Transcript 8th Edition APGO Objectives for Medical Students

8th Edition APGO Objectives
for Medical Students
Chronic Pelvic Pain
Rationale
Every physician should understand that
chronic pelvic pain (CPP) might be the
manifestation of a variety of problems.
Objectives
The student will be able to:
 Define chronic pelvic pain
 Cite the incidence and etiologies
 Cite clinical manifestations
 Cite diagnostic procedures
 List management options
Definition
Lower abdominal pain
 At least six months duration
 Alters quality of a woman’s life
 May or may not have gynecologic cause
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Epidemiology and etiologies
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Overall 9.5-10%
10-30% of gyn visits
12-19% of hysterectomies (~ 80,000/yr.)
30% of laparoscopy indications
Etiologies
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Irritable bowel - 40-80%
Abdominal cutaneous nerve - 70%
Atypical menstrual pain - ~20%
Urologic - < 5%
Infectious - < 2%
Clinical Manifestations
Subjective
 Dysmenorrhea most common
 Long-term debilitating pain > 6 mo.
 Impaired life style
 Incomplete relief with attempted therapies
 Dyspareunia
 Depression common
Clinical Manifestations
Psychosocial
 Age - 25-35 yr.
 Pain poorly localized
 Multiple somatic complaints
 Prior surgeries
 History of depression and/or abuse
(sexual or physical)
Etiology: Gyn disease
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Endometriosis-presence of functional endometrial tissues outside
uterus
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Sequelae of PID (25% CPP)
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Chronic endometritis
Pelvic fibrosis
Infertility
Neoplasia
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20% of CPP
30-40% with infertility
Uterine
Ovarian
Pelvic support defect/congestion
Postoperative adhesion
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Ovarian remnant syndrome
Bowel/omentum
Etiology: Non-gyn disease
Urology
 Chronic UTI
 Interstitial cystitis
 Bladder/ureteral/kidney stone
 Urethral diverticulum
 Urethral syndrome
Etiology: Non-gyn disease
Gastrointestinal
 Gall bladder disease (cholelithiasis)
 Chronic appendicitis/post appendectomy with
peritonitis
 Constipation
 Diverticulitis
 Irritable Bowel Syndrome
 Peptic ulcer
 Inflammatory bowel disease
 Neoplastic disease
Etiology: Non-gyn disease
Musculoskeletal
 Herniated disc
 Arthritis of spine
 Fibromyositis
 Hernia
 Nerve entrapment syndrome post-operative
 Osteoporosis (fractures)
 Trauma/sprains
 Spinal deformities
 Fibromyalgia
Etiology: Non-gyn disease
Psychosocial
 Abuse (physical/sexual)
 Depression
 Personality disorder
 Relationship dysfunction
 Somatoform disorders/confusion with
identity
 Substance abuse
Etiology: Non-gyn disease
Others
 Heavy metal poisoning
 Porphyria
 Sickle disease (hemolytic crises)
 Tertiary syphilis (tabes dorsalis)
Diagnosis
Complete history
 Pelvic pain questionnaire
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Characteristics of pain - location, radiation
Onset
Cyclic vs. non-cyclic pain
Impact on lifestyle
Relation to menses
Changes in menstrual pattern
Aggravating/alleviating factor
Diagnosis
Complete history (con’t)
 Dyspareunia +
 History of pelvic infection
 Dietary and bowel habits
 Urinary symptoms
 Surgeries
 Pelvic inflammatory disease
 Depression/mood disorders
 History of abuse (physical or sexual)
Complete physical examination
Skin
 Old scar
 Needle marks or “tracks” (substance
abuse)
Neuromuscular
 Low back tenderness
 Musculoskeletal pain
Complete physical examination
Abdomen
 Hernias
 Distension
 Bowel sounds
 Tenderness
 Trigger points
Complete physical examination
Pelvis
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Uterine mobility/fixation
Tenderness
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Masses
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Cervical/uterine
Adnexal
Rectal and/or vaginal exam
Size and shape of uterus
Adnexa
Uterosacral
Ovarian cyst
Enlarged, tender, boggy uterus - adenomyosis
