Prof. Salma Rouf Prof. ObGyn, DMCH Joint Secretary, OGSB

Prof. Salma Rouf Prof. ObGyn, DMCH Joint Secretary, OGSB

To facilitate and improve the understanding of chronic pelvic pain To provide evidence based guidelines for management

Pain is by definition, a sensory and emotional experience associated with actual or potential tissue damage Experience of pain will inevitably be affected by Physical, Psychological and Social factors Intensity of pain is often not proportional to tissue damage and affected by multiple factors

Chronic Pelvic Pain (CPP) can be defined as intermittent or constant pain in the lower abdomen or pelvis of at least 6 months in duration not occurring exclusively with menstruation or sexual exposure & not associated with pregnancy RCOG Green top Guideline, No. 41, May 2012 It is a symptom not a diagnosis Though not a life threatening condition, it has significant impact on quality of life and functional capability

Chronic Pelvic Pain syndrome usually encompasses following characteristics: Duration 6 months or longer arbitrary cut off points lack empiric validation because of delay in seeking help & referral Incomplete relief with most treatments Significantly impaired functional capability Associated with signs of depression insomnia, weight loss or anorexia Altered family relationship or role Int. Association for the study of pain, 1986

Pelvic pain can be characterized by acute, chronic or recurrent occurrence Acute pain usually lasts for less than 3 months reflects fresh tissue damage resolves as the tissue heals Chronic pain usually lasts longer than 3 months persists long after the original tissue damage exists in absence of any injury due to changes in afferent & efferent nerves path way of CNS & peripheral nervous system

Difficult to diagnose Difficult to treat Difficult to cure Frustration for patients and physicians

Pain! Pain! Pain! Every time is Pain But no Way to Cure it Ultimately woman is left with a feeling that Nothing can be done more than that

CPP is the most common & difficult problems encountered by health care providers which accounts for 1 in 10 outpatient Gynaecology visit 15% to 40% (Av 20%) of all laparoscopies 12% to 16% of all hysterectomies $3 Billions medical costs annually SOGC Clinical Practical Guideline, Cherrel Triplett MD.

CPP accounts for 16% reported problems with pelvic pain 11% limited their home activity 12% limited sexual activity 4% missed one day work per month Held P et Al, New York Springer Verlag 1990

Population at increased risk: Demographic profile of large surveys suggest that women with CPP are no different in terms of age, race, ethnicity, education, socioeconomic status or employment status Higher incidence in single, separated or divorced women Higher prevalence in reproductive age 40-50% women have history of physical & sexual abuse decrease the pain threshold

Gastrointestinal Psychological Urological Gynecological Musculoskeletal

Pelvic pain is associated with a wide range of conditions involving reproductive, gastrointestinal, genitourinary, muskuloskeletal or psychological systems 25-50% of women have more than one diagnosis Severity and consistency of pain increased with multi system symptoms

OAB Pelvic Tuberculosis Chronic Ectopic Post- Hysterectomy Pain Pelvic Congestion Syndrome SOGC Clinical Practice Guideline

Chronic Pelvic Pain carries a heavy economic and social burden with chronic morbidity Aim of management should focus on accurate diagnosis & effective treatment to Reduce disruption of women s life Avoid endless investigations and referrals Remove the women s Perception that it is not curable

Obtain a complete and detailed history is the most important key to formulating a diagnosis Useful model - Steege s Integrated Model Biological events initiating pain Alteration of life style & relationship over time Anxiety and affective disorders Circular interaction among these elements vicious cycle Initial interview convey interest, listen with attention, validate patients experience Avoid Cartecian Model No visible pathological condition Problem must be psychological Steege JF 1998

Diagnosis: Obtaining the History Duration of Pain Nature of the Pain Sharp, stabbing, throbbing, aching, dull Specific Location of Pain Associated with radiation to other areas Modifying Factors Things that make worse or better Timing of the Pain Intermittent or constant Temporal relationship with menses Temporal relationship with intercourse Predictable or spontaneous onset Detailed medical and surgical history Specifically abdominal, pelvic, back surgery

