COMMON CONDITION

1. Chronic
Pelvic
Pain
Dr.
Kawita
Bapat

2. PHYSIOLOGY
OF
PAIN
• Pelvic
pain
may
be
either
:
1. Visceral
(
Splanchnic)
pain
2. Parietal
(SomaFc)
pain
3. Referred
pain
• Pelvic
pain
may
be
either
:
1. NocepFve
or
2. Neuropathic

4. DiagnosFc
Dilemmas
• FrustraFon
for
both
the
physician
and
the
paFent.
• Disability
and
distress
• Significant
costs
to
health
services
around
8
billion

5. • Difficult
to
diagnose
• Difficult
to
treat
• Difficult
to
cure
Acute
pelvic
pain:
–
• Located
in
the
anatomic
pelvis
• Short
duraFon
• Sudden
onset

6.
Chronic
Pelvic
Pain
• Defini7on
• Character:
non
cyclic
pain
•
DuraFon:
6
or
more
months
• Site:
1. Localizes
to
the
anatomic
pelvis
2. The
anterior
abdominal
wall
3. or
below
the
umbilicus
4. The
lumbosacral
back

7. 5. the
buYocks
6. Not
related
to
menstruaFon,
or
pregnancy
Impact:
severe
to
cause
funcFonal
disability
or
lead
to
medical
care

8. Prevelance
• 1
in
6
of
the
adult
female
• 15%
common
in
women
in
the
reproducFve
and
older
age
groups
• 20%
of
all
laproscopies
• 12-­‐16%
of
all
hystrectomies

9. CAUSES
OF
ACUTE
PAIN
Pregnancy
related
•
Ectopic
• AborFon-­‐
Threatened,incomplete,
delayed
• Red
degeneraFon
of
fibroids
• Ovarian
cyst
accident
(torsion,
rupture,
bleed
within)
Gynae
• Ovarian
cyst
accident
• PID

10. Gynaecological
causes
• Tubo-­‐ovarian
abscess
• Bowel
&
Urinary
AppendiciFs
• ConsFpaFon
• Acute
obstrucFon
•
Urinary
retenFon
• Calculi
•
UTI
• Others:
Nerve
entrapment;
disc
prolapse

11. CAUSES
OF
CHRONIC
PAIN
Gynae
• Endometriosis/Adenomyosis
• Fibroids
Adhesions
•
Pelvic
inflammatory
disease
• Ovarian
cysts;
• residual/trapped
ovary
syndrome
• Pelvic
venous
congesFon
•
Bowel
&
Urinary
Irritable
bowel

12. • Urological
causes
1. IntersFFal
cysFFs
2. Calculi
3. Urethral
syndrome
4. Bladder
malignancy
• Gastrointes7nal
causes:
1. Irritable
bowel
syndrome
2.
AppendiciFs
3. ConsFpaFon

13. • DiverFculiFs
• Colon
cancer
Others:
1. Nerve
entrapment
(scar,
fascia,
narrow
foramen)
Referred
musculoskeletal
2. Hernias
3. Medical
disorders
4. Psychological
Psychosexual
Depression

14. CAUSES
• DefiniFve
diagnosis
is
not
made
for
61%
• Many
paFents
&
physicians
incorrectly
assume
that
all
CPP
results
from
a
gynecologic
sourc
• One
study
in
the
UK:
Urinary
&
GIT
are
more
common
than
gynecologic.

15. Pathogenesis
•
Ofen
laparoscopy
reveals
no
obvious
cause
Possible
explana7ons
in
absence
of
cause
1.
Undetected
IBS
2.
Central
sensiFsaFon
of
the
nervous
system
3.
Vascular
hypothesis
• pain
arises
from
dilated
pelvic
veins
in
which
blood
flow
is
markedly
reduced.
• {pathophysiology
is
not
well
understood}:
t/t
is
ofen
unsaFsfactory
and
limited
to
symptom
relief.

16. Principles
of
assessment
• Frequently
more
than
one
component
(&
psychological)
• Elicit
woman’s
own
theory
for
origin
of
pain
• Consider
involvement
of
other
specialFes
(anaestheFcs,
gastroenterologists,
urologists,
GUM,
psychologists,
physiotherapist,
psychosexual
counsellor)
-­‐
mulFdisciplinary
team
approach
• Consider
trial
of
medical
therapy
prior
to
diagnosFc
laparoscopy
(consequences
of
negaFve
laparoscopy)

17. ESSENTIAL
HISTORY
• When
was
your
last
period
•
Last
cervical
smear
• Are
you
sexually
acFve
• Were
you
using
any
contracepFon
• Could
you
be
pregnant
•
Perform
a
urine
pregnancy
test

18.
• DefiniFve
diagnosis
is
not
made
for
61%
• Many
paFents
&
physicians
incorrectly
assume
that
all
CPP
results
from
a
gynecologic
source.
• One
study
in
the
UK
shows:
Urinary
&
GIT
are
more
common
causes
than
gynecologic.

