Chronic Non Cancer Pelvic Pain Management

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Chronic Non Cancer Pelvic Pain Management
Sandesha Kothari Consultant in Anaesthetics
Pain Management Guys and St Thomas NHS
Foundation Trust
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Prevalence of CPP among reproductive-aged women

• United States 14.7
• United Kingdom 24.0.
• By extrapolating the data, more than 9 million
  reproductive-aged women in the United States
  would meet the criteria for chronic pelvic pain,
  with direct costs of more than 2.8 billion and
  indirect costs greater than 555 million.

Berkley KJ. Sex Diff in pain. Behav Brain Sci
20 371-380
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Chronic pelvic pain (CPP)

• Non malignant pain perceived in structures
  related to the pelvis of either men or women.
• Duration for at least 6 months.
• There may be associated negative cognitive,
  behavioural and social consequences.

Definition Guidelines on chronic pelvic pain.
European association of urology
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Chronic pelvic pain syndrome (CPSS)

• is the occurrence of persistent or recurrent
  episodic pelvic pain associated with symptoms
  suggestive of lower urinary tract, sexual, bowel
  or gynaecological dysfunction.
• no proven infection or other obvious pathology.

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Classification

• Pelvic pain syndrome
• Urological Bladder pain syndrome interstitial
  cystitis
• Gynaecological endometriosis assoc. pain
  vaginal pain syndrome vulvar pain syndrome
• Anorectal pain synd., anismus proctalgia fugax
• Neurological pudendal pain syndrome
• Muscular pelvic floor muscle pain syndrome
  perineal pain syndrome

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Classification

• Well defined conditions
• Uro infective cystitis, prostatitis, urethritis,
  epididymo- orchitis
• Gyn Endometriosis
• Anorectal proctitis, hemorrhoids, anal fissure
• Neuro ilioingunal, ilioypogastric,
  genitofemoral, pudendal neuropathy, sacral spinal
  cord pathology

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Pathophysiology

• Neurophysiology
• Viscero visceral hyperalgesia
• Hormonal influence
• Neurogenic inflammation

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Neurophysiology

• Neuropathic Result of insult to nervous system
• Burning, paraesthesia, dyaesthesia, Allodynia
• Nociceptive resulting from injury to a pain
  sensitive structure
• Visceral / Somatic

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Hormonal Influence

• Hormones may modulate nociceptive processesing
• Both oestrogens and progesterons affect the
  generation of pain signals from the pelvis both
  peripherally and centrally.
• Potential mechanisms include the effects of
  estrogen on neurogenic inflammation and other
  hormonal effects on the central and peripheral
  nervous systems

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Neurogenic Inflammation

• Stimulation of the peripheral nerves elicits
  vaodilation, plasma extravasation and other
  inflammatory changes in the skin and the viscera
• Complex interaction between the
  central/peripheral nervous system and the immune
  system, causing the release of neuromediators
  that activate receptors on specific cells,
  including mast cells, Langerhans cells,
  microvascular endothelial cells, fibroblasts and
  infiltrating immune cells

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Role of Neuropeptides

• Sensory afferents apart from being carriers of
  messages to the CNS, also act in the periphery
  through the release of neuropeptides e.g NGF
• Acute neurogenic inflammation can lead to chronic
  changes in the innervation, resulting in a
  persistent pain syndrome. in response to
  inflammation
• The role of purinergic signaling through the
  release of urothelial adenosine triphosphate and
  the stimulation of subepithelial nerve plexus via
  the purinergic P2X3 receptor, resulting in pain,
  may provide an explanation for the symptom
  profile seen in CPPS

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Viscero visceral hyperalgesia

• Inflammation or congestion in the reproductive
  organs, either physiological from ovulation or
  menses, or pathologic from endometriosis, could
  enhance pain in viscera, skin, or muscle that
  share common spinal cord segments.
• This might be one of the explanations for
  menstrual exacerbation of chronic pelvic pain, a
  common occurrence that should not be confused
  with dysmenorrhea.

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Management of Pelvic pain

• Assessment
• Pharmacotherapy
• Interventions
• Physiotherapy
• Psychological
• Multidisciplinary Approach
• Pain Management Programme

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Assessment

• Pschycosocial History
• Strong relationship between
• Abuse -physical/sexual Pain
• History of Abuse makes the pain experience worse
  But not cause it
• Cyclical ?
• Bladder / Bowel symptoms
• History of previous surgery / trauma

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Pharmacotherapy

• WHO analgesic Ladder
• TCA Amitriptyline
• Anticonvulsants Gabapentin/ Pregabalin
• Hormonal therapy if cyclical
• Minimise Opiods Manage constipation

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Pain Mapping

• If pain corresponds to the distribution of the
  iliohypogastric/ ilioinguinal/ genitofemoral/
  lumbar root/ sacral root/ lumbar sympathetic
  plexus / superior hypogastric plexus (presacral)
  nerves and an evaluation of the anterior
  abdominal wall should be performed to identify
  scar pain and trigger points.

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Pain in GF distribution
Pain in II/IH distribution
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Interventions

• TENS
• Nerve blocks
• Cryotherapy
• Radio frequency treatment
• Sacral Magnetic stimulation
• Electrical Neuromodulation

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Neuromodulation

• Dorsal column stimulation
• Sacral root stimulation
• Peripheral nerve stimulation
• Targeted stimulation

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Sacral Stimulation

• Transforaminal
• Anterogrde
• Retrograde
• S2-4
• Parallel to the sacral nerves

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Pelvic floor Physiotherapy

• Structure and form in the pelvic floor arise from
  the interaction of muscles, nerves and ligaments
  acting on the pelvic organs.
• Specific exercises to stretch or strengthen
  certain muscles or muscle groups may be advised
  and taught.

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Psychological intervention

• Individual
• Psychosexual counselling
• Cognitive behaviourial therapy

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Pain Management Programme

• Multidisciplinary approach
• Acceptance
• Education / Information
• Physiotherapy- Pacing
• Realistic Goals
• Impact of pain thoughts/ Feelings
• Relationships
• Relaxation- sleep
• Coping strategies

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Conclusion

• Chronic intractable pelvic pain despite a
  multidisciplinary approach is challenging to
  treat.
• Every structure in the abdomen and/or pelvis
  could have a role in the etiology of CPP.

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QUESTIONS ?
Flight of Pain !