Chronic Pelvic Pain

10,605 views

Published on

education tutorial on the management of chronic pelvic pain in women. Target audience: medical undergraduates.

Published in: Health & Medicine
0 Comments
27 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
10,605
On SlideShare
0
From Embeds
0
Number of Embeds
21
Actions
Shares
0
Downloads
673
Comments
0
Likes
27
Embeds 0
No embeds

No notes for slide

Chronic Pelvic Pain

  1. 1. PELVIC PAIN IN GYNAECOLOGY Rajesh Varma MA PhD MRCOG Consultant Obstetrician and Gynaecologist Guy’s and St.Thomas’ NHS Foundation Trust
  2. 2. Objectives: Pelvic Pain <ul><li>Definition </li></ul><ul><li>Epidemiology </li></ul><ul><li>Causes </li></ul><ul><li>History & Examination </li></ul><ul><li>Specialist investigations </li></ul><ul><li>Key conditions and their treatments </li></ul>
  3. 3. CHRONIC PELVIC PAIN PRE-TEST 1 A single pathology is common to most cases of chronic pelvic pain 2 Combination of clinical examination and transvaginal sonography can reliably detect ovarian endometriosis 3 Symptoms of dysmenorrhoea, dyspareunia and chronic pelvic pain are strongly predictive of finding endometriosis at laparotomy 4 Cyclical pelvic pain is usually gynaecological in nature 5 Symptoms alone may reliably diagnose irritable bowel syndrome 6 Diagnostic laparoscopy may have a beneficial role in improving women’s pain scores and changing their beliefs about her pain 7 Fibroids may become acutely painful during pregnancy 8 GnRHa is recommended prior to myomectomy & uterine artery embolisation 9 Medical treatment of mild-moderate endometriosis improves pelvic pain and fertility 10 Diagnostic laparoscopy carries a risk of death of 1 per 1000
  4. 4. Definition: Chronic Pelvic Pain (CPP) <ul><li>Intermittent or constant pain in pelvic area </li></ul><ul><li>for at least 6 months, </li></ul><ul><li>not exclusively related to </li></ul><ul><li>menstruation, intercourse or pregnancy </li></ul>CPP IS A SYMPTOM , NOT A DIAGNOSIS
  5. 5. Epidemiology <ul><li>CPP affects 38 per 1000 women aged 15-73, comparable with that of asthma (37/1000) and chronic back pain (41/1000) </li></ul><ul><li>Most common indication for referral to GOPD, accounting for 20% of all outpatient appointments in secondary care </li></ul>
  6. 6. Causes of Acute Pelvic Pain <ul><li>Pregnancy related Ectopic </li></ul><ul><li>Miscarriage-threatened, incomplete, delayed </li></ul><ul><li>Red degeneration of fibroids </li></ul><ul><li>Ovarian cyst accident (torsion, rupture, bleed within) </li></ul><ul><li>Gynae Ovarian cyst accident </li></ul><ul><li>PID, tubo-ovarian abscess </li></ul>Bowel & Urinary Appendicitis; constipation; acute obstruction Urinary retention; Calculi; UTI Others: Nerve entrapment; disc prolapse
  7. 7. Causes of Chronic Pelvic Pain <ul><li>Gynae Endometriosis/Adenomyosis </li></ul><ul><li>Fibroids </li></ul><ul><li>Adhesions </li></ul><ul><li>Pelvic inflammatory disease </li></ul><ul><li>Ovarian cysts; residual/trapped ovary syndrome </li></ul><ul><li>Pelvic venous congestion </li></ul>Bowel & Urinary Irritable bowel ; Inflammatory bowel; Constipation Interstitial cystitis Others: Nerve entrapment (scar, fascia, narrow foramen) Referred musculoskeletal; Hernias ; Medical disorders Psychological Psychosexual Depression Cause and Effect relationship
  8. 8. Principles of assessment <ul><li>Frequently more than one component (& psychological) </li></ul><ul><li>Elicit woman’s own theory for origin of pain </li></ul><ul><li>Consider involvement of other specialties (anaesthetics, gastroenterologists, urologists, GUM, psychologists, physiotherapist, psychosexual counsellor) - multidisciplinary team approach </li></ul><ul><li>Consider trial of medical therapy prior to diagnostic laparoscopy (consequences of negative laparoscopy) </li></ul>
