1. Chronic Pelvic Pain
Leslie Ablard M.D.

2. Chronic Pelvic Pain
There is no generally accepted definition of chronic pelvic pain
Many authors have used duration of at least 6 months that occurs below the umbilicus and is severe enough to cause functional disability or require treatment (some prefer non-cyclic)

3. Chronic Pelvic Pain
Approx 15-20% of women ages yrs have chronic pelvic pain greater than 1 yrs duration
20% of all hysterectomies performed for benign disease
40 % of all gynecological laparoscopies performed annually in the United States

4. Population at Increased Risk
Demographic profiles of large surveys suggest that women with chronic pelvic pain are no different in terms of age, race and ethnicity, education, socioeconomic status, or employment status
May be slightly more likely to be separated or divorced
Tend to be of reproductive age
Age is not a specific risk factor

5. Physical and Sexual Abuse
Significant association of physical and sexual abuse with various chronic pain disorders
40-50% have a history of abuse
May decrease threshold for pain
Important to ensure they are not currently being abused or in danger

6. Gynecologic Causes of Pelvic Pain
Endometriosis
Adhesions (chronic PID)
Leiomyomata
Adenomyosis
Pelvic congestion syndrome
Mittelschmerz
Adnexal masses

7. Non-gynecologic Causes of Pelvic Pain
Gastrointestinal
Urologic
Musculoskeletal
Psychologic

8. Gynevision

9. Etiology
Study from UK
Urinary Causes – 30.8%
GI Causes- 37.7%
Gynecologic- 20.2%
Many women with chronic pelvic pain have more than 1 disease that may lead to pain
25-50% women who received medical care in primary care practices have more than 1 diagnosis along with chronic pelvic pain
IBS, endometriosis, IC
Women with more than 1 organ system diagnosis have greater pain

10. History Characteristics of the pain: Location and radiation
Intensity, including intensity with menstrual cycle, urination, defecation, and physical activity, if relevant
Timing, especially if only at menses or with intercourse
Quality

11. Physical Exam

12. “Compartmentalized” Pelvic Exam
Perineum
Pelvic floor
Urethra / bladder
Cervix
Uterus / adnexa

13. Lab Tests
Laboratory 
Laboratory testing is of limited value in evaluating women with CPP
Baseline tests are obtained to screen for a chronic infectious or inflammatory process, and to exclude pregnancy
CBC with diff UA
G/C
Pregnancy test
Further laboratory testing is based on the clinical impression that emerges after a complete history and physical examination

14. Imaging
Pelvic US
Highly sensitive for identifying pelvic masses/cysts and determining the origin of the mass (ovary, uterus, fallopian tube)
Less reliable for distinguishing between benign and malignant neoplasms and diagnosing adenomyosis
Particularly useful for detecting small pelvic masses (less than 4 cm in diameter), which often cannot be palpated on bimanual examination
Useful for detecting hydrosalpinges, which point to pelvic inflammatory disease as the cause of CPP
MRI
Used to better define an abnormality suspected by sonography  and for diagnosis of adenomyosis

16. Gastrointestinal Causes of Pelvic Pain
Irritable bowel syndrome
Chronic appendicitis
Inflammatory bowel disease (Crohn’s)
Diverticulitis
Diverticulosis
Meckel’s diverticulum

17. Urologic Causes of Pelvic Pain
Unstable bladder (detrusor instability)
Urethral syndrome (chronic urethritis)
Interstitial cystitis

18. Musculoskeletal/Myofascial Causes of Pelvic Pain
Fibromyalgia
Hernias (inquinal, femoral, umbilical, incisional, spigelian)
Nerve entrapment (neuritis)
Fasciitis
Scoliosis
Disc disease
Spondylolisthesis
Osteitis pubis

19. “Top of the list” Etiologies
Gynecologic
PID
Endometriosis
Prior surgery? Pelvic Adhesions
Non-gynecologic IC
IBS
Musculoskeletal Disorders
Psychiatric

20. PID 18-35% of acute PID develop chronic pelvic pain
Actual mechanism not well known
Inpatient or outpatient treatment does not reduce the odds of developing subsequent chronic pelvic pain

21. PID

22. Endometriosis
Diagnosed laparoscopically in approx 33% of women with chronic pelvic pain
24% adhesive disease
35% no visible pathology
More than 50% with abnormal laparoscopic findings have normal pre-op exam

23. Endometriosis

24. Endometriosis Treatment Medical management
GnRH agonists – Lupron most commonly used
May be used for a “suggestive “diagnosis or treatment
6-12 months with add-back norethindrone 5mg for bone protection and symptom relief
Continuous OCPs or higher dose progestins
Depo Provera
Surgical Management
Hysterectomy
Laparoscopy with ablation for mild to mod disease

