Chronic Pelvic Pain (CPP) Khaled Zeitoun, M.D. Assistant Clinical Professor Columbia University

Chronic Pelvic Pain: Definition An unpleasant Sensory and Emotional experience associated with actual or potential tissue damage or described in terms of such damage Symptom and always Subjective Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Definition Temporal characteristics Severity Location Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Definition Noncyclic pain of at least 6 months duration Menstrual pain /Intermittent pain Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Definition Anatomic pelvis Anterior abdominal wall at or below the umbilicus Lumbosacral back and buttock region Vulvar pain ??? Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Definition Causes functional disability Medical care Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Definition Acute pain occurs in conjunction with autonomic reflex responses, and associated with signs of inflammation and infection. Chronic pain is characterized by physiological, affective and behavioral responses that differ from acute pain. Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Theories Classic medical or Cartesian model Pain perception results directly from and is related to the extent of local tissue destruction Pain in the absence of tissue injury is psychogenic Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Theories The gate-control theory of pain Somatic and psychogenic factors can potentiate or modify response to pain Failing to recognize the many social factors believed to affect a patient's responses to pain and to therapy Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Theories The biopsychosocial theory of pain Most comprehensive model for dealing with chronic pelvic pain Integrates all the factors that contribute to a patient's perception of pain: nociceptive stimuli, psychological state, and social determinants Explains symptom "shifting" Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Population Women of all ages are affected Studies focused on women between 18 and 50 years old Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Demographic Variables No difference in age, race, socioeconomic status, education, ethnic background, education or employment. More common in divorced / separated women than single and married women (Mathias et al, 1996) Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Prevalence 15% to 20% of women between 18 and 50 years old have chronic pelvic pain of more than one year’s duration CPP accounted for 2% to 10% of all outpatient gynecologic consultations annually ( Reiter, 1990) Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Health Impact General health scores are lower Associated disturbances of mood and energy levels (>50%) Depression is common Quality of life is decreased Restricted activity and decreased productivity Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Health Impact 90% of women with CPP complain of dyspareunia Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Health Care 20% see a gynecologist 10% other physician 1% mental health evaluation Rest see no one???? Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Health Care Very few are seen and evaluated by clinicians in more than one specialty 75% of women who report CPP have not seen a healthcare provider for 3 month despite persistent pain affecting daily activities Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Health Care 56% take one or more nonprescription drugs 25% take medications prescribed by a provider 12% oral contraceptives Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Health Care 61% no diagnosis given by physician 39% diagnosis given 25% endometriosis 49% a non-cycle related gynecologic disorder (e.g. yeast infection or chronic PID) 10% non-gynecologic disorder 16% other Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Health Care 10% to 35% of laparoscopies are for CPP 9% to 80% of laparoscopies report abnormalities Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Health Care Up to 70% of laparoscopies report endometriosis Even if pathology is found it might not be the reason for the pain Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Health Care between 10% to 12% of hysterectomies are done for CPP Mortality 0.1% ( 70 women a year) Not always beneficial Detrimental effect of castration on heart disease, bone and Alzheimer’s Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Economic Impact Direct medical costs Loss of productivity Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Causes Gynecologic causes: Cyclic Noncyclic Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Causes Gynecologic causes: Endometriosis Adhesions (?) Adenomyosis Chronic pelvic infection Hydrosalpinx Pelvic congestion (?) Leiomyomata(?) Malignancies Primary dysmenorrhea Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Causes Gynecologic causes: Ovarian remnant syndrome Ovulatory pain Adnexal cysts Cervical stenosis Chronic endometritis Endometrial polyps Chronic ectopic pregnancy Pelvic relaxation IUD Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Causes Nongynecologic disorders: Psychiatric and psychological Depression Physical or sexual abuse Somatization Hypochondriasis Opiod seeking Factitious Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Causes