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Chronic Pelvic Pain in Women: An Evidence based approach

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Chronic Pelvic Pain in Women: An Evidence based approach

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Chronic Pelvic Pain in Women: An Evidence based approach

  1. 1. Aboubakr Elnashar Chronic Pelvic Pain in Women An Evidence based approach Aboubakr Elnashar Prof Ob Gyn, Benha Universiy Hospital, Egypt
  2. 2. 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
  3. 3. Aboubakr Elnashar
  4. 4.  Diagnostic dilemmas.  : Frustration for both the physician and the patient.  Disability and distress  Significant costs to health services. CPP Aboubakr Elnashar
  5. 5. Aboubakr Elnashar OBJECTIVES  DEFINITIONS.  CAUSES.  PATHOGENESIS  DIAGNOSIS.  TREATMENT. CONCLUSION
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. 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.
  10. 10. 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.
  11. 11.  25-50%: more than one cause. Aboubakr Elnashar
  12. 12. Gastrointestinal: IBS celiac disease Colitis colon cancer inflammatory bowel disease Urologic: Interstitial cystitis bladder malignancy chronic urinary tract infection radiation cystitis urolithiasis Aboubakr Elnash
  13. 13. Aboubakr Elnashar •Gynecologic Extrauterine oAdhesions oChronic PID oEndometriosis oAdnexal cysts oOvarian remnant syndrome Uterine oAdenomyosis oChronic endometritis oFibroids oIntrauterine device oPelvic congestion syndrome oGyn malignancy
  14. 14. 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.
  15. 15. Diagnosis: Transuterine venography is the standard for diagnosis. U/S, doppler and laparoscopy may reveal varicosities. '
  16. 16. 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
  17. 17. 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.
  18. 18. II. Surgical III. Embolization IV. Psychotherapy: explanation, reassurance that she is normal, with some sedative drugs.
  19. 19. Musculoskeletal: Degenerative disk disease Fibromyalgia levator ani syndrome myofascial pain peripartum pelvic pain syndrome stress fractures Aboubakr Elnashar
  20. 20. Psychiatric/neurologic Abdominal epilepsy abdominal migraines Depression nerve entrapment neurologic dysfunction sleep disturbances Somatization Other Familial Mediterranean fever herpes zoster porphyria Aboubakr Elnashar
  21. 21. Aboubakr Elnashar
  22. 22. Aboubakr Elnashar Most commonly diagnosed causes  IBS  Interstitial cystitis  Endometriosis  Pelvic adhesions.
  23. 23. Aboubakr Elnashar DIAGNOSIS I. History II. Physical examination III. Investigations
  24. 24. 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 Aboubakr Elnashar
  25. 25. 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.
  26. 26. 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 Aboubakr Elnashar
  27. 27. 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 Aboubakr Elnashar
  28. 28. Aboubakr Elnashar Trigger points on abdominal wall Ultrasound showing hydrosalpinx - circled in red Ovary stuck up high in scar tissue - circled in blue
  29. 29. Tenderness over the “ovarian point” Suggests pelvic congestion syndrome. Aboubakr Elnashar
  30. 30. 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 Aboubakr Elnashar
  31. 31. Rectal examination Rectal or posterior uterine masses, nodularity, or pelvic floor point tenderness. Aboubakr Elnashar
  32. 32. 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. Aboubakr Elnashar
  33. 33. Aboubakr Elnashar
  34. 34. Aboubakr Elnashar 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
  35. 35. TVS: Adenomyosis endometriosis/endometrioma malignancy {B} MRI & CT should not be used routinely, but can help assess any abnormalities found on TVS {B}. Aboubakr Elnashar
  36. 36. 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. Aboubakr Elnashar
  37. 37. Aboubakr Elnashar TREATMENT Types of interventions Lifestyle: exercise, dietary, substance use. Psychological: cognitive behaviour therapy, psychotherapy, counselling, meditation, biofeedback, US as reassurance, hypnosis. Physical therapy.
  38. 38. Aboubakr Elnashar 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.
  39. 39. Aboubakr Elnashar 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
  40. 40. Aboubakr Elnashar 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}.
  41. 41. Aboubakr Elnashar Counseling supported by ultrasound scanning {B} Social problems Depression Sexual abuse Personality disorder Troubled marriage Family crisis.
  42. 42. Aboubakr Elnashar 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.
  43. 43. Aboubakr Elnashar 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.
  44. 44. 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)
  45. 45. Aboubakr Elnashar 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.
  46. 46. 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 Aboubakr Elnashar
  47. 47. NSAID or Acetaminophen Inadequate relief Cyclic pain Provera,COC, Depoprovera,GNRHa, Mirena Inadequate relief Noncyclic pain Gabapentin &Amitrytlyline Inadequate relief Laparoscopy Aboubakr Elnashar
  48. 48. Aboubakr Elnashar 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.
  49. 49. Aboubakr Elnashar

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