Aboubakr Elnashar

Chronic Pelvic Pain in

Women An Evidence based approach

Aboubakr Elnashar Prof Ob Gyn, Benha Universiy Hospital, Egypt

Aboubakr Elnashar

ACOG (2004).

RCOG (2005)

Cochrane Library. Syt Review: copyright (2010)

Interventions for treating chronic pelvic pain in

women. Stones W, Cheong YC, Howard FM, Singh S

Aboubakr Elnashar

Diagnostic dilemmas.

: Frustration for both the physician and the

patient.

Disability and distress

Significant costs to health services.

CPP

Aboubakr Elnashar

Aboubakr Elnashar

OBJECTIVES

DEFINITIONS.

CAUSES.

PATHOGENESIS

DIAGNOSIS.

TREATMENT.

CONCLUSION

DEFINITION

ACOG (2004).

Noncyclic pain that lasts 6 months or more;

localized to the pelvis, the anterior abd wall at or

below the umbilicus, or the buttocks

sufficient severity to cause functional disability or

require medical care

Other definitions

do not require that the pain be noncyclic.

Aboubakr Elnashar

RCOG (2005)

Intermittent or constant pain for at least 6 months

lower abdomen or pelvis.

Not occurring exclusively with menstruation or intercourse

Not associated with pregnancy.

Aboubakr Elnashar

Aboubakr Elnashar

PREVALENCE

1 in 6 of the adult female. (RCOG ; 2005)

15% (Mathias et al, 1999)

common in women in the reproductive and

older age groups

Aboubakr Elnashar

PATHOGENESIS

Often laparoscopy reveals no obvious cause

Possible explanations in absence of cause

1. undetected IBS (Prior 1989).

2. central sensitisation of the nervous system (Rapkin 1995)

3. vascular hypothesis (Taylor, 1949; Beard 1984)

pain arises from dilated pelvic veins in which blood

flow is markedly reduced.

{pathophysiology is not well understood}: tt is often

unsatisfactory and limited to symptom relief.

Aboubakr Elnashar

CAUSES

Definitive diagnosis is not made for 61% (Zondervan et al, 1999)

Many patients & physicians incorrectly

assume that all CPP results from a

gynecologic source.

One study in the UK:

Urinary&GIT: more common than gynecologic.

25-50%: more than one cause. Aboubakr Elnashar

Gastrointestinal: IBS celiac disease Colitis colon cancer inflammatory bowel disease

Urologic: Interstitial cystitis bladder malignancy chronic urinary tract infection radiation cystitis urolithiasis

Aboubakr Elnash

Aboubakr Elnashar

•Gynecologic

Extrauterine

oAdhesions

oChronic PID

oEndometriosis

oAdnexal cysts

oOvarian remnant syndrome

Uterine

oAdenomyosis

oChronic endometritis

oFibroids

oIntrauterine device

oPelvic congestion syndrome

oGyn malignancy

Pelvic congestion syndrome:

Pain:

consistent dull aching pelvic

accentuated before menses

associated with low backache, dyspareunia,

postcoital aching,

Discomfort on prolonged sitting and standing and

often associated with variable degree of

premenstrual tension.

The patient

usually multipara

in her 30s-

60% have some sort of psychopathology.

Diagnosis:

Transuterine venography is the standard for

diagnosis.

U/S, doppler and laparoscopy may reveal

varicosities. '

Treatment

I. Medical

1. Suppressive therapy:

Low estrogen- high gestagen OCs,

GnRHa or

continuous high dose progestogen, MPA (Provera)

50-300mg/day for up to 18 months, have achieved

promising results

2. Venoactive drugs

Micronised purified flavonoid fraction (Daflon 500

mg twice daily for 6 months

protective and tonic effect on the venous and

capillary wall: increase in venous tone, improvement

in lymphatic drainage and a reduction in capillary

hyperpermeability: ameliorate venous stasis. (Simsek et al.2007)

statistically significant improvement in pelvic pain

scores without any side effects.

Dihydroergotamine (DHE) (Migranal): Is a selective

venoconstricting agent which increases venous tone

and mobilizes blood which is present in capacitance

vessels.

II. Surgical

III. Embolization

IV. Psychotherapy:

explanation, reassurance that she is normal, with

some sedative drugs.

