Chronic Pelvic Pain Marvin L. Stancil, M.D. Associate Professor Obstetrics and Gynecology University of Nebraska Medical Center

Medical Student Objectives Define chronic pelvic pain. Cite the prevalence and common etiologies of chronic pelvic pain. Describe the symptoms & physical exam findings associated with chronic pelvic pain. Discuss the steps in the evaluation & management options for chronic pelvic pain. Discuss the psychosocial issues associated with chronic pelvic pain.

past six months and is affecting the patient’s quality of life Chronic Pelvic Pain Definition Chronic Pelvic Pain (CPP) is pain of apparent pelvic origin that has been present most of the time for the past six months and is affecting the patient’s quality of life

Chronic Pelvic Pain Definition Difficult to diagnose Frustration for patient and physician Difficult to treat Difficult to cure

Chronic Pelvic Pain Incidence Accounts for 20% of all laparoscopies Affects 15-20% of women of reproductive age Accounts for 20% of all laparoscopies Accounts for 12-16% of all hysterectomies Associated medical costs of $3 billion annually

Etiology Psychological Gastrointestinal Urological Gynecological Musculoskeletal

Chronic Pelvic Pain Demographics Demographics of age, race, ethnicity, education, and socioeconomic status do not differ between those with and without chronic pelvic pain Higher incidence in single, separated or divorced women 40-50% of women have a history of abuse

Chronic Pelvic Pain Etiology: United Kingdom Primary Care Database 25-50% of women had more than one diagnosis Severity and consistency of pain increased with multisystem symptoms Most common diagnoses: endometriosis adhesive disease irritable bowel syndrome interstitial cystitis Gastrointestinal Urinary Gynecological 37.7% 30.8% 20.2% Diagnosis Distribution Found that diagnoses related to the urinary and GI tracts were more common than gynecological diagnoses. For example, 43% of women with CPP without GI or urologic symptoms had moderate to severe pain; whereas 71% of women with both GI and urological symptoms had moderate to severe pain.

Chronic Pelvic Pain Diagnosis Obtaining a COMPLETE and DETAILED HISTORY is the most important key to formulating a diagnosis

Diagnosis: Obtaining the History Chronic Pelvic Pain Diagnosis: Obtaining the History Duration of Pain Nature of the Pain Sharp, stabbing, throbbing, aching, dull? Specific Location of Pain Associated with radiation to other areas? Modifying Factors Things that make worse or better? Timing of the Pain Intermittent or constant? Temporal relationship with menses? Temporal relationship with intercourse? Predictable or spontaneous onset? Detailed medical and surgical history Specifically abdominal, pelvic, back surgery

Chronic Pelvic Pain Use the REVIEW OF SYSTEMS Diagnosis: Obtaining the History Use the REVIEW OF SYSTEMS to obtain focused, detailed history of organ systems involved in the differential diagnosis

Gynecological Review of Systems Chronic Pelvic Pain Diagnosis: Obtaining the History Gynecological Review of Systems Associated with menses? Association with sexual activity? (Be specific) New sexual partner and/or practices? Symptoms of vaginal dryness or atrophy? Other changes with menses? Use of contraception? Detailed childbirth history? History of pelvic infections? History of gynecological surgeries or other problems?

Gastrointestinal Review of Systems Chronic Pelvic Pain Diagnosis: Obtaining the History Gastrointestinal Review of Systems Regularity of bowel movements? Diarrhea/ constipation/ flatus? Relief with defecation? History of hemorrhoids/ fissures/ polyps? Blood in stools, melena, mucous? Nausea, emesis or change in appetite? Abdominal bloating? Weight loss?

Urological Review of Systems Chronic Pelvic Pain Diagnosis: Obtaining the History Urological Review of Systems Pain with urination? History of frequent or recurrent urinary tract infection? Hematuria? Symptoms of urgency or urinary incontinence? Difficulty voiding? History of nephrolithiasis?

Musculoskeletal Review of Systems Chronic Pelvic Pain Diagnosis: Obtaining the History Musculoskeletal Review of Systems History of trauma? Association with back pain? Other chronic pain problems? Association with position or activity? Any abdominal wall complaints or surgery?

