Chronic Pelvic Pain (CPP)

1
Chronic Pelvic Pain (CPP)

• Khaled Zeitoun, M.D.
• Assistant Clinical Professor
• Columbia University

2
Chronic Pelvic Pain Definition

• An unpleasant Sensory and Emotional experience
  associated with actual or potential tissue damage
  or described in terms of such damage
• Symptom and always Subjective

3
Chronic Pelvic Pain Definition

• Temporal characteristics
• Severity
• Location

4
Chronic Pelvic Pain Definition

• Noncyclic pain of at least 6 months duration
• Menstrual pain /Intermittent pain

5
Chronic Pelvic Pain Definition

• Anatomic pelvis
• Anterior abdominal wall at or below the umbilicus
  
• Lumbosacral back and buttock region
• Vulvar pain ???

6
Chronic Pelvic Pain Definition

• Causes functional disability
• Medical care

7
Chronic Pelvic Pain Definition

• Acute pain occurs in conjunction with autonomic
  reflex responses, and associated with signs of
  inflammation and infection.
• Chronic pain is characterized by physiological,
  affective and behavioral responses that differ
  from acute pain.

8
Chronic Pelvic Pain Theories

• Classic medical or Cartesian model
• Pain perception results directly from and is
  related to the extent of local tissue destruction
  
• Pain in the absence of tissue injury is
  psychogenic

9
Chronic Pelvic Pain Theories

• The gate-control theory of pain
• Somatic and psychogenic factors can potentiate or
  modify response to pain
• Failing to recognize the many social factors
  believed to affect a patient's responses to pain
  and to therapy

10
Chronic Pelvic Pain Theories

• The biopsychosocial theory of pain
• Most comprehensive model for dealing with chronic
  pelvic pain
• Integrates all the factors that contribute to a
  patient's perception of pain nociceptive
  stimuli, psychological state, and social
  determinants
• Explains symptom "shifting"

11
Chronic Pelvic Pain Population

• Women of all ages are affected
• Studies focused on women between 18 and 50 years
  old

12
Chronic Pelvic Pain Demographic Variables

• No difference in age, race, socioeconomic status,
  education, ethnic background, education or
  employment.
• More common in divorced / separated women than
  single and married women
• (Mathias et al, 1996)

13
Chronic Pelvic Pain Prevalence

• 15 to 20 of women between 18 and 50 years old
  have chronic pelvic pain of more than one years
  duration
• CPP accounted for 2 to 10 of all outpatient
  gynecologic consultations annually ( Reiter,
  1990)

14
Chronic Pelvic Pain Health Impact

• General health scores are lower
• Associated disturbances of mood and energy levels
  (gt50)
• Depression is common
• Quality of life is decreased
• Restricted activity and decreased productivity

15
Chronic Pelvic Pain Health Impact

• 90 of women with CPP complain of dyspareunia

16
Chronic Pelvic Pain Health Care

• 20 see a gynecologist
• 10 other physician
• 1 mental health evaluation
• Rest see no one????

17
Chronic Pelvic Pain Health Care

• Very few are seen and evaluated by clinicians in
  more than one specialty
• 75 of women who report CPP have not seen a
  healthcare provider for 3 month despite
  persistent pain affecting daily activities

18
Chronic Pelvic Pain Health Care

• 56 take one or more nonprescription drugs
• 25 take medications prescribed by a provider
• 12 oral contraceptives

19
Chronic Pelvic Pain Health Care

• 61 no diagnosis given by physician
• 39 diagnosis given
• 25 endometriosis
• 49 a non-cycle related gynecologic disorder
  (e.g. yeast infection or chronic PID)
• 10 non-gynecologic disorder
• 16 other

20
Chronic Pelvic Pain Health Care

• 10 to 35 of laparoscopies are for CPP
• 9 to 80 of laparoscopies report abnormalities

21
Chronic Pelvic Pain Health Care

• Up to 70 of laparoscopies report endometriosis
• Even if pathology is found it might not be the
  reason for the pain

