Pelvic Pain1

8/6/2019 Pelvic Pain1

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Kireet Agrawal


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P elvic pain is a common complaint in women

Its nature and intensity may fluctuate, and itscause is often obscure

It can be categorized as acute or chronic


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Inflammation or direct irritation of nervescaused by acute or chronic trauma, fibrosis,pressure, or intraperitoneal inflammation

Muscular contractions or cramps of bothsmooth and skeletal muscles

P sychogenic factors, which can cause oraggravate pain


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E ctopic pregnancyP elvic inflammatory disease ( P ID)

Twisted or ruptured ovarian cystMiscarriage or threatened miscarriageUrinary tract infectionAppendicitisRuptured fallopian tube


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C hronic pelvic pain ( CPP ) refers to pain of atleast six months' duration that occurs below theumbilicus and is severe enough to causefunctional disability or require treatment.


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P revalence: 4 - 25%, but only about one-third ofwomen with CPP seek medical care10 percent of all ambulatory referrals to a

gynecologistA common indication for diagnostic andtherapeutic surgeryThe principal indication for approximately 20%

of all hysterectomies performed for benigndisease and at least 40 percent of allgynecological laparoscopies performedannually in the US


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G ynecologicG UG IMusculoskeletalP sychological


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G ynecologic:

E ndometriosis is the most common diagnosis.1/3 who undergo laparoscopy are diagnosedwith endometriosis.70% of CPP are given this diagnosis inpractices specializing in treatment ofendometriosis.


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P ID30% develop CPP

Related to severity of adhesive disease andtubal damage after acute infectionSmokers, 2 or more episodes of P ID, and lowcomposite mental health, are more likely to

develop CPP


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Adhesions: Limit organ mobility

P elvic congestion syndromeRelated to pelvic varicosities (dilated uterineand ovarian veins), reducing blood flow afterprolonged standing, dyspareunia, and

postcoital pain.


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AdenomyosisDue to bleeding and swelling of endometrialislands confined by myometrium.Typically age is 40-50


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LeiomyomaMay cause pressure symptoms.Acute pain occurs with degeneration, torsion, or

expulsion through the cervix.C hronic pain is uncommon


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Ovarian remnant and residual ovary syndromeO RS occurs in patients who have undergone bilateral

oophorectomy and subsequently present withsymptoms related to ovulatory function from ovariantissue inadvertently left behind.

In RO S the ovary was intentionally preserved andsubsequently developed pathology.

The typical patient presents with cyclic pelvic pain and a

mass, although the pain may be persistent with acuteflare-ups.O ccasionally, an asymptomatic mass is detected on pelvic

or sonographic examination.Ureteral obstruction may occur.


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P elvic organ prolapseSensation of pelvic pressure/heaviness orprotrusion of tissue from the vagina

Relieved by lying down, is less noticeable inthe morning, and worsens as the dayprogresses.P rotrusion of tissue from the vagina andresulting mucosal irritation may cause vaginalbleeding

C A ovary


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Interstitial cystitis/painful bladder syndromeA chronic inflammatory condition of thebladder that causes pelvic pain and irritable

bladder dysfunction with exaggerated urge tovoid and urinary frequency.

Incontinence is not usually a symptom.


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C hronic suprapubic pain, associated withfrequency, urgency, and/or hematuria suggestrecurrent UTI.Urethral diverticulum should be consideredwith suburethral mass, fullness, or tenderness


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B ladder neoplasia ( C A & C A in situ)Symptoms are similar to interstitial cystitisHigh suspicion with hematuria, h/o smoking, >60

yoC hronic urethral syndrome

Same symptoms as interstitial cystitis.

No longer a diagnosis distinct from interstitialcystitis/painful bladder syndrome


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Irritable bowel syndromeAbd pain associated with bowel function inabsence of any organic cause.Most pt have bowel dysfunction10% of general population, 2x in FMost common diagnosis in primary care

population with CPP


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Inflammatory bowel diseaseDiverticulitis: Multifactorial, mucosal prolapse,fecal stasis, localized ischemia.C olon C AC hronic interstitial pseudo-obstructionC hronic constipation (pain not common)C eliac disease (sprue)


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FibromyalgiaC occygodynia, pelvic floor tension myalgiaInvoluntary spasm of the pelvic floor muscles.E tiology: Any inflammatory painful disorder,childbirth, pelvic surg, traumaDyspareunia, and aching pelvic pain

aggravated by prolonged sitting, relieved byheat and lying down with hips flexed.