Psychological Review of Systems Chronic Pelvic Pain Diagnosis: Obtaining the History Psychological Review of Systems History of verbal, physical or sexual abuse? Diagnosis of psychiatric disease? Onset associated with life stressors? Exacerbation associated with life stressors? Familial or spousal support?

A bimanual exam alone is NOT sufficient for evaluation Chronic Pelvic Pain Diagnosis: The Physical Exam Evaluate each area individually Abdomen Anterior abdominal wall Pelvic Floor Muscles Vulva Vagina Urethra Cervix Viscera – uterus, adnexa, bladder Rectum Rectovaginal septum Coccyx Lower Back/Spine Posture and gait A bimanual exam alone is NOT sufficient for evaluation

Diagnosis: Objective Evaluative Tools Chronic Pelvic Pain Diagnosis: Objective Evaluative Tools Basic Testing Pap Smear Gonorrhea and Chlamydia Wet Mount Urinalysis Urine Culture Pregnancy Test CBC with Differential ESR or CRP Specialized Testing MRI or CT Scan Endometrial Biopsy Laparoscopy Cystoscopy Urodynamic Testing Urine Cytology Colonoscopy Electrophysiologic studies PELVIC ULTRASOUND Referral to Specialist

Differential Diagnosis Chronic Pelvic Pain Differential Diagnosis The differential diagnosis for Chronic Pelvic Pain is extensive Challenges the gynecologist to “think outside the uterus” Diagnosis, evaluation and treatment plans: Should align with pertinent positives and negatives from the History and Physical Often requires an interdisciplinary approach

Differential Diagnosis: Chronic Pelvic Pain Differential Diagnosis: Gynecological Conditions that may Cause or Exacerbate Chronic Pelvic Pain Level A Endometriosis Gynecologic malignancies Ovarian Retention Syndrome Ovarian Remnant Syndrome Pelvic Congestion Syndrome Pelvic Inflammatory Syndrome Tuberculosis Salpingitis Level B Adhesions Benign Cystic Mesothelioma Liomyomata Postoperative Peritoneal Cysts Level C Adenomyosis Dysmenorrhea/ Ovulatory Pain Nonendometriotic Adnexal Cysts Cervical Stenosis Chronic Ectopic Pregnancy Chronic Endometritis Endometrial or Cervical Polyps Endosalpingiosis Intrauterine Contraceptive Device Ovarian Ovulatory Pain Residual accessory ovary Symptomatic Pelvic Prolapse Source: ACOG Practice Bulletin #51, March 2004

Differential Diagnosis: Gynecological Conditions Chronic Pelvic Pain Differential Diagnosis: Gynecological Conditions Cyclical Non-cyclical Endometriosis Adenomyosis Primary Dysmenorrhea Ovulation Pain/ Mittleschmertz Cervical Stenosis Ovarian Remnant Syndrome Pelvic Masses Adhesive Disease Pelvic Inflammatory Disease Tuberculosis Salpingitis Pelvic Congestion Syndrome Symptomatic Pelvic Organ Prolapse Vaginismus Pelvic Floor Pain Syndrome

Chronic Pelvic Pain Endometriosis Presence of endometrial tissue outside of uterine cavity Usually found in dependent areas of the pelvis Most commonly in ovaries, posterior cul-de-sac, uterosacral ligaments Endometrial glands and stroma on biopsy May be at distant sites such as bowel, bladder, lung, skin, plurae Etiology not well understood Retrograde menstruation Lymphatic and hematologic spread of menstrual tissue Metaplasia of coelomic epithelium Immunologic dysfunction

Endometriosis: Prevalence Chronic Pelvic Pain Endometriosis: Prevalence Typically diagnosed in women 25 -35 years of age Diagnosed in approximately 45% of women undergoing laparoscopy for any indication Diagnosed in approximately 30% of women undergoing laparoscopy with primary complaint of chronic pelvic pain Found in 38% of women with infertility Family history increases risk ten-fold Significant cause of morbidity

