Chronic Pelvic Pain UNC School of Medicine
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Chronic Pelvic Pain UNC School of Medicine

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Chronic Pelvic Pain UNC School of Medicine




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Presentation on theme: "Chronic Pelvic Pain UNC School of Medicine"— Presentation transcript:

Slide1

Chronic Pelvic Pain

UNC School of Medicine

Obstetrics and Gynecology Clerkship

Case Based Seminar Series

Slide2

Objectives for Chronic Pelvic Pain

Define

chronic pelvic pain

Cite the prevalence and common etiologies of chronic pelvic pain

Describe

the symptoms and physical exam findings associated with chronic pelvic pain

Discuss

the psychosocial issues associated with chronic pelvic

pain

Discuss the steps in the evaluation and management options for chronic pelvic pain

Slide3

Pelvic pain of more than 6 months duration that has a significant effect on daily function and quality of life

Includes reproductive and non-reproductive related pelvic pain that is primarily acyclic

Definition

Slide4

Overall 15-20% of women aged 18 to 50

yrs have chronic pelvic pain that lasts > 1 year

10-30% of gynecologic visits

12-19% of hysterectomies (~ 80,000/yr.)30% of laparoscopy indications

Prevalence

Slide5

(Percentages vary widely depending on practice setting

No apparent pathology ~ 33%

Endometriosis ~ 33%

Adhesions or Chronic PID ~ 25%Other causes ~ 9%

Gynecologic

Genitourinary

Gastrointestinal

Neuromuscular

Psychological

Common Etiologies

Slide6

Gynecologic

Endometriosis

Adhesions

Chronic PIDOvarian remnant syndromePelvic congestion syndrome

Recurrent hemorrhagic ovarian cysts

Myomata

uteri (degenerating)

Uterine retroversion

Adenomyosis

Pelvic floor and hip muscle pain

Visceral

hyperalgesia

Etiology: Gynecologic

Slide7

Genitourinary

Urinary retention

Urethral syndrome

Interstitial cystitisGastrointestinalPenetrating neoplasms

Irritable bowel syndrome

Irritable bowel disease

Partial small bowel obstruction

Diverticulitis

Hernia

Etiology: Non-Gynecologic

Slide8

Neuromuscular

Nerve entrapment syndrome

Generalized myofascial pain syndrome

FibromyalgiaPsychological

Depression

PTSD (history of abuse/trauma)

Anxiety disorders

Personality disorder

Etiology: Non-Gynecologic

Slide9

Dysmenorrhea

Pain lasting > 6 months

Impaired lifestyle

DyspareuniaPain during daily activities

Symptoms

Slide10

Characteristics of the pain:

Onset

Location

DurationRadiationS

everity

Alleviating/aggravating factors

Relation to menstrual cycle

Cyclic vs. non-cyclic

Evolution over time

Responses to treatments

Patient Evaluation: History

Slide11

Psychological Evaluation

Use good clinical judgment in deciding when/if to ask about this!

History of traumatic event

History of abuse (emotional/physical/sexual)Depression

Anxiety

Hypochondriasis

Secondary gain

Therapy/counseling about these events?

How much do they enter the patient’s thoughts on a daily basis?

Patient Evaluation: Psychological

Slide12

Physical examObserve patient’s mobility as she gets up on the table.

Palpate the entire back, but especially the paraspinous and SI joint areasReferred pain?Then palpate abdomen

Slide13

Abdominal exam

Listen for bowel sounds

Ask patient to point to exact location of pain, radiation, and grade its severity (scale of 0 to 10)

Ask the patient to map and demonstrate her tender area(s) by palpating with and without abdominal wall flexionPalpate entire abdomen with a single digit, with and w/o abdominal wall flexion (Carnett sign)

Palpate from least painful area to most painful area

Referred pain?

Patient Evaluation: Physical Exam

Slide14

Evaluate for nerve entrapment

Trigger points

Ilioinguinal, iliohypogastric, and genitofemoral nerves

Abdominal wall and back dermatomesMark “jump signs” (points of motion tenderness )

Straight leg raise

Patient Evaluation: Physical Exam

Slide15

Pelvic Exam: ask one question at a time

Vulva

General anatomy; educational exam as needed

Retract labia; walk posterior vestibule with cotton-tipped applicator in cases of dyspareunia or constant vulvar pain.

Vagina

Discharge

Epithelial quality, lesions

Cervix: Pap, cultures if indicated; Q-tip walk to evaluate sensitivity

Single digit exam

: what hurts?

(Order determined by history)

Cervix; motion tenderness

Bladder and urethra

Uterus,

esp

lower uterine segment

Adnexa

Levators

,

obturators

,

piriformi

Referral of pain? Similarity to chief complaint?: “Does this hurt? Is it like the pain you get? Does it travel anywhere?”

