Transcript Chronic pelvic pain

Chronic Pelvic
Pain in
Gynecological
Practice
Yasser Orief, M.D
Agenda
BACHGROUND
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Definition of pain
Nociception & innervation
Innervation of urogenital system
PAIN EVALUATION & MEASUREMENT
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Pain Evaluation
Pain measurement
CHRONIC PELVIC PAIN
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Definitions of CPC
Classification of CPC syndromes
PELVIC PAIN IN
GYNAECOLOGICAL PRACTICE
 Diagnosis
 Dysmenorrhoea
 Infection
Adhesions
 Endometriosis
 Gynaecological malignancy
 Injuries related to childbirth
Background
Pain is the most common symptom of any
illness; the physician’s therapeutic task
is twofold:
 to discover and treat the cause of pain
 and to treat the pain itself, whether or
not the underlying cause is treatable.
PAIN
“AN UNPLEASANT SENSORY AND
EMOTIONAL EXPERIENCE ASSOCIATED
WITH ACTUAL OR POTENTIAL TISSUE
DAMAGE”*
* INTERNATIONAL ASSOCIATION FOR THE STUDY OF PAIN
Pain Pathway
Complex Neuro network
Actually two quite different kinds of pain exist:
 The first is termed nociceptive. This pain is
associated with tissue damage or
inflammation, so it is also called ‘inflammatory
pain’.
 The second is termed neuropathic and results
from a lesion to the peripheral or central
nervous systems.
 Many pains will have a mixed neuropathic
and nociceptive aetiology.
Levels of pain
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Pathology at the site of origin.
Referred Pain.
Trigger points .
Action of the Brain.
It is important to remember that all of these 4
levels of pain must be treated together for
CPP therapy to be successful.
Referred pain
Viscerosomatic Convergence and Pelvic Floor Myalgia
Referred pain
Viscerovisceral Hyperalgesia
Abdominal Wall Trigger Points
Pain Evaluation &
Measurement
Systematic evaluation of the pain
involves the following;
• Take a detailed history of the pain including an
assessment of the pain intensity and character
• Evaluate the psychological state of the patient,
including an assessment of mood and coping
responses
• Perform a physical examination emphasizing the
neurologic examination
• Appropriate diagnostic workup to determine the cause
of the pain which may include tumour markers,
radiologic studies, scans etc.
• Re-evaluate therapy.
Pain measurement
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A number of different rating scales have been
devised.
They all rely on a subjective assessment of
the pain and therefore make inter-individual
comparisons difficult.
Additionally, pain is a multidimensional
complex phenomenon and is not adequately
described by unidimensional scales
Scaling systems
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Categorical scales e.g., verbal rating
scales: mild, moderate, severe pain
Visual analogue scale (VAS)
Complex pain assessment
Brief Pain Inventory (BPI), McGill Pain
Questionnaire.
Chronic Pelvic Pain (CPP)
ACOG Definition of CPP
“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.”
ACOG Practice Bulletin No. 51. American College of Obstetricians and Gynecologists.
Obstet Gynecol. 2004;103:589-605.
Definition of Chronic Pelvic
Pain
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Duration
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3months if continues
6 months if cyclic
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Location
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Anatomic pelvis
Abdominal wall
below the umbilicus
Lower back
Non-cyclic
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± Dysmenorrhea
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± Dyspareunia
Severity
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Medical or surgical
therapy required
Functional
impairment
Why is Chronic Pelvic Pain
so Different?
ACUTE vs CHRONIC PAIN
ACUTE PELVIC PAIN: symptom of
underlying tissue injury and disease
CHRONIC PELVIC PAIN: pain becomes
the disease (etiology not found or
treatment of presumed etiology fails)
CPP Syndrome
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Is the occurrence of persistent or recurrent
episodic pelvic pain associated with
symptoms suggestive of lower urinary tract,
sexual, bowel or gynaecological
dysfunction. There is no proven infection or
other obvious pathology.
