Obstetrics and Gynecology Clerkship Case Based Seminar Series Chronic Pelvic Pain UNC School of Medicine Obstetrics and Gynecology Clerkship Case Based Seminar Series

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

Definition 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

Prevalence 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

Common Etiologies (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

Etiology: Gynecologic Endometriosis Adhesions Chronic PID Ovarian remnant syndrome Pelvic congestion syndrome Recurrent hemorrhagic ovarian cysts Myomata uteri (degenerating) Uterine retroversion Adenomyosis Pelvic floor and hip muscle pain Visceral hyperalgesia

Etiology: Non-Gynecologic Genitourinary Urinary retention Urethral syndrome Interstitial cystitis Gastrointestinal Penetrating neoplasms Irritable bowel syndrome Irritable bowel disease Partial small bowel obstruction Diverticulitis Hernia

Etiology: Non-Gynecologic Neuromuscular Nerve entrapment syndrome Generalized myofascial pain syndrome Fibromyalgia Psychological Depression PTSD (history of abuse/trauma) Anxiety disorders Personality disorder

Symptoms Dysmenorrhea Pain lasting > 6 months Impaired lifestyle Dyspareunia Pain during daily activities

Patient Evaluation: History Characteristics of the pain: Onset Location Duration Radiation Severity Alleviating/aggravating factors Relation to menstrual cycle Cyclic vs. non-cyclic Evolution over time Responses to treatments

Patient Evaluation: Psychological 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?

Physical exam Observe patient’s mobility as she gets up on the table. Palpate the entire back, but especially the paraspinous and SI joint areas Referred pain? Then palpate abdomen

Patient Evaluation: Physical Exam 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 flexion Palpate 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? Carnet sign?

Patient Evaluation: Physical Exam Evaluate for nerve entrapment Trigger points Ilioinguinal, iliohypogastric, and genitofemoral nerves Abdominal wall and back dermatomes Mark “jump signs” (points of motion tenderness ) Straight leg raise

Patient Evaluation: Physical Exam 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?” Single digit exam, obturator

Physical exam, continued Bimanual exam: size, shape, and mobility? Start with non-tender areas first Make two hands almost meet, sweep caudad Communicate with patient throughout Describe limits of exam due to habitus, guarding Examine to “count of 3” if patient is too uncomfortable.

Patient Evaluation: Physical Exam Pelvic Exam Fixed retroverted uterus & uterosacral tenderness/nodularity Endometriosis Bilateral, 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: Further Studies 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 Laparoscopy (% vary widely in different practice settings) Normal pelvis Pelvic adhesions Non-gyn disease Endometriosis Fibroids Hernias

Management 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 relationship Schedule regular follow-up appointments Patient should not be told to call ONLY if pain persists Deters pain behavior and secondary gain

Management Educate, educate, educate Reassure patient of no serious underlying pathology Chronic v. acute pain Educate patient to likely mechanisms of pain production Central nervous system: centralization Neuropathic Muscular Psychological (most often in reaction to pain events, not the primary etiology)

Management 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 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 Surgical therapies: Anesthesia: Guarded prognosis in patients with multiple pain syndromes Degree of relief has uncertain relationship to amount of pathology; most can be done laparoscopically Unilateral adnexectomy Hysterectomy + BSO Presacral neurectomy Uterine suspension Lysis of adhesions Resection/ablation of endometriosis Anesthesia: Acupuncture Nerve blocks Trigger point injections

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.

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, 9th 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 Hobel. Chapter 21 (p259-264). Katz: Comprehensive Gynecology, 5th edition, (2007), Vern Katz, Gretchen Lentz, Rogerio Lobo, David Gershenson. Chapter 8.