25. Treatment Surgical excision or destruction of endometriotic tissue
Significant pain relief for 1 yr in 45-85% of women
Recurrence range from %
Avg time to recurrence is months
Most effective in early disease (not stage IV endometriosis)
Hysterectomy (not just dx of endometriosis)
Several prospective cohort studies
90% of women had relief of pain at 1 and 2 yrs post hysterectomy
1 yr after hysterectomy for chronic pelvic pain, 74% had complete resolution of pain and 21% had decreased pain
Retrospective study of hysterectomy with no path found that 78% were pain free after 1 yr

26. Past Surgery
History of abdominopelvic surgery associated with chronic pelvic pain
Women without preoperative pain
3-9% develop pelvic pain or back pain in the 2 yrs after a hysterectomy
Cesarean delivery also may be a risk factor for chronic pelvic pain (OR of 3.7)

27. Pelvic adhesions

28. Treatment
Laparoscopic Adhesiolysis

29. Interstitial Cystitis
Clinically characterized by irritative voiding symptoms of urgency and frequency in the absence of objective evidence of other disease
70% of women with IC report pelvic pain
Suggested that 38-85% of women presenting to the gynecologist with chronic pelvic pain may have IC
Difficult to diagnose- no true gold standard
Intravesical K instillition of 40ml of KCL
Cystoscopy with Hunners ulcers (petechiae or glomerulations)
Decreased bladder capacity (less than 350cc) without anesthesia

30. IC

31. Interstitial Cystitis - Treatment
Hydrodistention
Dimethyl sulfoxide (DMSO) 50%
50cc periodically
Bladder retraining
Biofeedback
Antidepressant (e.g., Elavil, Tofranil)
Antihistamines
SSRIs
Pentosan polysulfate (Elmiron)

32. IBS
Characterized by chronic, relapsing pattern of abdominopelvic pain and bowel dysfunction with constipation or diarrhea
Symptoms consistent with 50-80% of women with chronic pelvic pain
Current diagnosis is the Rome II Criteria
At least 12 wks (not consecutive) in the preceding 12 mo with 2 of 3 features
1. Relieved by defecation
2. Onset associated with change in frequency of stool
3. Onset associated with a change in stool form or appearance

33. Medical Treatment of IBS
Symptom
Therapy
Typical daily dosage
Side effects
Diarrhea
Loperamide
4 mg
Constipation
Diphenoxylate
20 mg
Euphoria, sedation
Hyoscyamine
< 1.5 mg
Dry mouth
Dicyclomine mg
Blurred vision
Desipramine
150 Mg
Dry mouth, confusion, hypertension
Amitriptyline
25-50 mg
Dry mouth, confusion
Fiber (any source)
>30 g
Bloating, abdominal pain
Lactulose
10-30 g
Bloating
Sorbitol
10-30 mg
Cisapride
40-80 mg
Dizziness, headache
Abdominal pain
150 mg
Dry mouth, sedation, confusion, hypertension
Hyoscyamine sulfate
<1.5 mg
Hypotension, constipation
Dry mouth, blurred vision, dizziness

34. Musculoskeletal Disorders
Trigger points
Fibromyalgia
Myofacial pain
Lumbar vertebral disorders
Pelvic floor myalgia
Faulty posture
Exaggerated lumbar lordosis and thoracic kyphosis
May contribute to up to 75% of chronic pelvic pain

36. Lack or response to previous gynecologic intervention
Musculoskeletal Screening Examination for Patients Presenting with Chronic Pelvic Pain - History
Normal laparoscopy
History of trauma to low back or lower extremities, including motor vehicle accident or fall
Pain is altered by positional changes, particularly prolonged standing or sitting
Lack or response to previous gynecologic intervention
Exacerbation with stress

37. Muscle Relaxants for Patients Presenting with Chronic Pelvic Pain
Trade name
Generic name
Dosage
Parafon Forte
Chlorzoxazone
500 mg q tid or qid
Robaxin
Methocarbamol
500 mg 3 tabs qid
Soma compound
Carisoprodol
200 mg 1-2 tabs qid
Aspirin
325 mg qid
Valium
Diazepam
2-10 mg qid

38. What do you do if your work-up doesn’t point you to any etiology of the pain?

39. Laparoscopy When do you do one?
Suspicious of pathology based on imaging or PE
Failed medical management
When endometriosis is suspected on visual findings- biopsies and histological confirmation is important
Adolescents should not be excluded from the rest of the population for laparoscopic evaluation