22
Chronic Pelvic Pain Health Care

• between 10 to 12 of hysterectomies are done for
  CPP
• Mortality 0.1 ( 70 women a year)
• Not always beneficial
• Detrimental effect of castration on heart
  disease, bone and Alzheimers

23
Chronic Pelvic Pain Economic Impact

• Direct medical costs
• Loss of productivity

24
Chronic Pelvic Pain Causes

• Gynecologic causes
• Cyclic
• Noncyclic

25
Chronic Pelvic Pain Causes

• Gynecologic causes
• Endometriosis
• Adhesions (?)
• Adenomyosis
• Chronic pelvic infection
• Hydrosalpinx
• Pelvic congestion (?)
• Leiomyomata(?)
• Malignancies
• Primary dysmenorrhea

26
Chronic Pelvic Pain Causes

• Gynecologic causes
• Ovarian remnant syndrome
• Ovulatory pain
• Adnexal cysts
• Cervical stenosis
• Chronic endometritis
• Endometrial polyps
• Chronic ectopic pregnancy
• Pelvic relaxation
• IUD

27
Chronic Pelvic Pain Causes

• Nongynecologic disorders
• Psychiatric and psychological
• Depression
• Physical or sexual abuse
• Somatization
• Hypochondriasis
• Opiod seeking
• Factitious

28
Chronic Pelvic Pain Causes

• Nongynecologic disorders
• Pain processing disorder
• Fibromyalgia

29
Chronic Pelvic Pain Causes

• Nongynecologic disorders
• Gastrointestinal
• Functional bowl syndrome
• Inflammatory bowl disease
• Cancer
• Chronic appendicitis (?)
• Diverticulitis

30
Chronic Pelvic Pain Causes

• Nongynecologic disorders
• Urinary
• Interstitial cystitis
• Urethral syndrome
• Detrusor instability
• Chronic calculi

31
Chronic Pelvic Pain Causes

• Nongynecologic disorders
• Musculoskeletal
• Hernia
• Disc disease
• Arthritis
• Scoliosis and posture related disorders

32
Nongynecologic disordersPsychiatric and
psychological

• In depression pain is not an uncommon
  presentation
• Mood is an important modifier of pain
• The relationship between depression and pain may
  involve neurotransmitter
• abnormalities

33
Nongynecologic disordersPsychiatric and
psychological

• Physical and sexual abuse history is obtained in
  25 to 40 of CPP patients
• Trauma of abuse event can kindle a depressive or
  pain processing disorder in a genetically
  susceptible individual

34
Nongynecologic disordersPsychiatric and
psychological

• Somatization disorder patients have multiple
  physical complaints not explained by a known
  medical condition
• DSM-IV criteria
• Four different pain sites, two GI complaints,
  one neurologic symptom and one sexual or
  reproductive symptom

35
Nongynecologic disordersPsychiatric and
psychological

• Somatization disorder
• Emotional distress
• Common abnormality of sensation processing

36
Nongynecologic disordersPsychiatric and
psychological

• Hypochondriasis patients are preoccupied with
  fear of having a serious disease
• Obsessive
• Visit many health care providers

37
Nongynecologic disordersPsychiatric and
psychological

• Drug-seeking behavior patients often request
  opioids for pain relief
• Women with CPP may become addicted if they use
  opioids for pain relief
• Abdominal pain due to withdrawal leads to further
  drug use

38
Nongynecologic disorders Problematic substance
abuse

• Impaired control of substance use
• Guilt or regret about use, efforts to cut down,
  complaints or concerns from others
• Recent substance use with resultant neurologic or
  cardiovascular symptoms, confusion, anxiety, or
  sexual dysfunction
• Psychosocial dysfunction
• Tolerance

39
Nongynecologic disordersPsychiatric and
psychological

• Factitious disorder patients intentionally feign
  disease with the purpose of assuming the role of
  a sick person
• Malingering patients have external incentive to
  appear sick

40
Nongynecologic disordersPain Processing Disorder

• Fibromyalgia
• occurs in 2 to 4 of individuals, 80 are women
• Abnormal pain processing associated with
  neuroendocrine and autonomic disorders