Nongynecologic disorders: Pain processing disorder Fibromyalgia Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Causes Nongynecologic disorders: Gastrointestinal Functional bowl syndrome Inflammatory bowl disease Cancer Chronic appendicitis (?) Diverticulitis Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Causes Nongynecologic disorders: Urinary Interstitial cystitis Urethral syndrome Detrusor instability Chronic calculi Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Causes Nongynecologic disorders: Musculoskeletal Hernia Disc disease Arthritis Scoliosis and posture related disorders Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Nongynecologic disorders: Psychiatric and psychological In depression pain is not an uncommon presentation Mood is an important modifier of pain The relationship between depression and pain may involve neurotransmitter abnormalities Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Nongynecologic disorders: Psychiatric and psychological Physical and sexual abuse history is obtained in 25% to 40% of CPP patients Trauma of abuse event can kindle a depressive or pain processing disorder in a genetically susceptible individual Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Nongynecologic disorders: Psychiatric and psychological Somatization disorder patients have multiple physical complaints not explained by a known medical condition DSM-IV criteria: Four different pain sites, two GI complaints, one neurologic symptom and one sexual or reproductive symptom Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Nongynecologic disorders: Psychiatric and psychological Somatization disorder Emotional distress Common abnormality of sensation processing Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Nongynecologic disorders: Psychiatric and psychological Hypochondriasis patients are preoccupied with fear of having a serious disease Obsessive Visit many health care providers Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Nongynecologic disorders: Psychiatric and psychological Drug-seeking behavior patients often request opioids for pain relief Women with CPP may become addicted if they use opioids for pain relief Abdominal pain due to withdrawal leads to further drug use Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Nongynecologic disorders: Problematic substance abuse Impaired control of substance use Guilt or regret about use, efforts to cut down, complaints or concerns from others Recent substance use with resultant neurologic or cardiovascular symptoms, confusion, anxiety, or sexual dysfunction Psychosocial dysfunction Tolerance Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Nongynecologic disorders: Psychiatric and psychological Factitious disorder patients intentionally feign disease with the purpose of assuming the role of a sick person Malingering patients have external incentive to appear sick Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Nongynecologic disorders: Pain Processing Disorder Fibromyalgia occurs in 2% to 4% of individuals, 80% are women Abnormal pain processing associated with neuroendocrine and autonomic disorders Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Nongynecologic disorders: Fibromyalgia Criteria for diagnosis: Pain involving all 4 quadrants of body and axial skeleton Tenderness at 11 of 18 defined “tender points” Tenderness due to amplification of pain signals Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Nongynecologic disorders: Fibromyalgia Abnormal CNS processing of pressure Visceral sensations can also be abnormally processed Associated motility disorder of abdominal viscera Disordered sleep Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Nongynecologic disorders: Gastrointestinal Irritable bowel syndrome (IBS) Abdominal pain for at least 3 month duration in the last year Relieved by bowl movement Altered bowl habits (frequency and appearance) Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Nongynecologic disorders: Gastrointestinal Irritable bowel syndrome (IBS) Abnormal gastrointestinal motility Augmented sensation of visceral stimuli as pain Consistent with abnormal pain processing and autonomic dysfunction disorders Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Nongynecologic disorders: Gastrointestinal Inflammatory Bowel Disease Pain from inflammation of bowel or adjacent structures Nonspecific symptoms (pain, gas, distention, etc.) Fever and diarrhea Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Nongynecologic disorders: Gastrointestinal Diverticular disease Common after 40 years Left lower quadrant pain with diverticulitis Fever, diarrhea and constipation are common Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Nongynecologic disorders: Gastrointestinal Colon cancer uncommon before 40 years of age Altered bowl habits more than pain Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Nongynecologic disorders: Gastrointestinal Chronic appendicitis uncommon cause of CPP Existence is controversial??? Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Nongynecologic disorders: Urologic Interstitial cystitis Urinary urgency, bladder discomfort and sense of inadequate empting Bladder mucosal lesions consist of hemorrhage and petechiae (glomerulations) Some have only abdominal pain Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Interstitial cystitis ulceration

