Visceral and Urogenital pain. Natasha Curran FRCA FFPMRCA University College London Hospitals 28 th January 2010 Royal College of Anaesthetists

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1 Visceral and Urogenital pain Natasha Curran FRCA FFPMRCA University College London Hospitals 28 th January 2010 Royal College of Anaesthetists

2 Outline Visceral pain The chronic pelvic pain syndromes Patient assessment Treatments Cases Resources, questions, discussion

3 Features of visceral pain True visceral pain Usually first phase of a visceral pain attack Vague, poorly discriminated sensation eg discomfort, pressure, often midline Due to scarce innervation of viscera Autonomic signs and symptoms eg nausea, pallor, sweating, changes in heart rate and urinary frequency Strong emotional reactions common eg anxiety, anguish, impending death

4 Features of visceral pain Referred pain (without hyperalgesia) Usually after onset of true visceral pain Felt by patient in area of body wall which receives same sensory innervation Sharper, better defined, more localised, described as cramp-like or aching

5 Features of visceral pain Referred pain with hyperalgesia Hyperalgesia = increased sensitivity to normally painful stimuli Observed in skeletal muscle of body wall area of referral Spreads to involve overlying somatic tissues Can progress to allodynia as in acute peritonitis Residual hyperalgesia can last a long time eg years after renal stones, or revert after removal of primary visceral focus eg cholecystectomy

6 Dermatomes

7 Features of visceral pain Visceral hyperalgesia Increased reactivity to pain of an organ because of excess stimulation or inflammation of the same organ Inflammation awakening silent nociceptors, central sensitisation Suspect if patient has pain with physiological stimuli Pain in oesophagus or stomach on food ingestion Urinary pain on bladder distension Irritable bowel syndrome pain with intestinal transit

8 Features of visceral pain Viscero-visceral hyperalgesia Enhancement of painful symptoms, both direct and referred Due to at least partially overlapping sensory projections or convergence Heart & gallbladder T5 Uterus & colon T10-11 Uterus & urinary tract T10-L1 Ischaemic heart disease & gallbladder calculosis More angina attacks and referred muscle hyperalgesia in precodial area More typical biliary pain and referred muscle hyperalgesia in RUQ Coronary artery revascularisation improves biliary symptoms Cholecystectomy improves typical angina pain Occurs even if one disease latent eg asymptomatic endometriosis found at laparoscopy in urinary pain

9 Visceral pain extent of the problem

10 Visceral pain extent of the problem Community studies 25% intermittent non-specific abdominal pain F>M, 1 in 5 consult Dr, natural history unknown 6 th and 10 th commonest reason for hospital admission 100 million/year 20% of people have chest pain 24% of females have pelvic pain

11 Abdominal pain syndromes Irritable Bowel Syndrome Recurrent abdominal pain associated with defaecation 25-50% referrals to gastroenterologists Chronic functional abdominal pain syndrome 6 months of pain poorly related to gut function and associated with loss of daily activities Any organ problem can lead to chronic pain! Especially pancreas and kidney

12 Non-cardiac chest pain Treated as cardiac in origin until proven otherwise 10-20% on CCU have oesophageal disease 1 in 25 people consult their General Practitioner with chest pain every year Musculoskeletal chest pain 20.4% Reflux oesophagitis 13.4% Costochondritis 13.1% Stable angina pectoris was the primary diagnosis 10.3% Unstable angina or possible myocardial infarction 1.5%

13 Introduction to chronic urogenital pain Historical terms suggest inflammation, infection, psychiatric illness There can be considerable overlap between pelvic pain conditions Most have a disturbance of urinary, bowel and sexual function Difficult area with lack of evidence base

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15 European Association of Urology 2008 Chronic pelvic pain syndromes Urological Bladder pain syndrome Urethral Prostate Scrotal Testicular Epidydimal Post-vasectomy Penile Gynaecological Endometriosis associated pain syndrome Vaginal Vulvar (vulvodynia) Generalised vulvar Localised vulvar Vestibular Clitoral

16 European Association of Urology 2008 Chronic pelvic pain syndromes Anorectal Neurological eg pudendal pain syndrome Muscular pelvic floor muscle pain syndrome

17 Chronic pain mechanisms in the pelvis Visceral nociceptors usually non-specific eg bladder fullness Silent afferents can become sentisitised after a trigger Triggers Infection Endometriosis Surgery IBS Dysmenorrhoea Muscle tension

