Dr. Ahmed jasim Ass.Prof. MBChB-DOG-FICMS COSULTANT OF GYN. & OBST. Chronic pelvic pain Dr. Ahmed jasim Ass.Prof. MBChB-DOG-FICMS COSULTANT OF GYN. & OBST.

Def. Chronic pelvic pain refers to pain in the region between the hips, below the bellybutton. In order to be considered chronic, the pain must last for at least six months or longer. Chronic pelvic pain syndrome: chronic pelvic pain causing emotional and behavioral changes.

Type of pain Visceral pain Referred Pain Somatic Pain Myalgia Hyperalgesia Neuroinflammation

Sources of chronic pelvic pain Gynecological Urological Gastrointestinal Musculoskeletal Neuropathic Other

Incidence 14 – 24% of women b/w 18 and 50 years. 1/3 do not consult doctor. 60% who consult are not referred to tertiary centre. Population studies: GI (37%), Urinary (31%), Gynae (20%). Laparoscopic findings: No pathology (35%), Endometriosis (33%), Adhesions (24%).

Differential Diagnosis for Chronic Pelvic Pain Gynecologic Gastrointestinal Endometriosis syndrome Irritable bowel Adhesions (chronic pelvic Chronic Appendicitis inflammatory disease) Leiomyomata Inflammatory bowel disease Adenomyosis Diverticulosis Pelvic congestion syndrome Diverticulitis Meckel’s diverticulum

Differential Diagnosis Urologic Psychological Abnormal bladder function Depression (detrusor instability) Urethral syndrome Somatization (chronic urethritis) Interstitial cystitis Psychosexual dysfunction/ Personality disorder abuse

Differential Diagnosis Musculoskeletal Surgical Nerve entrapment (neuritis) Chronic appendicitis Fasciitis Hernia Scoliosis Bowel disease Disc disease Adhesive disease Spondylolisthesis Osteitis pubis

Signs and Symptoms Pain during intercourse Cramping or sharp pains Heaviness or a feeling of pressure inside the pelvis Extreme and constant pain Intermittent pain A dull ache Pain during bowel movements

General Examination: Gait- Musculoskeletal Check  Abdominal Wall – Point trigger, Ovarian point tenderness Inspection of Vulva & introitus- Vestibulitis Check for Pelvic Floor Myalgia Single Digit Pelvic Exam Bimanual exam Rectovaginal exam

Investigations WCC, ESR CA – 125 HVS / Endocervical swabs USS Laparoscopy.

Treatment: Possible treatments for chronic pelvic pain include: Birth control pills to stop menstruation Progestogen (medroxy progesterone acetate (MPA)) was effective after 4 months’ treatment Over the counter pain relief medications, such as ibuprofen or aspirin Relaxation exercises, massage or physical therapy Antibiotics Psychological counseling Surgery to correct pelvic abnormalities Antibiotics if infection is the source of the pain Antidepressants Trigger point injections

Surgical management Adhesion release. beware of prolapse and bladder. Presacral neurectomy: beware of vessel injury, bladder/bowel. Hysterectomy with BSO Surgical mx of non gynae causes.