Chronic Pelvic Pain - University of Nebraska Medical Center
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Transcript Chronic Pelvic Pain - University of Nebraska Medical Center
Marvin L. Stancil, M.D.
Associate Professor
Obstetrics and Gynecology
University of Nebraska Medical Center
Medical Student Objectives
Define chronic pelvic pain.
Cite the prevalence and common etiologies of chronic
pelvic pain.
Describe the symptoms & physical exam findings
associated with chronic pelvic pain.
Discuss the steps in the evaluation & management
options for chronic pelvic pain.
Discuss the psychosocial issues associated with chronic
pelvic pain.
Definition
Chronic Pelvic Pain (CPP) is pain of
apparent pelvic origin that has been
present most of the time for the
past six months and is affecting the
patient’s quality of life
Definition
Difficult to diagnose
Difficult to treat
Difficult to cure
Frustration for
patient and
physician
Incidence
Affects 15-20% of women of reproductive age
Accounts for 20% of all laparoscopies
Accounts for 12-16% of all hysterectomies
Associated medical costs of $3 billion annually
Psychological
Gastrointestinal
Urological
Gynecological
Musculoskeletal
Demographics
Demographics of age, race, ethnicity, education,
and socioeconomic status do not differ between
those with and without chronic pelvic pain
Higher incidence in single, separated or
divorced women
40-50% of women have a history of abuse
Etiology: United Kingdom Primary Care Database
25-50% of women had more than
one diagnosis
Diagnosis Distribution
Gastrointestinal
37.7%
Urinary
30.8%
Gynecological
20.2%
Severity and consistency of pain
increased with multisystem
symptoms
Most common diagnoses:
• endometriosis
• adhesive disease
• irritable bowel syndrome
• interstitial cystitis
Diagnosis
Obtaining a
COMPLETE and DETAILED HISTORY
is the most important key to
formulating a diagnosis
Diagnosis: Obtaining the History
Duration of Pain
Nature of the Pain
• Sharp, stabbing, throbbing,
aching, dull?
Specific Location of Pain
• Associated with radiation
to other areas?
Modifying Factors
• Things that make worse or
better?
Timing of the Pain
• Intermittent or constant?
• Temporal relationship with
menses?
• Temporal relationship with
intercourse?
• Predictable or
spontaneous onset?
Detailed medical and surgical
history
• Specifically abdominal,
pelvic, back surgery
Diagnosis: Obtaining the History
Use the REVIEW OF SYSTEMS
to obtain focused, detailed history of
organ systems involved in the
differential diagnosis
Diagnosis: Obtaining the History
Gynecological Review of Systems
Associated with menses?
Association with sexual activity? (Be specific)
New sexual partner and/or practices?
Symptoms of vaginal dryness or atrophy?
Other changes with menses?
Use of contraception?
Detailed childbirth history?
History of pelvic infections?
History of gynecological surgeries or other problems?
Diagnosis: Obtaining the History
Gastrointestinal Review of Systems
Regularity of bowel movements?
Diarrhea/ constipation/ flatus?
Relief with defecation?
History of hemorrhoids/ fissures/ polyps?
Blood in stools, melena, mucous?
Nausea, emesis or change in appetite?
Abdominal bloating?
Weight loss?
Diagnosis: Obtaining the History
Urological Review of Systems
Pain with urination?
History of frequent or recurrent urinary tract infection?
Hematuria?
Symptoms of urgency or urinary incontinence?
Difficulty voiding?
History of nephrolithiasis?
Diagnosis: Obtaining the History
Musculoskeletal Review of Systems
History of trauma?
Association with back pain?
Other chronic pain problems?
Association with position or activity?
Any abdominal wall complaints or surgery?
Diagnosis: Obtaining the History
Psychological Review of Systems
History of verbal, physical or sexual abuse?
Diagnosis of psychiatric disease?
Onset associated with life stressors?
Exacerbation associated with life stressors?
Familial or spousal support?