Uterosacral tenderness or nodularity - endometriosis
Complete physical examination
Psychological/personality evaluation
 Somatic complaints
 Sexual orientation
 History of substance abuse
 History of physical and/or sexual abuse
 Self-image (high or low self-esteem)
 Past mental health
Complete physical examination
Laboratory
 Complete blood count and sedimentation
rate
 Leukocytosis
 Elevated
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sedimentation rate
Cervical culture
 Gonorrhea
 Chlamydia
Complete physical examination
Sonography
 Neoplasm/uterine enlargement or
irregularity
 Adnexal mass (cyst or tumor)
Therapeutic trial
Therapy tailored to likely etiology
Therapeutic trial
Antibiotics
Therapeutic trial
Hormonal manipulation
 Cyclic therapy/regulation of menses
 Suppress ovulation (OCP, DMPA and
Lupron)
 Suppress menses (Lupron, DMPA)
Therapeutic trial
Therapy tailored to likely etiology
Therapeutic trial
Multidisciplinary approaches most
successful
 Psychosocial support
 Treat
depression
 Address sleep disorders
 Biofeedback
 Counseling
Therapeutic trial
Multidisciplinary approaches most
successful
 Physical modalities
 Physical
therapy
 Exercise Diet (functional bowel)
 Massage
 Transcutaneous electrical nerve stimulation
 Nerve blocks/trigger point injections
Therapeutic trial
Multidisciplinary approaches most successful
 Pharmacologic therapies
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Regular dosing schedule superior to “prn”
NSAIDs
Analgesics - use least potent which will control pain
• Nonnarcotic (ASA, acetaminophen, propoxyphene)
• Narcotic - use cautiously (tolerance, dependence)
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Serotonin uptake inhibitors
Tricyclic antidepressants
Oral contraceptives (endometriosis, menstrual pain)
Danocrine, Depo-Provera (endometriosis)
GnRH agonists
Therapeutic trial
Multidisciplinary approaches most successful
 Surgical therapies
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Tailored to suspected physical pathology
Offered if other approaches fail
May be unsuccessful, lead to complications, high
recurrence rates
Laparoscopic uterosacral nerve ablation (LUNA)
Presacral neurectomy
Conscious pain mapping
Fulguration/resection of endometriosis
Lysis of pelvic adhesions
Hysterectomy + oophorectomy
Therapeutic trial
Re-evaluation (2-6 mo.)
 Improvement
 Therapeutic failure
 Consideration of fertility
Therapeutic trial
Laparoscopy
 Endometriosis - 16-18%
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Staging (American Fertility Society)
Immediate treatment (ablation or excision and
adhesiolysis)
• Definitive (ablation)
• Conservative - excision and adhesiolysis
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Pelvic adhesions - 20%
• Severity
• Lyse adhesions
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Normal pelvis - 36%
Non-gyn disease - 15-20%
Follow-up visits
Initial history and physical with lab
 Lab
 Pain diary
Follow-up visits
Second visit
 Review lab finding
 Initiate therapy (empiric or specific
 Additional diagnostics
 Recommend counseling
Follow-up visits
Third visit
 Review pain diary
 Discuss results of therapy
 Scheduling laparoscopy
Postop management
Definitive Rx for objective physical disease
 Hysterectomy
with bilateral salpingo-
oophorectomy
Continued medical therapy
 Analgesics
 Hormonal
 Pain
clinic
 Antidepressants
References
Association of Professors of Gynecology and Obstetrics, Chronic Pelvic Pain:
An Integrated Approach. APGO Educational Series on Women’s Heath
Issues, APGO, Washington, DC, January 2000.
Adapted from Association of Professors of Gynecology and Obstetrics Medical
Student Educational Objectives, 7th edition, copyright 1997
Clinical Case
Chronic Pelvic Pain
Patient Presentation
A 24-year old woman presents to you as a
self-referral for pelvic pain. She describes
a four-year history of intermittent lower
abdominal and pelvic pain that is now
constant in nature. The pain is always
present, sometimes sharper in the left
lower quadrant and not related to
menses.