18 Chronic pain mechanisms in the pelvis Genetics association with TMJ dysfunction, fibromyalgia, other pains Pelvic organs afferent neurones converge with neurones from skin and muscles of the back, buttocks, abdomen, thighs, perineum other organs Cross talk!! referred pain, secondary muscle and viscero-visceral hyperalgesia disturbance of other pelvic viscera

19 Initial assessment - History Time, environment and support History of pain, gynaecological, urological, sexual Pelvic function Urinary and bladder Bowel Sexual Relation to activity Thoughts around cause of pain, how affects life, expectations PMH, DH, SH

20 Associated symptoms URINARY Frequency Nocturia Hesitance Poor flow Pis en deux Urge Urgency Incontinence GYNAECOLOGICAL Menstrual ANORECTAL Incontinence Constipation SEXUAL Dyspareunia- deep, superficial Erection & ejaculation Orgasm Infections Negative experiences Sexuality MUSCULAR Pain Dysfunction CUTANEOUS Allodynia

21 Examination Spine, hip, abdomen, Tendons and entheses especially conjoint, inguinal ligament, adductors, piriformis External genitalia PV/PR? Pain at introitus Muscular trigger points in the anal sphincter, levator ani, puborectalis, obturator internus and piriformis Reproduction of the pain on palpation around the ischial spine (PN)

22 Investigation and referral Usually all investigations done Cystoscopy, urodynamics, ultrasound, swabs, cultures MRI lumbar spine, pelvis Referral to gynaecologist, urogynaecologist, urologist or gastroenterologist to exclude serious disease and treatment of modifiable disease

23 Management of chronic pelvic pain Clinical practice model Neuropathic pain Central sensitisation Variable degree of spreading through the pelvis Pelvic floor muscle hyperalgesia and/or spasm Fear avoidance and secondary disuse Anxiety, catastrophising, hypervigilence Effects on work, relationships, fertility, family Psychiatric effects eg depression

24 Neuropathic / central sensitisation pain medication Amitryptiline/Nortryptiline Especially if muscle pain or bladder symptoms Gabapentin/Pregabalin Opioids Oxycodone More evidence in visceral pain Buprenorphine, Morphine, Fentanyl etc Evidence for low dose opioid in combination with other medication Constipation tends to worsen all pelvic pains IV lidocaine, ketamine infusions

25 Pudendal neuralgia (PN) Incidence : Female 3: Male 2 Clinical history is suggestive Neuropathic pain in perineum from anus to the clitoris usually arises insidiously, often after prolonged sitting or cycling sometimes period of paraesthesia a third recall a precise event eg surgery or a fall Common symptoms sitting on of a mass or hairbrush intolerance to light touch, underwear intolerance to sitting, unless on the toilet seat relief usually from lying down Can be secondary to pelvic floor muscle dysfunction

26 Pudendal neuralgia

27 Invasive treatments for pudendal neuralgia Pudendal nerve blocks Small group who gain long term benefit Gluteal approach with peripheral nerve stimulator & contrast to locate the pudendal nerve near the ischial spine under X-ray or in Alcock s canal with CT Pulsed radiofrequency lesioning Pudendal nerve S3 nerve root Surgery for entrapped nerve

28 Don t underestimate the muscles! Pelvic floor muscles can be Non-contracting or non-relaxing or both Normal, overactive, underactive or non-functioning Overactive pelvic floor muscles Pain in the pelvis/perineum, dyspareunia, low flow rates, constipation Tends to develop over a protracted period Variety of causes eg limited access to toilet, holding tension

29 Effects of muscle dysfunction A muscle that is continuously contracting will ache Compression of nerves and vessels that pass through the pelvic floor A contracting pelvic floor will increase afferent input to spinal cord In response the CNS may modify efferent signals to the pelvis Electromyography (EMG) assessment Tense baseline (suggesting spasm) and rapid fatigue in response to exercise Biofeedback probe

30 Myofascial assessment and treatments Role of physiotherapy Restoring normal rest and function by learning to locate and relax Stretching Pelvic floor muscle exercises alone can worsen pain Pacing and goal setting to challenge over and under activity cycles Injections Myofascial trigger point release and paradoxical relaxation (Stanford) Injections of local anaesthesic into trigger points or painful muscles May be a role for botulinum toxin