Nongynecologic disorders: Urologic Urethral Syndrome Irritative bladder symptoms often associated with coitus Lower abdominal pain may be chief presentation Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Causes Gynecologic causes Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Endometriosis GLANDS STROMA

EPIDEMIOLOGY AND PREVELANCE Endometriosis EPIDEMIOLOGY AND PREVELANCE - Diagnosed by laparoscopy in 25-33% of cases with infertility or chronic pelvic pain - 1-7% estimated prevalence among all reproductive age women

Endometriosis IMPLANTS - Red - Pink - Blue - Black - yellow - Brown - white - Clear - Peritoneal defect

Gynecologic disorders: Endometriosis: Pain Noncyclic pain Dyspareunia dysmenorrhea Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Gynecologic disorders: Endometriosis: Pain Peritoneal implants secrete factors that irritate the peritoneal surface Pelvic adhesions due to scarring and retraction of peritoneal surface Retroverted uterus or adherent ovaries in the C.D.S. cause dyspareunia due to compression of these structures or tension on surrounding peritoneum Uterosacral lesions due to compression or stretching of peritoneum Visceral pain due to invasion of urinary or GI tracts Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Endometriosis

Endometriosis

Endometriosis CLASSIFICATION - AFS original classification (1979) - AFS revised classification (1985) - ASRM revised classification (1996)

Gynecologic disorders: Endometriosis: Pain Not correlated with stage of disease Deep lesions are associated with more pain Vaginal endometriosis associated with dyspareunia Prostaglandins Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Endometriosis PHYSICAL FINDINGS - Normal examination - Focal tenderness - Retroverted fixed uterus - Nodularity and tenderness of the cul-de-sac or uterosacrals - Cervical stenosis - Pelvic masses

Endometriosis DIAGNOSTIC METHODS - CA-125 - Ultrasound, MRI, CT scans - Imaging urinary tract and bowl - Laparoscopy - Biopsy

Treatments of Pelvic Pain Due to Endometriosis Analgesics (NSAIDs) Estrogen/progestin combinations GnRH agonists / antagonists GnRH agonists with steroid add-back Danazol Others (aromatase inhibitors)

GnRH WITH ADD-BACK THERAPY Endometriosis GnRH WITH ADD-BACK THERAPY - Preservation of bone mass - Other effects of low estrogen - Prolonged Treatment - Improve compliance - Avoid surgery - May decrease efficacy

Treatments of Pelvic Pain Due to Endometriosis with GnRH Agonists Followed by Add-Back Therapy Transdermal estradiol patch: 25 µg/day, plus medroxyprogesterone acetate 2.5 mg daily This regimen does not completely prevent bone loss. The estradiol concentration achieved is in the range of 30 pg/mL. (Howell, 1995)

Treatments of Pelvic Pain Due to Endometriosis with GnRH Agonists Followed by Add-Back Therapy Norethindrone acetate 5 mg/day This is a very high dose of progestin. This dose of progestin is associated with a decrease in HDL-cholesterol (Hornstein, 1997)

Treatments of Pelvic Pain Due to Endometriosis with GnRH Agonists Followed by Add-Back Therapy Conjugated equine estrogen 0.625 mg/day, norethindrone acetate 5 mg/day This regimen prevents bone loss and markedly reduces the vasomotor symptoms reported. Pain relief was excellent. (Hornstein, 1997)

RECURRENCE: MEDICAL THERAPY Endometriosis RECURRENCE: MEDICAL THERAPY - Rates vary (29-51%) - Depend on duration

Endometriosis DEFINITIVE SURGERY - If pregnancy is not desired - Intractable disease - Hysterectomy +/- ovarian excision - Recurrence rates higher with ovarian conservation

Endometriosis CONSERVATIVE SURGERY - uterine and ovarian preservation - Usually done laparoscopically

Endometriosis RECURRENCE: SURGERY - Rates vary (7-66%) - Impossible to remove all lesions especially microscopic - Less recurrence after definitive surgery

Endometriosis RECURRENCE - Residual disease - Endometriosis prone patient - Aggressive lesions - Extra-ovarian estrogen production or ERT

Adenomyosis

Uterine Fibroids

Hydrosalpinx

Hydrosalpinx

Other lesions

ADHESIONS

Adhesions causing small bowel obstruction.

