Objectives Discuss the epidemiology Explore the neurobiology Introduce CPP as a systemic condition Run through the diagnostics Review therapies Chronic Pelvic Pain Dr. Jen Gunter MD, FRCS(C), FACOG, DABPM, ABPMR (Pain) Director Center for Pelvic Pain and Vulvovaginal Disorders Kaiser Northern California Nothing to declare Scope of the Problem Accounts for 10% of outpatient GYN visits v 15-40% laparoscopies 12% hysterectomies $1.2 billion/yr. on outpatient management Indirect costs in lost work $760 million/yr 1 Not having a strategy for evaluation and management is not an option 1. Steege JF, Siedhoff MT Chronic Pelvic Pain Obstet Gynecol 124, 3 How Many Women who Have a Hysterectomy for CPP have Endometriosis on Pathology? A. 95% B. 70% C. 35% D. 20% 9 5 % 0% 0% 0% 0% 7 0 % 3 5 % 2 0 % 4 10 1
What is chronic pelvic pain? Pain present for at least 2 weeks of the moth for 6 or more months that is located in the pelvis CPP is a diagnosis unto itself Which makes everyone feel like this Biomedical model of pain 2 Pain results from underlying nociceptive process Indicative of lesion or pathology Diagnosis leads to treatment of that lesion or pathology Treatment resolves the pain Implicit Pain experience is proportional to the extent of body injury/pathology In the absence of injury/pathology, no alternative way of explaining pain except maybe mental process NOS 2. C. de C Williams & Cella, 2012 65 Traditional Gyn Approach is Biomedical Endometriosis Adenomyosis Fibroids Adhesions Ovarian cysts Prolapse Pelvic congestion syndrome Severity endometriosis doesn t match disease, can be present in asymptomatic women, optimal outcome with surgery 70% 1,3 Same incidence CPP or no CPP Small fibroids don t cause pain Randomized trial shows no benefit, and how would pain develop years later when adhesions form quickly? 1 If ovarian cysts caused pain that would be awesome Prolapse doesn t cause pain 50% of gravidas has congested pelvic veins, no prospective studies 1 Pain is uncommon in Stage I and II ovarian cancer despite tumor invasion into ovarian stroma 3. Hsu AL et. al. Relating pelvic pain location to surgical findings of endometriosis 2
Peripheral Generator Organ Bowel Bladder Uterus Ovary Disease Endometriosis Somatic structure Muscle Nerve Blood vessels Inflammation Impingement Changes in blood flow Neuronal proliferation Spasm Tumor Neuroplasticity and Convergence Nocioception is born in the dorsal horn, but it s not pain until it reaches the brain Somatic nerves Autonomic nerves Enteric nerves Inflammation and pain induce changes in the CNS and PNS producing sensitization Peripheral nerves become more receptive to pain (wind up) How pain signal is processed in spinal cord changes Loss of descending inhibitory control Autonomic dysfunction Women with CPP have increased pain sensitivity in non pelvic sites Women with CPP have changes in brain morphology in regions known to affect pain processing 3
Pelvic Particularly Vulnerable Large number of somatic and visceral afferents converge Allows bodily functions to occur Allows pain and inflammation to spread from one organ system to another And then there is Expectations Catastrophizing Sleep Diet Depression Anxiety Poverty Disability Negative affect Catastrophizing Pacing Anger Distress intolerance Building Trust Let the Patient Tell Her Story High Affection Trust Caring Distrust Respect Low High Competence 4. Spence, J. Excellence by design: Leadership. Gainsville, FL: Adbiz Publishers, 2003. 4
Out of Control, Overwhelmed Cannot tolerate the excruciating sensationseeking Immediate Attention(Urgent Care/Emergency Room) Christine Evans, Ph.D., 2003 10/28/2016 Humanize and support 1. Normalize pain: 10% of women experience pelvic pain at some point in their lives 2. Normalize impact: It must be so hard to experience this, for you and for your [boyfriend/partner/husband/children] 3. Affirm path to relief: We will figure out what s causing the pain and get you feeling better. 