LESLIE ABLARD M.D.

Chronic Pelvic Pain

Chronic Pelvic Pain

There is no generally accepted definition of chronic pelvic pain

Many authors have used duration of at least 6 months that occurs below the umbilicus and is severe enough to cause functional disability or require treatment (some prefer non-cyclic)

Chronic Pelvic Pain

Approx 15-20% of women ages 18-50 yrs have chronic pelvic pain greater than 1 yrs duration

20% of all hysterectomies performed for benign disease

40 % of all gynecological laparoscopies performed annually in the United States

Population at Increased Risk

Demographic profiles of large surveys suggest that women with chronic pelvic pain are no different in terms of age, race and ethnicity, education, socioeconomic status, or employment status

May be slightly more likely to be separated or divorced

Tend to be of reproductive age Age is not a specific risk factor

Physical and Sexual Abuse

Significant association of physical and sexual abuse with various chronic pain disorders 40-50% have a history of abuse May decrease threshold for pain Important to ensure they are not currently being

abused or in danger

Gynecologic Causes of Pelvic Pain

EndometriosisAdhesions (chronic PID)LeiomyomataAdenomyosisPelvic congestion syndromeMittelschmerzAdnexal masses

Non-gynecologic Causes of Pelvic Pain

GastrointestinalUrologicMusculoskeletalPsychologic

Gynevision

Etiology

Study from UK Urinary Causes – 30.8% GI Causes- 37.7% Gynecologic- 20.2%

Many women with chronic pelvic pain have more than 1 disease that may lead to pain 25-50% women who received medical care in primary care

practices have more than 1 diagnosis along with chronic pelvic pain IBS, endometriosis, IC

Women with more than 1 organ system diagnosis have greater pain

History

Characteristics of the pain:

Location and radiation

Intensity, including intensity with menstrual cycle, urination, defecation, and physical activity, if relevant

Timing, especially if only at menses or with intercourse

Quality

Physical Exam

“Compartmentalized” Pelvic Exam

PerineumPelvic floorUrethra / bladderCervixUterus / adnexa

Lab Tests

Laboratory  Laboratory testing is of limited value in evaluating women

with CPP Baseline tests are obtained to screen for a chronic

infectious or inflammatory process, and to exclude pregnancy CBC with diff UA G/C Pregnancy test Further laboratory testing is based on the clinical

impression that emerges after a complete history and physical examination

Imaging

Pelvic US Highly sensitive for identifying pelvic masses/cysts and

determining the origin of the mass (ovary, uterus, fallopian tube)

Less reliable for distinguishing between benign and malignant neoplasms and diagnosing adenomyosis

Particularly useful for detecting small pelvic masses (less than 4 cm in diameter), which often cannot be palpated on bimanual examination

Useful for detecting hydrosalpinges, which point to pelvic inflammatory disease as the cause of CPP

MRI Used to better define an abnormality suspected by

sonography  and for diagnosis of adenomyosis

Gastrointestinal Causes of Pelvic Pain

Irritable bowel syndromeChronic appendicitisInflammatory bowel disease (Crohn’s)DiverticulitisDiverticulosisMeckel’s diverticulum

Urologic Causes of Pelvic Pain

Unstable bladder (detrusor instability)Urethral syndrome (chronic urethritis)Interstitial cystitis

Musculoskeletal/Myofascial Causes of Pelvic Pain

FibromyalgiaHernias (inquinal, femoral, umbilical,

incisional, spigelian)Nerve entrapment (neuritis)FasciitisScoliosisDisc diseaseSpondylolisthesisOsteitis pubis

“Top of the list” Etiologies

Gynecologic PID Endometriosis Prior surgery? Pelvic Adhesions

Non-gynecologic IC IBS Musculoskeletal Disorders Psychiatric

PID

18-35% of acute PID develop chronic pelvic pain Actual mechanism not well known Inpatient or outpatient treatment does not reduce the

odds of developing subsequent chronic pelvic pain

PID

Endometriosis

Diagnosed laparoscopically in approx 33% of women with chronic pelvic pain 24% adhesive disease 35% no visible pathology

More than 50% with abnormal laparoscopic findings have normal pre-op exam

Endometriosis

Endometriosis

Treatment Medical management

GnRH agonists – Lupron most commonly used May be used for a “suggestive “diagnosis or treatment 6-12 months with add-back norethindrone 5mg for

bone protection and symptom relief Continuous OCPs or higher dose progestins Depo Provera

Surgical Management Hysterectomy Laparoscopy with ablation for mild to mod disease

Treatment

Surgical excision or destruction of endometriotic tissue Significant pain relief for 1 yr in 45-85% of women Recurrence range from 15-100% Avg time to recurrence is 40-50 months Most effective in early disease (not stage IV endometriosis)

Hysterectomy (not just dx of endometriosis) Several prospective cohort studies 90% of women had relief of pain at 1 and 2 yrs post

hysterectomy 1 yr after hysterectomy for chronic pelvic pain, 74% had

complete resolution of pain and 21% had decreased pain Retrospective study of hysterectomy with no path found that

