Chronic Pelvic Pain in Primary Care GGPET March 2015 Mr Philip Kaloo Consultant Gynaecologist and Laparoscopic Surgeon Endometriosis and Pelvic Pain Clinic, CGH Interactive session, almost no neuroanatomy Cpp – many underlying causes, affecting all the pelvic organs. Major negative factors affecting qol of pt

Outline Definitions Importance Causes History – Including Red flags Examination / Investigations Initial management in primary care Quiz

Definition - Chronic Pelvic Pain Intermittent or constant pelvic pain of at least 6 months duration Not a disease, but a complex multifactorial syndrome i.e. cognitive, behavioural and physical consequences In the lower abdomen or pelvis. Not occurring exclusively with menstruation or intercourse • duration of 6 months or longer; • incomplete relief with most treatments; • significantly impaired function at home or work; • signs of depression, such as early awakening, weight loss, or anorexia; and • altered family roles.

Importance Prevalence rate: 38/1000 = similar to asthma, migraine and back pain in primary care 20% GOPD Consultations Cognitive consequences Physical consequences Behavioural consequences And therefore social consequences, sexual consequences Cognitive consequences – depression Behavioural consequences – Physical consequences – fatigue 30% of patients never have a definable cause for their pain Economic costs of lost earnings/ time off work. Repeat consultations and repeat investigations

Chronic Pelvic Pain Syndrome Gynae GI Musculoskeletal Urological Chronic Pelvic Pain Syndrome 1/3 of cpp = cpps Up to 60 % of cpp is gynae

Just a few more definitions! Chronic pelvic pain syndrome - Is the occurrence of chronic pelvic pain where there is no proven infection or other obvious local pathology that may account for the pain Neuropathic pain – Pain caused by a primary lesion or dysfunction of the nervous system – peripheral or central,.. Myofascial trigger point – localised areas of deep tenderness in muscles Nerve entrapment – Pain from a nerve within scar tissue, fascia or narrow foramen Visceral hyperalgesia – Increased pain from a stimulus that normally provokes pain Allodynia – Pain from a stimulus that does not normally provoke pain Opioid-induced hyperalgesia – paradoxical increased sensitivity to nerve stimulation following opioid use no proven infection or other obvious local pathology that may account for the pain Allodynia – no change in the quality of a sensation but the response is altered. Hyperaesthesia – increased sensitivity to stimulation , hyperalgesia related to cutaneous sensations Trigger points – may be secondary to repeat chronic contraction

Aetiological – infection, trauma surgery inflammation Causes: Anatomical Aetiological – infection, trauma surgery inflammation Functional bowel disease Commonly seen in patients with CPP. Multiple studies demonstrate visceral hyperalgesia (e.g. exaggerated hyperalgesia (e.g. exaggerated response to distension, Shared nerve supply Shared nerve supply – S2, S , S3, S , S4 Supra Supra-sacral effects commonly seen sacral effects commonly seen (e.g. stress, diet) (e.g. stress, diet) OVARIAN PATOHOLGY – CYSTS, RESIDUAL OVARY, OVARIAN REMNANT Anatomical Aetiological – infection, trauma surgery

GYNAECOLOGICAL Endometriosis Adenomyosis Adhesions Ovarian pathology PID Fibroids? Hypo-oestrogenism Endometriosis is the most common cause of cpp, 70% of women with CPP have endo. Significantly more nerve fibres in endometriotic peritoneum than in normal. Dyspareunia - Hypo-oestrogenism secondary to childbirth Vulvodynia (6 months)– generalised (Pain at different places at different times) vulvar vestibulitis (only at entrance to vagina), only comes on after touch/pressure, burning Vestibultis is initiated by touch not generalised vulvodynia Causes: hx chronic antibiotic use, hypersensitivity to yeast infection, hormonal changes, nerve or muscle injury Adhesions – including residual ovarian syndrome and ovarian remnant syndrome Pid – 25% develop cpp

MUSCULOSKELETAL Myofascial dysfunction Nerve entrapment (Inc. Pudendal nerve, post surgery) Herniae Sacroiliac Levator ani and pirformis pain Pelvic floor – non-contracting muscles, non-relaxing muscles and non-contracting and non-relaxing overactive causes dysfunctional voiding, overactive bladder, constipation and dyspareunia underactive causes Dysfunction of pelvic floor affects pelvic viscera and vice versa. Treatment – physiotherapy, biofeedback and Myofascial trigger point – repeated or chronic muscle overuse can activate trigger points in muscle = hyperirritable spots within a tight band. The affected muscle is shortened therefore limiting function. Pain aggravated by pressure Myofascial trigger point treatment: Manual therapy – pressure and release, compression etc Dry needling Wet needling – local /botulinum a toxin(inhibits acetylcholine release at the nm junction Nerve entrapment – highly localised , sharp stabbing pain. 3.7% after pfanenstiel