PATHOGENESIS Peritoneal Trauma Mechanical trauma Thermal, electrical or chemical trauma Foreign bodies Infection Inflammation Ischemia After a localized trauma to the peritoneum, the mesothelial cells die and degenerate, leaving a denuded area. The border of this damaged site contains dying cells, as shown on the slide. The process of re-epithelialization is initiated by the local production of chemotactic messengers that arise in conjunction with coagulation.

Initial Stage of Peritoneal Healing PATHOGENESIS Initial Stage of Peritoneal Healing Chemotactic messengers Coagulation Inflammatory exudate Fibroblast proliferation Healing of the peritoneum occurs primarily by re-epithelization of the damaged site. New peritoneal cells are attracted to the site of injury by chemotactic messengers released by platelets, blood clots, or leukocytes within the injured tissue. At this point, healing of the peritoneum differs from that seen with skin. With skin, healing occurs by granulation at the periphery of the injury. As a result, the duration of healing directly correlates with the size of the injury. Larger injuries take longer to heal than smaller ones. In contrast, re-epithelization of peritoneal injuries occurs by the formation of multiple "islands" of new mesolethial cells scattered upon the surface of the peritoneum. The source of these epithelial cells is controversial and includes adjacent normal mesothelial cells and subperitoneal stem cells. The mesothelial cells in each island continue to divide until the surface of the entire site of injury is covered by a new mesothelium.

Formation of Fibrin Bands PATHOGENESIS Formation of Fibrin Bands Inflammatory exudate Fibrin deposition Fibrin band formation After trauma to the peritoneum, there is increased vascular permeability, mediated by histamine, which often produces an inflammatory exudate and the formation of a fibrin matrix. Frequently, this fibrin matrix interconnects two adjacent pelvic structures leading to the formation of fibrin bands. These fibrin bands are usually resolved by finbrinolysis, converting the large fibrin molecules into small fibrin-spilt products that are readily removed from the peritoneal cavity.

PATHOGENESIS Fibrinolysis Fibrin Plasminogen Fibrin Split Products tPA Plasminogen PAI1 and PAI2 Fibrinolysis is a system for removal of fibrin from the peritoneal cavity. The peritoneal cells (mesothelial cells) contain plasminogen which is converted to the active enzyme, plasmin. The plasmin breaks down the fibrin into the biologically inactive fibrin split products by the tissue plasminogen activator pathway (tPA). The fibrinolytic system is modulated by plasminogen inhibitors (PAI1 and PAI2) which may regulate individual differences in fibrin removal. Inhibition Fibrin Split Products

Fully Healed Peritoneum PATHOGENESIS Fully Healed Peritoneum Fibrinolytic activity Tissue plasminogen activator 5-7 days normal surface healing Under normal conditions, where fibrinolytic activity occurs, mesothelial cell proliferation results in re-epithelialized of the injured site. The surface of peritoneal injuries is typically re-epithelialized 5 to 7 days after surgical injury. Beneath the surface, remodeling of collagen and other connective tissues continues for a few months.