19. History
relevant
to
Chronic
Pelvic
Pain
• Cyclical
vs.
Non-­‐cyclical:
Cyclical
is
usually
gynaecological
• PaYern
of
pain
(onset,
site,
radiaFon,
intensity
pain
score)
• AssociaFon
with
menstrual,
PV
discharge,
bladder
&
bowel
symptoms:
specifically
enquire
Rome
II
criteria
•
The
effect
of
movement
and
posture
with
the
pain
•
Previous
pelvic
infecFon,
STIs,
recent/previous
surgery

21. History
relevant
to
Chronic
Pelvic
Pain
• The
effect
of
movement
and
posture
with
the
pain
• Previous
pelvic
infecFon,
STIs,
recent/previous
surgery
• Biological
depression,
• Partner
violence
• Sexual
abuse
Red
flag
features
(suggesFve
of
life
threatening
disease)
• Pain
and
menstrual
diary
for
three
menstrual
cycles

22. Life-­‐threatening
symptoms
and
signs
(Red
Flag)
• Bleeding
per
rectum
• New
bowel
symptoms
over
50
yrs
• New
pain
afer
the
menopause
• Pelvic
mass
• Suicidal
ideaFon
• Excessive
weight
loss
• Irregular
vaginal
bleeding
over
40
yrs
• Post
coital
bleeding

23. INVESTIGATIONS
• CBC
• HIV
• VDRL
• HIGH
VAGINAL
SWAB
CULTURE
• URINE
R/E
• PAP
SMEAR
• ULTRASOUND
WHOLE
ABDOMEN
+PELVIS
• LAPROSCOPY
• HYSTEROSCOPY
• MRI

24. DIAGNOSIS
• Pelvic
ultrasound:
v
Fibroids,
ovarian
cysts/endometriomas,
adenomyosis
• Laparoscopy
v Diagnosis
and
treatment
of
endometriosis
v adhesions
risk
of
viscera
injury
(4/1000);
risk
of
death
(1/10,000)
•
Hysteroscopy
v Diagnosis
and
resecFon
of
intrauterine
fibroids

25. • MRI
v Pelvic
adhesions;
v
Adenomyosis
v Pelvic
and
rectovaginal
endometriosis
v Fibroids
prior
to
UAE

26. Most
commonly
diagnosed
causes
1. IBS
2.
IntersFFal
cysFFs
3.
Endometriosis
4.
Pelvic
adhesions.

27.
Possible
significance
1. Hematochezia:
GastrointesFnal
malignancy/
bleeding
2.
History
of
pelvic
surgery,
pelvic
infecFons,
or
use
of
intrauterine
device:
Adhesions
3. Nonhormonal
pain
fluctuaFon:
Adhesions,
intersFFal
cysFFs,
IBS,
musculoskeletal
causes
4. Pain
fluctuates
with
menstrual
cycle:
Adenomyosis
or
endometriosis

28. Types
of
IntervenFons
• Lifestyle:
exercise,
dietary,
substance
use.
• Psychological:
I. CogniFve
behaviour
therapy,
II. Psychotherapy,
III. Counselling,
IV. MeditaFon,
V. biofeedback,
US
as
reassurance,
hypnosis.

29. Medical
I.
NSAIDs
II. OCP,
oral
and
non-­‐oral
progestogen,
danazol,
GnRH
analogues
(alone
or
with
’add-­‐back’
oestrogen)
III.
Progestogen-­‐releasing
intra-­‐uterine
contracepFve
devices
(IUCD)
IV. Drugs
affecFng
blood
vessels,
V. AnFdepressants,
VI. AnFconvulsants

30. VI
Analgesics
VII
Combined
analgesic
and
caffeine
preparaFons,
VIII
Local
anaestheFc
infiltraFon
alone
or
in
combinaFon
with
corFcosteroids.

31. Surgical
I.
DiagnosFc
laparoscopy,
II. Adhesiolysis,
III.
Ventrosuspension,
IV. Presacral
neurectomy,
V. Laparoscopic
uterine
nerve
ablaFon
(LUNA),
VI. Ovarian
vein
ligaFon
(via
surgery
or
radiology),
hysterectomy,
VII. Oophorectomy,
VIII. ovarian
drilling,
IX. wedge
resecFon,
X. endometrial
ablaFon.