GASTROINTESTINAL IBS Chronic appendicitis Constipation Inflammatory bowel disease IBS – 50% of patients presenting with pelvic pain to a gynae clinic have symptoms of IBS

UROLOGICAL Interstitial cystitis (Bladder pain syndrome) Urethral pain syndrome Chronic UTI Calculi Urothelium line bladder and urethra and so would be reasonable to assume pathology affecting the bladder can also affect the urethra BPS – pain/pressure or discomfort associated with the bladder and urinary frequency. Having excluded all other causes. aetiology : unidentified bladder insult to the bladder causing inflammation and neural changes. Defect in bladder wall causing increased sensitivity to urine. Rx – Analgesia – respond poorly to nsaids Anti-histamines Amitryptyline >50mg/day

Points of referral Gynaecology Urology Gastroenterology Pain Medicine Genitourinary Medicine Dermatology Rheumatology Orthopaedics

Case study 1 44 year old business woman P1 (chronically ill) Medically fit and well 12 months ago, antibiotics for chest infection Severe thrush, initially responds Then severe vulvodynia and dyspareunia and urinary urgency Referred after 6 months. Examination – pain ++ , unable to do pv

Thoughts? Initial insult Peripheral nerve changes Central sensitisation Somato-viseral hyperalgesia Vulvodynia Neuroplasticity leading to allodynia (pain from stimuli that aren't normally painful) and hyperalgesia Similar aetiology to cpp following PID, BPS and ? Functional bowel disorder

History Pattern of pain (Pain diaries) Bladder, bowel, psychological symptoms Menstrual cycle Effects on lifestyle, family etc Sexual function “What do you think is causing the pain?” *Time* Site and Radiation Exacerbations in symptoms during bladder filling Intensity (Mild, Moderate, Severe) or 1-10 Duration (<I month, 1-6 month, >6 months) VAS

“Red flag” signs and symptoms PV bleeding – PCB, if >40yrs Pelvic mass New pelvic pain >50 yrs old Bowel - PR bleeding Urinary - Haematuria Excessive weight loss Suicidal ideation

Examination Abdomen – Carnetts' Test Vulva Vaginal examination/bimanual Speculum Back/hips *Time* Examination is very different from a routine gynae examination v.e single digit only, anterior tenderness - ?Bladder pain syndrome Explain why not examining patient can be helpful

Investigation FBC, CRP Urinanalysis Vaginal and endocervical swabs Imaging (Laparoscopy - Grade A recommendation to rule out treatable cause, a negative laparoscopy often helps) Negative laparoscopy help in symptom relief because of effects on beliefs about pain and the exclusion of serious disease

Case study 2 32 year old nullip 3 year history of CPP and bowel symptoms PMH: Myomectomy 4 yrs ago Referred to gynae with pelvic pain/dyspareunia. Treated with COCP – unsuccessful. Normal TVS Referred to pain clinic – amitryptyline, pregabalin and tramadol Referred to Endometriosis/pelvic pain clinic

Initial Management Remove the original insult Treat the pain i.e. NSAIDS, antispasmodics Hormonal manipulation Neuromodulators TENS Dietary modification Complementary therapies Psychological management

Medical management Regular review Oral imipramine or nortryptline Analgesia Simple analgesia Tramadol 50-100mg 4 hourly Neuromodulators Amitryptyline 10-75mg/day 150 - 600mg/day in 2 doses Pregabalin Other Buscopan Topical analgesics Hormonal manipulation Regular review Oral imipramine or nortryptline Gabapentin – side-effects; particularly drowsiness, peripheral oedema, dizziness Others – Topical capsaican / lidocaine plasters TCA’s i.e amitrypyline can be a problem in depressed patients because of problems re overdose So SNRI’s can be more beneficial when an anti-depressant acitivity and anti-neuropathic pain is required If little benefit with amitryptyline at 50-75mg/day, drop down slowly and then add a gabapentinoid

Referral criteria Consider referral at any stage Severe pain having significant effect on daily activity Deterioration in symptoms Red flag symptoms

Quiz What is the prevalence of chronic pelvic pain? What percentage of chronic pelvic pain (Excluding CPPS) is due to a gynaecological cause? What does a positive Carnetts’ test suggest? What could you use as a first line neuromodulator? Can TENS machines be used in CPP? In what type of CPP is this ‘helpful’?

Conclusion CPP is a very common condition in primary care It is often a complex condition but a lot can be done without referral into secondary care http://eng.mapofmedicine.com (chronic pelvic pain) RCOG Guidelines SOGC Guidelines IASP