chronic pelvic pain in women: an evidence based approach
TRANSCRIPT
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Aboubakr Elnashar
Chronic Pelvic Pain in
Women An Evidence based approach
Aboubakr Elnashar Prof Ob Gyn, Benha Universiy Hospital, Egypt
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Aboubakr Elnashar
ACOG (2004).
RCOG (2005)
Cochrane Library. Syt Review: copyright (2010)
Interventions for treating chronic pelvic pain in
women. Stones W, Cheong YC, Howard FM, Singh S
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Aboubakr Elnashar
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Diagnostic dilemmas.
: Frustration for both the physician and the
patient.
Disability and distress
Significant costs to health services.
CPP
Aboubakr Elnashar
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Aboubakr Elnashar
OBJECTIVES
DEFINITIONS.
CAUSES.
PATHOGENESIS
DIAGNOSIS.
TREATMENT.
CONCLUSION
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DEFINITION
ACOG (2004).
Noncyclic pain that lasts 6 months or more;
localized to the pelvis, the anterior abd wall at or
below the umbilicus, or the buttocks
sufficient severity to cause functional disability or
require medical care
Other definitions
do not require that the pain be noncyclic.
Aboubakr Elnashar
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RCOG (2005)
Intermittent or constant pain for at least 6 months
lower abdomen or pelvis.
Not occurring exclusively with menstruation or intercourse
Not associated with pregnancy.
Aboubakr Elnashar
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Aboubakr Elnashar
PREVALENCE
1 in 6 of the adult female. (RCOG ; 2005)
15% (Mathias et al, 1999)
common in women in the reproductive and
older age groups
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Aboubakr Elnashar
PATHOGENESIS
Often laparoscopy reveals no obvious cause
Possible explanations in absence of cause
1. undetected IBS (Prior 1989).
2. central sensitisation of the nervous system (Rapkin 1995)
3. vascular hypothesis (Taylor, 1949; Beard 1984)
pain arises from dilated pelvic veins in which blood
flow is markedly reduced.
{pathophysiology is not well understood}: tt is often
unsatisfactory and limited to symptom relief.
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Aboubakr Elnashar
CAUSES
Definitive diagnosis is not made for 61% (Zondervan et al, 1999)
Many patients & physicians incorrectly
assume that all CPP results from a
gynecologic source.
One study in the UK:
Urinary&GIT: more common than gynecologic.
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25-50%: more than one cause. Aboubakr Elnashar
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Gastrointestinal: IBS celiac disease Colitis colon cancer inflammatory bowel disease
Urologic: Interstitial cystitis bladder malignancy chronic urinary tract infection radiation cystitis urolithiasis
Aboubakr Elnash
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•Gynecologic
Extrauterine
oAdhesions
oChronic PID
oEndometriosis
oAdnexal cysts
oOvarian remnant syndrome
Uterine
oAdenomyosis
oChronic endometritis
oFibroids
oIntrauterine device
oPelvic congestion syndrome
oGyn malignancy
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Pelvic congestion syndrome:
Pain:
consistent dull aching pelvic
accentuated before menses
associated with low backache, dyspareunia,
postcoital aching,
Discomfort on prolonged sitting and standing and
often associated with variable degree of
premenstrual tension.
The patient
usually multipara
in her 30s-
60% have some sort of psychopathology.
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Diagnosis:
Transuterine venography is the standard for
diagnosis.
U/S, doppler and laparoscopy may reveal
varicosities. '
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Treatment
I. Medical
1. Suppressive therapy:
Low estrogen- high gestagen OCs,
GnRHa or
continuous high dose progestogen, MPA (Provera)
50-300mg/day for up to 18 months, have achieved
promising results
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2. Venoactive drugs
Micronised purified flavonoid fraction (Daflon 500
mg twice daily for 6 months
protective and tonic effect on the venous and
capillary wall: increase in venous tone, improvement
in lymphatic drainage and a reduction in capillary
hyperpermeability: ameliorate venous stasis. (Simsek et al.2007)
statistically significant improvement in pelvic pain
scores without any side effects.