Diagnosis: The Physical Exam
Evaluate each area individually
Abdomen
Anterior abdominal wall
Pelvic Floor Muscles
Vulva
Vagina
Urethra
Cervix
Viscera – uterus, adnexa, bladder
Rectum
Rectovaginal septum
Coccyx
Lower Back/Spine
Posture and gait
A bimanual exam alone is
NOT sufficient for evaluation
Diagnosis: Objective Evaluative Tools
Basic Testing
Specialized Testing
Pap Smear
MRI or CT Scan
Gonorrhea and Chlamydia
Endometrial Biopsy
Wet Mount
Laparoscopy
Urinalysis
Cystoscopy
Urine Culture
Urodynamic Testing
Pregnancy Test
Urine Cytology
CBC with Differential
Colonoscopy
ESR or CRP
Electrophysiologic studies
PELVIC ULTRASOUND
Referral to Specialist
Differential Diagnosis
The differential diagnosis for Chronic Pelvic Pain is extensive
Challenges the gynecologist to “think outside the uterus”
Diagnosis, evaluation and treatment plans:
•
Should align with pertinent positives and negatives from the
History and Physical
•
Often requires an interdisciplinary approach
Differential Diagnosis:
Gynecological Conditions that may Cause or Exacerbate
Chronic Pelvic Pain
Level A
Level B
Level C
Endometriosis
Adhesions
Adenomyosis
Gynecologic malignancies
Benign Cystic Mesothelioma
Dysmenorrhea/ Ovulatory Pain
Ovarian Retention Syndrome
Liomyomata
Nonendometriotic Adnexal Cysts
Ovarian Remnant Syndrome
Postoperative Peritoneal Cysts
Cervical Stenosis
Pelvic Congestion Syndrome
Chronic Ectopic Pregnancy
Pelvic Inflammatory Syndrome
Chronic Endometritis
Tuberculosis Salpingitis
Endometrial or Cervical Polyps
Endosalpingiosis
Intrauterine Contraceptive Device
Ovarian Ovulatory Pain
Residual accessory ovary
Symptomatic Pelvic Prolapse
Source: ACOG Practice Bulletin #51, March 2004
Differential Diagnosis: Gynecological Conditions
Cyclical
Non-cyclical
Endometriosis
Pelvic Masses
Adenomyosis
Adhesive Disease
Primary Dysmenorrhea
Pelvic Inflammatory Disease
Ovulation Pain/ Mittleschmertz
Tuberculosis Salpingitis
Cervical Stenosis
Pelvic Congestion Syndrome
Ovarian Remnant Syndrome
Symptomatic Pelvic Organ Prolapse
Vaginismus
Pelvic Floor Pain Syndrome
Endometriosis
Presence of endometrial tissue outside of uterine cavity
•
•
•
•
Usually found in dependent areas of the pelvis
Most commonly in ovaries, posterior cul-de-sac, uterosacral ligaments
Endometrial glands and stroma on biopsy
May be at distant sites such as bowel, bladder, lung, skin, plurae
Etiology not well understood
•
•
•
•
Retrograde menstruation
Lymphatic and hematologic spread of menstrual tissue
Metaplasia of coelomic epithelium
Immunologic dysfunction
Endometriosis: Prevalence
Typically diagnosed in women 25 -35 years of age
Diagnosed in approximately 45% of women undergoing
laparoscopy for any indication
Diagnosed in approximately 30% of women undergoing
laparoscopy with primary complaint of chronic pelvic pain
Found in 38% of women with infertility
Family history increases risk ten-fold
Significant cause of morbidity
Endometriosis: Signs and Symptoms
Symptoms
Dysmenorrhea
Dyspareunia
Infertility
Intermenstrual
Spotting
Physical Exam
Visible lesions on cervix or vagina
Tender nodules in the cul-de-sac,
uterosacral ligaments or rectovaginal
septum
Pain with uterine movement
Painful Defecation
Tender adnexal masses (endometriomas)
Pelvic Heaviness
Fixation (retroversion) of uterus
Asymptomatic
Rectal mass
Normal findings
Endometriosis: Diagnosis
Diagnosis can be made on clinical history and exam
Serum CA125 may be elevated but lacks sufficient specificity
and sensitivity to be useful
Imaging studies lack sufficient resolution to detect small
endometrial implants
Laparoscopy is gold standard for diagnosis
• Multiple appearances: red, brown, scar, white, powder
burn, vesicular lesions, adhesions, defects in peritoneum,
endometriomas
• Allows diagnosis and treatment
