Geeta Nagpal, MDOctober 26, 2012

…is a symptom, not a diagnosis

Multifactorial

26 year old female referred for evaluation and treatment of chronic pelvic pain

Constant pain in the pelvis and perineum for over one year.

Exacerbating factors include: Sitting, standing, walking, Valsava

maneuvers, sexual activity Pain relieved by:

Norco and Valium Prior Work-up

Gynecologic, Urologic, Gastroenterology

Chronic Pelvic Pain (CPP)

Definition (by Royal College of OB and GYN)• Intermittent, or constant pain in lower abdomen or

pelvis

• Not occurring exclusively with menstruation, intercourse or ass’d with pregnancy

• Duration > 6 months

• Localized to: anatomic pelvis, anterior abdominal wall, lumbrosacral back or buttocks

• Sufficient severity to cause functional disability or lead to medical care

American College of Obstetricians and Gynecologists Practice Bulletin No. 51, March 2004

15-20% of women between the ages of 15-73 years have pelvic pain lasting more than one year during their lifetime

Estimated prevalence 38/1000For perspective: 37/1000 asthma prevalence, 41/1000 chronic back pain prevalence

Primary indication for: 20% outpatient gynecology visits (most common

reason for referral 12% hysterectomy 40% diagnostic laparoscopy

BMJ. 2006 April 1; 332(7544): 749–755.

Among women with CPPUse 3x more medicationsHave 4x more GYN surgeriesAre 5x more likely to have a hysterectomy

In 2006, US spent $881.5 million on outpatient management of chronic pelvic pain

BMJ. 2006 April 1; 332(7544): 749–755.

Dysmenorrhia: Age (<30 yrs), weight (BMI <20), early

menarche (<12 years), longer cycles/ duration of bleeding, PID, sterilization, ho sexual assault

Dyspareunia: Ho circumcision, PID, anxiety, depression,

sexual assault Non-cyclic pelvic pain:

Abuse, psychologic morbidity (miscarriages), longer menstrual flow, endometrosis, PID, caesarian section scar, pelvic adhesions, sexual abuse, anxiety, depression

BMJ. 2006 April 1; 332(7544): 749–755.

Painful Bladder Syndrome/Interstitial Cystitis

Endometriosis (cyclic pain) Pelvic Floor Myalgia

H&P: cyclic, related to periods, related to intercourse, “chandelier sign” aka cervical motion tenderness

Labs/Studies: STD’s, HCG, WBC, Ultrasound for masses , CT Scan

Cystoscopy, Laparoscopy, Colonoscopy,

Ganglion Impar Block Hypogastric Block Sacral Neuromodulation Trigger Point Injections Lidocaine Infusion Pudendal Nerve Block

Ganglion Impar is a solitary retroperitoneal structure at the level of the sacrococcygeal junction

First described by Plancarte in 1990 for the treatment of intractable perineal cancer pain of sympathetic etiology

Ganglion Impar receives afferent fibers from:PerineumDistal rectumAnusDistal urethraVulvaDistal third of the vagina

Approaches:Transsacrococcyg

eal ligamentTranscoccygealAnococcygeal

ligamentParamedian

approach

Therapy:Local Anesthetic (diagnostic and possibly

therapeutic)Steroid6% phenolRadiofrequency Ablation

Is there evidence?Plancarte et al. Anesthesiology 1990

16 pts with advanced cancer (cervical, colon, bladder, rectum, endometrial) with persistent pain

Localized perineal pain in all 6% phenol using transanalcoccygeal approach:

8 pts with complete reliefRemainder with significant pain reduction (60-

90%)

Is there evidence?Swofford et al. Reg Anesth Pain Med 1998

20 pts with perineal pain unresponsive to previous Rx

18 bupivacaine/steroid5 had 100% relief, 10 >75% relief, 3 >50%

relief 2 with 6% phenol

Both with complete relief

Is there evidence?Reig et al. Pain Practice 2005

13 patients with chronic perineal, non-cancer related pain

All had positive result with diagnostic local anesthetic block

Radiofrequency ablation of the GI produced 50% decrease in pain scores with an average duration of 2.2 months and no complications