Musculoskeletal:

Degenerative disk disease

Fibromyalgia

levator ani syndrome

myofascial pain

peripartum pelvic pain syndrome

stress fractures

Aboubakr Elnashar

Psychiatric/neurologic

Abdominal epilepsy

abdominal migraines

Depression

nerve entrapment

neurologic dysfunction

sleep disturbances

Somatization

Other

Familial Mediterranean fever

herpes zoster

porphyria

Aboubakr Elnashar

Aboubakr Elnashar

Aboubakr Elnashar

Most commonly diagnosed causes

IBS

Interstitial cystitis

Endometriosis

Pelvic adhesions.

Aboubakr Elnashar

DIAGNOSIS

I. History

II. Physical examination

III. Investigations

I. HISTORY Characteristics of the pain

Quality, duration, modifying factors

its association with menses, sexual activity, urination, defecation

History of pelvic infections, or previous surgeries.

Urinary complaints:

Dysuria, Urgency, Frequency

Bowel complaints:

Constipation, flatulance, Diarrhea.

History of physical or sexual abuse

Aboubakr Elnashar

Aboubakr Elnashar

Red flag symptoms

unexplained weight loss

New bowel symptoms over 50

New pain after the menopause

Pelvic mass

Bleeding per rectum

Irregular vaginal bleeding over 40

Post coital bleeding

Rule out malignancy or serious systemic disease.

Possible significance

Hematochezia: Gastrointestinal malignancy/bleeding History of pelvic surgery, pelvic infections, or use of

intrauterine device: Adhesions Nonhormonal pain fluctuation: Adhesions, interstitial cystitis, IBS, musculoskeletal

causes Pain fluctuates with menstrual cycle: Adenomyosis or endometriosis

Aboubakr Elnashar

II. PHYSICAL EXAMINATION

Abdominal:

Slowly & gently {abdominal & pelvic components of

the examination may be painful}.

Palpation of the outer pelvis & back: trigger points:

myofascial cause

Tenderness

masses or

other anatomical findings

Lack of findings does not rule out intra-abdominal

pathology

Aboubakr Elnashar

Aboubakr Elnashar

Trigger points on abdominal wall

Ultrasound showing hydrosalpinx - circled in red Ovary stuck up high in scar tissue - circled in blue

Tenderness over the “ovarian point”

Suggests pelvic congestion syndrome.

Aboubakr Elnashar

Pelvic examination:

Single-digit, one-handed examination.

Bimanual examination:

Nodularity

point tenderness

cervical motion tenderness, or

lack of mobility of the uterus.

A moistened cotton swab:

point tenderness in the vulva & vagina

Aboubakr Elnashar

Rectal examination

Rectal or posterior uterine masses,

nodularity, or

pelvic floor point tenderness.

Aboubakr Elnashar

Carnett’s sign

Placing a finger on the painful, tender area of the

patient’s abdomen

patient raise both legs off the table while lying in the

supine position

Positive test: pain increases

Myofascial cause

Abdominal wall cause. e.g., fibromyalgia or trigger

point.

Visceral pain should not worsen during the

maneuver.

Aboubakr Elnashar

Aboubakr Elnashar

Aboubakr Elnashar

III. INVESTIGATIONS If the history & physical examination do not lead to a

diagnosis: {C}

Cancer screenings appropriate to age & risk factors.

β-hCG: rule out pregnancy

CBC:

Infection, systemic illness, or malignancy

(elevated/decreased WBC or anemia)

Urinalysis & urine culture:

Bladder malignancy, infection

ESR:

Infection, malignancy, systemic illness

Vaginal swabs:

gonorrhea & chlamydia: PID

TVS:

Adenomyosis

endometriosis/endometrioma

malignancy {B}

MRI & CT

should not be used routinely, but can help assess

any abnormalities found on TVS {B}.

Aboubakr Elnashar

Laparoscopy

in the past: ‘gold standard’.

2nd line of investigation if other therapeutic

interventions fail {C}

(RCOG, 2005).

Indication:

Diagnosis remains elusive after the initial

workup

Confirm or treat, suspected endometriosis,

adhesions, or both.

Aboubakr Elnashar

Aboubakr Elnashar

TREATMENT

Types of interventions

Lifestyle:

exercise, dietary, substance use.