41
Nongynecologic disorders Fibromyalgia

• Criteria for diagnosis
• Pain involving all 4 quadrants of body and axial
  skeleton
• Tenderness at 11 of 18 defined tender points
• Tenderness due to amplification of pain signals

42
(No Transcript)
43
Nongynecologic disorders Fibromyalgia

• Abnormal CNS processing of pressure
• Visceral sensations can also be abnormally
  processed
• Associated motility disorder of abdominal viscera
• Disordered sleep

44
Nongynecologic disordersGastrointestinal

• Irritable bowel syndrome (IBS)
• Abdominal pain for at least 3 month duration in
  the last year
• Relieved by bowl movement
• Altered bowl habits (frequency and appearance)

45
Nongynecologic disordersGastrointestinal

• Irritable bowel syndrome (IBS)
• Abnormal gastrointestinal motility
• Augmented sensation of visceral stimuli as pain
• Consistent with abnormal pain processing and
  autonomic dysfunction disorders

46
Nongynecologic disordersGastrointestinal

• Inflammatory Bowel Disease
• Pain from inflammation of bowel or adjacent
  structures
• Nonspecific symptoms (pain, gas, distention,
  etc.)
• Fever and diarrhea

47
(No Transcript)
48
(No Transcript)
49
(No Transcript)
50
(No Transcript)
51
Nongynecologic disordersGastrointestinal

• Diverticular disease
• Common after 40 years
• Left lower quadrant pain with diverticulitis
• Fever, diarrhea and constipation are common

52
(No Transcript)
53
(No Transcript)
54
Nongynecologic disordersGastrointestinal

• Colon cancer
• uncommon before 40 years of age
• Altered bowl habits more than pain

55
(No Transcript)
56
Nongynecologic disordersGastrointestinal

• Chronic appendicitis
• uncommon cause of CPP
• Existence is controversial???

57
Nongynecologic disordersUrologic

• Interstitial cystitis
• Urinary urgency, bladder discomfort and sense of
  inadequate empting
• Bladder mucosal lesions consist of hemorrhage and
  petechiae (glomerulations)
• Some have only abdominal pain

58
Interstitial cystitis
ulceration
59
(No Transcript)
60
Nongynecologic disordersUrologic

• Urethral Syndrome
• Irritative bladder symptoms often associated with
  coitus
• Lower abdominal pain may be chief presentation

61
(No Transcript)
62
Chronic Pelvic Pain Causes

• Gynecologic causes

63
Endometriosis
64
Endometriosis
EPIDEMIOLOGY AND PREVELANCE
- Diagnosed by laparoscopy in 25-33 of
cases with infertility or chronic pelvic pain
- 1-7 estimated prevalence among all
reproductive age women
65
Endometriosis
IMPLANTS
- Red - Pink - Blue - Black - yellow -
Brown - white - Clear - Peritoneal defect
66
(No Transcript)
67
Gynecologic disordersEndometriosis Pain

• Noncyclic pain
• Dyspareunia
• dysmenorrhea

68
Gynecologic disordersEndometriosis Pain

• Peritoneal implants secrete factors that irritate
  the peritoneal surface
• Pelvic adhesions due to scarring and retraction
  of peritoneal surface
• Retroverted uterus or adherent ovaries in the
  C.D.S. cause dyspareunia due to compression of
  these structures or tension on surrounding
  peritoneum
• Uterosacral lesions due to compression or
  stretching of peritoneum
• Visceral pain due to invasion of urinary or GI
  tracts

69
(No Transcript)
70
Endometriosis
71
Endometriosis
72
Endometriosis
CLASSIFICATION
- AFS original classification (1979) - AFS
revised classification (1985) - ASRM revised
classification (1996)
73
Gynecologic disordersEndometriosis Pain

• Not correlated with stage of disease
• Deep lesions are associated with more pain
• Vaginal endometriosis associated with dyspareunia
  
