Transcript Infertility and Assisted Reproductive Techniques

Chronic Pelvic Pain (CPP)
Khaled Zeitoun, M.D.
Assistant Clinical Professor
Columbia University
Chronic Pelvic Pain: Definition
• An unpleasant Sensory and Emotional
experience associated with actual or
potential tissue damage or described in
terms of such damage
• Symptom and always Subjective
Chronic Pelvic Pain: Definition
• Temporal characteristics
• Severity
• Location
Chronic Pelvic Pain: Definition
• Noncyclic pain of at least 6 months duration
• Menstrual pain /Intermittent pain
Chronic Pelvic Pain: Definition
• Anatomic pelvis
• Anterior abdominal wall at or below the umbilicus
• Lumbosacral back and buttock region
• Vulvar pain ???
Chronic Pelvic Pain: Definition
• Causes functional disability
• Medical care
Chronic Pelvic Pain: Definition
• Acute pain occurs in conjunction with
autonomic reflex responses, and associated
with signs of inflammation and infection.
• Chronic pain is characterized by
physiological, affective and behavioral
responses that differ from acute pain.
Chronic Pelvic Pain: Theories
Classic medical or Cartesian model
• Pain perception results directly from and is
related to the extent of local tissue
destruction
• Pain in the absence of tissue injury is
psychogenic
Chronic Pelvic Pain: Theories
The gate-control theory of pain
• Somatic and psychogenic factors can
potentiate or modify response to pain
• Failing to recognize the many social factors
believed to affect a patient's responses to
pain and to therapy
Chronic Pelvic Pain: Theories
The biopsychosocial theory of pain
• Most comprehensive model for dealing with
chronic pelvic pain
• Integrates all the factors that contribute to a
patient's perception of pain: nociceptive
stimuli, psychological state, and social
determinants
• Explains symptom "shifting"
Chronic Pelvic Pain: Population
• Women of all ages are affected
• Studies focused on women between 18
and 50 years old
Chronic Pelvic Pain: Demographic
Variables
• No difference in age, race,
socioeconomic status, education, ethnic
background, education or employment.
• More common in divorced / separated
women than single and married women
(Mathias et al, 1996)
Chronic Pelvic Pain: Prevalence
• 15% to 20% of women between 18 and
50 years old have chronic pelvic pain of
more than one year’s duration
• CPP accounted for 2% to 10% of all
outpatient gynecologic consultations
annually ( Reiter, 1990)
Chronic Pelvic Pain: Health Impact
• General health scores are lower
• Associated disturbances of mood and
energy levels (>50%)
• Depression is common
• Quality of life is decreased
• Restricted activity and decreased
productivity
Chronic Pelvic Pain: Health Impact
• 90% of women with CPP complain of
dyspareunia
Chronic Pelvic Pain: Health Care
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20% see a gynecologist
10% other physician
1% mental health evaluation
Rest see no one????
Chronic Pelvic Pain: Health Care
• Very few are seen and evaluated by
clinicians in more than one specialty
• 75% of women who report CPP have
not seen a healthcare provider for 3
month despite persistent pain affecting
daily activities
Chronic Pelvic Pain: Health Care
• 56% take one or more nonprescription
drugs
• 25% take medications prescribed by a
provider
• 12% oral contraceptives
Chronic Pelvic Pain: Health Care
• 61% no diagnosis given by physician
• 39% diagnosis given
25% endometriosis
49% a non-cycle related gynecologic disorder
(e.g. yeast infection or chronic PID)
10% non-gynecologic disorder
16% other
Chronic Pelvic Pain: Health Care
• 10% to 35% of laparoscopies are for
CPP
• 9% to 80% of laparoscopies report
abnormalities
Chronic Pelvic Pain: Health Care
• Up to 70% of laparoscopies report
endometriosis
• Even if pathology is found it might not be
the reason for the pain
Chronic Pelvic Pain: Health Care
• between 10% to 12% of hysterectomies are done
for CPP
Mortality 0.1% ( 70 women a year)
Not always beneficial
Detrimental effect of castration on heart
disease, bone and Alzheimer’s
Chronic Pelvic Pain: Economic Impact
• Direct medical costs
• Loss of productivity
Chronic Pelvic Pain: Causes
Gynecologic causes:
• Cyclic
• Noncyclic
Chronic Pelvic Pain: Causes
Gynecologic causes:
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Endometriosis
Adhesions (?)
