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Pelvic Pain Miss Tracy-Louise Appleyard Consultant O&G NBT 30 Jan 2018
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