40. Treatment Antidepressants
TCAs- imipramine, amitryptyline, desipramine, and doxepin, have been shown in placebo controlled studies to improve pain levels and pain tolerance in those with chronic pain syndromes
Not clear if others such as SSRIs are as effective
“Evidence is insufficient to substantiate efficacy of antidepressants although the efficacy of TCAs for other chronic pain syndromes suggest they also might be efficacious for chronic pelvic pain”

41. Response Following Administration of Three Major Antidepressants
# of trials
(in 116 pts)
Total
Antidepressant
No Relief
Relief
Trial
Imipramine (Tofranil)
11 (25%)
33 (75%) 44
Amitriptyline (Elavil)
4 (16%)
21 (84%) 25
Desipramine (Norpamin)
10 (23%)
34 (77%)
30 (22%)
105 (78%)
135

42. The Pelvic Witch Hunt

43. Be wary of claims for: Presacral neurectomy Uterine suspension
LUNA (lap US nerve ablation)
Surgery for pelvic congestion
Lysis of adhesions
Hysterectomy

44. Treatment
Analgesics
NSAIDS including COX-2 inhibitors relieve various pain
No clinical trials have addressed chronic pelvic pain
Opioids are increasingly used but randomized trials suggest no improvement in functional or psychological status with increased risk in addiction

45. Treatment Combined OCPs Provide significant relief
Suppress ovulation
Reduce spontaneous uterine activity
Stabilize estrogen and progesterone levels
Abrogate menstrual increases in prostaglandin levels
Reduce the amt of pain and symptoms associated with menses
Recommended for endometriosis-associated chronic pelvic pain
One study showed OCPs comparable to GnRH agonist goserelin in relieving chronic pelvic pain and dysparenia but less effective in relieving dysmenorrhea in women with endometriosis
OCPs do not significantly affect long-term recurrence of endometriosis
Continuous OCPs may be superior- no good data

46. Treatment GnRH Agonists
“down-regulate” Hypothalamic-pituitary gland production and release of LH and FSH to reduce estradiol levels significantly
Nafarenlin, Goserelin, Leuprolide
Emperic treatment with GnRH agonists have the same efficacy in women with symptoms consistent with endometriosis, whether or not they actually have endometriosis
Strongly suggests the response does not depend on surgical confirmation
Other pain from IBS, IC also vary with the menstrual cycle and respond to GnRH agonist treatment
Good evidence supports add-back therapy with estrogen, progesterone, or both can decrease side effects without loss of efficacy

47. Treatment Progestins MPA
30-100mg po per day effectively decreases pain from endometriosis and pelvic congestion syndromes
Depo Provera may also be effective but no good studies

48. Treatment
Exercise
Most studies suggest dysmenorrhea is decreased by exercise but not definitive data on chronic pelvic pain PT
Electrotherapy, fast and slow twitch exercises of the striated muscles of the pelvic floor, manual therapy of myofascial trigger points shown improvement of pain in 65-70% of patients

49. Treatment Psychotherapy
Many suggest various modes of psychotherapy including cognitive therapy, operant conditioning, and behavioral modification appear to be helpful
Up to 50% of women with chronic pelvic pain have a history of physical or sexual abuse

50. Treatment Herbal and Nutritional Therapies Magnestic Field Therapy
Many clinical trials of mag, B6, B1, omega 3s, Japanese herbal combinations have been studies with no conclusive data
Magnestic Field Therapy
Application of magnets to trigger paints may improve symptoms
Only one clinical trial has evaluated their use and had significant methodologic flaws
Acupuncture
Acupuncture, acupressure, and transcutaneous nerve stimulation therapies have shown better than placebo in the treatment of dysmenorrhea
Only case reports for nonmenstrual chronic pelvic pain

51. Key Points MULTIPLE ETIOLOGIES!!!!!
Detailed history of PE are the basis of differential diagnosis
Treatment is more of an art than a science
NSAIDs should be considered for mod pain and dysmenorrhea
Combined OCs primary dysmenorrhea
Continuous OCs for long term ovarian suppression
GnRH effective for multiple etiologies of pain
Empiric treatment without laparoscopy should be considered
High dose Progestins effective for chronic pelvic pain

52. Key Points
Laparoscopic surgical destruction of endometriosis best for stage I-III disease
Adding Psychotherapy to medical treatment often improves response
PT appears to be helpful in treatment and should be considered
Hysterectomy relieves 75-95% chronic pelvic pain
Antidepressants may be helpful (TCAs) in treatment of chronic pelvic pain

53. “If the only tool you have is a hammer, you tend to see every problem as a nail.”
-Abraham Maslow

54. Thank you