premenstrually, after prolonged sitting or standing, or following intercourse
• Diagnosis: Pelvic venogrpahy, CT, MRI, ultrasound, laparoscopy
• Treatment: Progestins, GnRH agonists, ovarian vein embolization or ligation, and hysterectomy with bilateral salpingo-oophorectomy (BSO)
Chronic Pelvic Pain
• Pelvic Floor Pain Syndrome
• Description: Spasm and strain of pelvic floor muscles
• Levator Ani Muscles
• Coccygeus Muscle
• Piriformis Miscle
• Symptoms: Chronic pelvic pain symptoms; pain in buttocks and down back of leg, dyspareunia
• Treatment: Biofeedback, Pelvic Floor Physical Therapy, TENS (Transcutaneous Electrical Nerve Stimulation) units, antianxiolytic therapy, cooperation from sexual partner
• Differential Diagnosis:
• Urological Conditions that may Cause or Exacerbate Chronic Pelvic Pain• Bladder Carcinoma
• Interstitial Cystitis
• Radiation Cystitis
• Urethral Syndrome
• Detrussor Dyssynergia
• Urethral Diverticulum
• Chronic Urinary Tract Infection
• Recurrent Acute Cystitis
• Recurrent Acute Urethritis
• Stone/urolithiasis
• Urethral Caruncle
• Source: ACOG Practice Bulletin #51, March 2004
• Interstitial Cystitis
• Description: Chronic inflammatory condition of the bladder
• Etiology: Loss of mucosal surface protection of the bladder and thereby increased bladder permeability
• Symptoms:
• Urinary urgency and frequency
• Pain is worse with bladder filling; improved with urination
• Pain is worse with certain foods
• Pressure in the bladder and/or pelvis
• Pelvic Pain in up to 70% of women
• Present in 38-85% presenting with chronic pelvic pain
Chronic Pelvic Pain
• Interstitial Cystitis• Diagnosis:
• Cystoscopy with bladder distension
• Presence of glomerulations (Hunner Ulcers)
• Treatment:
• Avoidance of acidic foods and beverages
• Antihistamines
• Tricyclic antidepressants
• Elmiron (pentosan polysulphate)
• Intravesical therapy: DMSO (dimethyl sulfoxide)
• Differential Diagnosis:
• Gastrointestinal Conditions that may Cause or Exacerbate Chronic Pelvic Pain
• Colon Cancer
• Constipation
• Inflammatory Bowel Disease
• Colitis
• Chronic Intermittent Bowel Obstruction
• Diverticular Disease
• Source: ACOG Practice Bulletin #51, March 2004
Irritable Bowel Syndrome
• Irritable Bowel Syndrome (IBS)
• Description: Chronic relapsing pattern of abdominopelvic pain and bowel dysfunction with diarrhea and constipation• Prevalence
• Affects 12% of the U.S. population
• 2:1 prevalence in women: men
• Peak age of 30-40’s
• Rare on women over 50
• Associated with elevated stress level
• Symptoms
• Diarrhea, constipation, bloating, mucousy stools
• Symptoms of IBS found in 50-80% women with CPP
• Irritable Bowel Syndrome (IBS)
• Treatment
• Dietary changes
• Decrease stress
• Cognitive Psychotherapy
• Medications
• Antidiarrheals
• Antispasmodics
• Tricyclic Antidepressants
• Serotonin receptor (3, 4) antagonists
• 40 – 50% of women with CPP have a history of abuse (physical, verbal , sexual)
Chronic Pelvic Pain• Psychological Associations
• Psychosomatic factors play a prominent role in CPP
• Approach patient in a gentle, non-judgmental manner
• Do not want to imply that “pain is all in her head”
• Psychotropic medications and various modes of psychotherapy appear to be helpful as both primary and adjunct therapy for treatment of CPP
• Chronic Pelvic Pain requires patience, understanding and collaboration from both patient and physician
• Obtaining a thorough history is key to accurate diagnosis and effective treatment
• Diagnosis is often multifactorial – may affect more than one pelvic organ
• Treatment options often multifactorial – medical, surgical, physical therapy, cognitive
Chronic Pelvic Pain
• Conclusions