• Prostaglandins

74
Endometriosis
PHYSICAL FINDINGS
- Normal examination - Focal tenderness -
Retroverted fixed uterus - Nodularity and
tenderness of the cul-de-sac or
uterosacrals - Cervical stenosis - Pelvic
masses
75
Endometriosis
DIAGNOSTIC METHODS
- CA-125 - Ultrasound, MRI, CT scans -
Imaging urinary tract and bowl - Laparoscopy -
Biopsy
76
Treatments of Pelvic Pain Due to Endometriosis

• Analgesics (NSAIDs)
• Estrogen/progestin combinations
• GnRH agonists / antagonists
• GnRH agonists with steroid add-back
• Danazol
• Others (aromatase inhibitors)

77
Endometriosis
GnRH WITH ADD-BACK THERAPY
- Preservation of bone mass - Other effects
of low estrogen - Prolonged Treatment - Improve
compliance - Avoid surgery - May decrease
efficacy
78
Treatments of Pelvic Pain Due to Endometriosis
with GnRH Agonists Followed by Add-Back Therapy

• Transdermal estradiol patch 25 µg/day, plus
  medroxyprogesterone acetate 2.5 mg daily
• This regimen does not completely prevent bone
  loss. The estradiol concentration achieved is in
  the range of 30 pg/mL.
• (Howell, 1995)

79
Treatments of Pelvic Pain Due to Endometriosis
with GnRH Agonists Followed by Add-Back Therapy

• Norethindrone acetate 5 mg/day
• This is a very high dose of progestin. This dose
  of progestin is associated with a decrease in
  HDL-cholesterol
• (Hornstein, 1997)

80
Treatments of Pelvic Pain Due to Endometriosis
with GnRH Agonists Followed by Add-Back Therapy

• Conjugated equine estrogen 0.625 mg/day,
  norethindrone acetate 5 mg/day
• This regimen prevents bone loss and markedly
  reduces the vasomotor symptoms reported. Pain
  relief was excellent.
• (Hornstein, 1997)

81
Endometriosis
RECURRENCE MEDICAL THERAPY
- Rates vary (29-51) - Depend on duration
82
Endometriosis
DEFINITIVE SURGERY
- If pregnancy is not desired - Intractable
disease - Hysterectomy /- ovarian excision -
Recurrence rates higher with ovarian
conservation
83
Endometriosis
CONSERVATIVE SURGERY
- uterine and ovarian preservation -
Usually done laparoscopically
84
Endometriosis
RECURRENCE SURGERY
- Rates vary (7-66) - Impossible to remove
all lesions especially microscopic - Less
recurrence after definitive surgery
85
Endometriosis
RECURRENCE
- Residual disease - Endometriosis prone
patient - Aggressive lesions - Extra-ovarian
estrogen production or ERT
86
Adenomyosis
87
(No Transcript)
88
Uterine Fibroids
89
(No Transcript)
90
(No Transcript)
91
Hydrosalpinx
92
Hydrosalpinx
93
Other lesions
94
(No Transcript)
95
(No Transcript)
96
(No Transcript)
97
(No Transcript)
98
(No Transcript)
99
(No Transcript)
100
ADHESIONS
101
(No Transcript)
102
PATHOGENESIS
Peritoneal Trauma

• Mechanical trauma
• Thermal, electrical or chemical trauma
• Foreign bodies
• Infection
• Inflammation
• Ischemia

103
PATHOGENESIS
Initial Stage of Peritoneal Healing

• Chemotactic messengers
• Coagulation
• Inflammatory exudate
• Fibroblast proliferation

104
PATHOGENESIS
Formation of Fibrin Bands

• Inflammatory exudate
• Fibrin deposition
• Fibrin band formation

105
PATHOGENESIS
Fibrinolysis
Fibrin
Plasmin
tPA
Plasminogen
PAI1 and PAI2
Inhibition
Fibrin Split Products
106
PATHOGENESIS
Fully Healed Peritoneum

• Fibrinolytic activity
• Tissue plasminogen activator
• 5-7 days normal surface healing