  9. 9. Essential history <ul><li>When was your last period </li></ul><ul><li>Last cervical smear </li></ul><ul><li>Are you sexually active </li></ul><ul><li>Were you using any contraception </li></ul><ul><li>Could you be pregnant </li></ul><ul><li>Perform a urine pregnancy test </li></ul>MEDICO LEGAL IMPLICATIONS OF MISSING PREGNANCY Missed ectopic Unnecessary exposure to X-rays, inappropriate management e.g. Unnecessary laparoscopy or laparotomy
  10. 10. History relevant to CPP <ul><li>Cyclical vs. Non-cyclical: cyclical is usually gynaecological </li></ul><ul><li>Pattern of pain (onset, site, radiation, intensity pain score ) </li></ul><ul><li>Association with menstrual, PV discharge, bladder & bowel symptoms: specifically enquire Rome II criteria </li></ul><ul><li>The effect of movement and posture with the pain </li></ul><ul><li>Previous pelvic infection, STIs, recent/previous surgery </li></ul><ul><li>(Biological depression, partner violence, sexual abuse) </li></ul><ul><li>Red flag features (suggestive of life threatening disease) </li></ul><ul><li>Pain and menstrual diary for three menstrual cycles </li></ul>
  11. 11. Examination in CPP <ul><li>Abdominal surgery </li></ul><ul><li>Abdominal / pelvic tenderness </li></ul><ul><li>Pelvic mass </li></ul><ul><li>Uterine enlargement </li></ul><ul><li>Uterine immobility </li></ul><ul><li>Nodules (PoD; rectally) </li></ul>
  12. 12. Life-threatening symptoms and signs (Red Flag) <ul><li>Bleeding per rectum </li></ul><ul><li>New bowel symptoms over 50 </li></ul><ul><li>New pain after the menopause </li></ul><ul><li>Pelvic mass </li></ul><ul><li>Suicidal ideation </li></ul><ul><li>Excessive weight loss </li></ul><ul><li>Irregular vaginal bleeding over 40 </li></ul><ul><li>Post coital bleeding </li></ul>
  13. 13. Diagnostic tests Pelvic ultrasound Fibroids, ovarian cysts/endometriomas, adenomyosis Laparoscopy Diagnosis and treatment of endometriosis, adhesions risk of viscera injury (4/1000); risk of death (1/10,000) Hysteroscopy Diagnosis and resection of intrauterine fibroids MRI Pelvic adhesions; adenomyosis Pelvic and rectovaginal endometriosis Fibroids prior to UAE STI screen STI screen 6 month Therapeutic Medical trial GnRHa or COC or Mirena (6 month) Anti-spasmodic bowel treatments/diet change (6 months)
  14. 14. Treating CPP: principles OFTEN NEEED TO COMBINE TREATMENTS (e.g. IBS & endometriosis) Expectant Medical Analgesia Ovarian suppression (GnRHa, COC, POP, Mirena) Anti-spasmodic bowel UAE and MRI focused ultrasound therapy Surgical Excision or ablation endometriosis Adhesiolysis Myomectomy Hysterectomy Psychological
  15. 15. Peritoneal Endometriosis
  16. 16. Ovarian endometriosis
  17. 17. Endometriosis <ul><li>Definition: </li></ul>Aetiology: Genetic predisposition Retrograde menstruation and implantation of menstrual debris What is adenomyosis ? Ectopic presence of endometrium-like glands and stroma outside the normal intrauterine location ( an oestrogen dependent disorder* )
  18. 18. Endometriosis: cardinal features <ul><li>Classical presentations </li></ul><ul><li>Dysmenorrhoea </li></ul><ul><li>Dyspareunia (deep) </li></ul><ul><li>Chronic Pelvic Pain (cyclical & non-cyclical) </li></ul><ul><li>Subfertility </li></ul><ul><li>Rare presentations </li></ul><ul><li>Abnormal uterine bleeding </li></ul><ul><li>Urinary symptoms </li></ul><ul><li>Bowel symptoms (painful defecation) </li></ul><ul><li>Pelvic mass </li></ul>However, symptoms are poorly predictive of diagnosing endometriosis
  19. 19. Endometriosis is surgically staged American Fertility Society (AFS)
  20. 20. Endometriosis treatment <ul><li>Determined by AFS Stage; infertility or pelvic pain needs </li></ul><ul><li>Mild, moderate, severe endometriosis AND Pelvic pain </li></ul><ul><li>medical :COC, GnRHa, oral progestins, Mirena </li></ul><ul><li>surgery: excision or ablation </li></ul><ul><li>Mild, moderate endometriosis AND Infertility </li></ul><ul><li>surgery : excision or ablation </li></ul><ul><li>fertility treatments : ovarian stimulation & intrauterine insemination </li></ul><ul><li>Severe endometriosis AND Pelvic pain medical or surgery </li></ul><ul><li>Severe endometriosis AND Infertility surgery or IVF </li></ul>