Endometriosis: Signs and Symptoms Chronic Pelvic Pain Endometriosis: Signs and Symptoms Symptoms Physical Exam Visible lesions on cervix or vagina Tender nodules in the cul-de-sac, uterosacral ligaments or rectovaginal septum Pain with uterine movement Tender adnexal masses (endometriomas) Fixation (retroversion) of uterus Rectal mass Normal findings Dysmenorrhea Dyspareunia Infertility Intermenstrual Spotting Painful Defecation Pelvic Heaviness Asymptomatic Symptoms are not well correlated with extent of disease – pain is out of proportion to the physical exam findings or radiologic findings or laparoscopic findings. Dyspareunia is usally with deep (rather than superficial) penetration. Symptoms usually regress with pregnancy and menopause

Endometriosis: Diagnosis Chronic Pelvic Pain Endometriosis: Diagnosis Diagnosis can be made on clinical history and exam Serum CA125 may be elevated but lacks sufficient specificity and sensitivity to be useful Imaging studies lack sufficient resolution to detect small endometrial implants Laparoscopy is gold standard for diagnosis Multiple appearances: red, brown, scar, white, powder burn, vesicular lesions, adhesions, defects in peritoneum, endometriomas Allows diagnosis and treatment

Laparoscopic Appearance of Endometriosis Chronic Pelvic Pain Laparoscopic Appearance of Endometriosis

Endometriosis: Diagnosis Chronic Pelvic Pain Endometriosis: Diagnosis Revised classification system by the ASRM (1996) Poor correlation between symptoms and extent of disease Classification system has been revised three times – last time in 1986. Useful for comparing patients to themselves and for comparing research. However, there is no correlation between stage of endometriosis and extent of disease. Some people can be found to have minimal disease but have excruiating pain whereas others can have extensive disease but have no pain at all.

Chronic Pelvic Pain Staging of Endometriosis

Endometriosis: Medical Treatment Chronic Pelvic Pain Endometriosis: Medical Treatment NSAIDS for mild disease First Line: Oral contraceptives Suppress ovulation and menstruation Cyclic or continuous therapy Improves symptoms in up to 70-80% Second Line: Progestins, GnRH agonists, Danazol Lupron Depot (x 6-12 months) Improves symptoms in up to 80-85% Side effects: hot flashes, vaginal dryness, insomnia, bone loss irritability “Add back” estrogen +/- progestin

Endometriosis: Surgical Treatment Chronic Pelvic Pain Endometriosis: Surgical Treatment Laparoscopic Removal or Destruction Treatment at time of diagnosis Used in conjunction with medical therapy Improves pain in up to 80-90% of patients Laparotomy (TAH/BSO) Inadequate response to medical treatment or conservative surgical treatment with no desire for future fertility May preserve ovaries in young women, but 30% with recurrent symptoms LUNA Laparoscopic Uterosacral Nerve Ablation (LUNA), Presacral neurectomy Involves transecting the nerve plexus at the base of the cervical-uterosacral ligament junction or retroperitoneum

Chronic Pelvic Pain Adenomyosis Description: Presence of endometrial glands and stroma within the myometrium Symptoms: Dysmenorrhea; Menorrhagia; Enlarged boggy uterus; typically affects women age 30-40’s Diagnosis: Pathology, MRI (ultrasound limited usefulness) Treatment: Hysterectomy; usually when diagnosis is made

Chronic Pelvic Pain Primary Dysmenorrhea Description: Pain associated with menses that usually begins 1-3 days prior to the onset of menses; last 1-3 days Risk Factors: Nulliparity, Young Age, Heavy menses, Cigarette Smoking Symptoms: Crampy lower abdominal pain; +/- nausea, emesis, diarrhea or headache, normal physical exam Treatment: NSAIDS, Multivits with B-complex, Hormonal Therapy (OCPs, OrthoEvra, Nuvaring, Mirena IUD, Depo-Provera. Usual improvement after childbirth.