107
PATHOGENESIS
Peritoneal Healing (approximately 5-7 days)
Peritoneal Injury
Increased Vascular Permeability
Inflammatory Exudate
Fibrin Deposition
Ischemia
Fibrinolysis
Suppressed Fibrinolysis
Fibrin Fixation
Normal Peritoneal Healing
Adhesion Formation
108
PATHOGENESIS
Adhesion Formation

• Fibroblast proliferation
• Mesothelial over-growth
• Neovascularization

109
INCIDENCE
Adhesions Following Reproductive Pelvic Surgery
by Laparotomy
Study Year N with adhesions Diamond et
al. 1988 106 86 DeCherney and Mezer 1984 61
75 Surrey and Friedman 1982 37 73 Pittaway
et al. 1985 23 100 Trimbos-Kemper et
al. 1985 188 55 Daneill and Pittaway 1983
25 96 TOTAL 440 72
Majority of second-look laparoscopy performed
between 1-12 weeks Adapted from Diamond M.P.
Obstet Gynecol, 1988.
110
Incidence

• Ovary (55)
• Pelvic sidewall (40)
• Fimbria (36)
• Omentum (19)
• Small Intestine (15)
• Colon (15)

111
INCIDENCE
Adhesions Following Laparoscopy
Procedure N with adhesions
Adhesiolysis 68 66 Ovarian surgery
25 65 Myomectomy 50 88 Endometriosis 32 87
Majority of second-look laparoscopy
performed between 12-14 weeks Diamond M. et
al. Fertil Steril 199155700-704. Mais
V. et al. Hum Reprod 1995103133-3135. Keckstein
J. et al. Hum Reprod 199611579-582.
Mais V. et al. Obstet Gynecol
199586512-515.
112
COMPLICATIONS
Clinical Consequences of Adhesions

• Infertility
• Chronic pelvic pain (CPP)
• Small bowel obstruction (SBO)
• Intraoperative complications
• Subsequent surgery

113
COMPLICATIONS
Chronic Pelvic Pain Laparoscopic Findings
114
COMPLICATIONS
Chronic Pelvic Pain Relief after Laparoscopic
Adhesiolysis
Howard, FM. Obstet Gynecol Surv 199348357-387.
115
COMPLICATIONS
Recurrence of Pain Following Adhesiolysis
Pain Rating
Time Since Surgery, Months
Time of pain return during daily
activities after laparoscopic lysis of
adhesions. Steege and Stout, Am J Obstet
Gynecol, 1991165278.
116
COMPLICATIONS
The Paradox of Chronic Pelvic Pain and Adhesions

• Pelvic adhesions present in 15 - 45 of patients
  with chronic pelvic pain
• Adhesions may or may not be the cause of chronic
  pelvic pain
• Adhesiolysis decreases pain or is beneficial in a
  large percentage of patients???
• Many patients have recurrence of pain or
  increased pain over time

Howard F.M. Obstet Gynecol Surv 199348357-387.
117
ADHESION PREVENTION
Surgical Techniques to Minimize Adhesions

• Directed hemostasis
• Avoid
• ischemia
• desiccation
• sponging
• tissue grafts
• introduction of foreign bodies

• Minimize tissue handling
• Use fine non-reactive sutures placed without
  tension
• Consider using heparin in irrigation fluid

118
ADHESION PREVENTION
Controlled Clinical Trials

• Non-efficacious Efficacious
• Dextran 70 Interceed (TC7) Absorbable
• Ibuprofen Adhesion Barrier
• Tolmetin Preclude Surgical Membrane
• Cortisone Seprafilm Bioresorbable Membrane
• Gynecare Intergel

Trademark of ETHICON, Inc. Trademark of W.L.
Gore Associates, Inc. Trademark of Genzyme
119
Chronic Pelvic Pain Evaluation
120
Chronic Pelvic Pain Recognition

• Duration of pain for 6 month
• Incomplete relief by most previous treatment
• Impaired function
• Signs of depression
• Pain out of proportion to pathology
• Altered family role

121
Chronic Pelvic Pain Evaluation

• Multidisciplinary approach to diagnosis
• Consultations with other health professionals
  needed