Dihydroergotamine (DHE) (Migranal): Is a selective
venoconstricting agent which increases venous tone
and mobilizes blood which is present in capacitance
vessels.
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II. Surgical
III. Embolization
IV. Psychotherapy:
explanation, reassurance that she is normal, with
some sedative drugs.
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Musculoskeletal:
Degenerative disk disease
Fibromyalgia
levator ani syndrome
myofascial pain
peripartum pelvic pain syndrome
stress fractures
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Psychiatric/neurologic
Abdominal epilepsy
abdominal migraines
Depression
nerve entrapment
neurologic dysfunction
sleep disturbances
Somatization
Other
Familial Mediterranean fever
herpes zoster
porphyria
Aboubakr Elnashar
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Most commonly diagnosed causes
IBS
Interstitial cystitis
Endometriosis
Pelvic adhesions.
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DIAGNOSIS
I. History
II. Physical examination
III. Investigations
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I. HISTORY Characteristics of the pain
Quality, duration, modifying factors
its association with menses, sexual activity, urination, defecation
History of pelvic infections, or previous surgeries.
Urinary complaints:
Dysuria, Urgency, Frequency
Bowel complaints:
Constipation, flatulance, Diarrhea.
History of physical or sexual abuse
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Aboubakr Elnashar
Red flag symptoms
unexplained weight loss
New bowel symptoms over 50
New pain after the menopause
Pelvic mass
Bleeding per rectum
Irregular vaginal bleeding over 40
Post coital bleeding
Rule out malignancy or serious systemic disease.
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Possible significance
Hematochezia: Gastrointestinal malignancy/bleeding History of pelvic surgery, pelvic infections, or use of
intrauterine device: Adhesions Nonhormonal pain fluctuation: Adhesions, interstitial cystitis, IBS, musculoskeletal
causes Pain fluctuates with menstrual cycle: Adenomyosis or endometriosis
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II. PHYSICAL EXAMINATION
Abdominal:
Slowly & gently {abdominal & pelvic components of
the examination may be painful}.
Palpation of the outer pelvis & back: trigger points:
myofascial cause
Tenderness
masses or
other anatomical findings
Lack of findings does not rule out intra-abdominal
pathology
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Trigger points on abdominal wall
Ultrasound showing hydrosalpinx - circled in red Ovary stuck up high in scar tissue - circled in blue
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Tenderness over the “ovarian point”
Suggests pelvic congestion syndrome.
Aboubakr Elnashar
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Pelvic examination:
Single-digit, one-handed examination.
Bimanual examination:
Nodularity
point tenderness
cervical motion tenderness, or
lack of mobility of the uterus.
A moistened cotton swab:
point tenderness in the vulva & vagina
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Rectal examination
Rectal or posterior uterine masses,
nodularity, or
pelvic floor point tenderness.
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Carnett’s sign
Placing a finger on the painful, tender area of the
patient’s abdomen
patient raise both legs off the table while lying in the
supine position
Positive test: pain increases
Myofascial cause
Abdominal wall cause. e.g., fibromyalgia or trigger
point.
Visceral pain should not worsen during the
maneuver.
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III. INVESTIGATIONS If the history & physical examination do not lead to a
diagnosis: {C}
Cancer screenings appropriate to age & risk factors.
β-hCG: rule out pregnancy
CBC:
Infection, systemic illness, or malignancy
(elevated/decreased WBC or anemia)
Urinalysis & urine culture:
Bladder malignancy, infection
ESR:
Infection, malignancy, systemic illness
Vaginal swabs:
gonorrhea & chlamydia: PID
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TVS:
Adenomyosis
endometriosis/endometrioma
malignancy {B}
MRI & CT
should not be used routinely, but can help assess
any abnormalities found on TVS {B}.
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Laparoscopy
in the past: ‘gold standard’.
2nd line of investigation if other therapeutic
interventions fail {C}
(RCOG, 2005).
Indication:
Diagnosis remains elusive after the initial
workup
Confirm or treat, suspected endometriosis,
adhesions, or both.
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TREATMENT
Types of interventions
Lifestyle:
exercise, dietary, substance use.