Diagnosis: Obtaining the History Use the REVIEW OF SYSTEMS to obtain focused, detailed history of organ systems involved in the differential diagnosis

Diagnosis: Obtaining the History Gynecological Review of Systems Associated with menses Association with sexual activity New sexual partner and/or practices Symptoms of vaginal dryness or atrophy Other changes with menses Use of contraception Detailed childbirth history History of pelvic infections History of gynecological surgeries or other problems

Diagnosis: Obtaining the History Gastrointestinal Review of Systems Regularity of bowel movements Diarrhea/ constipation/ flatus Relief with defecation History of hemorrhoids/ fissures/ polyps Blood in stools, melena, mucous Nausea, emesis or change in appetite Abdominal bloating Weight loss

Diagnosis: Obtaining the History Urological Review of Systems Pain with urination, bladder filling & relieved after voiding History of frequent or recurrent urinary tract infection Hematuria Symptoms of urgency or urinary incontinence Difficulty voiding History of nephrolithiasis

Diagnosis: Obtaining the History Musculoskeletal Review of Systems History of trauma Association with back pain Other chronic pain problems Association with position or activity

Diagnosis: Obtaining the History Psychological Review of Systems History of verbal, physical or sexual abuse Diagnosis of psychiatric disease Onset associated with life stressors Exacerbation associated with life stressors Familial or spousal support

Very different from a routine Gynaecological Exam May need to defer for second visit to allow her to recover from distressing history Best to exam her when she is in pain Elicit feedback from patient using a numeric scale & should always give feedback Bimanual exam should be done last - most threatening, most painful, least discriminatory part of exam

Diagnosis: The Physical Exam Evaluate each area individually Abdomen Anterior abdominal wall Pelvic Floor Muscles Vulva Vagina Urethra Cervix Viscera uterus, adnexa, bladder Rectum Rectovaginal septum Coccyx Lower Back/Spine Posture and gait Back - Scoleosis, sacroiliac tenderness, trigger points, pelvic asymmetry Abdomen Hypersensitivity around scars Trigger points Head raising test Decreased pain intraperitoneal, Increased - abdominal wall source Vulva - Exam vulvar vestibules

Single digit vaginal exam & then do bimanual exam- Introduce one finger and ask the patient to contract and relax pelvic floor- asses tone & vaginismus Palpate vaginal side wall - hypersensitivity Palpate levator anii Palpate urethra and bladder base Touch the cervix and uterosacral ligamets Cervical motion test Look for uterine mobility & tenderness Palpate vault - post hysterectomy patient

CPP has negative impact on woman s capacity to function in family, sexual, social, & occupational role Domains covered in psychological assessment I. Pain generators II. Impact on functional role III. Pain coping style Ignoring/inactive/Hospital attendance/medication IV. Pain Modulators Stress, work V. Women s Perception

Function 0 No pain; normal function 1 Some pain; with function 2 Moderate pain; with function 3 Severe pain; with function 4 Cannot function because of pain Bladder Bowel Intercourse Walking Running Lifting Working Sleeping Department of Obstetrics and Gynaecology, Foothills Provincial General Hospital, University of Calgary, Calgary AB, 1994

Differential diagnosis for CPP - extensive Challenges for the Gynaecologists to think out side the uterus Diagnosis, evaluation & treatment should align with positive & negative findings Often requires multidisciplinary approach

Complete blood count with ESR Urine analysis Endocervical swabs Screened for STIS Positive endocervical swab supports PID but does not prove Negative swab does not rule out PID CA125 - women reporting any of the following symptoms -- bloating, early satiety, pelvic pain, uneasiness or IBS symptoms should have a serum CA125

TVS Useful for evaluating pelvic masses/adnexal mass Differentiate cystic or solid massas Chochlate cyst,hydrosulpinx & fibroids Endometriosis & adenomyosis Vascularity with colour doppler Little Value to identify other causes of pelvic pain & peritoneal endometriosis May play a role to identify women who needs diagnostic laparoscopy MRI Diagnosis of deep seated endometriosis, adenomyosis sensitivity & specificity 69% & 75% Fail to detect small endometriotic deposits

