Pelvic Pain Miss Tracy-Louise Appleyard Consultant O&G NBT 30 Jan 2018
No commercial conflicts of interest Working Group for CPP PHE Endometriosis Centre, NBT GP Lt Col RAMC, Commissioned 1992
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
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
Improve understanding of pelvic pain Options available in GP
Chronic Pelvic Pain in Women Miss Tracy-Louise Appleyard Consultant O&G NBT 26 Sept 2014
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
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
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
Unfunded report from Pain Australia and the Faculty of Pain Medicine at the Australian and New Zealand College of Anaesthesia 2011
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
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
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;27:585 99. Zondervan et al Br J Obstet Gynaecol 1999;106:1149 55.
Prevalence
Prevalence Dysmenorrhoea (106 studies) 17-81% prevalence Dyspareunia (54 studies) 8-22% prevalence Non cyclical pain (18 studies) 2% to 24% prevalence
Potential causes?
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
Guidelines?
RCOG 2012
History Story.
Advanced listening
Suspect endometriosis
Endometriosis S & S CPP Dysmenorrhoea Premenstrual pain Deep dyspareunia Dyschezia Cyclical bowel symptoms Dysuria Subfertility with 1 or more of above
NICE Sept 2017
NICE May 2014
ESHRE 2013
Management
ICE Becker & Maiman (1975) Ideas Woman Expectations Concerns
Recently
Summarise Empathasise Empathasise Empathasise What is your expectation of today? Recognise, share and ask permission to explain
ICE Becker & Maiman (1975) Partnership Ideas Woman Management Expectations Concerns plan
Investigations?
Pain diary Offer abdo/pelvic exam
Diagnostic tests USS Ca125 MRI Diag lap
TVS Ovarian endometrioma?rectal endometriosis 3D not proven for RV disease
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*
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??
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
The new oscopy Micro-laparoscopy Conscious pain mapping Patient assisted laparoscopy (PAL) NOTES Not widely adopted?acceptability, validity, reproducibility
Endometriosis pain
Medical Mx Analgesia 3mths paracetamol+/- NSAIDs Neuropathic pain Amitriptyline, Duloxetine, Pregabalin, Gabapentin SSRI Hormonal treatment COCP, Prog, Mirena
NICE Nov 2013
Other Mx Dietary Mx Dyspepsia Physio Mindfulness CBT
Surgical Mx? Priorities for pain and fertility Laparoscopy Diag vs treatment?gnrha Excision > ablation Post-op medical Mx Hysterectomy + excision (TLH)
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
PR bleeding New bowel symps >50 yrs New pain postmenopause Pelvic mass Suicidal ideation ++ weight loss IMB/Irreg > 40yrs PCB
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
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
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