Adenomyosis
Chronic pelvic infection
Hydrosalpinx
Pelvic congestion (?)
Leiomyomata(?)
Malignancies
Primary dysmenorrhea
Chronic Pelvic Pain: Causes
Gynecologic causes:
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Ovarian remnant syndrome
Ovulatory pain
Adnexal cysts
Cervical stenosis
Chronic endometritis
Endometrial polyps
Chronic ectopic pregnancy
Pelvic relaxation
IUD
Chronic Pelvic Pain: Causes
Nongynecologic disorders:
Psychiatric and psychological
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Depression
Physical or sexual abuse
Somatization
Hypochondriasis
Opiod seeking
Factitious
Chronic Pelvic Pain: Causes
Nongynecologic disorders:
Pain processing disorder
• Fibromyalgia
Chronic Pelvic Pain: Causes
Nongynecologic disorders:
Gastrointestinal
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Functional bowl syndrome
Inflammatory bowl disease
Cancer
Chronic appendicitis (?)
Diverticulitis
Chronic Pelvic Pain: Causes
Nongynecologic disorders:
Urinary
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Interstitial cystitis
Urethral syndrome
Detrusor instability
Chronic calculi
Chronic Pelvic Pain: Causes
Nongynecologic disorders:
Musculoskeletal
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Hernia
Disc disease
Arthritis
Scoliosis and posture related disorders
Nongynecologic disorders:
Psychiatric and psychological
• In depression pain is not an uncommon
presentation
• Mood is an important modifier of pain
• The relationship between depression
and pain may involve neurotransmitter
abnormalities
Nongynecologic disorders:
Psychiatric and psychological
• Physical and sexual abuse history is
obtained in 25% to 40% of CPP patients
• Trauma of abuse event can kindle a
depressive or pain processing disorder
in a genetically susceptible individual
Nongynecologic disorders:
Psychiatric and psychological
• Somatization disorder patients have multiple
physical complaints not explained by a
known medical condition
• DSM-IV criteria:
Four different pain sites, two GI complaints,
one neurologic symptom and one sexual or
reproductive symptom
Nongynecologic disorders:
Psychiatric and psychological
Somatization disorder
• Emotional distress
• Common abnormality of sensation
processing
Nongynecologic disorders:
Psychiatric and psychological
• Hypochondriasis patients are
preoccupied with fear of having a
serious disease
• Obsessive
• Visit many health care providers
Nongynecologic disorders:
Psychiatric and psychological
• Drug-seeking behavior patients often
request opioids for pain relief
• Women with CPP may become addicted
if they use opioids for pain relief
• Abdominal pain due to withdrawal
leads to further drug use
Nongynecologic disorders:
Problematic substance abuse
• Impaired control of substance use
• Guilt or regret about use, efforts to cut down,
complaints or concerns from others
• Recent substance use with resultant
neurologic or cardiovascular symptoms,
confusion, anxiety, or sexual dysfunction
• Psychosocial dysfunction
• Tolerance
Nongynecologic disorders:
Psychiatric and psychological
• Factitious disorder patients intentionally
feign disease with the purpose of
assuming the role of a sick person
• Malingering patients have external
incentive to appear sick
Nongynecologic disorders:
Pain Processing Disorder
• Fibromyalgia
• occurs in 2% to 4% of individuals, 80%
are women
• Abnormal pain processing associated
with neuroendocrine and autonomic
disorders
Nongynecologic disorders:
Fibromyalgia
• Criteria for diagnosis:
• Pain involving all 4 quadrants of body
and axial skeleton
• Tenderness at 11 of 18 defined “tender
points”
• Tenderness due to amplification of pain
signals
Nongynecologic disorders:
Fibromyalgia
• Abnormal CNS processing of pressure
• Visceral sensations can also be
abnormally processed
• Associated motility disorder of
abdominal viscera
• Disordered sleep
Nongynecologic disorders:
Gastrointestinal
• Irritable bowel syndrome (IBS)
• Abdominal pain for at least 3 month
duration in the last year
• Relieved by bowl movement
• Altered bowl habits (frequency and
appearance)
Nongynecologic disorders:
Gastrointestinal
• Irritable bowel syndrome (IBS)
• Abnormal gastrointestinal motility
• Augmented sensation of visceral stimuli
as pain
• Consistent with abnormal pain
processing and autonomic dysfunction
disorders
Nongynecologic disorders:
Gastrointestinal
• Inflammatory Bowel Disease
• Pain from inflammation of bowel or
adjacent structures
• Nonspecific symptoms (pain, gas,
distention, etc.)
