Pelvic Pain. Miss Tracy-Louise Appleyard Consultant O&G NBT

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1 Pelvic Pain Miss Tracy-Louise Appleyard Consultant O&G NBT 30 Jan 2018

2 No commercial conflicts of interest Working Group for CPP PHE Endometriosis Centre, NBT GP Lt Col RAMC, Commissioned 1992

3

4 Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage International Association for the Study of Pain

5 Pelvic Pain - definition abdominal pain occurring below the level of the umbilicus International Association for the Study of Pain Acute vs Chronic Men vs Women

6 Improve understanding of pelvic pain Options available in GP

7 Chronic Pelvic Pain in Women Miss Tracy-Louise Appleyard Consultant O&G NBT 26 Sept 2014

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9 Definition exasperate, defeat and overwhelm their doctors by their behaviour Patient clinicians feeling helpless in the face of those patients who seek salvation for psychological, social and spiritual problems at a biomedical level Doctor

10 If there was a condition that made 10% of mens testicles hurt, with pain during intercourse, there would be a river flowing out of my GP surgery doors from the volume of male tears being shed in the waiting room Martin Hirsch

11 RCOG definition Intermittent or constant pain Lower abdomen or pelvis of a woman 6 mths Not occurring exclusively with menstruation or intercourse and not associated with pregnancy Symptom not a diagnosis

12 Unfunded report from Pain Australia and the Faculty of Pain Medicine at the Australian and New Zealand College of Anaesthesia 2011

13 Prof Michael Cousins.. pelvic pain has suffered from particularly inappropriate stigmatism and neglect, with resulting disastrous effects on women and young girls Chairman of the IASP International Pain Summit Montreal 2010

14 Remarks Reluctance of women to seek medical care Patients often given uniformed explanations of pain Often feel dismissed Gynaecology may be slow to pick up on some of the advances in pain research New nerve growth in endo lesions Chemical stimulation of inflammatory processes Inadvertent nerve damage as a result of surgery

15 Prevalence CPP - 38/1000 women in primary care asthma 37/1000 chronic back pain 41/1000 May significantly impact on a woman s ability to function Grace V, Zondervan K. Health Care Women Int 2006;27: Zondervan et al Br J Obstet Gynaecol 1999;106:

16 Prevalence

17 Prevalence Dysmenorrhoea (106 studies) 17-81% prevalence Dyspareunia (54 studies) 8-22% prevalence Non cyclical pain (18 studies) 2% to 24% prevalence

18 Potential causes?

19 Potential causes Recognised pathologies Endometriosis/aden omyosis* Adhesions Ovarian remnant* Residual ovary* * Cyclical pattern No obvious pathology Pelvic congestion* Primary dysmenorrhoea* Midcycle pain* IBS Entrapped nerve syndrome Neuropathic pain Painful bladder syndrome

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21

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23 Guidelines?

24 RCOG 2012

25 History Story.

26

27

28 Advanced listening

29 Suspect endometriosis

30 Endometriosis S & S CPP Dysmenorrhoea Premenstrual pain Deep dyspareunia Dyschezia Cyclical bowel symptoms Dysuria Subfertility with 1 or more of above

31 NICE Sept 2017

32 NICE May 2014

33 ESHRE 2013

34 Management

35 ICE Becker & Maiman (1975) Ideas Woman Expectations Concerns

36

37

38

39 Recently

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41 Summarise Empathasise Empathasise Empathasise What is your expectation of today? Recognise, share and ask permission to explain

42 ICE Becker & Maiman (1975) Partnership Ideas Woman Management Expectations Concerns plan

43 Investigations?

44 Pain diary Offer abdo/pelvic exam

45 Diagnostic tests USS Ca125 MRI Diag lap

46 TVS Ovarian endometrioma?rectal endometriosis 3D not proven for RV disease

47 Ca125 NOT to be used to diagnose endometriosis Persistent or frequent (>12 x/mth): Bloating Early satiety PP Urinary urgency or frequency >50yrs, any new IBS symptoms*

48 Refer? GOPC Severe, PPP or recurrent symptoms of endometriosis Pelvic signs of endometriosis Initial Mx not effective, not tolerated or contraindicated Specialist endo centre Suspected or confirmed deep endo involving bladder, bowel, ureter <17yrs??

49 Diagnostic laparoscopy Gold standard?? 50% of laparoscopies negative Accuracy of visual diagnosis No longer using the scoring systems?2 nd line Can develop woman s belief about her pain

50 The new oscopy Micro-laparoscopy Conscious pain mapping Patient assisted laparoscopy (PAL) NOTES Not widely adopted?acceptability, validity, reproducibility

51 Endometriosis pain

52 Medical Mx Analgesia 3mths paracetamol+/- NSAIDs Neuropathic pain Amitriptyline, Duloxetine, Pregabalin, Gabapentin SSRI Hormonal treatment COCP, Prog, Mirena

53 NICE Nov 2013

54 Other Mx Dietary Mx Dyspepsia Physio Mindfulness CBT

55 Surgical Mx? Priorities for pain and fertility Laparoscopy Diag vs treatment?gnrha Excision > ablation Post-op medical Mx Hysterectomy + excision (TLH)

56 HRT post oophorectomy Continuous combined tibolone or Combined oest/prog Begin immediately post-op Consider combined if: residual endometriosis after radical surgery severe disease obese patients?prog chance of hyperplasia or malig transformation in residual disease

57 PR bleeding New bowel symps >50 yrs New pain postmenopause Pelvic mass Suicidal ideation ++ weight loss IMB/Irreg > 40yrs PCB

58 GP role Avoid multiple diagnostic tests Focus on rtn to normal daily activities/qol Evidence based balance harms and benefits of all approaches Filter Ongoing management Refer

59 Role of the specialist? Endometriosis centre Avoid multiple diagnostic tests Avoid fertility destroying surgeries Filter Specific role within the CPP team Focus on return to normal daily activities/qol Evidence based balance harms and benefits of all approaches Assist the GP

60 Info & Support Endometriosis UK IBS network Cystitis and Overactive Bladder Foundation Women s Health Pelvic Pain Support Network Department of Health Expert Patient Initiative RCOG

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