1. Geeta Nagpal, MD October 26, 2012

2.  …is a symptom, not a diagnosis  Multifactorial

3.  26 year old female referred for evaluation and treatment of chronic pelvic pain  Constant pain in the pelvis and perineum for over one year.  Exacerbating factors include:  Sitting, standing, walking, Valsava maneuvers, sexual activity  Pain relieved by:  Norco and Valium  Prior Work-up  Gynecologic, Urologic, Gastroenterology

4. Chronic Pelvic Pain (CPP) Definition (by Royal College of OB and GYN) Intermittent, or constant pain in lower abdomen or pelvis Not occurring exclusively with menstruation, intercourse or ass’d with pregnancy Duration > 6 months Localized to: anatomic pelvis, anterior abdominal wall, lumbrosacral back or buttocks Sufficient severity to cause functional disability or lead to medical care American College of Obstetricians and Gynecologists Practice Bulletin No. 51, March 2004

5.  15-20% of women between the ages of 15-73 years have pelvic pain lasting more than one year during their lifetime  Estimated prevalence 38/1000 For perspective: 37/1000 asthma prevalence, 41/1000 chronic back pain prevalence  Primary indication for:  20% outpatient gynecology visits (most common reason for referral  12% hysterectomy  40% diagnostic laparoscopy BMJ. 2006 April 1; 332(7544): 749–755.

6.  Among women with CPP  Use 3x more medications  Have 4x more GYN surgeries  Are 5x more likely to have a hysterectomy In 2006, US spent $881.5 million on outpatient management of chronic pelvic pain BMJ. 2006 April 1; 332(7544): 749–755.

7.  Dysmenorrhia:  Age (<30 yrs), weight (BMI <20), early menarche (<12 years), longer cycles/ duration of bleeding, PID, sterilization, ho sexual assault  Dyspareunia:  Ho circumcision, PID, anxiety, depression, sexual assault  Non-cyclic pelvic pain:  Abuse, psychologic morbidity (miscarriages), longer menstrual flow, endometrosis, PID, caesarian section scar, pelvic adhesions, sexual abuse, anxiety, depression BMJ. 2006 April 1; 332(7544): 749–755.

8.  Painful Bladder Syndrome/Interstitial Cystitis  Endometriosis (cyclic pain)  Pelvic Floor Myalgia

9.  H&P: cyclic, related to periods, related to intercourse, “chandelier sign” aka cervical motion tenderness  Labs/Studies: STD’s, HCG, WBC, Ultrasound for masses, CT Scan  Cystoscopy, Laparoscopy, Colonoscopy,

10.  Ganglion Impar Block  Hypogastric Block  Sacral Neuromodulation  Trigger Point Injections  Lidocaine Infusion  Pudendal Nerve Block

11.  Ganglion Impar is a solitary retroperitoneal structure at the level of the sacrococcygeal junction  First described by Plancarte in 1990 for the treatment of intractable perineal cancer pain of sympathetic etiology

12.  Ganglion Impar receives afferent fibers from:  Perineum  Distal rectum  Anus  Distal urethra  Vulva  Distal third of the vagina

13.  Approaches:  Transsacrococcygeal ligament  Transcoccygeal  Anococcygeal ligament  Paramedian approach

14.  Therapy:  Local Anesthetic (diagnostic and possibly therapeutic)  Steroid  6% phenol  Radiofrequency Ablation

15.  Is there evidence?  Plancarte et al. Anesthesiology 1990 16 pts with advanced cancer (cervical, colon, bladder, rectum, endometrial) with persistent pain Localized perineal pain in all 6% phenol using transanalcoccygeal approach: 8 pts with complete relief Remainder with significant pain reduction (60-90%)

16.  Is there evidence?  Swofford et al. Reg Anesth Pain Med 1998 20 pts with perineal pain unresponsive to previous Rx 18 bupivacaine/steroid 5 had 100% relief, 10 >75% relief, 3 >50% relief 2 with 6% phenol Both with complete relief

17.  Is there evidence?  Reig et al. Pain Practice 2005 13 patients with chronic perineal, non-cancer related pain All had positive result with diagnostic local anesthetic block Radiofrequency ablation of the GI produced 50% decrease in pain scores with an average duration of 2.2 months and no complications