122
Chronic Pelvic Pain History

• Most important diagnostic tool
• Open interview approach
• Detailed questioning regarding the pain
• Previous interventions
• Menstrual history
• Surgical history
• Review of systems

123
Chronic Pelvic Pain Psychological History

• Early psychological evaluation
• Psychiatric illness
• Life stresses
• Personal loss and grieving process
• Substance abuse
• Family dysfunction / family support system
• Sexual relationships
• Sexual and physical abuse

124
Chronic Pelvic Pain Physical Examination

• General physical examination
• Abdominal examination
• Tenderness in lower abdominal quadrants
• Contract abdominal muscles
• Surgical scars and hernias
• Vaginal or rectal examination

125
Chronic Pelvic Pain Psychological testing

• Minnesota Multiphase Personality Inventory (MMPI)
  to evaluate psychopathology
• Beck Depression Inventory
• McGill pain questionnaire pain rating index
• Multidimensional pain inventory

126
Chronic Pelvic Pain Testing

• Laboratory testing
• Diagnostic nerve blocks
• Diagnostic imaging
• Diagnostic surgery / Pain mapping
• Empiric therapy

127
Chronic Pelvic Pain Treatment
128
Treatments for Some Nongynecologic Causes of CPP

• Depression Cognitive-behavioral therapy,
  antidepressants
• Somatization Psychotherapy
• Fibromyalgia Tricyclics, cognitive-behavioral
  therapy, aerobic exercise

129
Treatments for Some Nongynecologic Causes of CPP

• Irritable bowel syndrome Amitriptyline,
  antispasmodics, fiber
• Interstitial cystitis bladder overdistension,
  amitriptyline, intravesical dimethylsulfoxide
• Urethral syndrome antimicrobials, urethral
  dilatation

130
Treatments for Some Nongynecologic Causes of CPP

• Hernia surgical repair
• Disc disease anti-inflammatory medication,
  exercise, surgery
• Arthritis anti-inflammatory medication
• Posture-related problems physical therapy

131
Chronic Pelvic Pain Treatment

• Empiric treatment of CPP with GnRH Agonist
• Standard approach
• If no response to NSAIDs and OCs laparoscopy
  is done.

132
Chronic Pelvic Pain Treatment

• Empiric treatment of CPP with GnRH Agonist
• Alternative approach
• If no response to NSAIDs and OCs treat with
  GnRH agonist and avoid surgery
• (Ling, 1999)

133
Chronic Pelvic Pain Treatment

• Empiric treatment of CPP with GnRH Agonist
• Is effective for endometriosis
• Also relieves pain from other causes like
  interstitial cystitis or IBS and pelvic congestion

134
Chronic Pelvic Pain Treatment

• Treatment of CPP with OCPs
• Is effective for primary dysmenorrhea
• Endometriosis

135
Chronic Pelvic Pain Treatment

• Treatment of CPP with NSAIDs
• Is effective for dysmenorrhea
• Mild to moderate pain

136
Chronic Pelvic Pain Treatment

• Treatment of CPP with progestins
• Is effective for endometriosis
• Pelvic congestion

137
Chronic Pelvic Pain Treatment

• Treatment of CPP with laparoscopic surgery
• Is effective for endometriosis
• Stages I-III

138
Chronic Pelvic Pain Treatment

• Treatment of CPP with presacral neurectomy
• Is not effective during surgical treatment of
  endometriosis

139
Chronic Pelvic Pain Treatment

• Treatment of CPP with hysterectomy
• Is effective treatment of CPP
• Uterine pathology might not be found (65)
• Fibroids, pelvic congestion, adhesions,
  endometriosis
• About 75 are pain free after one year

140
Chronic Pelvic Pain Treatment

• Pain clinics
• Multidisciplinary approach to CPP that
  includes surgical, psychological, dietary and
  social interventions versus focused organic
  approach
• (peters et al, 1991)

141
Chronic Pelvic Pain Treatment

• Nontraditional approaches
• Very little evidence that these approaches are
  effective

142
THE END