Chronic Pelvic Pain. Bridget Kamen, MD Obstetrics and Gynecology, Confluence Health. I have no disclosures

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1 Chronic Pelvic Pain Bridget Kamen, MD Obstetrics and Gynecology, Confluence Health I have no disclosures

2 Objectives A little epidemiology Understand there are both gynecologic and non-gynecologic causes of CPP Structural and functional Common gynecologic causes of CPP Important history pearls Appropriate diagnostic tests When is surgery indicated Treatment options

3 Epidemiology of CPP Non cyclic pain below umbilicus present for 6 months and severe enough to cause distress or dysfunction Estimated 4-16% of women experience chronic pelvic pain Endometriosis present in 70-85% Many will not get specific diagnosis Indication for up to 20% hysterectomies and 40% laparoscopies

4 Copyrights apply

5 Gynecologic etiologies Structural Functional Endometriosis Central somatization of pain Adenomyosis Persistent ovarian cysts Hydrosalpinx Fibroids PID Pelvic congestion syndrome Pelvic adhesive disease Ovarian remnant syndrome Post ablation tubal ligation syndrome

6 Diagnosis Starts with directed history IPPS Form Reproductive hx and plans Functional impairment Characterization of pain Cyclic or non-cyclic Localization points to anatomic cause Worsening with movement musculoskeletal Pain with intercourse Bowel sx Bladder sx Psychosocial history

7 Physical Exam Finding anatomy structure causing pain Abdomen Iliac crest asymmetry associated with CPP Carnett s sign-abd palpation with muscle both flexed and relaxed Single digit palpation searching for focal vs diffuse pain and trigger points Pelvic Pelvic floor palpation Bimanual exam Assessing size and tenderness both abdominally and vaginally Speculum exam Cervical swabs Posterior cul de sac nodularity

8 Targeted testing Labs UA and culture if indicated GC/CT cultures Pregnancy test is indicated by history Imaging Ultrasound History of abnormal bleeding, abnormal pelvic exam Fibroids, ovarian cysts, hydrosalpinx NOT endometriosis MRI May identify deeply infilitrating endometriosis accurately

9 Laparoscopy Diagnosis and treatment of endometriosis Medical management Laparoscopy Hysterectomy Treatment of pathology Persistent adnexal cysts Hydrosalpinx Ovarian remnant Adhesions? Fibroids

10 Diagnostic laparoscopy Who needs one? Confirmation of suspected endometriosis Evaluation and treatment of infertility

11 Endometriosis

12 Treatment Options Endometriosis Pt desiring to become pregnant Consider dx laparoscopy to ensure patent fallopian tubes, tx of endometrioma Early referral to fertility specialist Currently not desiring fertility NSAIDs frequently used OCP, oral progestin, DMPA, Mirena IUD GnRH agonist Definitive surgery Hysterectomy +/- ovaries

13 Other treatment options Hormonal therapies: non-specific chronic pelvic pain, pelvic congestion syndrome Nerve transection procedures: endometriosis resistant to alternate treatments, chronic pelvic pain Trigger point injection Ovarian sclerotherapy: pelvic congestion Adhesiolysis Anti-depressant tx Gabapentin, amitriptyline

14 What can you do? Psychosocial history and referral to appropriate behavioral health providers Appropriate referrals to GI, urology, gyn Appropriate imaging prior to referral Follow up

15 Conclusion Chronic pelvic pain is common condition affecting the wellbeing of women Endometriosis is common but not all chronic pelvic pain is endometriosis! History and physical exam can be key in determining underlying etiology Treatment includes surgical and medical etiologies

16 Citations As-Sanie, Sawsan. Causes of Chronic Pain in Non-Pregnant Women. UptoDate, Assessed Apr Tu, Frank and As-Sanie, Sawsan. Evaluation of chronic pain in women. UptoDate, assessed Apr Tu, Frank and As-Sanie, Sawsan. Treatment of chronic pelvic pain in women. Uptodate, accessed Apr Management of endometriosis. ACOG Practice Bulletin No American College of Obstetricians ad Gynecologists. Obstet Gynecol Jul;116(1): Koninckx, Philippe, and Anastasia Drssa. Images of Endometriosis: Different Diseases and Different Severities. Gynsurgery, Apr. 2018, gynsurgery.org. Daniilidis, A. et al. Diagnostic Laparoscopy, infertility and endometriosis- 5 years experience. Gynecological Surgery Sept;5(3):

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