Chronic Pelvic Pain
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Transcript of Chronic Pelvic Pain
Fawaz EdrisMD, RDMS, FRCSC, FACOG, AAACS
IntroductionNon cyclical uterine or non-uterine pelvic
pain > 6/12GynecologicalGITUrologicalOrthopedicMusculoskeletal“superficial” (nerve entrapment, hernia,
referred) Psychological (by exclusion)
IntroductionSomatic painVisceral pain
Diffusely spread Lack of well defined areas in the sensory cortex Viscerosomatic convergence
No neurons in the spinal cord receives only visceral pain
Viscerosomatic neurons Larger receptive field than somatic Less numbers than somatic
HistoryPain history and its componentsRelationship to period, bowel movement, urination, intercourse
and activityPrevious episodesOther symptoms (GIT, urological, weight loss, etc)Effect on life (social, work, family)Relationship of onset to events (newly married, rape, lifting, chest
infection, etc) Hx of sexual, physical, or emotional abuseWhat medication usedWhat investigations doneOther stress or psychological symptoms (depression, anxiety, etc)
BUT!Secondary gain (off work, husband to stay, attention, etc) BUT!Full Gyn Hx (STD, PID, Infertility, dysparunia, surgeries including D&C, etc.)Full surgical HxMedical Hx (IBS, IC, IBD)
Examination Abdominal (point, superficial, deep)Pelvic (tenderness, mobility, nodularity) Nerve entrapment
DermatomesHead raising
InvestigationsLimited useScopes: if symptoms suggest (GIT,
Urological)Imaging: if symptoms suggest
musculoskeletal U/S: although of limited use Laparoscopy the ultimate but last methodPsychological evaluation
Gynecological Endometriosis (30%)
Pathogenesis20-30% missed on laparoscopyTreatment is medical (may start before Dx)
Cont. OCP Depot Provera Danzol GnRH analouge + add back therapy
If no response, surgical (TAH / TAH+BSO)Size and location doesn’t correlate with painPath0physiology of pain not well understoodInfertility
Chronic PID(25%)Recurrent exacerbations HydrosalpingesAdhesions !!
Gynecological Ovarian
Cysts are ASYMPTOMATIC, unless Rapid distention Bleeding Torsion Special cysts (Endometrioma, Dermoid)
Ovarian remnants retroperitonealy (with cyst)Uterine
Adenomyosis (rarely CPP)Fibroid are ASYMPTOMATIC, unless
Degeneration Torsion Prolapsed submucus fibroid
Retroverted uterus DOSE NOT cause CPP. Maybe dysparunia!
Gynecological Pelvic Congestion Syndrome
Myth! Non specific symptoms No agreed upon diagnostic measures No agreed upon therapeutic measures
Non-Gynecological G.U.T
Multiple examples, the most common: Urethral syndrome IC
Common: 1 in 5 women Urgency, frequency, nocturia, CPP Diagnosis & treatment
G.I.TMultiple examples, the most common:
IBS, IBD, Hernias.Innervation of the lower intestinal tract, same as
uterus and fallopian tubes pelvic pain
Psychological 30% of CPP remains undiagnosed even after
laparoscopy Is this a primary or secondary thing!
Pain Perception Every pain is a result of stimulus and response,
however: Chronic pain ≠Acute pain.Acute pain: response is appropriate to stimulus.Chronic pain is affected additionally by:
Patient’s reaction to painFamily’s reaction to the patient and her pain
(reinforce or persistence) So: Response to a stimulus is inappropriate,
exaggerated, inaccurate, and may persist even after the stimulus is gone
Management Therapeutic, supportive, and sympathetic
physician-patient relationship should be established (only few can do it!)
Regular F/U rather than “come back when pain persist”The latter reinforces pain behavior
If no pathology is found, patient should NOT be ignored!Reassurance + symptomatic treatment Multidisciplinary pain clinic
Management Multidisciplinary pain clinicGYN, Psychologist, Anesthetist, othersIf no team is in place, use referrals.Psychologist
Techniques for stress reduction, adaptive strategies Marital, sexual, and social counseling
Management Treat underlying cause if found!If none is found:
Multidisciplinary teamNSAIDsOvulatory/menstrual suppression
Cont. OCP, Depot Provera, Danzol, GnRH analouge + add back therapy May work for those with pain related to the period
(mid-cycle, premenstrual or menstrual) or those with ovarian causes (ovarian remnant)
Low dose TCA (increase inhibitory neuromodulators)
Management Surgeries
If no pathology NOT effectiveIf no strong evidence of pathology thorough
psychological evaluation before any surgery Lysis of adhesions:
NOT effective unless the site of adhesions = site of pain.
Vicious cycle
Thank you