Transcript Stump the Gynecologist: Differential Diagnosis of Chronic

Stump the Gynecologist: Differential
Diagnosis of Chronic Pelvic Pain
Jennifer K. McDonald DO F.A.C.O.G.
October 10, 2008
ACOG Definition
“Non-cyclic pain of 6 or more months
duration that localizes to the
anatomic pelvis, abdominal wall at or
below the umbilicus, lumbosacral back
or the buttocks and is of sufficient
severity to cause functional disability
or lead to medical care.”
Background
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10% out-patient gynecologic visits
20% of laparoscopies
15% of hysterectomies
$2.8 billion annually
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15% of American women
61% of CPP will have no definitive
diagnosis !!
Prevalence Rate per 1,000 Women
Prevalence
100
90
80
70
60
50
40
38
30
37
41
21
20
10
CPP
Migraine
Asthma
Back Pain
Age Prevalence
Features
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Present for six months or more
Conventional treatments have yielded little or no
relief
Degree or pain perceived seems out of proportion
to the degree of tissue damage detected by
conventional means
Physical appearance of depression is present
Physical activity is increasingly limited
Emotional roles in the family are altered
Distinction
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Acute pain
Pain is symptom of underlying
tissue damage
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Chronic pain
Pain itself becomes the
disease
Females - Unique Design
• Structural changes during
development
• Pelvis widens after menarche
• Gluteal stretching
• Internal rotation of the
femurs/lateral displacement of
the patella
• Ligamentous laxity
• Decreased muscular tone
increases lumbar lordosis and
exaggerated anterior pelvic tilt
• Pelvic organs connected
through shared common nerve
pathways
Where do we look?
Gynecologic - extra-uterine
Gynecologic - uterine
Urologic
Musculoskeletal
Gastrointestinal
Neurologic
Referred Pain
Ovary
T10
umbilical area
Uterus
T12
lower abdominal
wall
Vagina
L1
skin over groin
Most common culprits
Endometriosis
Adenomyosis
Interstitial cystitis
Irritable bowel
Pelvic Adhesions
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Endometriosis
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Presence of endometrial glands and stroma outside
the uterus
No difference among ethnic groups or
socioeconomic status
Genetic predisposition 6-10% increased risk with
history of first degree relative
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Dysmenorrhea
Abnormal bleeding
Dyspaurenia
GI complaints
Infertility
Urinary complaints
Low back pain
The many faces of
endometriosis
Location Location
76%
69%
47%
36%
11%
6%
4%
ovaries
posterior & anterior
cul de sac
posterior broad
ligament
uterosacral ligaments
uterus
fallopian tubes
sigmoid colon
Interstitial Cystitis
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Prevalence of bladder origin chronic pelvic
pain/interstitial cystitis is much greater
than previously believed
IC is a chronic inflammatory condition of the
bladder characterized by irritable voiding
symptoms of urgency and frequency in the
absence of objective evidence of another disease
that could cause the symptoms
Pathogenesis of IC:
Defective Urothelial Barrier
Irritating
Solutes
Urothelium
GAG
Layer
Inflammation
Irritated
Nerve
IC is Typically Diagnosed
Late in Disease Continuum
Average Time Between Initial Development of
Symptoms and Diagnosis is 5 Years
See at least
5 physicians
before diagnosis
Initial
Development of
IC Symptoms
Significant suffering
and reduced QOL
Diagnosis of IC
2-7 years
May have
unnecessary
hysterectomy
IC Concurrent with Endometriosis
Diagnosis of Patients With CPP by
Cystoscopy and Hydrodistention & Laparoscopy1
10%
IC Alone
70%
IC and
Endometriosis
20%
Endometriosis
Alone
Clinicians should consider the bladder to be the source
of CPP, even when endometriosis is present
Identifying Patients Is Important
A New Screening Questionnaire for
Pelvic Pain and Urgency/Frequency (PUF)
Circle the answer that best describes how you feel for each question.
0
1
2
3
4
3-6
7-10
11-14
15-19
20+
0
1
2
3
4+
None
Mild
Moderate
Severe
Never
Occasionally
Usually
Always
Never
Occasionally
Usually
Always
Do you have pain associated with your bladder or in
your pelvis, vagina, lower abdomen, urethra, perineum,
testes, or scrotum?
Never
Occasionally
Usually
Always
6
Do you still have urgency shortly after urinating?
Never
Occasionally
Usually
Always
7
a. When you have pain, is it usually—?
Mild
Moderate
Severe
Occasionally
Usually
Always
Mild
Moderate
Severe
Occasionally
Usually
Always
1
How many times do you void during waking hours?
2
a. How many times do you void at night?
b. If you get up at night to void, to what extent does
it usually bother you?
3
Are you currently sexually active?
YES _____ NO_____
4
a. If you are sexually active, do you now have or have you
ever had pain or urgency to urinate during or after
sexual intercourse?
b. Has pain or urgency ever made you avoid sexual intercourse?
5
b. How often does your pain bother you?
8
Never
a. When you have urgency, is it usually—?
b. How often does your urgency bother you?
Never
Symptom
Score
Bother
Score
SYMPTOM SCORE (1, 2a, 4a, 5, 6, 7a, 8a)
BOTHER SCORE (2b, 4b, 7b, 8b)
TOTAL SCORE (Symptom Score + Bother Score) =
PUF
PUF is
is aa constellation
constellation of
of symptoms
symptoms identified
identified by
by IC
IC experts
experts as
as characteristic
characteristic of
of interstitial
interstitial cystitis.
cystitis.
The
The more
more symptoms
symptoms aa patient
patient experiences,
experiences, the
the more
more likely
likely itit is
is that
that they’re
they’re caused
caused by
by interstitial
interstitial cystitis.
cystitis.
Parsons 2000
1
Pelvic Adhesions
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Distort normal blood/nerve supply
Decreased mobility of
organs/hypoxia
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Pelvic inflammatory disease (PID)
Most common Chlamydia
Inflammatory reaction
Secretion of prostaglandins
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Fibromyalgia Tender Points
11 or more TP
sensitivity of
88% and
specificity of
81%
Abdominal Wall Tenderpoints
Irritable Bowel
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12% US population
2:1 women
Peak age 30-40
Increased GI
motility and
sensitivity to
stimulants
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Pelvic Pain Assessment Forms
www.pelvicpain.org
Pain Diaries
www.reliefinsite.com
Keys to Treatment
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Pain and its perception are located in the nervous
system so its treatment must encompass a Mind
and Body approach
Multiple interactive problems are most likely with
CPP so it isn’t which treatment is best but which
treatments
It usually took time for things to get to where
they are so it will be take time to get them back
to normal as well
Chronic pain affects a family not just an individual
patient
How can chiropractic help
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Manipulation increases spinal mobility
and improves blood supply by
influencing the autonomic nervous
system
The patient with CPP needs a multidisciplinary
approach … are you ready?