Complications:Risk is very low In current published literature, there are no

major complications reportedDue to anatomic variation, there is risk of

ineffective blockTheoretical risks:

Bleeding into retroperitoneal space, nerve injury, discitis, puncture of surrounding organs (rectum)

The superior hypogastric plexus is also situated in the retroperitoneum

Extends from the lower third of the fifth lumbar vertebral body to the upper third of the first sacral vertebral body

The percutaneous approach to the SHP was also described by Plancarte et al. in 1990

At that time, used for the treatment of pelvic cancer pain

Since that time, this block has been successfully used for the relief of both noncancer and cancerous conditions.

Superior hypogastric plexus receives afferent pain fibers from:BladderUrethraUterusVaginaVulvaPerineumRectumDescending colon (prostate, penis, testes)

TherapyLocal anesthesticSteroidNeurolysis with phenol (5-8 cc per side)

Is there evidence? Plancarte et al. Anesthesiology 1990

Superior hypogastric block for pelvic CA pain 28 patients with neoplastic involvement of pelvic

viscera 2/2 cervical, prostate, testicular CA or radiation injury

Mean reduction in pain was 70% using VAS de Leon-Casasola et al. Pain 1993

26 pts with extensive gyn, colorectal, genitourinary CA who suffered incapacitating pelvic pain

All had VAPS 10/10 prior to injection (10% phenol) 69% had post injection VAPS <4, 31% VAPS 4-7 Both groups had significant reduction in oral opioid

use

Is there evidence? Plancarte et al. Reg Anesth 1997

227 pelvic pain pts with gyn, colorectal, genitourinary CA had bilateral diagnostic block with 0.25% bupi

159 with positive response to the block Of these, 72% with VAS <4 and mean opioid

decrease by 40% 28% with VAS 4-7 and mean opioid decrease by 26% No additional block for those with good response for

3 mon th follow up Rosenberg et al. Reg Anesth Pain Med, 1998

Case report of SHB with bupi and methylprednisolone relieving pain for over 6 months in a man with chronic penile pain after TURP

Is there evidence?Pollitt et al. Int J Gynaecol Obstet. 2011

Case report of chemical neurolysis or superior hypogastric plexus for non-cancerous pain

21 year old student nurse with 4-year chronic pelvic pain (lower abdomen) thought 2/2 endometriosis

Medical management and laparoscopy x 2 Diagnostic SHB with excellent relief of pain Pulsed RF with no benefit Phenol 6% (7cc in total) with complete pain relief

immediately afterward and at 8 weeks, 6, 12, and 24 months

ComplicationsThere are no reports in the literature of

neurologic complication as a result of this block

Neurologic complications could occur if retrograde spread of the neurolytic to the nerve roots

Discitis is a risk with transdiscal approach

FDA approved sacral neuromodulation in 1997 as a treatment option for Urge incontinenceUrgency/frequencyNon-obstructive urinary retention

In the past 10 years, sacral nerve stimulation has been studies in Rx of IC

More recently, this technique has been applied for the Rx of CPP

How does it decrease painCommon cause of pelvic pain is pelvic floor

dysfunction caused by hypertonus? Maybe by re-establishing pelvic floor

muscle awareness, and decreasing pelvic floor hypertonus

High-tone pelvic floor dysfunction present in 85% of patients with IC/PBS

Approaches

Approaches

Is there evidence?Siegel et al. J Urol. 2001

Measured the effectiveness of sacral nerve stimulation in 10 patients with chronic intractable pelvic pain

All had failed conservative measures Leads placed in either the S3 or S4 foramen 9/10 reported decrease in the severity of the

worst pain compared to baseline at median 19-month follow up

Average decrease in rate of pain from 9.7 to 4.4 Average decrease in daily duration of pain from

