1. Fawaz Edris MD, RDMS, FRCSC, FACOG, AAACS

2. Introduction Non cyclical uterine or non-uterine pelvic pain > 6/12 Gynecological GIT Urological Orthopedic Musculoskeletal “superficial” (nerve entrapment, hernia, referred) Psychological (by exclusion)

3. Introduction Somatic pain Visceral pain Diffusely spread Lack of well defined areas in the sensory cortex Viscerosomatic convergence No neurons in the spinal cord receives only visceral pain Viscerosomatic neurons Larger receptive field than somatic Less numbers than somatic

4. History Pain history and its components Relationship to period, bowel movement, urination, intercourse and activity Previous episodes Other symptoms (GIT, urological, weight loss, etc) Effect on life (social, work, family) Relationship of onset to events (newly married, rape, lifting, chest infection, etc) Hx of sexual, physical, or emotional abuse What medication used What investigations done Other stress or psychological symptoms (depression, anxiety, etc) BUT! Secondary gain (off work, husband to stay, attention, etc) BUT! Full Gyn Hx (STD, PID, Infertility, dysparunia, surgeries including D&C, etc.) Full surgical Hx Medical Hx (IBS, IC, IBD)

5. Examination Abdominal (point, superficial, deep) Pelvic (tenderness, mobility, nodularity) Nerve entrapment Dermatomes Head raising

6. Investigations Limited use Scopes: if symptoms suggest (GIT, Urological) Imaging: if symptoms suggest musculoskeletal U/S: although of limited use Laparoscopy the ultimate but last method Psychological evaluation

7. Gynecological Endometriosis (30%) Pathogenesis 20-30% missed on laparoscopy Treatment is medical (may start before Dx) Cont. OCP Depot Provera Danzol GnRH analouge + add back therapy If no response, surgical (TAH / TAH+BSO) Size and location doesn’t correlate with pain Path0physiology of pain not well understood Infertility Chronic PID(25%) Recurrent exacerbations Hydrosalpinges Adhesions !!

8. Gynecological Ovarian Cysts are ASYMPTOMATIC, unless Rapid distention Bleeding Torsion Special cysts (Endometrioma, Dermoid) Ovarian remnants retroperitonealy (with cyst) Uterine Adenomyosis (rarely CPP) Fibroid are ASYMPTOMATIC, unless Degeneration Torsion Prolapsed submucus fibroid Retroverted uterus DOSE NOT cause CPP. Maybe dysparunia!

9. Gynecological Pelvic Congestion Syndrome Myth! Non specific symptoms No agreed upon diagnostic measures No agreed upon therapeutic measures

10. Non-Gynecological G.U.T Multiple examples, the most common: Urethral syndrome IC Common: 1 in 5 women Urgency, frequency, nocturia, CPP Diagnosis & treatment G.I.T Multiple examples, the most common: IBS, IBD, Hernias. Innervation of the lower intestinal tract, same as uterus and fallopian tubes  pelvic pain

11. Psychological 30% of CPP remains undiagnosed even after laparoscopy Is this a primary or secondary thing!

12. Pain Perception Every pain is a result of stimulus and response, however: Chronic pain ≠ Acute pain. Acute pain: response is appropriate to stimulus. Chronic pain is affected additionally by: Patient’s reaction to pain Family’s reaction to the patient and her pain (reinforce or persistence) So: Response to a stimulus is inappropriate, exaggerated, inaccurate, and may persist even after the stimulus is gone

13. Management Therapeutic, supportive, and sympathetic physician- patient relationship should be established (only few can do it!) Regular F/U rather than “come back when pain persist” The latter reinforces pain behavior If no pathology is found, patient should NOT be ignored! Reassurance + symptomatic treatment Multidisciplinary pain clinic

14. Management Multidisciplinary pain clinic GYN, Psychologist, Anesthetist, others If no team is in place, use referrals. Psychologist Techniques for stress reduction, adaptive strategies Marital, sexual, and social counseling

15. Management Treat underlying cause if found! If none is found: Multidisciplinary team NSAIDs Ovulatory/menstrual suppression Cont. OCP, Depot Provera, Danzol, GnRH analouge + add back therapy May work for those with pain related to the period (mid-cycle, premenstrual or menstrual) or those with ovarian causes (ovarian remnant) Low dose TCA (increase inhibitory neuromodulators)

16. Management Surgeries If no pathology  NOT effective If no strong evidence of pathology  thorough psychological evaluation before any surgery Lysis of adhesions: NOT effective unless the site of adhesions = site of pain. Vicious cycle

17. Thank you