Patient Evaluation: Physical Exam

Slide16

Physical exam, continuedBimanual exam:

size, shape, and mobility?Start with non-tender areas firstMake two hands almost meet, sweep caudad

Communicate with patient throughoutDescribe limits of exam due to habitus, guardingExamine to “count of 3” if patient is too uncomfortable.

Slide17

Pelvic Exam

Fixed

retroverted uterus & uterosacral

tenderness/nodularity EndometriosisBilateral, tender, irregularly enlarged adnexal structures

Chronic

salpingitis

(PID)

Enlarged, tender, boggy uterus

Don’t forget the recto-vaginal examination!

Especially when history includes central pain,

dyschezia

, or

dyspareunia

.

To eliminate the recto-vaginal exam in such cases is malpractice.

Patient Evaluation: Physical Exam

Slide18

Laboratory

Complete blood count (CBC)

Elevated sedimentation rate (ESR) - nonspecific

Urinalysis (UA)Urine pregnancy test (UPT)Gonorrhea/Chlamydia

Testing

Transvaginal

ultrasound (adnexal mass, uterine irregularity)

Abdominal and pelvic CT (bowel or urinary signs)

Diagnostic laparoscopy

Ultimate method of diagnosis for CPP of undetermined etiology

Patient Evaluation: Further Studies

Slide19

Laparoscopy (% vary widely in different practice settings)

Normal pelvis

Pelvic adhesions

Non-gyn diseaseEndometriosis

Fibroids

Hernias

Patient Evaluation: Further Studies

Slide20

Make a list of contributing factors; involve family member or S.O. when possible.

Treat any underlying pathology, but don’t flog it to death.

Include treatment of contributing factors as a package deal

Establish a therapeutic, supportive, and sympathetic (but structured) physician-patient relationshipSchedule regular follow-up appointments

Patient should not be told to call ONLY if pain persists

Deters pain behavior and secondary gain

Management

Slide21

Educate, educate, educate

Reassure patient of no serious underlying pathology

Chronic v. acute pain

Educate patient to likely mechanisms of pain productionCentral nervous system: centralizationNeuropathic

Muscular

Psychological (most often in reaction to pain events, not the primary etiology)

Management

Slide22

Treating multiple components of pain has been showed to be more effective than traditional gynecologic management. This can be accomplished in a single clinic, or through collaboration among several specialists, such as

Gynecologist

Physical therapist

+ Anesthesiologist

+

Acupuncturist

Psychologist

Sex therapist

Management

Slide23

Pharmacologic therapies:

Initial trial of hormonal manipulation

Cyclic therapy/regulation of menses

Suppress ovulation (OCP, DMPA and Lupron)Suppress menses (DMPA, high dose intrauterine progestins)

NSAIDS

Analgesics

Nonnarcotic

(ASA,

Acetominophen

)

Narcotic – use cautiously (tolerance, dependence)

SSRI

s or SNRI

’s

TCA

s, anti-epileptics

Especially for pain with neuropathic components

Management

Slide24

Surgical therapies:

Guarded prognosis in patients with multiple pain syndromesDegree of relief has uncertain relationship to amount of pathology; most can be done

laparoscopically

Unilateral adnexectomyHysterectomy + BSOPresacral neurectomy

Uterine suspension

Lysis

of adhesions

Resection/ablation of endometriosis

Anesthesia:

Acupuncture

Nerve blocks

Trigger point injections

Management

Slide25

Bottom Line Concepts

Chronic pelvic pain is pelvic pain of more than 6 months duration that has a significant effect on daily function and quality of life.

It affects 15-24% of American women in varying degrees of severity and accounts for a large portion of office visit and time.

Chronic pelvic pain is caused by a variety of factors including gynecologic, genitourinary, gastrointestinal, neuromuscular, and psychological.

Diagnostic laparoscopy is the ultimate method of diagnosis for patients with chronic pelvic pain of undetermined etiology.

Multidisciplinary approach has been shown to be more effective than pharmacologic or surgical therapy alone.

Even when etiology is determined, chronic pelvic pain can be difficult to treat and patients need to be seen regularly and provided much support.

Slide26

References and Resources

APGO, Chronic Pelvic Pain: An Integrated Approach. APGO Educational Series on Women

s Heath Issues, APGO, Washington, DC, January 2000.

APGO Medical Student Educational Objectives

, 9

th

edition, (2009), Educational Topic 39 (p82-83).

Beckman & Ling:

Obstetrics and Gynecology

, 6th edition, (2010),

Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith.

Chapter 30 (p279-282).

Hacker & Moore:

Hacker and Moore's Essentials of Obstetrics and Gynecology

, 5th edition (2009)

, Neville F Hacker, Joseph C Gambone, Calvin J Hobe

l. Chapter 21 (p259-264).

Katz:

Comprehensive Gynecology

, 5

th

edition, (2007),

Vern Katz, Gretchen Lentz, Rogerio Lobo, David Gershenson

. Chapter 8.