13.1 to 6.9 hours

Is there evidence?Everaert et al. Int Urogynecol J Pelvic Floor

Dysfunct. 2001 111 patients with CPP (40 male, 70 female) Underwent pelvic floor training, TENS, intrarectal

or intravaginal electrostimulation applied Sacral nerve stimulation for therapy-resistant

pain Test stim was effective in 16/26 patients 11 patients were implanted successfully and

followed for 36 months 2 failed therapy soon after implantation 9 experienced extended and significant

reduction in pelvic pain

Is there evidence?Kapural et al. Pain Med 2006

Case-series report of spinal cord stimulation for chronic intractable visceral pelvic pain

6 females with CPP (ho endometriosis, multiple surgical explorations, dyspareunia)

All pts received repeated SHB (average 5.3 blocks) with significant pain relief from 1-6 weeks

3 received neurolytic HSB with 3,8, and 12 months of relief respectively

Is there evidence?Kapural et al. Pain Med 2006

All underwent SCS trial for 7-14 days and permanent dual lead implantation to T11-T12

Median VAS decreased from 8 to 3, all pts had over 50% pain relief

Opiate use decreased from 22.5 mg to 6.6 mg morphine equivalents per day

Abdominal/pelvic pain associated with active trigger points in the pelvis, abdominal or low back muscles

Pelvic floor has three functions: support, contraction and relaxation

History “heavy aching pelvic pressure, falling-out

sensation,” often later in the day after prolonged sitting

dyspareunia (genital pain associated with intercourse: before, during, or after)

Common Trigger Points:Piriformis Levator ani Obturator internus

The levator ani is composed of two distinct muscles: pubococcygeus and iliococcygeus.

Innervation via pudendal plexus. Function is to support and elevate the

pelvic floor

Most widely recognized source of referred pain in the perineal region

Pain can be referred to sacrum, coccyx, rectum, pelvic floor, vagina, low back

Pt are uncomfortable with sitting, defection, or lying on the back.

Pain and a feeling of fullness in the rectum and some times back of ispilateral thigh, and vagina

Physical therapy in the associated muscles. (Transvaginal pelvic floor message)

Botox

Combination of the two

PT philosophy and goals:Tender regions (trigger point) impedes

blood flow to the area painGoal is to place pressure, stretch the area,

then releaseThe release is associated with pulsation

(return of blood flow)Decreased pain

PT Average 2-17 sessions Improved pain, frequency, urgencyCase reports: 90+% improvement

Botox type AAbbott JA et al. Obstet Gynecol 2006

Double-blinded, randomized, placebo controlled trial

All patients with CPP > 2 years and evidence of pelvic floor muscle spasm

30 women had 80 U botulinum toxin type A injected into pelvic floor muscles

30 women received saline Dysmenorrhea, dyspareunia, dyschezia, and non

menstrual pelvic pain were assessed by pre and post VAS monthly for 6 months

Outcomes 26 week follow-upPain scores were reduced for both

groups in all parameters, no statistically significant intergroup differences

Improvements from pretreatment in both groups (dysparuenia) Botox (VAS 66 v. 12 p <0.001), placebo (VAS 64 v. 27, p < 0.05)

Significant reduction in pelvic floor pressure from baseline in Botox group

Complications Transient incontinence

Lidocaine has been shown to reduce pain scores in painful diabetic neuropathy

Mexilitene for painful diabetic neuropathy and peripheral nerve injury

Tocainide for trigeminal neuralgia Data for IV lidocaine infusion is sparse Gupta A and Valovska A. EJP 2012

15 female patients with CPP through medications, pelvic PT, surgeries treated with IV lidocaine (ave 3-4 treatments)

Pts had 40-70% pain relief for 1-3 weeks5 pts d/c opioid regimen after 3 treatments

References American College of Obstetricians and Gynecologists Practice

Bulletin No. 51, March 2004 Factors predisposing women to chronic pelvic pain: systematic

review. BMJ. 2006 April 1; 332(7544): 749–755. Fall M et al. EAU Guidelines on chronic pelvic pain. European

Urology 57 (2010) 35-48. Green I, et al. Interventional therapies for controlling pelvic

pain: what is the evidence? Curr Pain Headache Rep (2010) 14: 22-32

Fariello J et al. Sacral neuromodulation stimulation for IC/PBS, chronic pelvic pain, and sexual dysfunction. Int Urogynecol J (2010) 21: 1553-1558