78% were pain free after 1 yr

Past Surgery

History of abdominopelvic surgery associated with chronic pelvic pain

Women without preoperative pain 3-9% develop pelvic pain or back pain in the 2 yrs

after a hysterectomy

Cesarean delivery also may be a risk factor for chronic pelvic pain (OR of 3.7)

Pelvic adhesions

Treatment

Laparoscopic Adhesiolysis

Interstitial Cystitis

Clinically characterized by irritative voiding symptoms of urgency and frequency in the absence of objective evidence of other disease

70% of women with IC report pelvic pain

Suggested that 38-85% of women presenting to the gynecologist with chronic pelvic pain may have IC

Difficult to diagnose- no true gold standard Intravesical K instillition of 40ml of KCL Cystoscopy with Hunners ulcers (petechiae or glomerulations) Decreased bladder capacity (less than 350cc) without

anesthesia

IC

Interstitial Cystitis - Treatment

HydrodistentionDimethyl sulfoxide (DMSO) 50%

50cc periodicallyBladder retrainingBiofeedbackAntidepressant (e.g., Elavil, Tofranil)AntihistaminesSSRIsPentosan polysulfate (Elmiron)

IBS

Characterized by chronic, relapsing pattern of abdominopelvic pain and bowel dysfunction with constipation or diarrhea

Symptoms consistent with 50-80% of women with chronic pelvic pain

Current diagnosis is the Rome II Criteria At least 12 wks (not consecutive) in the preceding 12

mo with 2 of 3 features 1. Relieved by defecation 2. Onset associated with change in frequency of stool 3. Onset associated with a change in stool form or

appearance

Medical Treatment of IBSSymptomSymptom TherapyTherapy Typical daily dosageTypical daily dosage Side effectsSide effects

DiarrheaDiarrhea LoperamideLoperamide 4 mg4 mg ConstipationConstipation

DiphenoxylateDiphenoxylate 20 mg20 mg Euphoria, sedationEuphoria, sedation

HyoscyamineHyoscyamine < 1.5 mg< 1.5 mg Dry mouthDry mouth

DicyclomineDicyclomine 80-160 mg80-160 mg Blurred visionBlurred vision

DesipramineDesipramine 150 Mg150 Mg Dry mouth, confusion, Dry mouth, confusion, hypertensionhypertension

AmitriptylineAmitriptyline 25-50 mg25-50 mg Dry mouth, confusionDry mouth, confusion

ConstipationConstipation Fiber (any source)Fiber (any source) >30 g>30 g Bloating, abdominal painBloating, abdominal pain

LactuloseLactulose 10-30 g10-30 g BloatingBloating

SorbitolSorbitol 10-30 mg10-30 mg BloatingBloating

CisaprideCisapride 40-80 mg40-80 mg Dizziness, headacheDizziness, headache

Abdominal painAbdominal pain DesipramineDesipramine 150 mg150 mg Dry mouth, sedation, Dry mouth, sedation, confusion, hypertensionconfusion, hypertension

Hyoscyamine sulfateHyoscyamine sulfate <1.5 mg<1.5 mg Hypotension, constipationHypotension, constipation

DicyclomineDicyclomine 80-160 mg80-160 mg Dry mouth, blurred vision, Dry mouth, blurred vision, dizzinessdizziness

Musculoskeletal Disorders

Trigger pointsFibromyalgiaMyofacial painLumbar vertebral disordersPelvic floor myalgiaFaulty posture

Exaggerated lumbar lordosis and thoracic kyphosis May contribute to up to 75% of chronic pelvic pain

Musculoskeletal Screening Examination for Patients Presenting with Chronic Pelvic Pain -

History

Normal laparoscopyHistory of trauma to low back or

lower extremities, including motor vehicle accident or fall

Pain is altered by positional changes, particularly prolonged standing or sitting

Lack or response to previous gynecologic intervention

Exacerbation with stress

Muscle Relaxants for Patients Presenting with Chronic Pelvic

Pain

Trade nameTrade name Generic nameGeneric name DosageDosage

Parafon ForteParafon Forte ChlorzoxazoneChlorzoxazone 500 mg q tid or qid500 mg q tid or qid

RobaxinRobaxin MethocarbamolMethocarbamol 500 mg 3 tabs qid500 mg 3 tabs qid

Soma compoundSoma compound CarisoprodolCarisoprodol 200 mg 1-2 tabs qid200 mg 1-2 tabs qid

AspirinAspirin 325 mg qid325 mg qid

ValiumValium DiazepamDiazepam 2-10 mg qid2-10 mg qid

What do you do if your work-up doesn’t point you to any etiology of

the pain?

