1. Chronic Pelvic Pain Max Brinsmead MB BS PhD May 2015

2. Intermittent or constant pain in the lower abdomen or pelvis for >6 months – With or without menstruation – Can be coital or postcoital – Not associated with pregnancy Is as common as low back pain or headache Definition and Incidence

3. Patient needs to feel that she is being taken seriously Give her time to tell her story A single diagnosis at initial presentation is often impossible The cause of the patient’s dis-ease is often multifactorial... So attempt to list all these possible factors And aim for an explanation or process of management for the patient Approach

4. Endometriosis –External (peritoneal) –Adenomyosis (intra uterine) Pelvic Congestion/Ovulation sensitivity Chronic PID Irritable Bowel Syndrome/Interstital Cysitis Musculoskeletal –Includes the pelvic floor muscles Post inflammatory or Postsurgical –Adhesions –Nerve entrapment The Short List

5. Depression May be secondary to the pain Check sleeping patterns Libido and sexual activity Sexual and physical abuse Complex May be problems of self esteem Other family/inter relationship issues Drug use and abuse Smoking Other drugs Psychological and Social Factors

6. If there is a strong cyclical component to the pain it is likely to be of reproductive tract origin Nature of the pain may be useful Localised, sharp or stabbing suggests neuropathic cause How much does it interfere with daily life, work, sleep and sexual function? Careful bowel and bladder history Relationship to posture and activity Unlocking psychosexual history or dysfunction can be difficult History

7. Sexual and contraceptive history Past surgical and gynaecological history Reproductive history Family History Endometriosis Hysterectomy Cancer More History

8. Examine the abdomen, PV +/- PR and also lower back and sacro-iliac joints Look for tenderness, enlargement, distortion or tethering Prolapse Any trigger points? Including those in the pelvic floor Examination

9. Screen sexually active for STD Ultrasound useful for assessing enlarged uterus and adnexal mass – But has a limited role otherwise MRI little better except in the detection of deep rectovaginal endometriosis Diagnostic Laparoscopy – Risks and benefits should be discussed – Should not be a reason for gynaecological absolution – Much controversy about the Dx of endometriosis CA125 – for bloating, early satiety and those >50 Investigations

10. If not clearly gynaecological in origin then it should be MULTIDISCIPLINARy If the pain is cyclical then trial hormonal Rx for 3m before laparoscopy COC, Progestins, Danazol or Mirena Trial antispasmodics for suspected IBS + diet modification Mebeverine plus bulking agents Multidisciplinary approach to pain management Regular NSAID, Compound analgesics, Amytriptaline/Gabapentin, Counselling, Hypnotherapy, Self-help groups etc Management

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