Chronic pelvic pain-when surgery fails

Transcription

1 Chronic pelvic pain-when surgery fails Sherif Tawfeek FRANZCOG, FRCOG, FICS, MSc, Dip-Endoscopy Consultant in Obstetrics and Gynaecology Senior lecturer at University of Otago

2 Objectives Identify the common causes of chronic persistent pelvic pain that Gynaecology surgery failed to relief Identify the relationship (Cross-talk) between the common causes of CPP Evaluate Bladder Pain Syndrome (BPS)

3 Clinical Scenario GP Referral Dear Doctor I will be grateful if you could see Mrs KS who presented with 2ys history of pelvic pain who underwent Laparoscopy for moderate endometriosis which is completely resected. Her symptom was initially resolved for 4 months following her surgery. Mrs KS came back to see me today as her pain have gradually recurred.?recurrence of endometriosis for repeat laparoscopy. Yours sincerely

4 Clinical Scenario Mrs KS was reviewed at Gyn clinic and opted for repeat laparoscopy which was performed. On repeat laparoscopy, mild endometriosis was found which is completely resected. 3 months later, came back to see you as she continue to have the same pain. Why did she not improve?

5 What is wrong? 1. Was it wrong diagnosis? 2. Was an incomplete surgery? 3. Is there persistent / deep Endometriosis? 4. Is the patient malingering? 5. Other reasons?

6 Why CPP is a challenge 82% are multifactorial* Varieties of disorders/syndromes can cause pain The real challenge: 1. Consider the likely cause(s) 2. How significantly does each cause contribute to this pain 3. Offer the appropriate management *Howard et al 2011

7 Evil Quintuplet 1. Endometriosis 2. Bladder pain Syndrome / IC 3. Inflammatory bowel diseases 4. Pelvic floor muscle dysfunction 5. Pelvic neuritis Psychological Iatrogenic e.g. post mesh repair

8 Only 18% of patients of CPP have endometriosis as the only reason for pain Howard et all 2011

9 Chung et al 2005 Endo Issa et al 2012 BPS PFMD 21% PN 25% IBD 23% 55% Koziol et al % OF PATINENTS HAVE MORE REASON FOR PAIN Howard et al 2011

10 Cross-talk Viscer-Somatic Viscero-Visceral Butrick et al 2003

11 Central sensitization 1. Stimulus which is not painful became painful 2. Painful stimulus became more painful.

12 Bladder Pain Syndrome/ Interstitial Cystitis The American Urological Association (AUA) defines IC/BPS as an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection of other identifiable causes.

13 Painful bladder syndrome/ interstitial cystitis 3-6% of women have symptoms consistent with PBS 81% of patients with CPP have bladder involvement 5 times more likely to occur in women Women with BPS/IC had a statistically higher prevalence of hysterectomies 42%. 79% of women with persistent CPP after hysterectomy have bladder pain syndrome Casellanos et all 2012

14 Non specific symptoms Suprapubic pain usually in the morning Urinary urgency Frequency mainly nocturia Double voiding Pressure feeling with full bladder Pain relieved by voiding Certain food aggravating symptoms

15 BPS vs Overactive bladder BPS/IC OAB Frequency Voiding to avoid pain Voiding to avoid incontinence Urgency Continuous Intermittent

16 Progression of symptoms

17 How good we are in diagnosis of BPS Parsons et al: 244 women with CPP 84% had urological symptoms ONLY 2% received initial diagnosis of BPS 88% of these eventually had BPS

18 Parsons et al Useful links

19 Pelvic examination Anterior vaginal wall tenderness in 85% Increase pelvic floor muscles tone Occasional cervical / vaginal cuff tenderness Vulvodynia

20 Summary Chronic pelvic pain: Is usually multifactorial Needs comprehensive multidisciplinary input Cross-talk cause chronic neurogenic inflammation with central sensitization Painful bladder syndrome can be easily missed-objective assessment is helpful