31 Muscles

32 Cognitive behavioural therapy and other psychological treatments Graded exposure to specific fears such as of sitting or sexual activity Taught to modify any catastrophic thoughts Helping the patient refocus attention on somatic sensations and erotic cues for sexual activity Coaching in communication with partners about sexual issues and rehearsing ways to raise concerns can be very important Distraction and relaxation No evidence that pelvic pain in the absence of demonstrable pathology stems from negative childhood sexual experiences

33 Sacral nerve stimulation (or neuromodulation) Approved by NICE for urge incontinence, urgency-frequency and faecal incontinence Role in pain management has yet to be fully appraised MDT assessment

34 Mr P: Chronic prostatitis = chronic prostate pain syndrome 45 year old man referred by urologist Symptoms of acute prostatitis 2 years previously pain at base of penis, radiating to testicles, burning on micturition, fever, discharge, pain on ejaculation Settled with antibiotics, but pain recurred No evidence of infection on samples from prostate massage, antibiotics and alpha blockers not helping Fearful and avoiding any sexual activity Not communicating about sex life and concerned about relationship Tender prostate and pelvic floor muscles

35 Mr P: Chronic prostate pain syndrome - treatment Explanation of chronic pain mechanisms Neuropathic pain medication Trial prior to sexual activity Gabapentin mg, Tramadol mg Psychological therapy to address communication with partner about sexual issues and rehearsing ways to raise concerns

36 Miss V: Vulvodynia = generalised vulvar pain syndrome 28 year old full time teacher In a supportive 10 year relationship Pain at first tampon use, excruciating pain at first intercourse Constant burning, stinging, like thrush All treatments useless Seen by dermatologist, gynaecologist, psychologist Only help from vulval pain society Unable to have penetrative intercourse Fearful and avoiding any sexual activity Not communicating about sex life Concerned about relationship Both partners wanted to have baby Depressed

37 Miss V: Chronic vulvar pain syndrome - treatment Explanation of chronic pain mechanisms Neuropathic pain medication Desensitisation using self stimulation and dilators with support from physiotherapist and clinical nurse specialist Psychological therapy to address communication and sexual relationship Referral to fertility specialist Encouragement to continue with support group

38 Mr T: Chronic testicular pain syndrome 36 year old man Pain in testicles left>right Low back pain Investigated by urologist Ultrasound showed varicolele, operation made no difference Offered denervation Pain exacerbated by movement Unable to exercise, wear loose boxer shorts, sex difficult Trigger points in entheses, v tender pelvic floor, and adductor muscles

39 Mr T: Chronic testicular pain syndrome - treatment MRI lumbar spine - normal Trial neuropathic agents, ilioinginal and trigger point injections EMG to localise pelvic floor muscles Physiotherapy to stretch, pace and desensitise Psychological therapy Graded exposure to specific fears around exercise and sexual activity Help to refocus attention on somatic sensations and erotic cues for sexual activity Pain management program

40 Mr PN: Pudendal pain syndrome 29 year old van driver Anxious Can t sit, work threatened Undisclosed concern he has cancer Not told anyone about pain, avoiding entering into relationship History suggestive of PN Tender obturator internus muscles and around ischial spine

41 Mr PN: Pudendal pain syndrome - treatment Explanation and reassurance Pudendal protocol Pudendal nerve blocks 2 x X-ray 2 x CT nerve blocks or obturator internus injections Psychological therapy for anxiety and modification of catastrophic thoughts, distraction and relaxation

42 Mrs B: interstitial cystitis = bladder pain syndrome 50 year old woman Years of bladder pain, urge, frequency, very debilitated Had full range of intravesical treatments Tried most pain medications Optimised medication in conjunction with urology consultant Trial of sacral nerve stimulation Includes physiotherapy, nurse and psychology assessments

43 Resources Association of Urology guidelines on Chronic Pelvic Pain 2008: International Association for Study of Pain: Real pain, real women 18 fact sheets in 9 languages Patient support groups Headache in the Pelvis by David Wise Visceral pain by Maria Giamberardino Urogenital Pain Management Team, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG natasha.curran@uclh.nhs.uk

44 Shameless advert Monday 8 th March Chronic Pelvic Pain workshop (with particular reference to the musculature) Full MDT Queen Square, London 50 quid only! me natasha.curran@uclh.nhs.uk

45 Questions?