Increased Vascular Permeability Normal Peritoneal Healing PATHOGENESIS Peritoneal Healing (approximately 5-7 days) Peritoneal Injury Increased Vascular Permeability Inflammatory Exudate Fibrin Deposition Ischemia This slide shows the steps that occur after the peritoneum is injured. Injuries to the peritoneal surface can cause stimulation of mast cells, resulting in the release of histamine and vasoactive kinins. These substances cause an increase in capillary permeability that leads to the formation of an inflammatory exudate that, in turn, results in deposition of fibrin. Fibrinolysis is vital to the removal of this fibrin deposit. Under ischemic conditions that result from peritoneal injury, the tissue loses its abundant fibrinolytic activity. The fibrin is allowed to persist as re-epithelization occurs. The fibrin becomes covered with a mesolethial surface and, in some cases, actually undergoes endothelial cell migration and neovascularization. This process leads to adhesions. Adhesion formation, therefore, requires both raw surface areas weeping fibrin exudate, as well as the failure to remove fibrin by fibrinolysis. Fibrinolysis Suppressed Fibrinolysis Fibrin Fixation Normal Peritoneal Healing Adhesion Formation

PATHOGENESIS Adhesion Formation Fibroblast proliferation Mesothelial over-growth Neovascularization Under the ischemic conditions present after surgical trauma, fibrinolytic activity is suppressed, which results in persistence of fibrin bands. Once the fibrin bands are infiltrated with fibroblasts, they become organized to form what are clinically identified as adhesions. It is important to note that healing of the peritoneal surface is not complete for about 5 to 7 days. Deposition of fibrin actually begins during the surgical procedure. Thus, adhesions can form at any time during this healing period.

Adhesions Following Reproductive Pelvic Surgery by Laparotomy INCIDENCE Adhesions Following Reproductive Pelvic Surgery by Laparotomy Study Year N % with adhesions Diamond et al. 1988 106 86% DeCherney and Mezer 1984 61 75% Surrey and Friedman 1982 37 73% Pittaway et al. 1985 23 100% Trimbos-Kemper et al. 1985 188 55% Daneill and Pittaway 1983 25 96% TOTAL 440 72% The incidence of pelvic adhesions varies following pelvic reconstructive surgery. The table above provides an overview of the studies reviewed by Diamond. Diamond et al noted an 86% incidence of pelvic adhesions at second-look laparoscopy after reconstructive pelvic surgery. DeCherney and Mezer observed a 75% incidence of adhesions after the initial procedures at 4-16 weeks. Surrey and Friedman noted a 71% incidence of adhesion formation. When a subset of these patients was studied long-term, 83% of them had adhesions. Pittaway et al found that all 23 of their patients had adhesions. Trimbos-Kemper et al observed adhesions in 55% of their patients. Finally, Daniell and Pittaway noted adhesion formation in 96% of women at second-look laparoscopy following conservative surgery. It is important to note that the adhesions seen in these studies represent not only adhesion reformation, but de novo adhesions as well. Majority of second-look laparoscopy performed between 1-12 weeks Adapted from Diamond M.P. Obstet Gynecol, 1988.

Incidence Ovary (55%) Pelvic sidewall (40%) Fimbria (36%) Omentum (19%) Small Intestine (15%) Colon (15%)

INCIDENCE Adhesions Following Laparoscopy Procedure N % with adhesions Adhesiolysis 68 66% Ovarian surgery 25 65% Myomectomy 50 88% Endometriosis 32 87% This slide shows the incidence of postoperative adhesion formation after laparoscopic surgery. Note that rate of adhesion formation after laparoscopy is similar to that following laparotomy. Majority of second-look laparoscopy performed between 12-14 weeks Diamond M. et al. Fertil Steril 1991;55:700-704. Mais V. et al. Hum Reprod 1995;10:3133-3135. Keckstein J. et al. Hum Reprod 1996;11:579-582. Mais V. et al. Obstet Gynecol 1995;86:512-515.

Clinical Consequences of Adhesions COMPLICATIONS Clinical Consequences of Adhesions Infertility Chronic pelvic pain (CPP) Small bowel obstruction (SBO) Intraoperative complications Subsequent surgery There are many different complications associated with post-surgical adhesions. Among the most common are infertility, chronic pelvic pain, pelvic pain, and small bowel obstruction.