• Fever and diarrhea
Nongynecologic disorders:
Gastrointestinal
• Diverticular disease
• Common after 40 years
• Left lower quadrant pain with
diverticulitis
• Fever, diarrhea and constipation are
common
Nongynecologic disorders:
Gastrointestinal
• Colon cancer
• uncommon before 40 years of age
• Altered bowl habits more than pain
Nongynecologic disorders:
Gastrointestinal
• Chronic appendicitis
• uncommon cause of CPP
• Existence is controversial???
Nongynecologic disorders:
Urologic
• Interstitial cystitis
• Urinary urgency, bladder discomfort
and sense of inadequate empting
• Bladder mucosal lesions consist of
hemorrhage and petechiae
(glomerulations)
• Some have only abdominal pain
Interstitial cystitis
ulceration
Nongynecologic disorders:
Urologic
• Urethral Syndrome
• Irritative bladder symptoms often
associated with coitus
• Lower abdominal pain may be chief
presentation
Chronic Pelvic Pain: Causes
Gynecologic causes
Endometriosis
STROMA
GLANDS
Endometriosis
EPIDEMIOLOGY AND PREVELANCE
- Diagnosed by laparoscopy in 25-33%
of cases with infertility or chronic pelvic
pain
- 1-7% estimated prevalence among all
reproductive age women
Endometriosis
IMPLANTS
- Red - Pink
- Blue
- Black
- yellow - Brown
- white
- Clear
- Peritoneal defect
Gynecologic disorders:
Endometriosis: Pain
• Noncyclic pain
• Dyspareunia
• dysmenorrhea
Gynecologic disorders:
Endometriosis: Pain
• Peritoneal implants secrete factors that irritate the
peritoneal surface
• Pelvic adhesions due to scarring and retraction of
peritoneal surface
• Retroverted uterus or adherent ovaries in the C.D.S.
cause dyspareunia due to compression of these
structures or tension on surrounding peritoneum
• Uterosacral lesions due to compression or stretching
of peritoneum
• Visceral pain due to invasion of urinary or GI tracts
Endometriosis
Endometriosis
Endometriosis
CLASSIFICATION
- AFS original classification (1979)
- AFS revised classification (1985)
- ASRM revised classification (1996)
Gynecologic disorders:
Endometriosis: Pain
• Not correlated with stage of disease
• Deep lesions are associated with more
pain
• Vaginal endometriosis associated with
dyspareunia
• Prostaglandins
Endometriosis
PHYSICAL FINDINGS
- Normal examination
- Focal tenderness
- Retroverted fixed uterus
- Nodularity and tenderness of the
cul-de-sac or uterosacrals
- Cervical stenosis
- Pelvic masses
Endometriosis
DIAGNOSTIC METHODS
- CA-125
- Ultrasound, MRI, CT scans
- Imaging urinary tract and bowl
- Laparoscopy
- Biopsy
Treatments of Pelvic Pain Due to
Endometriosis
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Analgesics (NSAIDs)
Estrogen/progestin combinations
GnRH agonists / antagonists
GnRH agonists with steroid add-back
Danazol
Others (aromatase inhibitors)
Endometriosis
GnRH WITH ADD-BACK THERAPY
- Preservation of bone mass
- Other effects of low estrogen
- Prolonged Treatment
- Improve compliance
- Avoid surgery
- May decrease efficacy
Treatments of Pelvic Pain Due to
Endometriosis with GnRH Agonists
Followed by Add-Back Therapy
• Transdermal estradiol patch: 25 µg/day, plus
medroxyprogesterone acetate 2.5 mg daily
• This regimen does not completely prevent
bone loss. The estradiol concentration
achieved is in the range of 30 pg/mL.