4. Ask for partnership I would like to ask you some questions and examine you. When we are done today I ll need your help to follow my directions very closely at home, so that we can work towards you feeling better ASAP. Does this sound ok? History and Physical What does it feel like? Bloating Location Discrete or vague, widespread v local Cyclic Relation to bladder/bowel function Constipation Pain with sex Fatigue 17 16 FUNCTIONAL PAIN SCALE PAIN SENSATION The actual feeling of the pain you are experiencing (stabbing, throbbing, aching, burning, tightness) 0 - No Pain Somatosensory Cortex Where is the ovary? Pain Free 1234 - Functional The pain is present It does not get in the way No effect on my daily activities and my life 567 - Uncomfortable Hard to move, cannot concentrate Impacting my abilities Affects my daily activities and my life 89 - Severe Not able to leave my home Unable to do anything: I am in BedHigh Effect on my daily activities and my life 10 - Unbearable 5
Beware of Chart Lore Recurrent bladder infections Recurrent yeast infections Ultrasound results Laparoscopy results External Exam Q-tip test: Is pain local or diffuse? Apply light pressure around the clock between hymen and vestibule Document if pain is local and pain location If any lesion, take a picture It feels weird but it doesn t hurt - confirm weird feeling is normal Pelvic Exam I. Single finger: Do not attempt if vaginismus severity high Pressure should not cause pain and muscle should be soft Palpate vaginal mucosa lightly on: II. i. Side walls ii. iii. iv. Levator ani muscles Bladder Cul-de-sac v. Cervix Bimanual exam Vaginismus/Pelvic Floor Muscle Spasm Exam: 1 st degree: spasm is relieved by reassuring patient, coaching her to take deep breaths. 2 nd degree: spasm despite reassurance. Patient unable to relax for exam. 3 rd degree: elevation of buttocks to avoid being examined. 4 th degree: retreat on table, closing of thighs Patient s may say: It feels like he s hitting a wall He s too big for me Fear or anticipation of pain increases spasm 6
This is a Work Up NOT a Fishing Expedition Cyclic Pain Rule out cancer U/A for hematuria Pelvic ultrasound if bloating or > 40 years Colonoscopy if appropriate Pain work up U/A and culture Mycology culture Bladder diary Menstrual calendar Food diary CBC, TSH, diabetes screen PT evaluation Imaging as appropriate based on exam Mass Does not mean endometriosis many pain syndromes and inflammatory conditions are impacted by hormonal changes Migraines IBS Fibromyalgia Lupus, RA Cyclic pain, progression from dysmenorrhea, RV tender fixed uterus, cul de sac nodularity If You Operate Be prepared to remove all the endometriosis Whether excision is better than ablation is not known for superficial disease, it is better for diagnosis Continuous OCPs LNG IUS DMPA/ETNG Implant TENS Laparoscopy with biopsies and removal of endometriosis if identified Visual diagnosis of endometriosis not accurate 5 Recommend a Mirena IUS at the time of the surgery, especially if positive for endometriosis, as removes the pain of insertion Pre-sacral neurectromy/luna not indicated 27-32% placebo response with laparoscopy Best outcomes are with deeply infiltrating disease Do not keep operating over and over again Don t just send the patient out into the ether 5. Walter AJ, Obstet Gynecol 2001;184 7
Physical Therapy Almost every pelvic pain patient can benefit from PT For many patients this is the only condition Psoas, abdominal wall, back, pelvic floor are all pain generators They can address topics repeatedly Home exercises, must be done every other day. Warn patients about internal work EMGs: Levator Ani/Puborectalis TENS unit Surface EMG with high resting tone >2 mv abnormal Needle EMG with abnormal insertional activity and myoclonus Myofascial Pain Syndrome Disease of muscles, characterized by spasm or hyperirritability a.k.a high-tone dysfunction Characterized by trigger points Taut bands of contracted muscle Abnormal twitch response Local and referred pain May be a primary disorder or occur secondary to other visceral or somatic pathology Irritable Bowel Syndrome Affects 12% population, up to 50% in pelvic pain clinics Pain associated with bowel movements, bloating Diffuse pain Get GI involvement 8
