Chronic pelvic pain-lsmu


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Lugansk State Medical University (LSMU) is attested according to the highest (the fourth) Level of accreditation. Lugansk State Medical University ranks third in Ukraine among the higher medical schools and university of the 4th accreditation level according to the last rating list of the Ministry of Health of Ukraine.The University activities conform with The Constitution of Ukraine, Ukrainian legislation, acts issued by the President and the Cabinet of Ministers of Ukraine, Decrees of the Health Department and Education Department of Ukraine, the University Rules.

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Chronic pelvic pain-lsmu

  1. 1. CHRONIC PELVIC PAIN Lugansk State Medical University Block 50 years, Of lugansk defence, 1. Lugansk - 91045, Ukraine. email : / Official website - +38-091-9484-428
  2. 2.  An unpleasant sensory and emotional experience associated with actual or potential tissue damage Why is Chronic Pelvic Pain so Different? Difficult / Unsatisfactory
  3. 3.  Acute pelvic pain: symptom of underlying tissue injury. Chronic pelvic pain: pain becomes the disease Recurrent, unrelated to menses, intercourse, pregnancy Chronic pain: pain lasting 6 months or longer. Chronic pelvic pain syndrome: chronic pelvic pain causing emotional and behavioral changes.
  4. 4. Type of pain Visceral pain Referred Pain Somatic Pain Myalgia Hyperalgesia Neuroinflammation
  5. 5. Sources of chronic pelvic pain  Gynecological  Urological  Gastrointestinal  Musculoskeletal  Neuropathic  Other
  6. 6. Incidence 14 – 24% of women b/w 18 and 50 years. 1/3 do not consult doctor. 60% who consult are not referred to tertiary centre. Population studies: GI (37%), Urinary (31%), Gynae (20%). Laparoscopic findings: No pathology (35%), Endometriosis (33%), Adhesions (24%).
  7. 7. Differential Diagnosis for Chronic Pelvic PainGynecologic GastrointestinalEndometriosis syndrome Irritable bowelAdhesions (chronic pelvic Chronic Appendicitis inflammatory disease)Leiomyomata Inflammatory bowel diseaseAdenomyosis DiverticulosisPelvic congestion syndrome Diverticulitis Meckel’s diverticulum
  8. 8. Differential DiagnosisUrologic PsychologicalAbnormal bladder function Depression (detrusor instability)Urethral syndrome Somatization (chronic urethritis)Interstitial cystitisPsychosexual dysfunction/ Personality disorder abuse
  9. 9. Differential DiagnosisMusculoskeletal SurgicalNerve entrapment (neuritis) ChronicappendicitisFasciitis HerniaScoliosis Bowel diseaseDisc disease Adhesive diseaseSpondylolisthesisOsteitis pubis
  10. 10. MOST FREQUENTLY MISSED COMPONENTS OF CPP Abdominal trigger points Vestibulitis Pelvic floor myalgia Hernias Pelvic congestion Interstitial cystitis
  11. 11. History: questionnairesA. Who have you consulted about your current medical complaint? What did they tell you?B. How are you currently coping with your pain?C. Do you have any history of a major episode of depression?D. Do you feel you are experiencing symptoms of depression? Yes No Check those that apply: Mood disturbances Feelings of hopelessness Low energy Sleep disturbance Loss of pleasure in activities Feelings of worthlessness Loss of appetite Thoughts or plans of suicide
  12. 12. History: questionnaires E. Has anyone ever abused you sexually? (40% vs 17%) If yes, at what age? By whom? F. Has anyone ever touched you in any way that made you feel uncomfortable? If yes, at what age? By Whom? n Has anyone ever asked you to touch them when you did not want to? If yes, at what age? By whom? n Vaginal discharge, Dyspareunia(41%vs 14%), Dysmenorrhoea(81%vs 58%).Adapted from Carter JE. “Chronic Pelvic Pain Diagnosis and Management”
  13. 13. History: activities Work  Sports/exercise School  Patient deems Social activities important Childcare
