Priscilla Abercrombie, RN, NP, PhD, AHN-BC HS Clinical Professor Obstetrics, Gynecology & Reproductive Sciences UCSF Community Health Systems UCSF Chronic Pelvic Pain Clinic UCSF Osher Center for Integrative Medicine SFGH Women s Health Center Founder, Women s Health & Healing 1
Define chronic pelvic pain (CPP) and identify the most common causes of CPP. Identify myofascial sources of pain that are rarely recognized and treated in patients with CPP. Explore the many different treatment modalities that are available for patients with CPP. Provide a systematic approach for the successful assessment and management of CPP. 2
I have no affiliation with any pharmaceutical companies, etc. I will discuss off-label use of drugs. 3
Continuous or episodic pain in the lower abdomen or pelvis lasting >=6 months and associated with a negative impact on qualityof-life (Williams, et al., 2004) Definitions vary greatly throughout the clinical and research literature. 5
Prevalence 12-39% Medical Care 20% of all referrals to gynecologists >40% of all laparoscopies 12% of all hysterectomies Costs to Society $882 million in outpatient visits alone 15% time lost from work 45% reduced productivity Total costs estimated at > $2 billion / yr Howard FM. Obstetrical and Gynecological Survey 1993;48:357-87. Mathias SD, Kuppermann M, et al. Obstetrics & Gynecology 1996;87:321-7. 6
Rarely caused by a single condition Usually multifactorial (Howard, 2003) Involves both physiological and psychological conditions Can be classified as cyclic or noncyclic Seldom fits into those categories clinically 7
39 yo with crampy lower abdominal pain x 3 years Daily pain 3/10, worsens to 8/10 twice a week Limits activities (including sex), enjoyment of life Worse with her period Pain with intercourse Has constipation with bloating Urinary frequency 8
No standard diagnostic criteria No standard method of evaluating patients 9
ACOG Society of obstetricians and gynecologists of Canada European Association of Urology Review articles: Howard Learman 10
Listen to her story about living with CPP Discuss concerns, fears and insights Reflect back what you have heard Build trust and rapport Distrust health care providers Endured multiple diagnostic tests No cause for pain found Have not been heard/believed Must be psychological 11
Pain history: quality, location, timing with cycle, contributing or relieving factors, body map Medical/surgical history including Rxs Ob/Gyn: menstrual history GI symptoms/pain Urinary symptoms, IC screening Quality of life Health habits: ETOH, substance abuse Review records See International Pelvic Pain Society Website for history and PE forms: English, Spanish, French 12
Assess impact on functioning and quality of life What things would you like to be able to do that you can t do because of the pain? How are things at home? At work? Elicit patient s view of illness, fears and concerns Do you have any thoughts or concerns about what might be causing the pain? Screen for current or prior physical or sexual violence, including events in childhood Screen for depression 13
Test Urinalysis and culture Wet mount, STI screening ALT and creatinine TSH, CBC, FBS, Vitamin D OH 25 Pelvic sonogram CT and MRI Laproscopy Cystoscopy FOBT x 3 or referral for colonoscopy Rationale Bladder symptoms suggestive of UTI Signs or risk factors for genital tract infection Taking multiple medications or concern for liver or kidney disease Depressive or constitutional symptoms Bimanual exam limited or abnormal Other diagnostic studies are abnormal or inadequate Persistent symptoms, infertility, large ovarian cysts, treatment of endometriosis or adhesions Concern for IC or other bladder abnormalities GI symptoms or concern for colon cancer 14
Identify underlying pathology Reproduce pain 15
Observe gait, posture, balance Examine hip flexibility and symmetry Test for weakness, tenderness or sensory disturbances in the back, buttocks, legs, and pelvis Palpate the abdomen for masses, muscle tension, tenderness and trigger points Don t confine your exam to the gyn table 16
Differentiates pain originating from the abdominal wall versus peritoneal cavity (Suleiman et al., 2001) The patient raises her head and shoulders from the examination table while the provider palpates the tender area on the abdomen. Positive Carnett s sign: pain remains unchanged or increases when the abdominal muscles are tensed. 17
Trigger points are hyperirritable palpable nodules that are taut bands of muscle fibers (Tough et al., 2007) When palpated the pain usually radiates to another location Found in abdominal wall and pelvic floor locations Major contributor to CPP See also: Lavelle, E., Lavelle, W., & Smith, H. (2007). Myofascial trigger points. Anesthesiology Clinics, 25, 841-51. 18
19
External genitalia: vulvar / vestibular lesions and tenderness (Q tip test) Urethra and bladder: mass or tenderness, prolapse Vagina, cervix: inspection (lesion, trauma, infection, prolapse) 12-point unimanual exam Wet mount/sti screening if clinical suspicion Uterus, adnexae bimanual Size, shape, consistency, mobility, mass, tenderness Rectal or rectovaginal Lesion, rectocele, uterine retroflexion, uterosacral nodules 20
From National Vulvodynia Association CME Course 2010 21
Purpose: identify and map changes in sensation including allodynia Gently touch with a q-tip Start at the thigh and work down to perineum bilaterally Include clitoris and perianal areas Proceed from labia majora to labia minora then the vestibule Record findings 22
