Chronic Pelvic Pain

Max Brinsmead MB BS PhD

May 2015

Intermittent or constant pain in the lower abdomen or pelvis for >6 months– With or without menstruation– Can be coital or postcoital– Not associated with pregnancy

Is as common as low back pain or headache

Definition and Incidence

Patient needs to feel that she is being taken seriously

Give her time to tell her story

A single diagnosis at initial presentation is often impossible

The cause of the patient’s dis-ease is often multifactorial...

So attempt to list all these possible factors

And aim for an explanation or process of management for the patient

Approach

Endometriosis– External (peritoneal)– Adenomyosis (intra uterine)

Pelvic Congestion/Ovulation sensitivity

Chronic PID

Irritable Bowel Syndrome/Interstital Cysitis

Musculoskeletal– Includes the pelvic floor muscles

Post inflammatory or Postsurgical– Adhesions– Nerve entrapment

The Short List

Depression• May be secondary to the pain• Check sleeping patterns• Libido and sexual activity

Sexual and physical abuse• Complex• May be problems of self esteem

Other family/inter relationship issues

Drug use and abuse• Smoking• Other drugs

Psychological and Social Factors

If there is a strong cyclical component to the pain it is likely to be of reproductive tract origin

Nature of the pain may be useful• Localised, sharp or stabbing suggests neuropathic cause

How much does it interfere with daily life, work, sleep and sexual function?

Careful bowel and bladder history

Relationship to posture and activity

Unlocking psychosexual history or dysfunction can be difficult

History

Sexual and contraceptive history

Past surgical and gynaecological history

Reproductive history

Family History• Endometriosis• Hysterectomy• Cancer

More History

Examine the abdomen, PV +/- PR and also lower back and sacro-iliac joints

Look for tenderness, enlargement, distortion or tethering

Prolapse

Any trigger points?• Including those in the pelvic floor

Examination

Screen sexually active for STD

Ultrasound useful for assessing enlarged uterus and adnexal mass– But has a limited role otherwise

MRI little better except in the detection of deep rectovaginal endometriosis

Diagnostic Laparoscopy– Risks and benefits should be discussed– Should not be a reason for gynaecological absolution– Much controversy about the Dx of endometriosis

CA125 – for bloating, early satiety and those >50

Investigations

If not clearly gynaecological in origin then it should be MULTIDISCIPLINARy

If the pain is cyclical then trial hormonal Rx for 3m before laparoscopy

• COC, Progestins, Danazol or Mirena

Trial antispasmodics for suspected IBS + diet modification

• Mebeverine plus bulking agents

Multidisciplinary approach to pain management• Regular NSAID, Compound analgesics, Amytriptaline/Gabapentin,

Counselling, Hypnotherapy , Self-help groups etc

Management

Any Questions or Comments?

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