  14. 14. Pain QuestionnaireDate:Name: Age: G: P: LMP: Cycle day:A. Fill in the following chart on pain location Pain site: Date pain first noticed: Describe events preceding pain (and indicate cycle day): Describe pain using adjectives (and indicate cycle day): Rate pain intensity from 0 (no pain) to 10 (most severe): List additional pain sites on back of formB. Rate the overall interference of pain from 0 (low) to 10 (high) for each of the following: Work: School: Social activities: Childcare: Sports and exercise: Relationships: Other:C. Check or list things that: Increase pain Decrease pain Intercourse Lying down Bowel movement Heating padUrination Hot bath Physical activities Medication OtherD. List prior treatments or tests: Surgeries GI studies Type: Type: Date: Date: Diagnosis: Diagnosis:E. List medications, dates used, and effectiveness using the 0 to 10 scale Drug Dates Used RatingF. Check off symptoms you are experiencing other than pain: Bleeding Bowel problems Nausea Headache Fatigue Other
  15. 15.  General Examination: Gait- Musculoskeletal Check Abdominal Wall – Point trigger, Ovarian point tenderness Inspection of Vulva & introitus- Vestibulitis Q-tip test for vestibulitis Check for Pelvic Floor Myalgia Single Digit Pelvic Exam Bimanual exam Rectovaginal exam
  16. 16. Investigations WCC, ESR CA – 125 HVS / Endocervical swabs USS Laparoscopy.
  17. 17. Pelvic congestion syndrome Equal in parous& nulliparous ??? Underlying endocrine disorder Peripheral hormone levels normal Prolonged standing, dysparuenia, postcoital aching Stress m/g Hormonal- MPA/ GnRH agonists Hyst & BSO Vein occlusion- Intervention radiology
  18. 18.  Endometriosis- Laparoscopic ablation LUNA- unclear PSN- Positive Adhesions- Often coincidental Adhesiolysis effective only in dense Chronic PID- Salpingectomy/ BSO Nerve entrapment- LA/ Release Neuropathic& post surgical- gabapentin/ Behavioural
  19. 19. Non-gynecologic Causes Non-gyn causes account for significant CPP Complete history and physical essential Pain, symptoms checklist and history questionnaire is helpful
  20. 20. Non-gynecologic Causes Irritable bowel syndrome is most common Urethral synd / IC common- often missed Tenderness specific to abdominal wall- consider nerve entrapment Myalgia, disc disease and referred pain must be ruled out Abdominal wall, umbilical and spigelian hernias Psychological factors
  21. 21. IBS Cramping, colicky pain ( lower abd ) Worsens 1 to 1.5 hrs after meal Abdominal distention Relief of pain with bm Freq/loose bm with onset pain Palpable, tender sigmoid colon Hard pellet-like stool
  22. 22. Urethral syndrome Interstitial cystitis Dysuria, Urgency and  Dysuria, Urgency, Frequency Frequency Without nocturia  With nocturia ( 2 to 3x /night) Treatment: Responds-- long term antibiotic  Treatment (3 mos ) Correct hypoestrogen Responds-- urethral dilation Bladder drills/training Amitryptiline
  23. 23. Musculoskeletal Ergonomic impairments Exaggeration lumbar lordotic curve Anterior pelvic tilt Scoliosis Poor posture
  24. 24. MusculoskeletalNerve entrapment Ilioinguinal/iliohypogastric-- L1 abdominal wall Lateral femoral cutaneous -- L2-3 meralgia parasthetica Genitofemoral -- muscle entrapment bifurcates at iliacus
  25. 25. Psychological Depression Sexual abuse Anxiety disorder Personality disorder
  26. 26. Medical Management Multi disciplinary approach: Gynae, pain specialist, psychologist, anaesthetist, surgeon, physiotherapist, nurse, proper FU. Analgesics. Anxiolytics and antidepressants. Medroxyprogesterone acetate. Antibiotics. Gabapentin: Post hysterectomy pain.
  27. 27. Surgical management Adhesion release: RCT’s dense LUNA: beware of prolapse and bladder dysfx Presacral neurectomy: beware of vessel injury, bladder/bowel dysfx. Hysterectomy with BSO Surgical mx of non gynae causes.
  28. 28. Non conventional therapy Static magnetic therapy: RCTs showed use after 4 week treatment. Cognitive and behavioral therapy. TENS: formal trials are lacking Photographic reassurance??!! Writing therapy??!!
  29. 29. Summary Thoroughness, continuity, multidisciplinary approach and compassion are central themes of successful management
  30. 30. THANK YOU Lugansk State Medical University Block 50 years, Of lugansk defence, 1. Lugansk - 91045, : / Official website - +38-091-9484-428