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Chronic Pelvic Pain

Basics

Description

- Basic testing: - Pap smear - Gonorrhea and chlamydia cultures - Wet mount if associated discharge or odor - Urinalysis - Urine culture - Pregnancy test - CBC with differential - ESR (nonspecific for inflammatory process) - Pelvic ultrasound, which could possibly lead to MRI or CT

- Specialized testing (as directed by findings of history and physical examination): - Potassium sensitivity testing - IC requires evaluation by urology or urogynecology - Cystoscopy/ureteroscopy - IC, urethral diverticulum, neoplasia - Urodynamics - detrusor instability - Electrophysiologic studies - nerve compression, muscular spasm - X-ray - fracture - Laparoscopy - endometriosis, adhesions, hernia - Specialists may consider "awake laparoscopy"пїЅ for pain mapping.

- CPP often remains undiagnosed. - The identification of the source of CPP is elusive. - Patient complaints can too often be ignored by the provider. - The differential diagnosis for CPP is extensive. - If the pain seems gynecologic in origin, the differential includes: - Adenomyosis - Adhesions - Chronic ectopic pregnancy - Chronic infection - Endometriosis - Ovarian carcinoma - Ovarian cysts - Ovulation pain (Mittelschmerz) - Pelvic congestion syndrome - Pelvic organ prolapse - Postpartum lordosis - Tuberculous salpingitis - Uterine fibroids

  • Chronic pelvic pain (CPP) is any nonmenstrual pain lasting >6 months.
  • CPP is often vague and difficult to assess.
  • The degree of pain is often out of proportion to the clinical findings.
  • CPP is extremely distressing to women.
  • CPP is extremely frustrating for physicians.
  • Over 60% of patients never receive a diagnosis.

Epidemiology

Incidence

  • As high as 20% of women of reproductive age
  • Accounts for 20% of laparoscopies
  • Accounts for 12-16% of hysterectomies
  • Associated medical costs total nearly $3 billion annually

Etiology

  • CPP is a syndrome whose etiology remains unknown.
  • In patients without a clear source of pain, one theory is that an acute event triggers the pain, but the pain continues even after the trigger is gone.

Associated Conditions

  • Interstitial cystitis (IC)
  • Irritable bowel syndrome
  • Depression/anxiety
  • Dyspareunia
  • Vulvar dystrophy

Diagnosis

History

  • Obtaining a complete history is the key to the diagnosis.
  • Assess the nature of the pain, intensity, distribution, associated symptoms, and temporal relations.
  • Identify prior surgeries, infections, infertility, and birth complications.
  • Evaluate the patient's bleeding patterns.
  • Evaluate the patient for associated psychiatric symptoms such as depression or anxiety.
  • Evaluate the patient for current or prior sexual abuse.
  • Determine the role pain plays in the patient's life.
  • A 3-month pain diary may be helpful.
  • Signs and symptoms to help assess possible etiology:Vague pain is associated with a visceral/intra-abdominal process.Localized pain is associated with a musculoskeletal origin.Constipation/flatulence/bloating are associated with a GI origin.Urinary frequency or burning is associated with a urinary origin.

Physical Exam

  • Evaluate each anatomic area individually:Anterior abdominal wall/herniasPelvic bones/symphysisPelvic floor musculature/levator aniVulva/vestibuleVaginaUrethraCervixViscera-uterus, adnexa, bladderRectumRectovaginal septumCoccyxPosture and gait
  • Perform the exam standing, sitting, supine, and lithotomy.
  • A bimanual exam alone is insufficient as it cannot differentiate between anterior abdominal wall, cervix, and intra-abdominal organs.

Tests

Surgery

  • Basic testing:Pap smearGonorrhea and chlamydia culturesWet mount if associated discharge or odorUrinalysisUrine culturePregnancy testCBC with differentialESR (nonspecific for inflammatory process)Pelvic ultrasound, which could possibly lead to MRI or CT
  • Specialized testing (as directed by findings of history and physical examination):Potassium sensitivity testing - IC requires evaluation by urology or urogynecologyCystoscopy/ureteroscopy - IC, urethral diverticulum, neoplasiaUrodynamics - detrusor instabilityElectrophysiologic studies - nerve compression, muscular spasmX-ray - fractureLaparoscopy - endometriosis, adhesions, herniaSpecialists may consider "awake laparoscopy"пїЅ for pain mapping.

