Stump the Gynecologist: Differential Diagnosis of Chronic Pelvic Pain Jennifer K. McDonald DO F.A.C.O.G. October 10, 2008

ACOG Definition “Non-cyclic pain of 6 or more months duration that localizes to the anatomic pelvis, abdominal wall at or below the umbilicus, lumbosacral back or the buttocks and is of sufficient severity to cause functional disability or lead to medical care.”

Background l 10% out-patient gynecologic visits l 20% of laparoscopies l 15% of hysterectomies l $2.8 billion annually 15% of American women

61% of CPP will have no definitive diagnosis !!

Prevalence CPPMigraineAsthmaBack Pain

Age Prevalence

Features l Present for six months or more l Conventional treatments have yielded little or no relief l Degree or pain perceived seems out of proportion to the degree of tissue damage detected by conventional means l Physical appearance of depression is present l Physical activity is increasingly limited l Emotional roles in the family are altered

Distinction l Acute pain Pain is symptom of underlying tissue damage l Chronic pain Pain itself becomes the disease

Females - Unique Design Structural changes during development Pelvis widens after menarche Gluteal stretching Internal rotation of the femurs/lateral displacement of the patella Ligamentous laxity Decreased muscular tone increases lumbar lordosis and exaggerated anterior pelvic tilt Pelvic organs connected through shared common nerve pathways

Gynecologic - extra-uterine Gynecologic - uterine Urologic Gastrointestinal Musculoskeletal Neurologic Where do we look?

OvaryT10umbilical area UterusT12lower abdominal wall VaginaL1skin over groin Referred Pain

Most common culprits l Endometriosis l Adenomyosis l Interstitial cystitis l Irritable bowel l Pelvic Adhesions

Endometriosis l Presence of endometrial glands and stroma outside the uterus l No difference among ethnic groups or socioeconomic status l Genetic predisposition 6-10% increased risk with history of first degree relative DysmenorrheaAbnormal bleeding DyspaureniaGI complaints InfertilityUrinary complaints Low back pain

The many faces of endometriosis

Location 76% ovaries 69% posterior & anterior cul de sac 47% posterior broad ligament 36% uterosacral ligaments 11% uterus 6% fallopian tubes 4% sigmoid colon

Interstitial Cystitis l Prevalence of bladder origin chronic pelvic pain/interstitial cystitis is much greater than previously believed IC is a chronic inflammatory condition of the bladder characterized by irritable voiding symptoms of urgency and frequency in the absence of objective evidence of another disease that could cause the symptoms

Pathogenesis of IC: Defective Urothelial Barrier Irritating Solutes GAG Layer Urothelium Irritated Nerve Inflammation

Initial Development of IC Symptoms Diagnosis of IC See at least 5 physicians before diagnosis May have unnecessary hysterectomy Significant suffering and reduced QOL 2-7 years IC is Typically Diagnosed Late in Disease Continuum Average Time Between Initial Development of Symptoms and Diagnosis is 5 Years

IC Concurrent with Endometriosis Clinicians should consider the bladder to be the source of CPP, even when endometriosis is present 10% IC Alone 20%EndometriosisAlone 70% IC and Endometriosis Diagnosis of Patients With CPP by Cystoscopy and Hydrodistention & Laparoscopy 1

Pelvic Adhesions l Distort normal blood/nerve supply l Decreased mobility of organs/hypoxia l Pelvic inflammatory disease (PID) l Most common Chlamydia l Inflammatory reaction l Secretion of prostaglandins

Fibromyalgia Tender Points 11 or more TP sensitivity of 88% and specificity of 81%

Abdominal Wall Tenderpoints

Irritable Bowel l 12% US population l 2:1 women l Peak age l Increased GI motility and sensitivity to stimulants

Pelvic Pain Assessment Forms

Pain Diaries

Keys to Treatment l Pain and its perception are located in the nervous system so its treatment must encompass a Mind and Body approach l Multiple interactive problems are most likely with CPP so it isn’t which treatment is best but which treatments l It usually took time for things to get to where they are so it will be take time to get them back to normal as well l Chronic pain affects a family not just an individual patient

How can chiropractic help l Manipulation increases spinal mobility and improves blood supply by influencing the autonomic nervous system

The patient with CPP needs a multidisciplinary approach … are you ready?