(Howell, 1995)
Treatments of Pelvic Pain Due to
Endometriosis with GnRH Agonists
Followed by Add-Back Therapy
• Norethindrone acetate 5 mg/day
• This is a very high dose of progestin. This
dose of progestin is associated with a
decrease in HDL-cholesterol
(Hornstein, 1997)
Treatments of Pelvic Pain Due to
Endometriosis with GnRH Agonists
Followed by Add-Back Therapy
• Conjugated equine estrogen 0.625 mg/day,
norethindrone acetate 5 mg/day
• This regimen prevents bone loss and
markedly reduces the vasomotor symptoms
reported. Pain relief was excellent.
(Hornstein, 1997)
Endometriosis
RECURRENCE: MEDICAL THERAPY
- Rates vary (29-51%)
- Depend on duration
Endometriosis
DEFINITIVE SURGERY
- If pregnancy is not desired
- Intractable disease
- Hysterectomy +/- ovarian excision
- Recurrence rates higher with ovarian
conservation
Endometriosis
CONSERVATIVE SURGERY
- uterine and ovarian preservation
- Usually done laparoscopically
Endometriosis
RECURRENCE: SURGERY
- Rates vary (7-66%)
- Impossible to remove all lesions especially
microscopic
- Less recurrence after definitive surgery
Endometriosis
RECURRENCE
- Residual disease
- Endometriosis prone patient
- Aggressive lesions
- Extra-ovarian estrogen production or ERT
Adenomyosis
Uterine Fibroids
Hydrosalpinx
Hydrosalpinx
Other lesions
ADHESIONS
PATHOGENESIS
Peritoneal Trauma
• Mechanical trauma
• Thermal, electrical or
chemical trauma
• Foreign bodies
• Infection
• Inflammation
• Ischemia
PATHOGENESIS
Initial Stage of Peritoneal Healing
• Chemotactic messengers
• Coagulation
• Inflammatory exudate
• Fibroblast proliferation
PATHOGENESIS
Formation of Fibrin Bands
• Inflammatory exudate
• Fibrin deposition
• Fibrin band formation
PATHOGENESIS
Fibrinolysis
Fibrin
Plasminogen
tPA
Plasmin
PAI1
and
PAI2
Inhibition
Fibrin Split Products
PATHOGENESIS
Fully Healed Peritoneum
• Fibrinolytic activity
• Tissue plasminogen
activator
• 5-7 days normal surface
healing
PATHOGENESIS
Peritoneal Healing (approximately 5-7 days)
Peritoneal Injury
Increased Vascular Permeability
Inflammatory Exudate
Fibrin Deposition
Fibrinolysis
Ischemia
Suppressed Fibrinolysis
Fibrin Fixation
Normal Peritoneal
Healing
Adhesion Formation
PATHOGENESIS
Adhesion Formation
• Fibroblast proliferation
• Mesothelial over-growth
• Neovascularization
INCIDENCE
Adhesions Following Reproductive Pelvic
Surgery by Laparotomy
Study
Year
N
% with adhesions
Diamond et al.
DeCherney and Mezer
Surrey and Friedman
Pittaway et al.
Trimbos-Kemper et al.
