1. Chronic pelvic pain Dr. Mridula A. Benjamin. Dept of Obs and Gyn RIPAS Hospital, Brunei

2. An unpleasant sensory and emotional experience associated with actual or potential tissue damage Why is Chronic Pelvic Pain so Different? Difficult / Unsatisfactory

3. Acute pelvic pain: symptom of underlying tissue injury. Chronic pelvic pain: pain becomes the disease Recurrent, unrelated to menses, intercourse, pregnancy Chronic pain: pain lasting 6 months or longer.  Chronic pelvic pain syndrome: chronic pelvic pain causing emotional and behavioral changes.

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

5. Sources of chronic pelvic pain Gynecological Urological Gastrointestinal Musculoskeletal Neuropathic Other

6. 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%).

7. Differential Diagnosis for Chronic Pelvic Pain GynecologicGastrointestinal Endometriosis syndrome Irritable bowel Adhesions (chronic pelvic Chronic Appendicitis inflammatory disease) Leiomyomata Inflammatory bowel disease AdenomyosisDiverticulosis Pelvic congestion syndromeDiverticulitis Meckel’s diverticulum

8. Differential Diagnosis UrologicPsychological Abnormal bladder functionDepression (detrusor instability) Urethral syndromeSomatization (chronic urethritis) Interstitial cystitis Psychosexual dysfunction/Personality disorder abuse

9. Differential Diagnosis MusculoskeletalSurgical Nerve entrapment (neuritis) Chronic appendicitis Fasciitis Hernia Scoliosis Bowel disease Disc disease Adhesive disease Spondylolisthesis Osteitis pubis

10. MOST FREQUENTLY MISSED COMPONENTS OF CPP Abdominal trigger points Vestibulitis Pelvic floor myalgia Hernias Pelvic congestion Interstitial cystitis

11. History: questionnaires A. Who have you consulted about your current medical complaint? What did they tell you? B.How are you currently coping with your pain? C.Do you have any history of a major episode of depression? D.Do you feel you are experiencing symptoms of depression? Yes No Check those that apply:Mood disturbances Feelings of hopelessness Low energy Sleep disturbance Loss of pleasure in activities Feelings of worthlessness Loss of appetite Thoughts or plans of suicide

12. History: questionnaires E. Has anyone ever abused you sexually? (40% vs 17%) If yes, at what age? By whom? F.Has anyone ever touched you in any way that made you feel uncomfortable? If yes, at what age? By Whom? G. Has anyone ever asked you to touch them when you did not want to? If yes, at what age? By whom? H. Vaginal discharge, Dyspareunia(41%vs 14%), Dysmenorrhoea(81%vs 58%). Adapted from Carter JE. “Chronic Pelvic Pain Diagnosis and Management”

13. History: activities Work School Social activities Childcare Sports/exercise Patient deems important

14. Date:Name: Age: G: P: LMP:Cycle day: A.Fill in the following chart on pain location Pain site: Date pain first noticed: Describe events preceding pain (and indicate cycle day): Describe pain using adjectives (and indicate cycle day): Rate pain intensity from 0 (no pain) to 10 (most severe): List additional pain sites on back of form B.Rate the overall interference of pain from 0 (low) to 10 (high) for each of the following: Work: School: Social activities: Childcare: Sports and exercise: Relationships: Other: C.Check or list things that: Increase pain Decrease pain Intercourse Lying down Bowel movement Heating pad Urination Hot bathPhysical activitiesMedicationOther D.List prior treatments or tests:SurgeriesGI studies Type:Type: Date:Date: Diagnosis:Diagnosis: E.List medications, dates used, and effectiveness using the 0 to 10 scale DrugDates UsedRating F.Check off symptoms you are experiencing other than pain: BleedingBowel problems Nausea HeadacheFatigue Other Pain Questionnaire

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

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

19. Pelvic congestion syndrome Equal in parous& nulliparous ??? Underlying endocrine disorder Peripheral hormone levels normal Prolonged standing, dysparuenia, postcoital aching Stress m/g Hormonal- MPA/ GnRH agonists Hyst & BSO Vein occlusion- Intervention radiology

20. Endometriosis- Laparoscopic ablation LUNA- unclear PSN- Positive  Adhesions- Often coincidental Adhesiolysis effective only in dense  Chronic PID- Salpingectomy/ BSO  Nerve entrapment- LA/ Release  Neuropathic& post surgical- gabapentin/ Behavioural

21. Non-gynecologic Causes Non-gyn causes account for significant CPP Complete history and physical essential Pain, symptoms checklist and history questionnaire is helpful

22. Non-gynecologic Causes Irritable bowel syndrome is most common Urethral synd / IC common- often missed Tenderness specific to abdominal wall- consider nerve entrapment Myalgia, disc disease and referred pain must be ruled out Abdominal wall, umbilical and spigelian hernias Psychological factors

23. IBS Cramping, colicky pain ( lower abd ) Worsens 1 to 1.5 hrs after meal Abdominal distention Relief of pain with bm Freq/loose bm with onset pain Palpable, tender sigmoid colon Hard pellet-like stool

24. Urethral syndrome Dysuria, Urgency and Frequency Without nocturia Treatment: Responds-- long term antibiotic (3 mos ) Responds-- urethral dilation Interstitial cystitis Dysuria, Urgency, Frequency With nocturia ( 2 to 3x /night) Treatment Correct hypoestrogen Bladder drills/training Amitryptiline

25. Musculoskeletal Ergonomic impairments Exaggeration lumbar lordotic curve Anterior pelvic tilt Scoliosis Poor posture

26. Musculoskeletal Nerve entrapment Ilioinguinal/iliohypogastric-- L1 abdominal wall Lateral femoral cutaneous -- L2-3 meralgia parasthetica Genitofemoral -- muscle entrapment bifurcates at iliacus

27. Psychological Depression Sexual abuse Anxiety disorder Personality disorder

28. Medical Management Multi disciplinary approach: Gynae, pain specialist, psychologist, anaesthetist, surgeon, physiotherapist, nurse, proper FU. Analgesics. Anxiolytics and antidepressants. Medroxyprogesterone acetate. Antibiotics. Gabapentin: Post hysterectomy pain.

29. Surgical management Adhesion release: RCT’s dense LUNA: beware of prolapse and bladder dysfx Presacral neurectomy: beware of vessel injury, bladder/bowel dysfx. Hysterectomy with BSO Surgical mx of non gynae causes.

30. Non conventional therapy Static magnetic therapy: RCTs showed use after 4 week treatment. Cognitive and behavioral therapy. TENS: formal trials are lacking Photographic reassurance??!! Writing therapy??!!

31. Summary Thoroughness, continuity, multidisciplinary approach and compassion are central themes of successful management

32. THANK YOU