Chronic Pelvic Pain

Chronic Pelvic Pain
Presentation lecture by:Jennifer Griffin, MD
University of Nebraska Medical Center

Chronic Pelvic Pain
* Definition = Pain of apparent pelvic origin that has been present most of the time for 6 months
* Difficult to diagnose.
* Difficult to treat.
* Difficult to cure.
* =Physician and patient frustration.
Just because you’re a hammer doesn’t necessarily make every problem a nail.

* Gynecologic
* Gastrointestinal
* Urologic
* Musculoskeletal/ Pelvic Floor
* Psychological

Getting the History
* Nature of the Pain:
* Timing of the Pain:
* Modifying factors:

Review of Systems
* Gynecologic:
o Association with menses?
o Association with sexual activity? (be specific)
o New sexual partners/ practices?
o Symptoms of vaginal dryness / atrophy?
o Other changes in menses?
o Use of contraceptives?
o Childbirth history and any associations?
o History of pelvic infections?
o History of other gyn problems/ surgeries?

* Gastrointestinal:
o Regularity of bowel movements?
o Diarrhea/ constipation/ flatus?
o Relief with defecation?
o History of hemorrhoids/ fissures/ polyps?
o Blood in stools, melena, or mucous?
o Nausea, vomiting, or appetite change?
o Weight loss?

* Urologic:
o Pain with urination?
o History of frequent / recurrent UTIs?
o Blood in urine?
o Symptoms of urgency or incontinence?
o Difficulty voiding?

* Musculoskeletal:
o History of trauma?
o Association with back pain?
o Other chronic pain problems?
o Association with position or activity?

* Psychological:
o History of abuse (verbal/ physical/ sexual)?
o Diagnosis of psychiatric disease?
o Association with life stressors?
o Exacerbated by life stressors?
o Family/ spousal support?

* Diagnosis
o History and Physical
o Targeted imaging studies (U/S best for gyn evaluation)
o EMB/D&C
o Laparoscopy
o Cystoscopy/ Colonoscopy
o Physical therapy evaluation

* Gynecologic Origin
o Endometriosis
o Primary Dysmenorrhea
o Leiomyomas
o Dyspareunia
o Vaginismus
o Adenomyosis
o Infectious causes
o Pelvic congestion syndrome
o Pelvic organ immobility
o Cancer


* ACOG Practice


Gyn Causes

* Cyclic:
o Primary dysmenorrhea
o Endometriosis
o Adenomyosis
o Mittleschmertz
* Non-cyclic:
o Pelvic masses
o Adhesions
o Infections
o Non-gyn causes
* Related to intercourse:
o Endometriosis
o Vaginismus
o Vaginal atrophy
o Musculoskeletal
o Any non-cyclic cause could be exacerbated.

* Endometriosis
o 7-10% of women (up to 50% in premenopausal women)
o 33% of women undergoing laparoscopy for pelvic pain will be diagnosed with endometriosis
o Found in 38% of infertile women
o Family history increases risk 10x
o Significant cause of morbidity

Chronic Pelvic Pain: Cyclic
* Endometriosis: Etiology
o Retrograde menstruation
o Hematogenous/lymphatogenous
o Coelomic metaplasia
o Immunologic dysfunction

* Endometriosis: Classic Triad
o Dysmenorrhea
o Dyspareunia
o Infertility
* But may present with:
o Chronic pelvic pain
o Adnexal mass

* Endometriosis: Diagnosis
o Clinical suspicion
o Presence of endometrial glands in biopsy outside endometrial cavity
o Elevated CA-125 without evidence of other pathology
o Relief of pain with empiric GnRH agonist
o Laparoscopy
+ Multiple appearances: red, brown, scar, white, puckering, powder burn, adhesions, endometriomas
+ Multiple locations: ovary, uterosacral ligaments, cul-de-sac, rectovaginal septum, and others