Chronic Pelvic Pain: Laparoscopic Findings COMPLICATIONS Chronic Pelvic Pain: Laparoscopic Findings This chart demonstrates that adhesions were present in 15% - 45% of the patients suffering from chronic pelvic pain.

Chronic Pelvic Pain Relief after Laparoscopic Adhesiolysis COMPLICATIONS Chronic Pelvic Pain Relief after Laparoscopic Adhesiolysis Chronic pelvic pain in patients with associated intrapelvic adhesive disease is usually reduced after adhesiolysis indicating that adhesions often cause pelvic pain. It is as difficult to confirm that adhesions cause chronic pelvic pain as it is to confirm that adhesiolysis relieves chronic pelvic pain. Investigative reports found that adhesiolysis relieved the pain in approximately 60% to 90% of the patients. Howard, FM. Obstet Gynecol Surv 1993;48:357-387.

Recurrence of Pain Following Adhesiolysis COMPLICATIONS Recurrence of Pain Following Adhesiolysis Pain Rating Although most patients with chronic pelvic pain and adhesions experience a decrease in pain during the first few weeks after adhesiolysis, many note a recurrence of pain within the first few months following surgery. Time Since Surgery, Months Time of pain return during daily activities after laparoscopic lysis of adhesions. Steege and Stout, Am J Obstet Gynecol, 1991;165:278.

The Paradox of Chronic Pelvic Pain and Adhesions COMPLICATIONS The Paradox of Chronic Pelvic Pain and Adhesions Pelvic adhesions present in 15% - 45% of patients with chronic pelvic pain Adhesions may or may not be the cause of chronic pelvic pain Adhesiolysis decreases pain or is beneficial in a large percentage of patients??? Many patients have recurrence of pain or increased pain over time There is much controversy when trying to correlate chronic pelvic pain and adhesion formation. It has been reported that adhesions were present in 15-45% of patients suffering chronic pelvic pain. However, some patients who have adhesions have no pelvic pain and some patients who have pelvic pain do not have adhesions. While adhesiolysis decreases CPP in a large percentage of patients, many experience a recurrence of, or increase in, pain over time. Howard F.M. Obstet Gynecol Surv 1993;48:357-387.

Surgical Techniques to Minimize Adhesions ADHESION PREVENTION Surgical Techniques to Minimize Adhesions Directed hemostasis Avoid: ischemia desiccation sponging tissue grafts introduction of foreign bodies Minimize tissue handling Use fine non-reactive sutures placed without tension Consider using heparin in irrigation fluid The following steps can be taken during surgery to minimize the incidence of adhesions: 1) Achieve directed hemostasis: Inadequate hemostasis and the resultant fibrin deposition promote adhesion formation. 2) Avoid ischemia, drying of tissues, the use of gauze or dry sponging, tissue grafts and the introduction of foreign bodies, such as talc. 3) Minimize tissue handling: Manipulating tissue increases the possibility of vascular and tissue damage. When direct manipulation of the peritoneum is necessary, use either traumatic instruments or fingers. In addition, cutting and coagulating should be kept to a minimum to reduce the possibility of trauma and maintain vascularity. 4) Use fine, non-reactive sutures: To minimize foreign body reactions, use the smallest size suture composed of synthetic material. 5) Frequent peritoneal irrigation throughout the surgical procedure with a crystalloid solution containing a buffering capacity (i.e., lactated Ringer’s solution) with an anti-coagulant, such as Heparin, may rinse away some fibrinous exudates and, if suctioned out of the pelvic cavity, may reduce formation of adhesions; however, no data support the effectiveness of Heparin to prevent adhesion formation in humans.

