Chronic Pelvic PainAnnick Poirier MD FRCSC

Erin Kelly MD FRCSC

Family Medicine Summit

March 6th, 2020

Presenter: Dr. Erin Kelly

• Speakers Bureau/Honoraria: N/A

• Consulting Fees: N/A

• Grants/Research Support: N/A

• Patents: N/A

• Other: N/A

• The Alberta College of Family Physicians has provided support in the form of a speaker fee and/or expenses.

Presenter: Dr. Annick Poirier

• Speakers Bureau/Honoraria: N/A

• Consulting Fees: N/A

• Grants/Research Support: N/A

• Patents: N/A

• Other: N/A

• The Alberta College of Family Physicians has provided support in the form of a speaker fee and/or expenses.

Disclosure

• We are not pain specialists by training

• We seek support and advocate for our pain program and its patients

• There is very little evidence supporting our practice

Outline & Learning Objectives

1. Differentiate the underlying causes of dyspareunia and chronic pelvic pain

2. Identify the initial investigations for patients with dyspareunia and chronic pelvic pain

3. Discuss management options for dyspareunia/CPP

4. Recognize when to refer

What we are hoping you take home…

• To recognize some elusive causes of chronic pelvic pain, when other causes have been ruled out

• To gain skill performing a pelvic exam for chronic pelvic pain- as it is the single best diagnostic tool!

• To develop an approach to chronic pelvic pain, from diagnosis to simple initial treatment plans and other resources

• When to refer to chronic pelvic pain program, and what we provide to our patients

What we are not going to cover…

Definition

Chronic Pelvic PainNoncyclical pain of 3- 6 or more months’ duration that is perceived to be in the pelvic area and is unrelated to pregnancy and of sufficient severity to cause functional disability or lead to medical care.

American College of Obstetricians and Gynaecologists

Chronic Pain SyndromeInitial source of pain

Pelvic fracture

Delivery

Bladder infection

Painful menstruation

MSK

Surgery

Myofascial dysfunction

Peripheral nerve dysfunctionCentral sensitization

Causes of Chronic Pelvic Pain

What we are not going to cover…

Myofascial Pelvic Pain

Common painful condition

…trigger points may be identified in as many as 85 % of patients suffering from urological, colorectal and gynaecological pelvic pain syndromes… can be responsible for some, if not all, symptoms related to these syndromes…

Robert M. Moldwin and Jennifer Yonaitis Fariello. Myofascial Trigger Points of the

Pelvic Floor: Associations with Urological Pain Syndromes and Treatment Strategies

Including Injection Therapy. Curr Urol Rep (2013) 14: 409-417.

Myofascial Pelvic Pain

• Short, tight, tender pelvic floor muscles (hypertonic pelvic floor)

• Myofascial trigger point• Focus of hyperirritability and pain in a muscle.

Persistent fibre contraction

• Twitch response

• Refers pain on direct compression

• Referred autonomic phenomena

Hoffman B. L. et all. William Gynecology. 3rd edition. Chapter 11: Pelvic Pain

Myofascial trigger point

Vulvodynia

• vulvar pain of at least 3 months duration that has no identifiable cause

• further subdivided by:

• Location – The symptoms can be localized, generalized, or mixed

• Provocation – Provoked, spontaneous, or mixed

• Onset – Primary or secondary

• Temporal pattern – Intermittent, persistent, constant, immediate

Vulvodynia: Theories, Pathogenesis

Vulvodynia

Neurologic Proliferation

and sensitization

Chronic inflammation

Chronic Infection

Genetics

allergy

Hormonal

myofascial

Psychological

Vaginismus

• Involuntary contraction of the pelvic musculature surrounding the outer third of the vagina

• Vaginismus• lifelong (primary)

• acquired (secondary)

• complete, partial

• situational

No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain. J Obstet Gynaecol Can

2018;40(11):e747−e787 https://doi.org/10.1016/j.jogc.2018.08.015

Vaginismus

• Difficult to differentiate vaginismus from provoked vulvodynia and it is likely that both occur on a continuum with some women having more of a prominence of pelvic floor muscle tightness symptoms and other women having a predominance of pain symptoms

Pudendal Neuralgia

Pudendal Neuralgia• Cardinal symptoms of neuropathic pain:

• Hyperalgesia• Allodynia• No sensory deficit

• The diagnosis is made on the basis of characteristic clinical findings that include:• Pain in the anatomical territory of the pudendal nerve

• Pain worsened by sitting

• Pain does not wake the patient at night

• Pain without superficial sensory deficit

• Pain relieved by diagnostic pudendal nerve block

Pelvic Examination-the single best diagnostic tool!