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P osture, causing muscle imbalance leading tolocal or referred painC hronic abd wall pain: Muscular injury, nerveinjury


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P ain originates from myofascial trigger pointsin skeletal muscle. C ompression ofhyperirritable spot results in local as well asreferred pain, sometimes accompanied byautonomic phenomena, and visceral symptomsAfter injury (direct or overuse), or otherpostural/joint abnormalitiesAbdominal wall hernias


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Somatization disorderAt least 4 different sites of pain, 2 G I Symptomsother than pain, 1 neurologic Symptom, and 1sexual or reproductive problem other than pain

O piate dependancy


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P ts with CPP have a higher incidence

P ast traumatic experiences may alterneuropsychological processing of pain signals,and can permanetly alter pituitary-adrenal andautonomic responses to stress


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Depression: Result from, and contributes toCPP

Sleep disorders


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P elvic pain assessment form by InternationalP elvic P ain Society facilitates H& P , screeningQs for depression, sexual and physical abuse,

and somatization, as well as pelvic painquantification and pain mapping.


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W hen and where does the pain occur?How long does the pain last?

Is the pain related to your menstrual cycle,urination, and/or sexual activity?W hat does the pain feel like (i.e., sharp, dull,etc.)?

Under what circumstances does the painbegin?


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Nature and location (visceral vs. somatic)C yclic pelvic pain (endometriosis,adenomyosis)O nset during pregnancy or immediatelypostpartum suggests a musculoskeletaletiology. O nset prior to menarche is unlikelygynecologic


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B e gentle

Look for localized or general tenderness

Inspect for surgical scars, hernias, and masses

C heck for orthopedic and posturalabnormalities


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Labs not much helpful

CBC with diff, UA, chlamydia GC , pregnancytest


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P elvic US is highly sensitive for masses/cysts,and determining the origin of the mass

C T scan/MRI for abnormalities suspected byUS, and for diagnosis of adenomyosis


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1/3 of outpatient laparoscopic surgicalprocedures in females are performed forabdominal/pelvic pain

Results: No visible pathology 35%,endometriosis 33%, adhesions 24%, chronicP ID 5%, ovarian cysts 3%, and occasional otherdiagnoses


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Success is facilitated by earning trust andconfidence, by through eval, listening,validating that the pain is real, offering

explanations and reassurance, and making acommitment to try to help.Discuss with pt preferences and valuesregarding testing, medical vs surgical Tx, andchildbearing plans.


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In suspicion of endometriosis, start empiric Txwith NSAIDs, and/or combined estrogen-

progestin contraceptives (cyclic or continuous)for 2-3 months prior to laparoscopy (At thetime, offer G nRH-analogue).Improvement is not an absolute confirmationof DxThis can improve pelvic congestion syndrome,irritable bowel syndrome, or interstitial cystitis.CPP resolves in 50%, and laparoscopy avoided


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P elvic congestion syndromeMedical Treatment with gonadotropin-releasing hormone agonists or syntheticprogestins effectively decrease pain

O ther Txs were not studied, including

hysterectomy andB

L salpigo-oophorectomy,embolization of ovarian veins +/- internal iliacveins, sclerotherapy, surgical ligation ofovarian veins


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Adenomyosis: Hysterectomy

O varian remnant syndrome/retained ovarysyndrome: O ophorectomy

Leiomyoma: Removal or reduction in size can

relieve chronic pressure symptoms


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AdhesionsAdhesiolysis is controversial

Myofascial pain syndrome (trigger point pain)P T (Icing, moist heat, stretching, massage,transcutaneous electrical stimulation, galvanic

muscle stimulation, biofeedback)


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Depression is common and warrants treatment.Data regarding efficacy of antidepressants inTx of pain in CPP are limited

C hronic P IDTreat ongoing or suspected subclinical

infections


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Ceftriaxone 250 mg IM in a single dosePLUS Doxycycline 100 mg orally twice a day for 14 daysWITH OR WITHOUT

Metronidazole 500 mg orally twice a day for 14 days

OR

Cefoxitin 2 g IM in a single dose and Probenecid , 1 g orallyadministered concurrently in a single dose

PLUSDoxycycline 100 mg orally twice a day for 14 days

WITH OR WITHOUTMetronidazole 500 mg orally twice a day for 14 days

OR

Other parenteral third-generation cephalosporin (e.g., ceftizoxime orcefotaxime )

PLUSDoxycycline 100 mg orally twice a day for 14 days

WITH OR WITHOUTMetronidazole 500 mg orally twice a day for 14 days


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Failure or no Dx made

P harmacological, surgical, psychological, orneurological (nerve blocks or neurodestructiveprocedures)


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E sp for musculoskeletal pain

Increases blood flow and decreases jointstiffness

Includes mental relaxation


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Irritable bowel syndromeModifications in diet, behavioral changes,meds, and psychotherapy

Interstitial cystitis/painful bladder syndromeNo curative Treatment available

P hysical and pharmacologic therapy


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Nerve transection procedures

Acupuncture, behavioral and relaxationfeedback therapy, transcutaneous electricalnerve stimulation, implantable nervestimulation devices.

P sychological counseling


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THANK Y O U

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Pelvic Pain1

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