Chronic Vulvar Pain PE No visible findings Erythema Hyperalgesia Allodynia R/O Infectious, inflammatory, neoplastic and neurologic cause Vulvodynia Generalized pain Burning, stabbing, stinging, etc. Vestibulodynia Pain at vestibule only Provoked Burning Treat accordingly Incidence: 3-5% of reproductive age women 23
25
Palpate in 4 quadrants x 3 depths NO abdominal palpation Just beyond hymen 12:00 urethra, 6:00 rectum 3:00/9:00 obturator internus Mid-vagina 12:00 bladder base, 6:00 rectum 3:00/9:00 puborectalis Just before cervix 12:00 bladder, 6:00 rectum/cul-de-sac 3:00/9:00 pubo/iliococcygeus 26
Improve functional status Improve quality of life Decrease pain 27
Gynecologic Gastrointestinal Urinary tract Musculoskeletal Psychological 28
Endometriosis Adenomyosis Adhesions entrap ovaries, tether pelvic organs Vulvodynia, vulvar vestibulitis Prolapse of the uterus Ovarian dystrophy: ischemia Ovarian vein congestion: edema Pain during ovulation ( mittelschmerz ) 29
Irritable bowel syndrome Inflammatory bowel disease, diverticular disease Hernias Cancer (rarely) Urinary Tract Conditions Interstitial cystitis: painful bladder syndrome Infection: usually acute symptoms Kidney stones: usually acute symptoms Cancer (rarely) 30
Low back, abdominal wall, and pelvic floor muscle dysfunction 38
Inciting Pain Event: uterus, ovary, bowel, bladder, muscles, nerves Local Muscle Tension Secondary Muscle Adaptations : Lower back, buttocks, hips, pelvic floor Initial Event Resolves (naturally or with treatment) 39
Hypertonus and tenderness are common Refer patients to physical therapists specializing in pelvic floor muscle work (advanced training) Myofascial release Biofeedback Abdominal breathing, rescue poses, stretching exercises Home exercise program 40
Ultrasound energy, manual therapy Local anesthetic injection: 93% success by 5 th injection Lidocaine 1% x 10-15cc, bupivicaine 0.25% - 0.5% x 10-15cc 41
Address anxiety, depression, and sexual dysfunction 42
Patient A Depressed Patient B Not Depressed 43
Pain has impact on quality of life and functional capacity Women become isolated and have difficulty communicating needs Relationships become strained Pre-existing psych issues such as PTSD exacerbated by pain Anxiety and depression common 44
(Main, et al., BMJ, 2002) 45
Identify and treat psychological morbidity Assist in the development of: Positive coping techniques Communication strategies Problem solving skills Set realistic treatment goals Acknowledge and support woman Provide medication management 46
Dyspareunia is common Can lead to sexual dysfunction and strained sexual relationships 68% of women with CPP have sexual dysfunction Hypoactive desire 54% Arousal disorder 33% Orgasmic disorder 22% Sexual pain 74% 47
Learn about your body Explore your pleasure spots Educate your partner Connect with your partner in sexual and non-sexual ways Prepare for sex: relax the PF muscles, use lubricants, take time for arousal Reinvent your sex life Avoid painful activities 48
Definition: an amplification of neural signaling within the central nervous system that elicits pain hypersensitivity (Woolf, 2011). Body continues to experience pain despite healing from a precipitating injury Pain in the setting of no known pathology 49
CNS perpetuates pain by demonstrating exaggerated or prolonged responses to painful stimuli this is referred to as windup Reduced capacity for inhibition Occurs in many CPP disorders such as vulvodynia (Zhan, Z., 2011), dysmenorrhea (Bajaj, P., 2002), and endometriosis (He, W., 2010) 50
51
52
Analgesics: Opioids NSAIDS Topical anesthetics* Antidepressants Tricyclics* SSRI s/snri s* Anticonvulsants Muscle relaxants Nerve blocks Neurologics: pregabalin Neurotoxin: OnabotulinumtoxinA* *Off label use 53
Referral to pain management specialist: nerve blocks, medication consult Mind/body interventions: breathing exercises, imagery, MBSR, laughter yoga, etc. Movement therapies: yoga, Tai Chi, Feldenkrais, etc. Anti-inflammatory diet/herbs Support health: multivitamins, B complex, fish oil, calcium/magnesium, herbal tonics Alternative providers: TCM, craniosacral, chiropractic, energy medicine, strain/counter strain, etc. 54
Some Improvement Celebrate, adjust meds, encourage adherence, focus on activity limitation endpoints No Improvement Optimize treatment of depression if present Facilitate pelvic floor PT if not yet done Consider empiric treatments vs. invasive diagnostic studies (e.g., GnRHa vs. laparoscopy for presumed endometriosis) Continues without Improvement Begin work-up anew Consider hysterectomy only if conditions are met 55
Set realistic goals with your patient: improved function vs. complete remission Have a systematic approach to assessment Be wary of the assumption pain is linked to pathology or obvious tissue damage Use medication contracts Work as an interdisciplinary team- Build a community Have lots of tools in your tool kit Keep learning about innovative strategies 56
57
International Pelvic Pain Society: www.pelvicpain.org National Vulvodynia Association: www.nva.org Endometriosis treatment guidelines: http://guidelines.endometriosis.org/ Interstitial Cystitis Association: www.icahelp.com Irritable Bowel Syndrome: http://digestive.niddk.nih.gov/ddiseases/pubs/ibs_ez/inde x.htm American Physical Therapy Association: http://www.apta.org//am/template.cfm?section=home UCSF Chronic Pelvic Pain Clinic: https://www.obgyn.medschool.ucsf.edu/gynecology/ccss/ pelvic_pain/index.aspx 58