  21. 21. Fibroids (leiomyoma) <ul><li>Occur in 10% of HMB </li></ul><ul><li>Benign, but have 0.2% risk of malignant transformation </li></ul><ul><li>May undergo degeneration (hyaline, fatty, Red during pregnancy) </li></ul><ul><li>May become acutely painful (torsion, haemorrhage, sepsis, degeneration) </li></ul>
  22. 22. MRI uterine fibroids
  23. 23. Hysteroscopic Resection of uterine fibroids Versapoint ® Resectoscope
  24. 24. <ul><li>* GnRHa treatment 4 months prior to myomectomy or hysterectomy:- </li></ul><ul><li>reduces fibroid size, pre-op anaemia and intra-operative blood loss </li></ul><ul><li>may help avoid mid-line incision or allow vaginal hysterectomy </li></ul>Fibroid Treatment HIERARCHY Hormones acceptable Not wishing to conceive Hormones unacceptable Wishing to conceive 1 st Line Medical: COC, LNG-IUS Long-acting progestins <6m course of GnRHa * (temporary treatment) Medical: ( Tranexamic Acid, NSAIDS ) Uterine artery embolisation (UAE) MRI-guided focused ultrasound Uterus-conserving Myomectomy ( hysteroscopic, laparoscopic, laparotomy 1 st or 2 nd Line Hysterectomy
  25. 25. Uterine artery embolisation (UAE) <ul><li>Treatment for fibroids </li></ul><ul><li>Pre-operative GnRHa is preferably avoided </li></ul><ul><li>Interventional radiological procedure where both uterine arteries are blocked </li></ul>
  26. 26. Rome II criteria for Irritable Bowel Syndrome <ul><li>At least 12w of continuous/recurrent abdominal </li></ul><ul><li>Pain with AT LEAST TWO of the following </li></ul><ul><li>Pain relieved by defecation </li></ul><ul><li>Change in frequency of stool </li></ul><ul><li>Altered stool appearance </li></ul><ul><li>Other associated symptoms: </li></ul><ul><li>Abdominal bloating </li></ul><ul><li>Passage of mucus PR </li></ul><ul><li>Non-intestinal: lethargy, backache, dyspareunia </li></ul>
  27. 27. CHRONIC PELVIC PAIN POST-TEST 1 A single pathology is common to most cases of chronic pelvic pain 2 Combination of clinical examination and transvaginal sonography can reliably detect ovarian endometriosis 3 Symptoms of dysmenorrhoea, dyspareunia and chronic pelvic pain are strongly predictive of finding endometriosis at laparotomy 4 Cyclical pelvic pain is usually gynaecological in nature 5 Symptoms alone may reliably diagnose irritable bowel syndrome 6 Diagnostic laparoscopy may have a beneficial role in improving women’s pain scores and changing their beliefs about her pain 7 Fibroids may become acutely painful during pregnancy 8 GnRHa is recommended prior to myomectomy & uterine artery embolisation 9 Medical treatment of mild-moderate endometriosis improves pelvic pain and fertility 10 Diagnostic laparoscopy carries a risk of death of 1 per 1000
  28. 28. CHRONIC PELVIC PAIN POST-TEST 1 A single pathology is common to most cases of chronic pelvic pain F 2 Combination of clinical examination and transvaginal sonography can reliably detect ovarian endometriosis T 3 Symptoms of dysmenorrhoea, dyspareunia and chronic pelvic pain are strongly predictive of finding endometriosis at laparotomy F 4 Cyclical pelvic pain is usually gynaecological in nature T 5 Symptoms alone may reliably diagnose irritable bowel syndrome T 6 Diagnostic laparoscopy may have a beneficial role in improving women’s pain scores and changing their beliefs about her pain T 7 Fibroids may become acutely painful during pregnancy T 8 GnRHa is recommended prior to myomectomy & uterine artery embolisation F 9 Medical treatment of mild-moderate endometriosis improves pelvic pain and fertility F 10 Diagnostic laparoscopy carries a risk of death of 1 per 1000 F

×