18.  Complications:  Risk is very low  In current published literature, there are no major complications reported  Due to anatomic variation, there is risk of ineffective block  Theoretical risks: Bleeding into retroperitoneal space, nerve injury, discitis, puncture of surrounding organs (rectum)

19.  The superior hypogastric plexus is also situated in the retroperitoneum  Extends from the lower third of the fifth lumbar vertebral body to the upper third of the first sacral vertebral body

20.  The percutaneous approach to the SHP was also described by Plancarte et al. in 1990  At that time, used for the treatment of pelvic cancer pain  Since that time, this block has been successfully used for the relief of both noncancer and cancerous conditions.

21.  Superior hypogastric plexus receives afferent pain fibers from:  Bladder  Urethra  Uterus  Vagina  Vulva  Perineum  Rectum  Descending colon  (prostate, penis, testes)

24.  Therapy  Local anesthestic  Steroid  Neurolysis with phenol (5-8 cc per side)

25.  Is there evidence?  Plancarte et al. Anesthesiology 1990 Superior hypogastric block for pelvic CA pain 28 patients with neoplastic involvement of pelvic viscera 2/2 cervical, prostate, testicular CA or radiation injury Mean reduction in pain was 70% using VAS  de Leon-Casasola et al. Pain 1993 26 pts with extensive gyn, colorectal, genitourinary CA who suffered incapacitating pelvic pain All had VAPS 10/10 prior to injection (10% phenol) 69% had post injection VAPS <4, 31% VAPS 4-7 Both groups had significant reduction in oral opioid use

26.  Is there evidence?  Plancarte et al. Reg Anesth 1997 227 pelvic pain pts with gyn, colorectal, genitourinary CA had bilateral diagnostic block with 0.25% bupi 159 with positive response to the block Of these, 72% with VAS <4 and mean opioid decrease by 40% 28% with VAS 4-7 and mean opioid decrease by 26% No additional block for those with good response for 3 mon th follow up  Rosenberg et al. Reg Anesth Pain Med, 1998 Case report of SHB with bupi and methylprednisolone relieving pain for over 6 months in a man with chronic penile pain after TURP

27.  Is there evidence?  Pollitt et al. Int J Gynaecol Obstet. 2011 Case report of chemical neurolysis or superior hypogastric plexus for non-cancerous pain 21 year old student nurse with 4-year chronic pelvic pain (lower abdomen) thought 2/2 endometriosis Medical management and laparoscopy x 2 Diagnostic SHB with excellent relief of pain Pulsed RF with no benefit Phenol 6% (7cc in total) with complete pain relief immediately afterward and at 8 weeks, 6, 12, and 24 months

28.  Complications  There are no reports in the literature of neurologic complication as a result of this block  Neurologic complications could occur if retrograde spread of the neurolytic to the nerve roots  Discitis is a risk with transdiscal approach

29.  FDA approved sacral neuromodulation in 1997 as a treatment option for  Urge incontinence  Urgency/frequency  Non-obstructive urinary retention  In the past 10 years, sacral nerve stimulation has been studies in Rx of IC  More recently, this technique has been applied for the Rx of CPP

30.  How does it decrease pain  Common cause of pelvic pain is pelvic floor dysfunction caused by hypertonus  ? Maybe by re-establishing pelvic floor muscle awareness, and decreasing pelvic floor hypertonus  High-tone pelvic floor dysfunction present in 85% of patients with IC/PBS

31.  Approaches

33.  Is there evidence?  Siegel et al. J Urol. 2001 Measured the effectiveness of sacral nerve stimulation in 10 patients with chronic intractable pelvic pain All had failed conservative measures Leads placed in either the S3 or S4 foramen 9/10 reported decrease in the severity of the worst pain compared to baseline at median 19-month follow up Average decrease in rate of pain from 9.7 to 4.4 Average decrease in daily duration of pain from 13.1 to 6.9 hours

34.  Is there evidence?  Everaert et al. Int Urogynecol J Pelvic Floor Dysfunct. 2001 111 patients with CPP (40 male, 70 female) Underwent pelvic floor training, TENS, intrarectal or intravaginal electrostimulation applied Sacral nerve stimulation for therapy-resistant pain Test stim was effective in 16/26 patients 11 patients were implanted successfully and followed for 36 months 2 failed therapy soon after implantation 9 experienced extended and significant reduction in pelvic pain