Regarded in the past as gold standard in the diagnosis of chronic pelvic pain Should be better seen as second line investigation if therapeutic intervention fail Diagnostic laparoscopy may have a role in developing women s belief about pain Should be offered with an aim to have both diagnostic & therapeutic contribution

Diagnostic laparoscopy - 40% done for CPP 40% reveal no abnormality Out of 60% of revealing abnormality 85% shows endometriosis & adhesions Reliable for diagnosing peritoneal endometriosis although some form of endometriosis could be missed Negative results of laparoscopy does not exclude disease or organic causes Laparoscopy is not risk free & estimated death risk is 1 in 10000 & visceral injury 2-4/1000 Laparoscopy should only be indicated when index of suspicion of adhesion or endometriosis require surgical intervention is higher Only diagnostic laparoscopy will not improve the pain perception with positive & negative findings

Laparoscopic pain mapping or patient assisted laparoscopy (PAL) involving technique of doing Lap with conscious sedation & local anesthesia to identify source of pain by reproducing patient s symptoms with probing or traction on pelvic tissues Questions arise as to the acceptability, reproducibility & validity of the procedure PAL remains an experimental procedure

After entry through standardized examination Panaromic view of pelvis looked for with trendelenburg position Manipulate - bowel, appendix, look at liver, diaphragm, upper abdomen, mobilize pelvic structures Visualize all peritoneal surfaces, ovarian fossa, pouches both anterior or posterior Surgeons should be aware of varied visual appearances of endometriosis, atypical lesions, peritoneal scars & windows palpated with probe All suspicious lesions should be biopsied Keep video for feed back

Adequate time should be allowed for initial assessment of women with CPP Many women want an explanation of their pain The multi factorial nature of chronic pelvic pain should be discussed Integrated approach should be taken to address organic, psychological & environmental causes Daily pain diary may be helpful for identifying provoacting factors & temporal association Appropriate referral for non Gynaecological component of pain should be done gastroenterologist, urologist, genitourinary-medicine, physio-therapist, psychologist or psycho sexual counselor

Endometriosis Pelvic pain which varies markedly over the menstrual cycle is likely to be due to endometriosis Cardinal symptoms of diagnosis are dysmenorrhoea, dyspareunea & CPP Diagnosed in 45% of women undergoing laparoscopy for any indication 30% women undergoing laparoscopy for CPP How endometriosis causes CPP is poorly understood as 45% endometriosis is asymptomatic Severity of endometriosis does not correlate with severity of pain Pain may be due to inflammation, adhesion, imbalance of PG, release of local factors TNF & chemokines, etc. Endometriosis associated CPP may be managed by combination OCP, progestin alone, Danazol, GnRH agonist with or without NSAIDs Surgical treatment may include laparoscopic laser treatment, adhesionolysis, uterine nerve transection - LUNA, TAH with BSO

Laparoscopic Appearance of Endometriosis

Adenomyosis: Diagnosed by typical presentation of cyclical dysmenorrhoea, menorrhagia, enlarged boggy uterus, Not all women are symptomatic Medical treatment with Danazol or GnRH agonist or surgical treatment by adenomyomectomy or hysterectomy are the options

Retrograde flow through incompetent venous valves causing tortuous, congested pelvic & ovarian varicosities of unknown aetiology Symptoms pelvic pain & heaviness more pronounced premenstrually, after prolonged sitting or standing or sexual exposure No valid diagnostic test pelvic venography, Doppler USG, MRI may help Treatment therapeutic trial with ovarian suppression by progestin, OCP, GnRH agonist, ovarian vein embolization or hysterectomy

Endosalpingiosis Presence of ectopic fallopian tube like ciliated epithelium without stroma may be associated with CPP Plays only a minor role may be an incidental findings Pelvic peritoneal defects or pockets Is usually associated with endometriosis Caused by peritoneal irritation or invasion by endometriotic tissues Hystopathology shows Endometriosis 39% Chronic inflammation 20% Endosulpingiosis 12%