Laparoscopic
Appearance of
Endometriosis
Endometriosis: Diagnosis
Revised classification system
by the ASRM (1996)
Poor correlation between
symptoms and extent of
disease
Staging of
Endometriosis
Endometriosis: Medical Treatment
NSAIDS for mild disease
First Line: Oral contraceptives
Suppress ovulation and menstruation
Cyclic or continuous therapy
Improves symptoms in up to 70-80%
Second Line: Progestins, GnRH agonists, Danazol
Lupron Depot (x 6-12 months)
Improves symptoms in up to 80-85%
Side effects: hot flashes, vaginal dryness, insomnia,
bone loss irritability
“Add back” estrogen +/- progestin
Endometriosis: Surgical Treatment
Laparoscopic Removal or Destruction
Treatment at time of diagnosis
Used in conjunction with medical therapy
Improves pain in up to 80-90% of patients
Laparotomy (TAH/BSO)
Inadequate response to medical treatment or conservative
surgical treatment with no desire for future fertility
May preserve ovaries in young women, but 30% with
recurrent symptoms
Laparoscopic Uterosacral Nerve Ablation (LUNA), Presacral
neurectomy
Involves transecting the nerve plexus at the base of the
cervical-uterosacral ligament junction or retroperitoneum
Adenomyosis
Description: Presence of endometrial glands and stroma
within the myometrium
Symptoms: Dysmenorrhea; Menorrhagia; Enlarged boggy
uterus; typically affects women age 30-40’s
Diagnosis: Pathology, MRI (ultrasound limited usefulness)
Treatment: Hysterectomy; usually when diagnosis is made
Primary Dysmenorrhea
Description: Pain associated with menses that usually
begins 1-3 days prior to the onset of menses; last 1-3 days
Risk Factors: Nulliparity, Young Age, Heavy menses,
Cigarette Smoking
Symptoms: Crampy lower abdominal pain; +/- nausea,
emesis, diarrhea or headache, normal physical exam
Treatment: NSAIDS, Multivits with B-complex, Hormonal
Therapy (OCPs, OrthoEvra, Nuvaring, Mirena IUD, DepoProvera. Usual improvement after childbirth.
Pelvic Inflammatory Disease
Description: Spectrum of inflammation and infection in the
upper female genital tract
Endometritis/ endomyometritis
Salpingitis/ salpingo-oophritis
Tubo-ovarian Abscess
Pelvic Peritonitis
Pathophysiology: Ascending infection of vaginal and
cervical microorganisms
Chlamydia ,Gonorrhea (developed countries)
Tuberculosis (developing countries)
Acute PID usually polymicrobial infection
Pelvic Inflammatory Disease
Risk Factors
Adolescent
Multiple sexual partners
Greater than 2 sexual partners in past 4 weeks
New partner in the past 4 weeks
Prior history of PID
Prior history of gonorrhea or chlamydia
Smoking
None or inconsistent condom use
Instrumentation of the cervix and lower reproductive
tract
Pelvic Inflammatory Disease: CDC Diagnostic Guidelines (2006)
Minimum Criteria (one required):
Uterine Tenderness
Adnexal Tenderness
Cervical Motion Tenderness
No other identifiable causes
Additional criteria for dx:
Oral temperature greater than 101F
Abnormal cervical or vaginal
discharge
Presence of increased WBC in
vaginal secretions
Elevated ESR or C-reactive protein
Documented of GC or CT
Specific criteria for dx:
Pathologic evidence of
endometritis
US or MRI showing
hydrosalpinx, TOA
Laparosopic findings
consistent with PID
Pelvic Inflammatory Disease
Treatment: Outpatient and Inpatient Abx dosing regimens;
Total therapy for 14 days, maybe longer if TOA
Sequelae
Infertility
Ectopic Pregnancy
Chronic Pelvic Pain
Occurs in 18-35% of women who develop PID
May be due to inflammatory process with
development of pelvic adhesions
Refer to www.CDC.gov/std; revised 2010,
updated Aug. 2012 for outpt. GC treatment
Pelvic Congestion Syndrome
Description: Retrograde flow through incompetent valves
venous valves can cause tortuous and congested pelvic and
ovarian varicosities; Etiology unknown.