Pelvic Inflammatory Disease Chronic Pelvic Pain Pelvic Inflammatory Disease Description: Spectrum of inflammation and infection in the upper female genital tract Endometritis/ endomyometritis Salpingitis/ salpingo-oophritis Tubo-ovarian Abscess Pelvic Peritonitis Pathophysiology: Ascending infection of vaginal and cervical microorganisms Chlamydia ,Gonorrhea (developed countries) Tuberculosis (developing countries) Acute PID usually polymicrobial infection

Pelvic Inflammatory Disease Chronic Pelvic Pain Pelvic Inflammatory Disease Risk Factors Adolescent Multiple sexual partners Greater than 2 sexual partners in past 4 weeks New partner in the past 4 weeks Prior history of PID Prior history of gonorrhea or chlamydia Smoking None or inconsistent condom use Instrumentation of the cervix and lower reproductive tract

Pelvic Inflammatory Disease: CDC Diagnostic Guidelines (2006) Chronic Pelvic Pain Pelvic Inflammatory Disease: CDC Diagnostic Guidelines (2006) Minimum Criteria (one required): Uterine Tenderness Adnexal Tenderness Cervical Motion Tenderness No other identifiable causes Specific criteria for dx: Pathologic evidence of endometritis US or MRI showing hydrosalpinx, TOA Laparosopic findings consistent with PID Additional criteria for dx: Oral temperature greater than 101F Abnormal cervical or vaginal discharge Presence of increased WBC in vaginal secretions Elevated ESR or C-reactive protein Documented of GC or CT

Pelvic Inflammatory Disease Chronic Pelvic Pain Pelvic Inflammatory Disease Treatment: Outpatient and Inpatient Abx dosing regimens; Total therapy for 14 days, maybe longer if TOA Sequelae Infertility Ectopic Pregnancy Chronic Pelvic Pain Occurs in 18-35% of women who develop PID May be due to inflammatory process with development of pelvic adhesions Refer to www.CDC.gov/std; revised 2010, updated Aug. 2012 for outpt. GC treatment

Pelvic Congestion Syndrome Chronic Pelvic Pain Pelvic Congestion Syndrome Description: Retrograde flow through incompetent valves venous valves can cause tortuous and congested pelvic and ovarian varicosities; Etiology unknown. Symptoms: Pelvic ache or heaviness that may worsen premenstrually, after prolonged sitting or standing, or following intercourse Diagnosis: Pelvic venogrpahy, CT, MRI, ultrasound, laparoscopy Treatment: Progestins, GnRH agonists, ovarian vein embolization or ligation, and hysterectomy with bilateral salpingo-oophorectomy (BSO)

Pelvic Floor Pain Syndrome Chronic Pelvic Pain Pelvic Floor Pain Syndrome Description: Spasm and strain of pelvic floor muscles Levator Ani Muscles Coccygeus Muscle Piriformis Muscle Symptoms: Chronic pelvic pain symptoms; pain in buttocks and down back of leg, dyspareunia Levator Ani Muscle: supports pelvic viscera, constricts lower end of rectum and vagina Coccygeus muscle: aids in raising and supporting pelvic floor Piriformis: rotates thigh laterally Treatment: Biofeedback, Pelvic Floor Physical Therapy, TENS (Transcutaneous Electrical Nerve Stimulation) units, antianxiolytic therapy, cooperation from sexual partner

Chronic Pelvic Pain Differential Diagnosis: Urological Conditions that may Cause or Exacerbate Chronic Pelvic Pain Level A Bladder Carcinoma Interstitial Cystitis Radiation Cystitis Urethral Syndrome Level B Detrusor Dyssynergia Urethral Diverticulum Level C Chronic Urinary Tract Infection Recurrent Acute Cystitis Recurrent Acute Urethritis Stone/urolithiasis Urethral Caruncle Source: ACOG Practice Bulletin #51, March 2004

Interstitial Cystitis Chronic Pelvic Pain Interstitial Cystitis Description: Chronic inflammatory condition of the bladder Etiology: Loss of mucosal surface protection of the bladder and thereby increased bladder permeability Also called Painful Bladder Syndrome Symptoms: Urinary urgency and frequency Pain is worse with bladder filling; improved with urination Pain is worse with certain foods Pressure in the bladder and/or pelvis Pelvic Pain in up to 70% of women Present in 38-85% presenting with chronic pelvic pain

