Chronic Pelvic Pain

1
Chronic Pelvic Pain

• Fawaz Edris
• MD, RDMS, FRCSC, FACOG, AAACS

2
Introduction

• Non cyclical uterine or non-uterine pelvic pain gt
  6/12
• Gynecological
• GIT
• Urological
• Orthopedic
• Musculoskeletal
• superficial (nerve entrapment, hernia,
  referred)
• Psychological (by exclusion)

3
Introduction

• Somatic pain
• Visceral pain
• Diffusely spread
• Lack of well defined areas in the sensory cortex
• Viscerosomatic convergence
• No neurons in the spinal cord receives only
  visceral pain
• Viscerosomatic neurons
• Larger receptive field than somatic
• Less numbers than somatic

4
History

• Pain history and its components
• Relationship to period, bowel movement,
  urination, intercourse and activity
• Previous episodes
• Other symptoms (GIT, urological, weight loss,
  etc)
• Effect on life (social, work, family)
• Relationship of onset to events (newly married,
  rape, lifting, chest infection, etc)
• Hx of sexual, physical, or emotional abuse
• What medication used
• What investigations done
• Other stress or psychological symptoms
  (depression, anxiety, etc) BUT!
• Secondary gain (off work, husband to stay,
  attention, etc) BUT!
• Full Gyn Hx (STD, PID, Infertility, dysparunia,
  surgeries including DC, etc.)
• Full surgical Hx
• Medical Hx (IBS, IC, IBD)

5
Examination

• Abdominal (point, superficial, deep)
• Pelvic (tenderness, mobility, nodularity)
• Nerve entrapment
• Dermatomes
• Head raising

6
Investigations

• Limited use
• Scopes if symptoms suggest (GIT, Urological)
• Imaging if symptoms suggest musculoskeletal
• U/S although of limited use
• Laparoscopy the ultimate but last method
• Psychological evaluation

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Gynecological

• Endometriosis (30)
• Pathogenesis
• 20-30 missed on laparoscopy
• Treatment is medical (may start before Dx)
• Cont. OCP
• Depot Provera
• Danzol
• GnRH analouge add back therapy
• If no response, surgical (TAH / TAHBSO)
• Size and location doesnt correlate with pain
• Path0physiology of pain not well understood
• Infertility
• Chronic PID(25)
• Recurrent exacerbations
• Hydrosalpinges
• Adhesions !!

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Gynecological

• Ovarian
• Cysts are ASYMPTOMATIC, unless
• Rapid distention
• Bleeding
• Torsion
• Special cysts (Endometrioma, Dermoid)
• Ovarian remnants retroperitonealy (with cyst)
• Uterine
• Adenomyosis (rarely CPP)
• Fibroid are ASYMPTOMATIC, unless
• Degeneration
• Torsion
• Prolapsed submucus fibroid
• Retroverted uterus DOSE NOT cause CPP. Maybe
  dysparunia!

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Gynecological

• Pelvic Congestion Syndrome
• Myth!
• Non specific symptoms
• No agreed upon diagnostic measures
• No agreed upon therapeutic measures

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Non-Gynecological

• G.U.T
• Multiple examples, the most common
• Urethral syndrome
• IC
• Common 1 in 5 women
• Urgency, frequency, nocturia, CPP
• Diagnosis treatment
• G.I.T
• Multiple examples, the most common
• IBS, IBD, Hernias.
• Innervation of the lower intestinal tract, same
  as uterus and fallopian tubes ? pelvic pain

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Psychological

• 30 of CPP remains undiagnosed even after
  laparoscopy
• Is this a primary or secondary thing!

12
Pain Perception

• Every pain is a result of stimulus and response,
  however Chronic pain ?Acute pain.
• Acute pain response is appropriate to stimulus.
• Chronic pain is affected additionally by
• Patients reaction to pain
• Familys reaction to the patient and her pain
  (reinforce or persistence)
• So Response to a stimulus is inappropriate,
  exaggerated, inaccurate, and may persist even
  after the stimulus is gone

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Management

• Therapeutic, supportive, and sympathetic
  physician-patient relationship should be
  established (only few can do it!)
• Regular F/U rather than come back when pain
  persist
• The latter reinforces pain behavior
• If no pathology is found, patient should NOT be
  ignored!
• Reassurance symptomatic treatment
• Multidisciplinary pain clinic

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Management

• Multidisciplinary pain clinic
• GYN, Psychologist, Anesthetist, others
• If no team is in place, use referrals.
• Psychologist
• Techniques for stress reduction, adaptive
  strategies
• Marital, sexual, and social counseling

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Management

• Treat underlying cause if found!
• If none is found
• Multidisciplinary team
• NSAIDs
• Ovulatory/menstrual suppression
• Cont. OCP, Depot Provera, Danzol, GnRH analouge
  add back therapy
• May work for those with pain related to the
  period (mid-cycle, premenstrual or menstrual) or
  those with ovarian causes (ovarian remnant)
• Low dose TCA (increase inhibitory neuromodulators)

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Management

• Surgeries
• If no pathology ? NOT effective
• If no strong evidence of pathology ? thorough
  psychological evaluation before any surgery
• Lysis of adhesions
• NOT effective unless the site of adhesions site
  of pain.
• Vicious cycle

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• Thank you