Symptoms: Pelvic ache or heaviness that may worsen
premenstrually, after prolonged sitting or standing, or
following intercourse
Diagnosis: Pelvic venogrpahy, CT, MRI, ultrasound,
laparoscopy
Treatment: Progestins, GnRH agonists, ovarian vein
embolization or ligation, and hysterectomy with bilateral
salpingo-oophorectomy (BSO)
Pelvic Floor Pain Syndrome
Description: Spasm and strain of pelvic floor muscles
Levator Ani Muscles
Coccygeus Muscle
Piriformis Muscle
Symptoms: Chronic pelvic pain symptoms; pain in buttocks
and down back of leg, dyspareunia
Treatment: Biofeedback, Pelvic Floor Physical Therapy,
TENS (Transcutaneous Electrical Nerve Stimulation) units,
antianxiolytic therapy, cooperation from sexual partner
Differential Diagnosis:
Urological Conditions that may Cause or Exacerbate
Chronic Pelvic Pain
Level B
Level A
Level C
Bladder Carcinoma
Detrusor Dyssynergia
Chronic Urinary Tract Infection
Interstitial Cystitis
Urethral Diverticulum
Recurrent Acute Cystitis
Radiation Cystitis
Recurrent Acute Urethritis
Urethral Syndrome
Stone/urolithiasis
Urethral Caruncle
Source: ACOG Practice Bulletin #51, March 2004
Interstitial Cystitis
Description: Chronic inflammatory condition of the bladder
Etiology: Loss of mucosal surface protection of the bladder
and thereby increased bladder permeability
Symptoms:
Urinary urgency and frequency
Pain is worse with bladder filling; improved with urination
Pain is worse with certain foods
Pressure in the bladder and/or pelvis
Pelvic Pain in up to 70% of women
Present in 38-85% presenting with chronic pelvic pain
Interstitial Cystitis
Diagnosis:
Cystoscopy with bladder distension
Intravesicular Potassium Sensitivity Test
Presence of glomerulations (Hunner Ulcers)
Treatment:
Avoidance of acidic foods and beverages
Antihistamines
Tricyclic antidepressants
Elmiron (pentosan polysulfate sodium)
Intravesical therapy: DMSO (dimethyl sulfoxide)
Differential Diagnosis:
Gastrointestinal Conditions that may Cause or
Exacerbate Chronic Pelvic Pain
Level A
Colon Cancer
Constipation
Inflammatory Bowel Disease
Irritable Bowel Syndrome
Source: ACOG Practice Bulletin #51, March 2004
Level B
None
Level C
Colitis
Chronic Intermittent Bowel
Obstruction
Diverticular Disease
Irritable Bowel Syndrome (IBS)
Description: Chronic relapsing pattern of abdomino-pelvic pain
and bowel dysfunction with diarrhea and/or constipation
Prevalence
Affects 12% of the U.S. population
2:1 prevalence in women: men
Peak age of 30-40’s
Rare on women over 50
Associated with elevated stress level
Symptoms
Diarrhea, constipation, bloating, mucousy stools
Symptoms of IBS found in 50-80% women with CPP
Irritable Bowel Syndrome (IBS)
Diagnosis based on Rome II
criteria
Treatment
Dietary changes
Decrease stress
Cognitive Psychotherapy
Medications
Antidiarrheals
Antispasmodics
Tricyclic Antidepressants
Serotonin receptor (3, 4)
antagonists
Differential Diagnosis:
Musculoskeletal Conditions that may Cause or
Exacerbate Chronic Pelvic Pain
Level B
Level A
Abdominal Wall Myofascial
Pain (Trigger Points)
Chronic Back Pain
Poor Posture
Fibromyalgia
Neuralgia of pelvic nerves
Pelvic Floor Myalgia
Peripartum Pelvic Pain
Syndrome
Source: ACOG Practice Bulletin #51, March 2004
Level C
Herniated Disk
Lumbar Spine Compression
Low Back Pain
Degenerative Joint Disease
Neoplasia of spinal
cord or sacral nerve
Hernia
Muscular Strains and Sprains
Rectus Tendon Strains
Spondylosis
Differential Diagnosis:
Psychological/Other Conditions that may Cause or
Exacerbate Chronic Pelvic Pain
Level B
Level A
Abdominal cutaneous nerve
entrapment in surgical scar
Depression
Somatization Disorder
Source: ACOG Practice Bulletin #51, March 2004
Level C
Celiac Disease
Abdominal Epilepsy
Neurologic Dysfunction
Abdominal Migraines
Porphyria
Bipolar Personality Disorder
Shingles
Familial Mediterranean Fever
Sleep Disturbances
Psychological Associations
40 – 50% of women with CPP have a history of abuse
(physical, verbal , sexual)
Psychosomatic factors play a prominent role in CPP
Psychotropic medications and various modes of psychotherapy
appear to be helpful as both primary and adjunct therapy for
treatment of CPP– Multidisciplinary pain clinic
Approach patient in a gentle, non-judgmental manner
• Do not want to imply that “pain is all in her head”
Conclusions
Chronic Pelvic Pain requires patience, understanding and
collaboration from both patient and physician
Obtaining a thorough history is key to accurate diagnosis
and effective treatment
Diagnosis is often multifactorial – may affect more than
one pelvic organ
Treatment options often multifactorial – medical, surgical,
physical therapy, cognitive therapy