May cause pain due to organ distension or stretching Usually caused by surgery, endometriosis, inflammation, or infection On diagnostic laparoscopy adhesions are found in 25% to 50% of CPP but their role is controversial. Correlation between pelvic pain & adhesion remains uncertain Evidence concluded that laparoscopic adhesionolysis is not indicated for the treatment of pelvic pain with mild to moderate adhesion but may be benefited with severe adhesion

CPP is reported to occur in 18% to 33% of women with an episode of PID Exact aetiology not known but pelvic adhesion & cellulites may be the cause of pain Diagnosed by CDC diagnostic guideline (2006) Treated by multiple inpatient & out patient antibiotic therapy Pelvic TB may be a cause of CPP specially in young and unmarried woman Laparoscopy & guided biopsy may help in diagnosis

Unilateral or bilateral preservation of both ovaries following hysterectomy is burried in dense adhesion- Trapped Ovary Syndrome or ROS Small amount of ovarian tissue inadvertently left behind following oophorectomy & burried in adhesion - ORS Presented by either recurrent /cyclical pelvic pain or persistent pelvic mass after hysterectomy Diagnosed by pelvic tenderness, ill-defined tender mass on PV,TVS, premenstrual level of FSH & E2 Surgical removal of ovaries or remnant or GnRH analogue suppression may relief pain

CPP is 10-20% of preoperative indications of hysterectomy for relief of pain Average follow up of 2 years 74% reported complete resolution 22% reported persistent or increased pain 5% reported unchanged pain Possibilities are - higher in women <45, with no indentified pelvic disease, low socioeconomic condition, nulliparous with history of PID Unilateral or bilateral SO not found to play any role

Spasm or strain of pelvic floor muscles Symptoms CPP with pain in buttocks radiating to back of legs, Dyspareunea Treatment pelvic floor exercise, physiotherapy, anxiolytic drugs

Chronic Inflammatory condition of bladder with unknown & uncertain pathophysiology Possible causes infections, lymphatic or vascular obstruction, imunological deficiency, glycosamioglycan layer deficiency Pelvic pain with irritative voiding syndrome Frequency, urgency, nocturia, pain with bladder filling & relief with voiding 70% pelvic pain with dyspareunea, pelvic, uterine & bladder tenderness

Symptom base clinical diagnosis - more popular Urine analysis, urine culture to rule out infection & haematuria Cystoscopy glomerulation, submucosal haemorrhage Treatment Avoid acidic food & beverage Trycyclic anti-depressant Elmiron (Pentosan Polysulphate Sodium) Cystoscopic hydrodistention Intra vesical KCL sensitivity test Premenstrual flare of symptom treat with OCP

Chronic abdominal pelvic pain of relapsing pattern associated with bowel dysfunction, bloating, disturbed bowel habit in the form of diarrhoea, constipation or both Associated with 50-80% of patients with CPP with dyspareunea and bowel symptom, worsen during menses Rome III criteria: standard for clinical diagnosis Pain or discomfort relieved after defecation, Onset of pain or discomfort with change in stool frequency, Change in appearance of stool Continuous or recurrent abdominal pain or discomfort on at least 3 days a month in the last 3 months

CPP may arise from damage to muscles of abdominal or pelvic floor, joints in pelvis, etc Trigger point identification gaining interest Nerve entrapment in scar tissues or narrow foramen highly localized sharp stabbing pain Pain exacerbated by particular position

Women with cyclical pain should be offered a therapeutic trial of ovarian suppression by OCP, progestins, Danazol or GnRH analogue Women with IBS should be given a trial of antispasmodic, smooth muscle relaxant (Mebeverine HCl), bulking agents, avoidance of provocating dietary products NSAIDs with or without paracetamol particularly useful Adjuvant treatment with amitriptyline or gabapentin could be tried

Management of CPP requires patience, understanding, collaboration from both patient & physician As aetiology often remain unclear Diagnosis is often multi factorial involving physical as well as psychological & social factors Treatment options are also multi-dimentional with involvement of multidisciplinary Gynaecological & non-gynaecological approach

CPP is disappointing for the physicians to treat & frustrating for the patients to get cure Physician must be concerned not to dismiss organic cause as psychological Many often organic causes are masked by overwhelming psychosocial factors Women should not leave with a feeling that she has to live with pain

Thank you all