35.  Is there evidence?  Kapural et al. Pain Med 2006 Case-series report of spinal cord stimulation for chronic intractable visceral pelvic pain 6 females with CPP (ho endometriosis, multiple surgical explorations, dyspareunia) All pts received repeated SHB (average 5.3 blocks) with significant pain relief from 1-6 weeks 3 received neurolytic HSB with 3,8, and 12 months of relief respectively

36.  Is there evidence?  Kapural et al. Pain Med 2006 All underwent SCS trial for 7-14 days and permanent dual lead implantation to T11-T12 Median VAS decreased from 8 to 3, all pts had over 50% pain relief Opiate use decreased from 22.5 mg to 6.6 mg morphine equivalents per day

37.  Abdominal/pelvic pain associated with active trigger points in the pelvis, abdominal or low back muscles  Pelvic floor has three functions: support, contraction and relaxation  History  “heavy aching pelvic pressure, falling-out sensation,” often later in the day after prolonged sitting  dyspareunia (genital pain associated with intercourse: before, during, or after)

38. Common Trigger Points:  Piriformis  Levator ani  Obturator internus

39.  The levator ani is composed of two distinct muscles: pubococcygeus and iliococcygeus.  Innervation via pudendal plexus.  Function is to support and elevate the pelvic floor

41.  Most widely recognized source of referred pain in the perineal region  Pain can be referred to sacrum, coccyx, rectum, pelvic floor, vagina, low back  Pt are uncomfortable with sitting, defection, or lying on the back.

42.  Pain and a feeling of fullness in the rectum and some times back of ispilateral thigh, and vagina

43.  Physical therapy in the associated muscles. (Transvaginal pelvic floor message)  Botox  Combination of the two

44.  PT philosophy and goals:  Tender regions (trigger point) impedes blood flow to the area  pain  Goal is to place pressure, stretch the area, then release  The release is associated with pulsation (return of blood flow)  Decreased pain

45.  PT  Average 2-17 sessions  Improved pain, frequency, urgency  Case reports: 90+% improvement

46.  Botox type A  Abbott JA et al. Obstet Gynecol 2006 Double-blinded, randomized, placebo controlled trial All patients with CPP > 2 years and evidence of pelvic floor muscle spasm 30 women had 80 U botulinum toxin type A injected into pelvic floor muscles 30 women received saline Dysmenorrhea, dyspareunia, dyschezia, and non menstrual pelvic pain were assessed by pre and post VAS monthly for 6 months

47.  Outcomes  26 week follow-up  Pain scores were reduced for both groups in all parameters, no statistically significant intergroup differences  Improvements from pretreatment in both groups (dysparuenia) Botox (VAS 66 v. 12 p <0.001), placebo (VAS 64 v. 27, p < 0.05)  Significant reduction in pelvic floor pressure from baseline in Botox group  Complications Transient incontinence

48.  Lidocaine has been shown to reduce pain scores in painful diabetic neuropathy  Mexilitene for painful diabetic neuropathy and peripheral nerve injury  Tocainide for trigeminal neuralgia  Data for IV lidocaine infusion is sparse  Gupta A and Valovska A. EJP 2012  15 female patients with CPP through medications, pelvic PT, surgeries treated with IV lidocaine (ave 3-4 treatments)  Pts had 40-70% pain relief for 1-3 weeks  5 pts d/c opioid regimen after 3 treatments

49.  References  American College of Obstetricians and Gynecologists Practice Bulletin No. 51, March 2004  Factors predisposing women to chronic pelvic pain: systematic review. BMJ. 2006 April 1; 332(7544): 749–755.  Fall M et al. EAU Guidelines on chronic pelvic pain. European Urology 57 (2010) 35-48.  Green I, et al. Interventional therapies for controlling pelvic pain: what is the evidence? Curr Pain Headache Rep (2010) 14: 22-32  Fariello J et al. Sacral neuromodulation stimulation for IC/PBS, chronic pelvic pain, and sexual dysfunction. Int Urogynecol J (2010) 21: 1553-1558