(adopted from ICS 2002)
CPP Syndrome
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Bladder pain syndrome
Urethral pain syndrome
Penile pain syndrome
Prostate pain syndrome
Scrotal pain syndrome
Testicular pain syndrome
Post vasectomy pain syndrome
Epididymal pain syndrome
Endometriosis associated pain
syndrome
Vaginal pain syndrome
Vulvar pain syndrome
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Generalized vulvar pain
syndrome
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Localized vulvar pain
syndrome
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Vestibular pain syndrome
Clitorial pain syndrome
Anorectal pain syndrome
Anismus pain syndrome
Pudendal pain syndrome
Perineal pain syndrome
Pelvic floor muscle pain
syndrome
Epidemiology
CPP Is a Significant and
Common Disorder in Women
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Magnitude of CPP
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>9 million women in the United States1
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20% of women had pelvic pain >1 year in duration2
CPP accounts for
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10% of referrals for OB/Gyn visits3
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Over 20% of laparoscopies4
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12 -18 % of hysterectomies5
Patients with CPP have significantly lower general health scores
compared with patients without CPP1
1. Mathias SD et al. Obstet Gynecol. 1996;87:321-327.
4. Howard FM. Obstet Gynecol Surv. 1993;48:357-387.
2. Jamieson DJ, Steege JF. Obstet Gynecol. 1996;87:55-58. 5. Carlson KJ et al. Obstet Gynecol. 1994;83:556-565.
3. Reiter RC. Clin Obstet Gynecol. 1990;33:130-136.
Prevalence Rate per 1,000
Women
Prevalence of CPP is Comparable to
Other Common Medical Problems
100
90
80
N=24,053
70
60
50
40
38
37
30
41
21
20
10
CPP
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Migraine
Asthma
Back Pain
Cross-sectional analysis by UK Mediplus Primary Care database.
Zondervan KT et al. Br J Obstet Gynaecol. 1999:106;1149-1155.
Medical costs for CPP
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Direct outpatient medical costs for CPP:
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$881.5 million/year1
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Total annual direct costs $2.8 billion/year
15% of women with CPP missed >1 hr paid
work/month1
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Cost of work time lost for CPP $555.3
million/year
1. Mathias SD et al. Obstet Gynecol. 1996;87:321-327.
Etiology
Introduction
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Pelvic pain has
multifactorial etiology
Overlapping cerebral
representation for
somatic and visceral
structures
Multiple stakeholders
involved in evaluation
and management
Neurology
/
pain med
GI/GU
GYN
PM&R
Systems Based Evaluation
Gastrointestinal
Skeletal
Muscular
Vascular
Reproductive
Urinary
Neurologic
Don’t forget the most important extra-abdominal organ!
Psychiatric evaluation
Etiology
Physical vs. Psychiatric
100% Physical
100% Psychiatric
ACOG Practice Bulletin
Number 51; March 2004
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CPP is common in women and presents a
diagnostic challenge
Most common disorders that cause CPP are
endometriosis, interstitial cystitis and irritable
bowel syndrome
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38-85% of women presenting to a gynecologist
for CPP may have IC
ACOG Practice Bulletin No. 51. American College of Obstetricians and Gynecologists.
Obstet Gynecol. 2004;103:589-605.
Necessity of Multidisciplinary
Approach
Pelvic Pain Assessment Forms
International Pelvic Pain
Society Assssment Form
History
Detailed
Focused
Pelvic Review of systems
Biopsychosocial Model
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Chronic Pelvic Pain: History
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Pain duration > 6 months
Incomplete relief by most previous
treatments, including surgery and nonnarcotic analgesics
Significantly impaired functioning at
home or work
Signs of depression such as early
morning awakening, weight loss, and
anorexia
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Pain out of proportion to pathology
History of childhood abuse, incest, rape
or other sexual trauma
Current sexual dysfunction
Previous consultation with one or more
health care providers and dissatisfaction
with their management of her condition
Physical Examination
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General Examination
Check for Fibromyalgia
Check Abdominal Wall trigger points
Systematic physical exam of abdominal, pelvic, and rectal areas,
focusing on the location and intensity of the pain.
Q-tip test for vestibulitis
Check for Pelvic Floor Myalgia
Single Digit Pelvic Exam
Speculm exam
Bimanual exam
Rectovaginal exam
Palpate the coccyx, both internally and externally
Patient Evaluation for
Bladder Tenderness
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Suprapubic
tenderness
Anterior vaginal
wall/
bladder base
tenderness
X
Levator muscle
spasm
Rectal spasm
Howard FM, Perry CP, Carter JE, El-Minawi AM. Pelvic Pain: Diagnosis and Management. Lippincott. 2000:35-39.
Physical Examination: Pelvic
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Traditional bimanual
examination is the
last portion of the
pelvic examination
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Uterus
Adnexa
Anorectum
Many layers palpated;
non-specific findings
likely
Investigations
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Should be selected discriminately as indicated by the
findings of the history and physical exam
Avoid unnecessary and repetitive diagnostic testing
Vaginal smearing
Cervical cultures
HSG
Stool analysis
Ultrasound
Diagnostic laparascopy
Dysmenorrhoea
Dysmenorrhoea
Pain in association with menstruation may be primary or
secondary.
