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.

1. CHRONIC PELVIC PAIN
Lugansk State Medical University
Block 50 years, Of lugansk defence, 1.
Lugansk - 91045, Ukraine.
email : info@lsmuedu.com / kanc@lsmuedu.com
Official website - http://www.lsmuedu.com
+38-091-9484-428

2.  An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage
 Why is Chronic Pelvic Pain so Different?
Difficult / Unsatisfactory

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. Type of pain
 Visceral pain
 Referred Pain
 Somatic Pain
 Myalgia
 Hyperalgesia
 Neuroinflammation

5. Sources of chronic pelvic pain
 Gynecological
 Urological
 Gastrointestinal
 Musculoskeletal
 Neuropathic
 Other

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. Differential Diagnosis for
Chronic Pelvic Pain
Gynecologic Gastrointestinal
Endometriosis syndrome Irritable bowel
Adhesions (chronic pelvic Chronic Appendicitis
inflammatory disease)
Leiomyomata Inflammatory bowel disease
Adenomyosis Diverticulosis
Pelvic congestion syndrome Diverticulitis
Meckel’s diverticulum

8. Differential Diagnosis
Urologic Psychological
Abnormal bladder function Depression
(detrusor instability)
Urethral syndrome Somatization
(chronic urethritis)
Interstitial cystitis
Psychosexual dysfunction/ Personality disorder
abuse

9. Differential Diagnosis
Musculoskeletal Surgical
Nerve entrapment (neuritis) Chronic
appendicitis
Fasciitis Hernia
Scoliosis Bowel disease
Disc disease Adhesive disease
Spondylolisthesis
Osteitis pubis

10. MOST FREQUENTLY MISSED
COMPONENTS OF CPP
 Abdominal trigger points
 Vestibulitis
 Pelvic floor myalgia
 Hernias
 Pelvic congestion
 Interstitial cystitis

11. History: questionnaires
A. 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. 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. History: activities
 Work  Sports/exercise
 School  Patient deems
 Social activities important
 Childcare

14. Pain Questionnaire
Date: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 form
B. 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 pad
Urination
Hot bath Physical activities Medication Other
D. 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 Rating
F. Check off symptoms you are experiencing other than pain:
Bleeding Bowel problems Nausea Headache Fatigue Other

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

18. Investigations
 WCC, ESR
 CA – 125
 HVS / Endocervical swabs
 USS
 Laparoscopy.

19. 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

20.  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

21. Non-gynecologic Causes
 Non-gyn causes account for significant CPP
 Complete history and physical essential
 Pain, symptoms checklist and history
questionnaire is helpful

22. 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

23. 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

24. 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

25. Musculoskeletal
 Ergonomic impairments
 Exaggeration lumbar lordotic curve
 Anterior pelvic tilt
 Scoliosis
 Poor posture

26. Musculoskeletal
Nerve entrapment
 Ilioinguinal/iliohypogastric-- L1
abdominal wall
 Lateral femoral cutaneous -- L2-3
meralgia parasthetica
 Genitofemoral -- muscle entrapment
bifurcates at iliacus

27. Psychological
 Depression
 Sexual abuse
 Anxiety disorder
 Personality disorder

28. 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.

29. 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.

30. 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??!!

31. Summary
 Thoroughness, continuity,
multidisciplinary approach and compassion
are central themes of successful
management

32. THANK YOU
Lugansk State Medical University
Block 50 years, Of lugansk defence, 1.
Lugansk - 91045, Ukraine.
email : info@lsmuedu.com / kanc@lsmuedu.com
Official website - http://www.lsmuedu.com
+38-091-9484-428