Pain Management –A European Approach

Prof Vik KhullarConsultant Urogynaecologist

St Mary’s HospitalImperial College Healthcare NHS Trust

London

Chronic Pelvic Pain: Definition

• Temporal characteristics

• Severity

• Location

Chronic Pelvic Pain: Definition

• Noncyclic pain of at least 6 months duration

• Menstrual pain /Intermittent pain

Chronic Pelvic Pain: Definition

• Anatomic pelvis

• Anterior abdominal wall at or below the umbilicus

• Lumbosacral back and buttock region

• Vulvar pain ???

Chronic Pelvic Pain: Prevalence

• 15% to 20% of women between 18 and 50 years old have chronic pelvic pain of more than one year’s duration

• CPP accounted for 2% to 10% of all outpatient gynecologic consultations annually ( Reiter, 1990)

Chronic Pelvic Pain: Health Care

• 20% see a gynecologist• 10% other physician• 1% mental health evaluation• Rest see no one????

Chronic Pelvic Pain: Health Care

• Very few are seen and evaluated by clinicians in more than one specialty

• 75% of women who report CPP have not seen a healthcare provider for 3 month despite persistent pain affecting daily activities

Chronic Pelvic Pain: Health Care

• 56% take one or more nonprescription drugs

• 25% take medications prescribed by a provider

• 12% oral contraceptives

Chronic Pelvic Pain: Health Care

• 61% no diagnosis given by physician• 39% diagnosis given

25% endometriosis49% a non-cycle related gynecologic disorder

(e.g. yeast infection or chronic PID)10% non-gynecologic disorder16% other

Chronic Pelvic Pain: Health Care

• 10% to 35% of laparoscopies are for CPP

• 9% to 80% of laparoscopies report abnormalities

Chronic Pelvic Pain: Health Care

• Up to 70% of laparoscopies report endometriosis

• Even if pathology is found it might not be the reason for the pain

Chronic Pelvic Pain: Health Care

• between 10% to 12% of hysterectomies are done for CPP

Mortality 0.1% ( 70 women a year)Not always beneficialDetrimental effect of oophorectomy on heart disease, bone and Alzheimer’s

Chronic Pelvic Pain: Causes

Gynecologic causes:

• Cyclic• Noncyclic

Chronic Pelvic Pain: Causes

Gynecologic causes:• Endometriosis• Adhesions (?)• Adenomyosis• Chronic pelvic infection • Hydrosalpinx• Pelvic congestion (?) • Leiomyomata(?)• Malignancies• Primary dysmenorrhea

Chronic Pelvic Pain: Causes

Gynecologic causes:• Ovarian remnant syndrome• Ovulatory pain• Adnexal cysts• Cervical stenosis • Chronic endometritis• Endometrial polyps • Chronic ectopic pregnancy• Pelvic relaxation• IUD

Chronic Pelvic Pain: Causes

Nongynecologic disorders:Psychiatric and psychological• Depression• Physical or sexual abuse• Somatization• Hypochondriasis• Opiod seeking• Factitious

Chronic Pelvic Pain: Causes

Nongynecologic disorders:Pain processing disorder• Fibromyalgia

Chronic Pelvic Pain: Causes

Nongynecologic disorders:Gastrointestinal• Functional bowl syndrome• Inflammatory bowl disease• Cancer• Chronic appendicitis (?)• Diverticulitis

Chronic Pelvic Pain: Causes

Nongynecologic disorders:Urinary• Interstitial cystitis• Urethral syndrome• Detrusor overactivity• Chronic calculi

Chronic Pelvic Pain: Causes

Nongynecologic disorders:Musculoskeletal• Hernia• Disc disease• Arthritis• Scoliosis and posture related disorders

Nongynecologic disorders:Psychiatric and psychological

• In depression pain is not an uncommon presentation

• Mood is an important modifier of pain• The relationship between depression

and pain may involve neurotransmitterabnormalities

Nongynecologic disorders:Pain Processing Disorder

• Fibromyalgia• occurs in 2% to 4% of individuals, 80%

are women • Abnormal pain processing associated

with neuroendocrine and autonomic disorders

Nongynecologic disorders:Fibromyalgia

• Criteria for diagnosis:• Pain involving all 4 quadrants of body

and axial skeleton• Tenderness at 11 of 18 defined “tender

points”• Tenderness due to amplification of pain

signals

Nongynecologic disorders:Fibromyalgia

• Abnormal CNS processing of pressure• Visceral sensations can also be

abnormally processed• Associated motility disorder of

abdominal viscera• Disordered sleep

Nongynecologic disorders:Urologic

• Interstitial cystitis • Urinary urgency, bladder discomfort

and sense of inadequate empting• Bladder mucosal lesions consist of

hemorrhage and petechiae (glomerulations)

• Some have only abdominal pain

Interstitial cystitis

ulceration

Nongynecologic disorders:Urologic

• Urethral Syndrome• Irritative bladder symptoms often

associated with coitus• Lower abdominal pain may be chief

presentation

Chronic Pelvic Pain: Causes

Gynecologic causes

Endometriosis

GLANDS

STROMA

EndometriosisEPIDEMIOLOGY AND PREVELANCE

- Diagnosed by laparoscopy in 25-33% of cases with infertility or chronic pelvic pain

- 1-7% estimated prevalence among all reproductive age women

Gynecologic disorders:Endometriosis: Pain

• Noncyclic pain• Dyspareunia• dysmenorrhea

Gynecologic disorders:Endometriosis: Pain

• Peritoneal implants secrete factors that irritate the peritoneal surface

• Pelvic adhesions due to scarring and retraction of peritoneal surface

• Retroverted uterus or adherent ovaries in the C.D.S. cause dyspareunia due to compression of these structures or tension on surrounding peritoneum

• Uterosacral lesions due to compression or stretching of peritoneum

• Visceral pain due to invasion of urinary or GI tracts

Endometriosis

Gynecologic disorders:Endometriosis: Pain

• Not correlated with stage of disease• Deep lesions are associated with more

pain• Vaginal endometriosis associated with

dyspareunia • Prostaglandins

EndometriosisPHYSICAL FINDINGS

- Normal examination- Focal tenderness- Retroverted fixed uterus- Nodularity and tenderness of thecul-de-sac or uterosacrals

- Cervical stenosis- Pelvic masses

Adenomyosis

Uterine Fibroids

Hydrosalpinx

Hydrosalpinx

0102030405060708090

100

Normal Adhesions Endometriosis% o

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Liston et al. 1972 (75;15;5)Lundberg et al. 1973 (35;30;13)Renager et al. 1979 (25;20;19)Kresch et al. 1984 (15;45;30)Rapkin, 1986 (33;22;37)

Chronic Pelvic Pain: Laparoscopic FindingsCOMPLICATIONS

Conclusion

•Many causes for chronic pelvic pain

•Important to determine if there is an underlying cause

•Then to treat co-existent problems and consequences

•Often long-standing and takes time!