 Primary dysmenorrhoea classically commences with
the onset of ovulatory menstrual cycles and tends to
decrease following childbirth
 Explanation and reassurance may be helpful,
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together with the use of simple analgesics
progressing
 to the use of non-steroidal anti-inflammatory drugs
(NSAIDs), which are particularly helpful if they are
started before the onset of menstruation.
Dysmenorrhoea
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Suppression of ovulation using the oral contraceptive
pill reduces dysmenorrhoea dramatically in most
cases.
Because of the chronic nature of the condition,
potentially addictive analgesics should be avoided.
Secondary dysmenorrhoea would suggest the
development of a pathological process, and the
exclusion of endometriosis and pelvic infection is
essential
Infection
Infection
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A history of possible exposure to infection should be sought and
it is mandatory in all cases to obtain swabs to exclude
chlamydia and gonorrhoea, as well as vaginal and genital tract
pathogens.
Patient’s sexual contacts will need to be traced in all cases with
positive cultures. If there is doubt about the diagnosis then
laparoscopy may be of great assistance.
The treatment of infection depends on the causative organisms.
Infection
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Subclinical chlamydial infection may lead to tubal pathology.
Screening for this organism in sexually active young women
may reduce the incidence of subsequent subfertility.
Chronic pelvic inflammatory disease is no longer common in
developed countries, but still poses a significant problem with
chronic pain in the Third World.
Gynaecological malignancy
Gynaecological malignancy
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The spread of gynaecological malignancy of
the cervix, uterine body or ovary will lead to
pelvic pain depending on the site of spread.
Treatment is of the primary condition, but all
physicians dealing with pelvic pain must be
fully aware of the possibility of gynaecological
malignancy.
Injuries related to childbirth
Injuries related to childbirth
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Tissue trauma and soft tissue injuries
occurring at the time of childbirth may lead to
chronic pelvic pain related to the site of
injury.
Dyspareunia is a common problem leading to
long-term difficulties with intercourse and
female sexual dysfunction.
Denervation of the pelvic floor with reinnervation may also lead to dysfunction and
pain.
Pelvic Adhesion
PELVIC ADHESIONS
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If adhesions
are found
adhesiolysis is
beneficial in
only 40%
(especially in
patients with
chronic pain
syndromes)
Steege, 1991
Endometriosis & CPP
Endometriosis?
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characterized by the presence of
endometrium-like tissue in ectopic sites
outside the uterus, primarily on pelvic
peritoneum and ovaries
affects nearly 1 in 7 women of reproductive
age
third most common gynecologic disorder
that requires hospitalization, and a leading
cause of hysterectomy.
Commonly affected organs and structures: Ovaries and
the sacral ligament
Endometriosis on bowel surfaces
Endometriosis on appendix
Endometriosis Symptoms
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Chronic pelvic pain
Dysmenorrha
Dyspareunia
Infertility
Endometriosis and Pain
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Chronic pelvic pain is the most consistent
symptom with a prevalence of 30-70% in
adults, and 45-58% in adolescents.
Dysmenorrhea is associated with
endometriosis in more than 50% of adults,
and up to 75% of adolescents
Dyspareunia is variable ranging from 4%55%
Endometriosis Treatment
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Medical Treatment
• Established Medical Treatments
• Experimental Treatments
Surgical Treatment
• Conservative
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Vaporization
Coagulation/ablation
•
Radical
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Excision
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Role of laparoscopy
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Best evidence suggests that
symptomatic relief can be achieved with
either medical or surgical therapy for
mild to moderate disease.
For severe or nodular disease or for
patients with endometriomas, surgical
alternatives are most effective.
ACOG technical bulletin
Endometriosis & the endometrium Diamond & Osteen
•Pain Control
•Restoration of Fertility
•Prevention of Recurrence
The optimal medical treatment
No menopausal symptoms
No proliferation
Menopausal
Symptoms
Therapeutic
Window
Proliferation of implants
Estradiol level
pg/ml
Established Medical
Treatments
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Oral Contraceptives
Progestins
Danazol
NSAIDs
GnRH analogues
Pain-Medical therapy
(Comparative Trials)
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GnRHa vs. Danazol
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GnRHa vs. Progestins
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15 Trials No difference
2 Trials, No difference
GnRHa vs. OCP
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1 Trial, No difference for pelvic
pain, GnRH more effective for
dysmenorrhea and dyspareunia
Established Medical Therapy for Total
Pain
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These drugs are equally effective in reducing
the endometriotic implant mass/severity of the
disease as well as reducing pelvic pain
associated with endometriosis
Initial treatment the choice should be based
on cost and side effect profile of the drug
NSAID’s appropriate and successful in many
cases
GnRH agonists have been proved effective
after the failure of a prior medical hormonal
therapy
Suggested approach to
endometriosis-associated pain
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1st line: continuous low-dose monophasic oral
contraceptive with NSAIDs as needed
2nd line: progestins (start with oral dosing,
consider switching to levonorgestrel intrauterine
device or depo if well tolerated)
3rd line: GnRH agonist with immediate add-back
therapy
4th line: repeat surgery, followed by 1, 2, or 3
May consider low-dose (100–200 mg every day)
danazol if other therapies poorly tolerated.