Physical Exam ComponentsComponents description

General appearance, demeanor Gait, mobility, posture, guarding, eye contact…

Abdominal exam abdominal wall trigger points

Hand-held mirrorHand-held mirror education/validation, helps decrease anxiety of any contact, facilitate how to apply topical etc

Cotton-swab test Palpation of genital areas with cotton-tipped applicatorEvidence of allodyniaCan be performed on any area of the body as well

Single digit exam if speculum or bimanual not tolerable

Assess pelvic floor musclesResponse to pressure/stretch applied to: Transverse perneii ,Bulbocavernosus + ishiocavernosus, Pubococcygeus, iliococcygeus, cocygeus, Obturator internus

Assess pelvic floor tone PFM strength and relaxation

Physical Exam

Physical Exam ComponentsComponents description

General appearance, demeanor Gait, mobility, posture, guarding, eye contact…

Abdominal exam abdominal wall trigger points

Hand-held mirrorHand-held mirror education/validation, helps decrease anxiety of any contact, facilitate how to apply topical etc

Cotton-swab test Palpation of genital areas with cotton-tipped applicatorEvidence of allodyniaCan be performed on any area of the body as well

Single digit exam if speculum or bimanual not tolerable

Assess pelvic floor musclesResponse to pressure/stretch applied to: Transverse perneii ,Bulbocavernosus + ishiocavernosus, Pubococcygeus, iliococcygeus, cocygeus, Obturator internus

Assess pelvic floor tone PFM strength and relaxation

Physical Exam

Initial Treatments and Resources

Rule out other causes of pelvic pain…

Then focus on education and expectations

… it should be made clear that pelvic pain syndromes are chronic conditions in which symptoms are managed but are likely to be ongoing, characterized by periods of remission and symptom flare. Improvements may be slow, as there is not a treatment that is one size fits all, finding the correct treatment for a patient may take some trial and error, time and patience…

Then focus on education and expectations

• Realistic goals and expectations

• Stress management

• Pacing

• Body posture

• Voiding and defecation techniques

Vulvar Hygiene

Pelvic floor Physiotherapy

• Primary treatment of myofascial pelvic pain

• Manual myofascial release

• Stretching

• Strengthening

• Physical therapy works!

• A small trial comparing PFPT and trigger point injections in women with MPPS reported >50 % improvement in symptoms for each group

• A retrospective review of 146 women with MPPS who received PFPT, 63 % of patients reported significant improvement in pain scores

Available in the community

Other Important Therapies

• Acupuncture

• Hypnosis

• Transcutaneous Electrical Nerve Stimulation (TENS)

• Dilators, self massage

• Yoga, stretching

• Sexual Health Counselling/Psychotherapy/Cognitive Behavioral Therapy

• Mindfulness Cognitive Behavioral Therapy

Web Resources

• https://www.retrainpain.org/

• https://www.pelvicpain.org/IPPS/Patients/Patient-Resources/IPPS/Content/Professional/Patient-Resources.aspx?hkey=19cefdcc-cf5e-49f7-9508-68f450a207a3

• https://palousemindfulness.com/index.html

• Acetaminophen

• NSAIDS: Voltarensuppositories

• Opium & Belladonna suppositories

• Gabapentin suppositories

• Vaginal diazepam

Local Medications

Topical Medications• Lidocaine 2 or 5% ointment

• Topical /Local estrogen (vagifem, estragyn vs. Premarin cream)

• Gabapentin compounded ointment/cream 2 to 10%

• Amitriptyline compounded ointment/cream 2 to 10% with baclofen or ketamine

• Capsacin

• Corticosteroids

• Cromolyn

• Enoxaparin

• Cutaneous Fibroblast Lysate

• Meloxicam

Oral Medications

• Antidepressants

• SNRIs: venlafaxine, duloxetine, Milnacipran

• SSRIs: no controlled studies

• TCAs: Amitriptyline

• Anticonvulsants

• including gabapentin

• pregabalin Therapies used in other pain syndrome are appropriate

When to refer to our program, and what we provide to our

patients

Lois Hole Chronic Pelvic Pain Program

• Multi-disciplinary team• Tertiary level care for

refractory cases• Intensive program

• Goal setting• Education classes• Exercises classes• Mindfulness classes

Referral process

• Compulsory gynecology consultation

• Referral information and form available through Alberta Referral Directory

• Patient are triage according to clinical criteria

• Currently long waiting list