Daneill and Pittaway
1988
1984
1982
1985
1985
1983
106
61
37
23
188
25
86%
75%
73%
100%
55%
96%
440
72%
TOTAL
Majority of second-look laparoscopy performed between 1-12 weeks
Adapted from Diamond M.P. Obstet Gynecol, 1988.
Incidence
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Ovary
Pelvic sidewall
Fimbria
Omentum
Small Intestine
Colon
(55%)
(40%)
(36%)
(19%)
(15%)
(15%)
INCIDENCE
Adhesions Following Laparoscopy
Procedure
N
% with adhesions
Adhesiolysis
68
66%
Ovarian surgery
25
65%
Myomectomy
50
88%
Endometriosis
32
87%
Majority of second-look laparoscopy performed between 12-14 weeks
Diamond M. et al. Fertil Steril 1991;55:700-704.
Keckstein J. et al. Hum Reprod 1996;11:579-582.
Mais V. et al. Hum Reprod 1995;10:3133-3135.
Mais V. et al. Obstet Gynecol 1995;86:512-515.
COMPLICATIONS
Clinical Consequences of Adhesions
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Infertility
Chronic pelvic pain (CPP)
Small bowel obstruction (SBO)
Intraoperative complications
Subsequent surgery
COMPLICATIONS
% of patients with chronic pelvic pain
Chronic Pelvic Pain: Laparoscopic Findings
100
90
80
70
60
50
40
30
20
10
0
Normal
Adhesions
Liston et al. 1972 (75;15;5)
Lundberg et al. 1973 (35;30;13)
Renager et al. 1979 (25;20;19)
Kresch et al. 1984 (15;45;30)
Rapkin, 1986 (33;22;37)
Endometriosis
COMPLICATIONS
Chronic Pelvic Pain Relief after
Laparoscopic Adhesiolysis
100
% of Patients
80
60
40
20
0
Sutton &
MacDonald, 1990
Goldstein et al.,
1980
Pain Improved
Howard, FM. Obstet Gynecol Surv 1993;48:357-387.
Steege & Stout,
1991
Total
Pain Not Improved
COMPLICATIONS
Recurrence of Pain Following Adhesiolysis
Time Since Surgery, Months
Time of pain return during daily activities after laparoscopic lysis of adhesions.
Steege and Stout, Am J Obstet Gynecol, 1991;165:278.
COMPLICATIONS
The Paradox of Chronic Pelvic Pain and Adhesions
• Pelvic adhesions present in 15% - 45% of patients
with chronic pelvic pain
• Adhesions may or may not be the cause of chronic
pelvic pain
• Adhesiolysis decreases pain or is beneficial in a
large percentage of patients???
• Many patients have recurrence of pain or
increased pain over time
Howard F.M. Obstet Gynecol Surv 1993;48:357-387.
ADHESION PREVENTION
Surgical Techniques to Minimize Adhesions
• Directed hemostasis
• Avoid:
–
–
–
–
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ischemia
desiccation
sponging
tissue grafts
introduction of foreign
bodies
• Minimize tissue
handling
• Use fine non-reactive
sutures placed without
tension
• Consider using
heparin in irrigation
fluid
ADHESION PREVENTION
Controlled Clinical Trials
Non-efficacious
Dextran 70
Ibuprofen
Tolmetin
Cortisone
Efficacious
Interceed* (TC7) Absorbable
Adhesion Barrier
Preclude** Surgical Membrane
Seprafilm*** Bioresorbable Membrane
Gynecare Intergel
*Trademark of ETHICON, Inc.