32. No
Cause
•
Mul7disciplinary
approach:
I. Dietary
Social
Environmental
II.
Psychological
factors
in
addiFon
to
medicaFon
therapy)
improve
outcomes
over
medicaFon
therapy
alone
III. Counseling
supported
by
ultrasound
scanning
IV.
Social
problems
V. Depression

33. VI.
Sexual
abuse
VII.
Personality
disorder
VIII.
Troubled
marriage
IX.
Family
crisis.

34. • Trigger
point
injecFons
of
the
abdominal
wall
for
myofascial
causes:
some
benefit
• Botulinum
toxin
type
A
injecFons
into
the
pelvic
floor
muscles:
some
benefit
• Oral
analgesics:
Acetaminophen
NSAID
• Opioid
analgesics:
commonly
used
to
treat
moderate
pain

35.
• GabapenFn
(NeuronFn)
alone
or
in
combinaFon
with
amitriptyline:
significant
pain
relief
in
women
with
CPP

36. Pelvic
CongesFon
Syndrome
• Pain:
v Consistent
dull
aching
pelvic
v Accentuated
before
menses
v Associated
with
low
backache,
dyspareunia,
postcoital
aching
v Discomfort
on
prolonged
sipng
and
standing
and
ofen
associated
with
variable
degree
of
premenstrual
tension.
v The
paFent
usually
mulFpara
in
her
30s-­‐
60%
have
some
sort
of
psychopathology.

37. Physical
ExaminaFon
• Abdominal:
gentle
abdominal
&
pelvic
components
of
the
examinaFon
may
be
painful}.
• PalpaFon
of
the
outer
pelvis
&
back:
trigger
points:
myofascial
cause
•
Tenderness
,masses

38. • CarneL’s
sign
• Placing
a
finger
on
the
painful,
tender
area
of
the
paFent’s
abdomen
• paFent
raise
both
legs
off
the
table
while
lying
in
the
supine
posiFon

39. • Posi7ve
test:
pain
increases
• Myofascial
cause
• Abdominal
wall
cause.
e.g.,
fibromyalgia
or
trigger
point.
• Visceral
pain
should
not
worsen
during
the
maneuver.
• Pelvic
examina7on:
Single-­‐digit,
one-­‐handed
examinaFon.

40.
Bimanual
examina7on:
v Nodularity
point
tenderness
v Cervical
moFon
tenderness,
v or
lack
of
mobility
of
the
uterus.
• A
moistened
coLon
swab:
point
tenderness
in
the
vulva
&
vagina

41. Rectal
examina7on
Ø Rectal
or
posterior
uterine
masses,
Ø Nodularity
Ø or
pelvic
floor
point
tenderness.

42. Diagnosis
ü Transuterine
venography
is
the
standard
for
diagnosis.
ü
U/S,
doppler
and
laparoscopy
may
reveal
varicosiFes.

43. Treatment
v Medical
I. Suppressive
therapy:
II. Low
estrogen-­‐
high
gestagen
OCs,
III. GnRHa

44. Ultrasound
of
Pelvic
CongesFon
a)
Normal
Blood
Supply
To
Uterus
b)
Pelvic
CongesFon
Syndrome

45. IV.
or
conFnuous
high
dose
progestogen,
V. MPA
(Provera)
50-­‐300mg/day
for
up
to
18
months,
have
achieved
promising
results
• Venoac7ve
drugs
I. Micronised
purified
flavonoid
fracFon
(Daflon
500
mg
twice
daily
for
6
months
v It
has
protecFve
and
tonic
effect
on
the
venous
and
capillary
wall:

46. • Increase
in
venous
tone
• Improvement
in
lymphaFc
drainage
• And
a
reducFon
in
capillary
hyperpermeability:
• Ameliorate
venous
stasis.
• StaFsFcally
significant
improvement
in
pelvic
pain
scores
without
any
side
effects.

47. II.
Dihydroergotamine
(DHE)
(Migranal):
Is
a
selecFve
veno
constricFng
agent
which
increases
venous
tone
and
mobilizes
blood
which
is
present
in
capacitance
vessels.
III.
Surgical
IV.
EmbolizaFon
V.
Psychotherapy:
explanaFon,
reassurance
that
she
is
normal,
with
some
sedaFve
drugs.

48. HISTORY
&
EXAMINATION
WARNING
SIGNS
NO
YES
HISTORY
&EXAMINATION
SUGGESTIVE
OF
IBS,
IC,
ENDOMETRIOSIS
MYOFASCIAL
NO
CBC,
URINE,
B
HCG
ESR,STD,
TVS
NORMAL
ADDRESS
COMORBID
(PSYCHOSOCIAL,
ENVIORNMENTAL
DIETRY
REASSURENCE
ABNORMAL
EVALUATE
&
TREATMENT
EXCLUDE
MALIGNANCY
DISEASES
YES
EVALUATE
AND
TREATMENT
OF
SUBSEQUENT
ABNORMALITY

49.
THANKS