IBS: Nonpharmacologic Therapy Moderation in fat intake Lipid amplify gut sensations and motor reflexes Diarrhea predominant avoid lactose, excess fruit, sorbitol Constipation predominant increase fiber intake (> 25 g/day) FODMAP diet Bifidobacterium infantis (probiotic) Exercise (from uncontrolled studies) NO OPIOIDS IBS: Pharmacotherapy Antispasmodics/anticholinergics Relax smooth muscle of gut and reduce contractility More effective for pain than diarrhea or constipation Mild and generally reversible side effects Some combinations with benzodiazepine or barbiturates Tricyclic antidepressants Most effective agent in meta-analyses, odds ratio for benefit 4.2 Unknown if effect is relate to anticholinergic side effects Caution if constipation predominant IC: Nonpharmacologic Therapy Elimination diets Avoiding acidic foods, chocolate, alcohol, caffeine, and carbonated beverages Some patients can benefit greatly for both voiding habits and pain; some patients have one or two particular triggers Physical therapy Phenazopyridine Antihistamines Pentosan polysulfate Instillations TCAs Refer to UroGyn Adjuvant Medications Work on norepinephrine, GABA, As all chronic pain syndromes involve CNS changes Low quality studies most studied Gabapentin TCAs Other options Topiramate Pregabalin Venlafaxine 9
TCAs Central and/or peripheral effect Antidepressant action not required, doses lower for pain; start at 10-25 mg gradual escalation, max 100 mg SSRIs do not have same benefit Side effects anticholinergic and sedation Increased in elderly Contraindications: narrow angle glaucoma, cardiac conduction problems, drug interactions Inexpensive and qday dosing Tertiary amines amitriptyline, imipramine More anticholinergic effects, more effective for pain Secondary amines nortriptyline, desipramine Hysterectomy Only 20% of women with CPP have a GYN etiology 6 Likely to be of best benefit for women with stage 3 or 4 endometriosis (i.e. identifiable pathology) Pelvic pain, depression, and other pain conditions = risk factors for continued pain after hysterectomy In one study despite 60% of women reported decreased dyspareunia, sexual frequency remained unchanged Satisfaction scores after surgery typically quite high, but we don t know if that is truly pain relief versus doing something. If you are doing a hysterectomy why do you think it will help? 6. Lamvu G, Role of Hysterectomy in the Treatment of Chronic Pelvic Pain Obstet Gynecol 2011 117,5 What Percentage of Women Diagnosed with Endometriosis will have it at Hysterectomy Hysterectomy A. 83% B. 71% C. 52% D. 43% 64% Oophrectomy not needed, even with endometriosis conservations is usually possible Among women with a pre-operative indication of CPP 21% had endometriosis at hysterectomy Among women with a pre-operative diagnosis of endometriosis 43% did not have endometriosis on pathology 7 26% 3% 7% 7. Mowers El et. Al. Obstet Gynecol 2016 127.6 8 3 % 7 1 % 5 2 % 4 3 % 39 10
Lifestyle Changes Some people think only a big dramatic thing or intervention can possibly treat their pain, they can t see how correcting their posture or exercise could possibly help when those are very big things medically Weight loss Diabetes management Don t get pushed into doing something surgical Pain Psychologist Sleep hygiene Depression Relationships Anxiety Cognitive distortions Catastrophizing Compliance Anger How Long Does it Take to Develop Dependence on Opioids? Opioids A. 2 months B. 2 weeks C. 2 days D. 2 doses 13% 56% 16% 16% It takes 2 doses to induce dependence Studies do not show benefit, significant harm Pain contract essential Vaginal diazepam Ineffective in randomized double blinded placebo controlled trial, works on GABA which is central thus local action not possible 2 m o n t h s 2 w e e k s 2 d a y s 2 d o s e s 43 11
Summary Discuss the epidemiology - 10% women, significant economic burden. Explore the neurobiology CPP is unlikely an end organ phenomenon, multiple organ systems, only 20% are true GYN cause, ovarian cysts don t cause CPP Introduce CPP as a systemic condition central changes make pain worse and can be the only pain Run through the diagnostics not many! Bladder diary, pain diary, UA/C&S, biopsy at laparoscopy Review therapies PT, pain psychology, adjuvant medications, laparoscopy, hysterectomy Thank You! 12