Patient Presentation
She has occasional nausea and is sometimes
constipated. Nothing makes the pain better or
worse. Over the years, she has used
acetaminophen and ibuprofen, and has not
found any relief. She began her menses at age
13 and they have come on a regular monthly
basis. She experiences some premenstrual
bloating and has cramps with her periods, and
reports discomfort at other times of the month.
Patient Presentation
She had a trial of oral contraceptives and
then a subsequent laparoscopy by a prior
gynecologist. She was told that everything
looked normal. She is otherwise a healthy
non-smoker, but reports that this pain is
making her life miserable.
Patient Presentation
She has a bachelor’s degree from a local
college, works as computer processor
and lives at home with her parents. She
has never been sexually active. Upon
further questioning, she reports that her
oldest brother sexually abused her as a
child.
Patient Presentation
Physical exam
Somewhat flattened affect, but smiles occasionally. 5
feet 4 inches; 142 pounds. Trapezius and paraspinous
muscles tender on palpation. No costovertebral angle
tenderness. Abdomen is soft with 2 well-healed
pelviscopy incisions. There is no rebound or guarding or
mass. Tenderness is elicited with deep palpation of the
lower quadrants. External genitalia, vagina and cervix
are normal. Uterus is mid-position, mobile and the
adnexa are mildly tender. The rectal vault is palpably
normal with soft stool that is heme negative.
Differential diagnosis of chronic
pelvic pain
Gynecologic origin
 Gastrointestinal disorders
 Urinary problems
 Musculoskeletal disease
 Pain processing disorders
 Psychiatric and psychological
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Management Plan
The patient was counseled about the multiple possible causes of
chronic pelvic pain. The provider was empathic and sensitive in
regards to this challenging problem. A plan of care was devised
jointly and she was scheduled for a follow-up. The patient’s
previous records and operative report was obtained and
reviewed. On a subsequent visit, the patient did note that the
pain worsens when her older brother returns home for family
holidays. She reports that she has never mentioned this to the
therapist that she has recently started seeing. A trial of low dose
tricyclic antidepressants was initiated which helped the patient
with sleeping, but did not make the pain go away. The patient
continued to follow up at regularly scheduled intervals with her
gynecologist and therapist, and had less emergency room visits.
Teaching points
Chronic pelvic pain can be defined as cyclic pain
of 6 months duration or non-cyclic pain of 3
months duration and the pain interferes with
normal activities. The problem of chronic pelvic
pain is under-recognized. It may affect 15% to
24% of American women and accounts for a
large proportion of office visit time and many
invasive surgical procedures.
Teaching points
Chronic pelvic pain can be derived from a variety
of sources, including gynecologic,
gastrointestinal, rheumatologic,
musculoskeletal, urologic or psychiatric. It can
be difficult to diagnose the etiology and can be
challenging to treat. The health care provider
must perform a thorough history and physical
exam, which are often much more valuable in
making a diagnosis than any laboratory or
radiologic tests.
Teaching points
Patients present to different specialists based on their
belief of what is causing the pain. Gastrointestinal
diseases may cause symptoms such as nausea,
vomiting, bloating or changes in bowel habits. Urinary
tract disorders my cause dysuria, urgency or vague
pelvic discomfort. Patients need to be asked about
fatigue, sleep disturbances, or mood disorders and
fibromyalgia and depression considered. Patients also
need to be queried about physical and sexual abuse, or
any history of substance abuse. Musculoskeletal
disorders can be determined by a thorough motor and
sensory examination, with attention to the back, hips
and legs.
Teaching points
Possible gynecologic causes of chronic pelvic pain include
endometriosis, adenomyosis, chronic pelvic infection or
adhesions. A normal laparoscopy does not completely
rule out endometriosis, as the changes can be subtle
and occasionally missed. Providers can consider an
empiric trial of oral contraceptives or GnRH agonists
after non-gynecologic causes have been ruled out.
Some providers recommend a trial of antibiotics or nonsteroidal anti-inflammatories for potential infectious
causes. In the case of depression, whether overt or
covert, antidepressants should be initiated.
Teaching points
Even when the etiology is determined,
chronic pelvic pain can be difficult to treat.
The patient may need to be seen
regularly and provided with much support.
Co-management with a psychologist,
social worker or therapist may be helpful.