Interstitial Cystitis Chronic Pelvic Pain Interstitial Cystitis Diagnosis: Cystoscopy with bladder distension Intravesicular Potassium Sensitivity Test Presence of glomerulations (Hunner Ulcers) Treatment: Avoidance of acidic foods and beverages Antihistamines Tricyclic antidepressants Elmiron (pentosan polysulfate sodium) Intravesical therapy: DMSO (dimethyl sulfoxide) Elmiron: helps to prevent the formation of Hunner Ulcers by coating the bladder wall, thus making it harder for the acid in the urine to irritate the bladder wall lining which can lead to ulceration.

Differential Diagnosis: Chronic Pelvic Pain Differential Diagnosis: Gastrointestinal Conditions that may Cause or Exacerbate Chronic Pelvic Pain Level A Colon Cancer Constipation Inflammatory Bowel Disease Irritable Bowel Syndrome Level B None Level C Colitis Chronic Intermittent Bowel Obstruction Diverticular Disease Source: ACOG Practice Bulletin #51, March 2004

Irritable Bowel Syndrome (IBS) Chronic Pelvic Pain Irritable Bowel Syndrome (IBS) Description: Chronic relapsing pattern of abdomino-pelvic pain and bowel dysfunction with diarrhea and/or constipation Prevalence Affects 12% of the U.S. population 2:1 prevalence in women: men Peak age of 30-40’s Rare on women over 50 Associated with elevated stress level Symptoms Diarrhea, constipation, bloating, mucousy stools Symptoms of IBS found in 50-80% women with CPP

Irritable Bowel Syndrome (IBS) Chronic Pelvic Pain Irritable Bowel Syndrome (IBS) Diagnosis based on Rome II criteria Treatment Dietary changes Decrease stress Cognitive Psychotherapy Medications Antidiarrheals Antispasmodics Tricyclic Antidepressants Serotonin receptor (3, 4) antagonists

Differential Diagnosis: Chronic Pelvic Pain Differential Diagnosis: Musculoskeletal Conditions that may Cause or Exacerbate Chronic Pelvic Pain Level A Abdominal Wall Myofascial Pain (Trigger Points) Chronic Back Pain Poor Posture Fibromyalgia Neuralgia of pelvic nerves Pelvic Floor Myalgia Peripartum Pelvic Pain Syndrome Level B Herniated Disk Low Back Pain Neoplasia of spinal cord or sacral nerve Level C Lumbar Spine Compression Degenerative Joint Disease Hernia Muscular Strains and Sprains Rectus Tendon Strains Spondylosis Source: ACOG Practice Bulletin #51, March 2004

Differential Diagnosis: Chronic Pelvic Pain Differential Diagnosis: Psychological/Other Conditions that may Cause or Exacerbate Chronic Pelvic Pain Level A Abdominal cutaneous nerve entrapment in surgical scar Depression Somatization Disorder Level B Celiac Disease Neurologic Dysfunction Porphyria Shingles Sleep Disturbances Level C Abdominal Epilepsy Abdominal Migraines Bipolar Personality Disorder Familial Mediterranean Fever Source: ACOG Practice Bulletin #51, March 2004

Psychological Associations Chronic Pelvic Pain Psychological Associations 40 – 50% of women with CPP have a history of abuse (physical, verbal , sexual) Psychosomatic factors play a prominent role in CPP Psychotropic medications and various modes of psychotherapy appear to be helpful as both primary and adjunct therapy for treatment of CPP– Multidisciplinary pain clinic Approach patient in a gentle, non-judgmental manner Do not want to imply that “pain is all in her head”

Chronic Pelvic Pain Conclusions Chronic Pelvic Pain requires patience, understanding and collaboration from both patient and physician Obtaining a thorough history is key to accurate diagnosis and effective treatment Diagnosis is often multifactorial – may affect more than one pelvic organ Treatment options often multifactorial – medical, surgical, physical therapy, cognitive therapy