Mahutte and Arici, 2003
Experimental Treatments
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RU486 (mifepristone) and SPRMs
GnRH antagonists
TNF-a Inhibitors
Angiogenesis Inhibitors
MMP Inhibitors
Immunomodulators
Estrogen Receptor-b Agonists
Aromatase Inhibitors
Suggested approach to
endometriosis-associated pain
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1st line: continuous low-dose monophasic oral
contraceptive with NSAIDs as needed
2nd line: progestins (start with oral dosing, consider
switching to levonorgestrel intrauterine device or depo if
well tolerated)
AROMATASE INHIBITORS with OC or a Progestin
3 rd (4th) line : GnRH agonist with immediate add-back
therapy
AROMATASE INHIBITORS with a GnRH analogue
4th (6th) line: repeat or no surgery, followed by 1, 2, or 3 ,
or AIs with OC, progestin and GnRH analogue
Surgical Excision
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Aggressive
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Entire visible lesion should be removed.
Any abnormal peritoneum is suspect (50%
positive path)
Appendix should go. (Lyons et al JAAGL 2002)
Conservative
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Uterus, tubes and ovaries most often can be
conserved.
Surgical Pearls
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Identify ureters & bowel first.
Use the avascular spaces.
Work from known to unknown.
Maintain hemostasis moment to
moment.
Save the bowel to last if possible.
Avoid hydro-dissection when possible
Be patient
What do you consider as
Endometriosis Treatment
failure?
IC Can Appear Concurrently With
Endometriosis. THE EVIL TWINS!
Two Studies Confirm the Overlap Between
IC and Endometriosis1,2
Study 1:
Chung et al1
(n=60)
Study 2:
Chung et al2
(n=178)
IC/PBS
90%
89%
Endometriosis
80%
75%
Diagnosis
Both
70%
1. Chung MK et al. J Soc Laparoendosc Surg. 2002;6:311-314.
2. Chung MK et al. J Soc Laparoendosc Surg. 2005;9:25-29
65%
Consider the Bladder in Women With
Unresolved CPP
61% have no obvious etiology for CPP1
80% of women with CPP receive an initial
diagnosis of endometriosis2
Up to 54% of women treated medically for
endometriosis continue to experience CPP3
▪ 5% to 26% have reported continued CPP
1 year after hysterectomy4-9
The bladder is believed to be the source
of CPP in over 30% of female patients10
1. Mathias SD et al. Obstet Gynecol. 1996;87:321-327. 2. Carter JE. J Am Assoc Gynecol Laparos. 1994;2:43-47.
3. Dlugi AM et al. Fertil Steril. 1990;54:419-427. 4. Carlson KJ et al. Obstet Gynecol. 1994;83:556-565. 5. Kjerulff KH
et al. Obstet Gynecol. 2000;95:319-326. 6. Kjerulff KH et al. Am J Obstet Gynecol. 2000;183:1440-1447. 7. Stovall TG
et al. Obstet Gynecol. 1990;75:676-679. 8. Hillis SD et al. Obstet Gynecol. 1995;86:941-945. 9. Hartmann KE, et al.
Obstet Gynecol. 2004;104:701-709. 10. Zondervan KT et al. Br J Obstet Gynaecol. 1999;106:1156-1161.
Chronic Pelvic Pain Is Characterized by Overlapping Disease Conditions
Interstitial
Cystitis/PBS
Endometriosis
Adenomyosis
GI Disorders
IBS
Chronic
Pelvic Pain
Overlapping
Disease
Conditions
Recurrent UTI
Vulvodynia
Pelvic Infection
and Adhesions
Cardinal Principles of Pain Management
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Believe the Patient
Have Realistic Goals
Institute Adequate Pain Relief
Identify All Pain Generators
Setup Appropriate Diagnostic Studies
Explain the Reasons for Complexity
THANK YOU FOR
YOUR
ATTENTION