Psychological:

cognitive behaviour therapy, psychotherapy,

counselling, meditation, biofeedback, US as

reassurance, hypnosis.

Physical therapy.

Aboubakr Elnashar

Medical:

NSAIDs, OCP, oral and non-oral progestogen,

danazol, GnRH analogues (alone or with ’add-back’

oestrogen), progestogen-releasing intra-uterine

contraceptive devices (IUCD), drugs affecting blood

vessels, antidepressants, anticonvulsants,

analgesics, combined analgesic and caffeine

preparations, local anaesthetic infiltration alone or

in combination with corticosteroids.

Aboubakr Elnashar

Surgical:

diagnostic laparoscopy, adhesiolysis,

ventrosuspension, presacral neurectomy,

laparoscopic uterine nerve ablation (LUNA), ovarian

vein ligation (via surgery or radiology),

hysterectomy, oophorectomy, ovarian drilling,

wedge resection, endometrial ablation.

Other:

Transcutaneous nerve stimulation, complementary

medicine, referral to standard versus

multidisciplinary clinic setting

Aboubakr Elnashar

Cochrane analysis, 2010: Few RCT

Of the cause: IBS, interstitial cystitis, endometriosis,

PID, dysmenorrhea,

No cause:

Multidisciplinary approach{A}:

Dietary

Social

Environmental

Psychological factors in addition to

medication therapy)

improve outcomes over medication therapy alone {B}.

Aboubakr Elnashar

Counseling supported by ultrasound

scanning {B}

Social problems

Depression

Sexual abuse

Personality disorder

Troubled marriage

Family crisis.

Aboubakr Elnashar

I. Non surgical therapies:

Excluded: endometriosis,primary dysmenorrhea,

PID,IBS, interstitial cystitis

Only the following tts have shown benefit:

Oral MPA (Provera) 50 mg/d {B}

GnRHa Goserelin (Zoladex) for 3-6 m before

laparoscopy {A}

Progestogen (MPA): reduction of pain during tt while

goserelin gave a longer duration of benefit.

Aboubakr Elnashar

Cyclic pain: hormonal treatments

(continuous or cyclic low-dose COC {A}, progestins,

or GnRHa) should be considered, even if the

cause is thought to be IBS, interstitial cystitis, or

pelvic congestion syndrome {these conditions may

also respond to hormone tts}

Although selective serotonin reuptake inhibitors

have not been shown to be effective for treating

CPP, they may be used to treat concomitant

depression

Writing therapy and static magnetic field therapy

showed some evidence of short-term benefit.

Trigger point injections of the abdominal wall for

myofascial causes: some benefit (Langford et al, 2007).

Botulinum toxin type A injections into the pelvic

floor muscles: some benefit (Abbott et al, 2006)

Oral analgesics:

Acetaminophen

NSAID {C}

opioid analgesics: commonly used to treat

moderate pain

No RCT

Gabapentin (Neurontin)

alone or in combination with amitriptyline:

significant pain relief in women with CPP (Sator-Katzenschlager et al, 2005, RCT)

Aboubakr Elnashar

II. Surgical Therapies

Benefit was not demonstrated for

adhesiolysis (apart from where adhesions were severe)

uterine nerve ablation

LUNA

sertraline or photographic reinforcement after

laparoscopy.

Total abdominal hysterectomy: some benefit in

observational & cohort studies.

History, Examination

Warning signs

No: History`&Exam suggestive of IBS, IC, endometriosis, myofacial

No: CBC, urine, BHCG ESR,STD, TVS

Normal

Address comorbid (pschosocial,

enviromental, dietary) Reassurance

Abnormal

Evaluate & TT specific abnormality

Yes: Evaluate & TT

Yes: Exclude malignancy or serious disease

ACOG, 2005

Aboubakr Elnashar

NSAID or Acetaminophen

Inadequate relief

Cyclic pain

Provera, COC, Depoprovera, GNRHa, Mirena

Inadequate relief

Noncyclic pain

Gabapentin &Amitrytlyline

Inadequate relief

Laparoscopy Aboubakr Elnashar

Aboubakr Elnashar

Conclusion Main approaches to treatment include

Counselling or psychotherapy,

Attempts to provide reassurance using laparoscopy

to exclude serious pathology,

Progestogen therapy such as with MPA and

Surgery to interrupt nerve pathways.

Aboubakr Elnashar