Controlled Clinical Trials ADHESION PREVENTION Controlled Clinical Trials Non-efficacious Efficacious Dextran 70 Interceed* (TC7) Absorbable Ibuprofen Adhesion Barrier Tolmetin Preclude** Surgical Membrane Cortisone Seprafilm*** Bioresorbable Membrane Gynecare Intergel Dextran and other high molecular weight fluids have been instilled into the peritoneal cavity to "float" the organs but they have not shown a significant reduction in adhesion formation. Ibuprofen and Tolmetin have also been shown to be non-efficacious due to rapid absorption from the peritoneal cavity. A number of studies, however, demonstrate that the use of barriers is an effective method to prevent adhesion formation. *Trademark of ETHICON, Inc. **Trademark of W.L. Gore & Associates, Inc. ***Trademark of Genzyme

Chronic Pelvic Pain: Evaluation Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Recognition Duration of pain for 6 month Incomplete relief by most previous treatment Impaired function Signs of depression Pain out of proportion to pathology Altered family role Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Evaluation Multidisciplinary approach to diagnosis Consultations with other health professionals needed Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: History Most important diagnostic tool Open interview approach Detailed questioning regarding the pain Previous interventions Menstrual history Surgical history Review of systems Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Psychological History Early psychological evaluation Psychiatric illness Life stresses Personal loss and grieving process Substance abuse Family dysfunction / family support system Sexual relationships Sexual and physical abuse Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Physical Examination General physical examination Abdominal examination Tenderness in lower abdominal quadrants Contract abdominal muscles Surgical scars and hernias Vaginal or rectal examination Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Psychological testing Minnesota Multiphase Personality Inventory (MMPI) to evaluate psychopathology Beck Depression Inventory McGill pain questionnaire – pain rating index Multidimensional pain inventory Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Testing Laboratory testing Diagnostic nerve blocks Diagnostic imaging Diagnostic surgery / Pain mapping Empiric therapy Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Treatment Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Treatments for Some Nongynecologic Causes of CPP Depression: Cognitive-behavioral therapy, antidepressants Somatization: Psychotherapy Fibromyalgia: Tricyclics, cognitive-behavioral therapy, aerobic exercise

Treatments for Some Nongynecologic Causes of CPP Irritable bowel syndrome: Amitriptyline, antispasmodics, fiber Interstitial cystitis: bladder overdistension, amitriptyline, intravesical dimethylsulfoxide Urethral syndrome: antimicrobials, urethral dilatation

Treatments for Some Nongynecologic Causes of CPP Hernia: surgical repair Disc disease: anti-inflammatory medication, exercise, surgery Arthritis: anti-inflammatory medication Posture-related problems: physical therapy

Chronic Pelvic Pain: Treatment Empiric treatment of CPP with GnRH Agonist Standard approach: If no response to NSAIDs and OCs laparoscopy is done. Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Treatment Empiric treatment of CPP with GnRH Agonist Alternative approach: If no response to NSAIDs and OCs treat with GnRH agonist and avoid surgery (Ling, 1999) Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Treatment Empiric treatment of CPP with GnRH Agonist Is effective for endometriosis Also relieves pain from other causes like interstitial cystitis or IBS and pelvic congestion Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Treatment Treatment of CPP with OCP’s Is effective for primary dysmenorrhea Endometriosis Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Treatment Treatment of CPP with NSAID’s Is effective for dysmenorrhea Mild to moderate pain Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Treatment Treatment of CPP with progestins Is effective for endometriosis Pelvic congestion Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Treatment Treatment of CPP with laparoscopic surgery Is effective for endometriosis Stages I-III Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Treatment Treatment of CPP with presacral neurectomy Is not effective during surgical treatment of endometriosis Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Treatment Treatment of CPP with hysterectomy Is effective treatment of CPP Uterine pathology might not be found (65%) Fibroids, pelvic congestion, adhesions, endometriosis About 75% are pain free after one year Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Treatment Pain clinics Multidisciplinary approach to CPP that includes surgical, psychological, dietary and social interventions versus focused organic approach (peters et al, 1991) Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

Chronic Pelvic Pain: Treatment Nontraditional approaches Very little evidence that these approaches are effective Patient selection is important prior to gonadotropin use b/c of its great expense and its greater complication rates

THE END