pelvic pain · 2018-01-31 · pelvic pain miss tracy-louise appleyard consultant o&g nbt 30 jan...

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/adenomyosis*

• 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)

Woman

Ideas

Concerns Expectations

Recently…

• Summarise

• Empathasise

– Empathasise • Empathasise

• What is your expectation of today?

• Recognise, share and ask permission to explain

‘ICE’… Becker & Maiman (1975)

Woman

Ideas

Concerns Expectations

Partnership

Management 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

• ?2nd 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