**Trademark of W.L. Gore & Associates, Inc.
***Trademark of Genzyme
Chronic Pelvic Pain: Evaluation
Chronic Pelvic Pain: Recognition
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Duration of pain for 6 month
Incomplete relief by most previous treatment
Impaired function
Signs of depression
Pain out of proportion to pathology
Altered family role
Chronic Pelvic Pain: Evaluation
• Multidisciplinary approach to
diagnosis
• Consultations with other health
professionals needed
Chronic Pelvic Pain: History
• Most important diagnostic tool
• Open interview approach
• Detailed questioning regarding the
pain
• Previous interventions
• Menstrual history
• Surgical history
• Review of systems
Chronic Pelvic Pain: Psychological
History
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Early psychological evaluation
Psychiatric illness
Life stresses
Personal loss and grieving process
Substance abuse
Family dysfunction / family support
system
• Sexual relationships
• Sexual and physical abuse
Chronic Pelvic Pain: Physical
Examination
• General physical examination
• Abdominal examination
• Tenderness in lower abdominal
quadrants
• Contract abdominal muscles
• Surgical scars and hernias
• Vaginal or rectal examination
Chronic Pelvic Pain: Psychological
testing
• Minnesota Multiphase Personality
Inventory (MMPI) to evaluate
psychopathology
• Beck Depression Inventory
• McGill pain questionnaire – pain rating
index
• Multidimensional pain inventory
Chronic Pelvic Pain: Testing
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Laboratory testing
Diagnostic nerve blocks
Diagnostic imaging
Diagnostic surgery / Pain mapping
Empiric therapy
Chronic Pelvic Pain: Treatment
Treatments for Some
Nongynecologic Causes of CPP
• Depression: Cognitive-behavioral therapy,
antidepressants
• Somatization: Psychotherapy
• Fibromyalgia: Tricyclics, cognitivebehavioral therapy, aerobic exercise
Treatments for Some
Nongynecologic Causes of CPP
• Irritable bowel syndrome: Amitriptyline,
antispasmodics, fiber
• Interstitial cystitis: bladder overdistension,
amitriptyline, intravesical dimethylsulfoxide
• Urethral syndrome: antimicrobials, urethral
dilatation
Treatments for Some
Nongynecologic Causes of CPP
• Hernia: surgical repair
• Disc disease: anti-inflammatory medication,
exercise, surgery
• Arthritis: anti-inflammatory medication
• Posture-related problems: physical therapy
Chronic Pelvic Pain: Treatment
Empiric treatment of CPP with GnRH Agonist
• Standard approach:
If no response to NSAIDs and OCs
laparoscopy is done.
Chronic Pelvic Pain: Treatment
Empiric treatment of CPP with GnRH Agonist
• Alternative approach:
If no response to NSAIDs and OCs treat with
GnRH agonist and avoid surgery
(Ling, 1999)
Chronic Pelvic Pain: Treatment
Empiric treatment of CPP with GnRH Agonist
• Is effective for endometriosis
• Also relieves pain from other causes like
interstitial cystitis or IBS and pelvic
congestion
Chronic Pelvic Pain: Treatment
Treatment of CPP with OCP’s
• Is effective for primary dysmenorrhea
• Endometriosis
Chronic Pelvic Pain: Treatment
Treatment of CPP with NSAID’s
• Is effective for dysmenorrhea
• Mild to moderate pain
Chronic Pelvic Pain: Treatment
Treatment of CPP with progestins
• Is effective for endometriosis
• Pelvic congestion
Chronic Pelvic Pain: Treatment
Treatment of CPP with laparoscopic surgery
• Is effective for endometriosis
• Stages I-III
Chronic Pelvic Pain: Treatment
Treatment of CPP with presacral neurectomy
• Is not effective during surgical treatment of
endometriosis
Chronic Pelvic Pain: Treatment
Treatment of CPP with hysterectomy
• Is effective treatment of CPP
• Uterine pathology might not be found (65%)
• Fibroids, pelvic congestion, adhesions,
endometriosis
• About 75% are pain free after one year
Chronic Pelvic Pain: Treatment
Pain clinics
Multidisciplinary approach to CPP that
includes surgical, psychological, dietary and
social interventions versus focused organic
approach
(peters et al, 1991)
Chronic Pelvic Pain: Treatment
Nontraditional approaches
Very little evidence that these approaches
are effective
THE END