* Endometriosis:
o Classification
o ASRM 1996

* Endometriosis: Treatment
o Laparoscopic removal/destruction
o NSAID’s
o OCP’s
o Danazol
o GnRH analogs x 6-12 months
o LUNA
o TAH-BSO
o Pain clinic/TENS units
o Presacral neurectomy

* Dysmenorrhea
o NSAID’s
o OCP’s
o Vitamins: B6, B1
o Mg++
o Omega-3-Fatty acids

* Leiomyomas
o Pressure
o Pain
o Degeneration
o Treatment:
+ NSAID’s
+ OCP’s
+ Lupron
+ Myomectomy
+ Hysterectomy

* Adenomyosis =endometrial glands within the myometrium

o Rarely diagnosed via ultrasound
o May be inferred with laparoscopy
o Will have complaints related to bleeding and pain.
o May be anemic.
o Definitive Dx and Tx: hysterectomy/pathology

* Dyspareunia
o Endometriosis
o Adnexal masses
o Vulvovaginitis
o Chronic endometritis
o Vaginal dryness
o Vaginal atrophy
o Obstetrical trauma
o Surgical scars
o Vaginismus

* Vaginismus
o Primary
o Secondary
o Treatment:

* Pelvic Floor Muscle Spasm and Strain
o Piriformis m.
o Coccygeus m.
o Levator ani m.
o Peripartum pelvic pain syndrome
o Treatment:

Chronic Pelvic Pain: Non-cyclic

* Pelvic congestion syndrome
* Pelvic organ immobility
* PID
* Infectious causes
* Gynecologic malignancies
* Other Gynecologic origin:
o IUD
o Intra-uterine, cervical polyps
o Ovulatory pain (Mittelschmerz)
o Ovarian retention/remnant syndrome
o Adhesions
o Adnexal cysts
o Pelvic relaxation

* Treatment of Gynecologic Problems
o Empathic listening
o Analgesics (preferably NSAID’s, avoid opioids)
o OTC products (Astroglide, Replens, KY)
o OCP’s
o Antibiotics
o Removal of IUD, polyps
o GnRH analogs
o Surgery (Destruction/removal lesions, adhesiolysis, LUNA, hysterectomy, presacral neurectomy etc)
o Biofeedback/PT
o Antidepressants and Psychotherapy
o Marital/partner counseling
o Massage
o Acupuncture
o Exercise

* Urologic Origin, Level A:
o Bladder malignancy
o Interstitial Cystitis
o Radiation Cystitis
o Urethral Syndrome

Chronic Pelvic Pain
* Bladder origin, Level B:
o Uninhibited Bladder Contractions (Detrusor dyssynergia)
o Urethral diverticulum

* Urologic origin, Level C:
o Chronic UTI
o Recurrent, acute UTI
o Urolithiasis
o Urethral caruncle
o Urologic evaluation:
+ Urinalysis
+ Urine culture
+ Urine cytology
+ Cystourethroscopy +/- hydrodistension
+ IVP

* Urologic origin: Interstitial Cystitis
o Urinary urgency/frequency
o Glomerulations
o Potassium chloride test
o Emuron
o Antihistamines
o Tricyclic antidepressants (Imipramine 25-50mg @ hs)
o Intravesical treatments: DMSO, BCG
o Avoidance of acidic foods

* Gastrointestinal Origin, Level A:
o Carcinoma of colon
o Constipation
o Inflammatory bowel disease
o Irritable Bowel Syndrome
* IBS

Chronic Pelvic Pain
* IBS Treatment
* Colon carcinoma
* Constipation
* Inflammatory Bowel Disease
* Gastrointestinal origin, Level C (no Level B):
* Musculoskeletal, Level A:
* Musculoskeletal origin, Level B:
* Musculoskeletal origin, Level C:
* Other Non-Gynecologic Origin, Level A:
* Psychological
* Other Non-Gynecologic origins, level B:
* Other Non-Gynecologic origin, Level C:
Clinical Pearl of Wisdom
Pelvic Pain Treatment Triad
6 Case Studies
* Conclusions:

Chronic Pelvic Pain.ppt