Psychological:
cognitive behaviour therapy, psychotherapy,
counselling, meditation, biofeedback, US as
reassurance, hypnosis.
Physical therapy.
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Medical:
NSAIDs, OCP, oral and non-oral progestogen,
danazol, GnRH analogues (alone or with ’add-back’
oestrogen), progestogen-releasing intra-uterine
contraceptive devices (IUCD), drugs affecting blood
vessels, antidepressants, anticonvulsants,
analgesics, combined analgesic and caffeine
preparations, local anaesthetic infiltration alone or
in combination with corticosteroids.
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Surgical:
diagnostic laparoscopy, adhesiolysis,
ventrosuspension, presacral neurectomy,
laparoscopic uterine nerve ablation (LUNA), ovarian
vein ligation (via surgery or radiology),
hysterectomy, oophorectomy, ovarian drilling,
wedge resection, endometrial ablation.
Other:
Transcutaneous nerve stimulation, complementary
medicine, referral to standard versus
multidisciplinary clinic setting
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Cochrane analysis, 2010: Few RCT
Of the cause: IBS, interstitial cystitis, endometriosis,
PID, dysmenorrhea,
No cause:
Multidisciplinary approach{A}:
Dietary
Social
Environmental
Psychological factors in addition to
medication therapy)
improve outcomes over medication therapy alone {B}.
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Counseling supported by ultrasound
scanning {B}
Social problems
Depression
Sexual abuse
Personality disorder
Troubled marriage
Family crisis.
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I. Non surgical therapies:
Excluded: endometriosis,primary dysmenorrhea,
PID,IBS, interstitial cystitis
Only the following tts have shown benefit:
Oral MPA (Provera) 50 mg/d {B}
GnRHa Goserelin (Zoladex) for 3-6 m before
laparoscopy {A}
Progestogen (MPA): reduction of pain during tt while
goserelin gave a longer duration of benefit.
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Cyclic pain: hormonal treatments
(continuous or cyclic low-dose COC {A}, progestins,
or GnRHa) should be considered, even if the
cause is thought to be IBS, interstitial cystitis, or
pelvic congestion syndrome {these conditions may
also respond to hormone tts}
Although selective serotonin reuptake inhibitors
have not been shown to be effective for treating
CPP, they may be used to treat concomitant
depression
Writing therapy and static magnetic field therapy
showed some evidence of short-term benefit.
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Trigger point injections of the abdominal wall for
myofascial causes: some benefit (Langford et al, 2007).
Botulinum toxin type A injections into the pelvic
floor muscles: some benefit (Abbott et al, 2006)
Oral analgesics:
Acetaminophen
NSAID {C}
opioid analgesics: commonly used to treat
moderate pain
No RCT
Gabapentin (Neurontin)
alone or in combination with amitriptyline:
significant pain relief in women with CPP (Sator-Katzenschlager et al, 2005, RCT)
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II. Surgical Therapies
Benefit was not demonstrated for
adhesiolysis (apart from where adhesions were severe)
uterine nerve ablation
LUNA
sertraline or photographic reinforcement after
laparoscopy.
Total abdominal hysterectomy: some benefit in
observational & cohort studies.
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History, Examination
Warning signs
No: History`&Exam suggestive of IBS, IC, endometriosis, myofacial
No: CBC, urine, BHCG ESR,STD, TVS
Normal
Address comorbid (pschosocial,
enviromental, dietary) Reassurance
Abnormal
Evaluate & TT specific abnormality
Yes: Evaluate & TT
Yes: Exclude malignancy or serious disease
ACOG, 2005
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NSAID or Acetaminophen
Inadequate relief
Cyclic pain
Provera, COC, Depoprovera, GNRHa, Mirena
Inadequate relief
Noncyclic pain
Gabapentin &Amitrytlyline
Inadequate relief
Laparoscopy Aboubakr Elnashar
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Conclusion Main approaches to treatment include
Counselling or psychotherapy,
Attempts to provide reassurance using laparoscopy
to exclude serious pathology,
Progestogen therapy such as with MPA and
Surgery to interrupt nerve pathways.
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