Laparoscopy

When do you do one? Suspicious of pathology based on imaging or PE Failed medical management

When endometriosis is suspected on visual findings- biopsies and histological confirmation is important

Adolescents should not be excluded from the rest of the population for laparoscopic evaluation

Treatment

Antidepressants TCAs- imipramine, amitryptyline, desipramine, and

doxepin, have been shown in placebo controlled studies to improve pain levels and pain tolerance in those with chronic pain syndromes Not clear if others such as SSRIs are as effective

“Evidence is insufficient to substantiate efficacy of antidepressants although the efficacy of TCAs for other chronic pain syndromes suggest they also might be efficacious for chronic pelvic pain”

Response Following Administration of Three Major

Antidepressants

# of trials# of trials (in 116 pts)(in 116 pts) TotalTotal

AntidepressantAntidepressant No ReliefNo Relief ReliefRelief TrialTrial

Imipramine Imipramine (Tofranil)(Tofranil)

11 (25%)11 (25%) 33 (75%)33 (75%) 4444

Amitriptyline Amitriptyline (Elavil)(Elavil)

4 (16%)4 (16%) 21 (84%)21 (84%) 2525

Desipramine Desipramine (Norpamin)(Norpamin)

10 (23%)10 (23%) 34 (77%)34 (77%) 4444

TotalTotal 30 (22%)30 (22%) 105 (78%)105 (78%) 135135

The Pelvic Witch Hunt

Be wary of claims for:

Presacral neurectomyUterine suspensionLUNA (lap US nerve ablation)Surgery for pelvic congestionLysis of adhesionsHysterectomy

Treatment

Analgesics NSAIDS including COX-2 inhibitors relieve various

pain No clinical trials have addressed chronic pelvic pain Opioids are increasingly used but randomized trials

suggest no improvement in functional or psychological status with increased risk in addiction

Treatment

Combined OCPs Provide significant relief

Suppress ovulation Reduce spontaneous uterine activity Stabilize estrogen and progesterone levels Abrogate menstrual increases in prostaglandin levels Reduce the amt of pain and symptoms associated with menses

Recommended for endometriosis-associated chronic pelvic pain One study showed OCPs comparable to GnRH agonist goserelin

in relieving chronic pelvic pain and dysparenia but less effective in relieving dysmenorrhea in women with endometriosis

OCPs do not significantly affect long-term recurrence of endometriosis

Continuous OCPs may be superior- no good data

Treatment

GnRH Agonists “down-regulate” Hypothalamic-pituitary gland production and

release of LH and FSH to reduce estradiol levels significantly Nafarenlin, Goserelin, Leuprolide Emperic treatment with GnRH agonists have the same

efficacy in women with symptoms consistent with endometriosis, whether or not they actually have endometriosis

Strongly suggests the response does not depend on surgical confirmation

Other pain from IBS, IC also vary with the menstrual cycle and respond to GnRH agonist treatment

Good evidence supports add-back therapy with estrogen, progesterone, or both can decrease side effects without loss of efficacy

Treatment

ProgestinsMPA

30-100mg po per day effectively decreases pain from endometriosis and pelvic congestion syndromes

Depo Provera may also be effective but no good studies

Treatment

Exercise Most studies suggest dysmenorrhea is decreased by

exercise but not definitive data on chronic pelvic pain

PT Electrotherapy, fast and slow twitch exercises of the

striated muscles of the pelvic floor, manual therapy of myofascial trigger points shown improvement of pain in 65-70% of patients

Treatment

Psychotherapy Many suggest various modes of psychotherapy

including cognitive therapy, operant conditioning, and behavioral modification appear to be helpful

Up to 50% of women with chronic pelvic pain have a history of physical or sexual abuse

Treatment

Herbal and Nutritional Therapies Many clinical trials of mag, B6, B1, omega 3s, Japanese herbal

combinations have been studies with no conclusive data

Magnestic Field Therapy Application of magnets to trigger paints may improve

symptoms Only one clinical trial has evaluated their use and had

significant methodologic flaws

Acupuncture Acupuncture, acupressure, and transcutaneous nerve

stimulation therapies have shown better than placebo in the treatment of dysmenorrhea

Only case reports for nonmenstrual chronic pelvic pain

Key Points

MULTIPLE ETIOLOGIES!!!!! Detailed history of PE are the basis of differential diagnosis Treatment is more of an art than a science

NSAIDs should be considered for mod pain and dysmenorrhea

Combined OCs primary dysmenorrhea Continuous OCs for long term ovarian suppression

GnRH effective for multiple etiologies of pain Empiric treatment without laparoscopy should be considered

High dose Progestins effective for chronic pelvic pain

Key Points

Laparoscopic surgical destruction of endometriosis best for stage I-III disease

Adding Psychotherapy to medical treatment often improves response

PT appears to be helpful in treatment and should be considered

Hysterectomy relieves 75-95% chronic pelvic pain

Antidepressants may be helpful (TCAs) in treatment of chronic pelvic pain

“If the only tool you have is a hammer, you tend to see every problem as a

nail.”

--Abraham MaslowAbraham Maslow

Thank you