Differential Diagnosis

  • CPP often remains undiagnosed.
  • The identification of the source of CPP is elusive.
  • Patient complaints can too often be ignored by the provider.
  • The differential diagnosis for CPP is extensive.
  • If the pain seems gynecologic in origin, the differential includes:AdenomyosisAdhesionsChronic ectopic pregnancyChronic infectionEndometriosisOvarian carcinomaOvarian cystsOvulation pain (Mittelschmerz)Pelvic congestion syndromePelvic organ prolapsePostpartum lordosisTuberculous salpingitisUterine fibroids

Treatment

Medication

  • Oral contraceptive
  • Gonadotropin-releasing hormone (GnRH) agonist
  • Progesterone
  • NSAIDs
  • Antidepressants for depression, but not pain
  • Narcotic analgesics should be used under a "drug contract"пїЅ for refractory pain.

Additional Treatment

General Measures

  • A multidisciplinary approach to CPP has been shown to be most effective (1)[B].
  • Identify the most likely organ system causing CPP and treat or refer appropriately.
  • Recommend therapy for pain management techniques and emotional support.
  • If the pain is gynecologic in origin:Trial of NSAIDsSuppress the menstrual cycle with oral contraceptive or GnRH agonist for a 3-month trial.If suppression fails, perform diagnostic laparoscopy.A negative pelvic sonogram and diagnostic laparoscopy can be very reassuring to the patient.A positive laparoscopy can be curative.If muscular "trigger"пїЅ points are identified, lidocaine injections may be considered.

Additional Therapies

  • Physical therapyFor patients where the pain originates from muscular spasms, physical therapy can be helpful (2)[B].Transcutaneous electrical nerve stimulation (TENS) units may be of benefit.

Complementary and Alternative Medicine

  • Results of clinical trials are limited.
  • Acupressure and acupuncture have demonstrated efficacy equal to ibuprofen (2)[B].
  • Chiropractic and osteopathic spinal manipulations may be of benefit.
  • Meditation and breathing improve symptoms and relieve anxiety.
  • Journaling may be of benefit.
  • Saw palmetto has insufficient information to support its use.

Surgery

  • Laparoscopic fulguration of endometriosis
  • Lysis of adhesions has shown some benefit for thin adhesions where movement could cause tension on the band (3)[A].
  • Lysis of adhesions for dense adhesions has shown little benefit (3)[A].
  • Hysterectomy should be reserved for refractory cases where the etiology of the pain is thought to be gynecologic in origin.
  • Laparoscopic uterine nerve ablation has not been shown to be helpful.
  • Hernia repair if hernia present

Ongoing Care

Follow-Up Recommendations

  • Establishing a supportive relationship is essential to care of the patient with CPP.
  • It is very important to schedule regular visits to establish trust.
  • Scheduled visits also eliminate the patient's need to have pain in order to have an office visit (eliminate secondary gain).
  • A team approach with specialists improves patient care and outcome.

Diet

  • Identify triggers associated with food, such as lactose intolerance, celiac sprue, and acid reflux.
  • Recommend a diet high in complex carbohydrates and fiber for general health and regular bowel movements.
  • Avoid constipating food or foods that cause gaseous distension.

Patient Education

  • Activity:Regular exercise has been shown to increase endorphins and, thus, pain tolerance is increased.Exercise has also been shown to improve symptomatic depression.Unless there is a specific indication (i.e., fracture), bed rest should be avoided.

References

1Stones пїЅRW. Chronic pelvic pain in women: New perspectives on pathophysiology and management. Reprod Med Rev. 2000;8:229-240.2ACOG. Pelvic Pain Practice Bulletin. No. 51 (March) 2004:364-374.3Peters пїЅAA, Trimbos-Kemper пїЅGC. A randomized clinical trial on the benefit of adhesiolysis in patients with intraperitoneal adhesions and chronic pelvic pain. Br J Obstet Gynaecol. 1992;99:59-62. пїЅ[View Abstract]

Additional reading

1Carter пїЅJE. Chronic pelvic pain: Diagnosis and management. International Pelvic Pain Society. Available at www.pelvicpain.org [Accessed 2005].2Daniels пїЅJP, Kahn пїЅKS. Chronic pelvic pain in women. BJM. 2010;341:c4834. пїЅ[View Abstract]3Stones пїЅW, Cheong пїЅYC, Howard пїЅFM. Interventions for treating chronic pelvic pain in women. The Cochrane Collaboration. 2005, Vol. 4.4Wenof пїЅM, Perry пїЅCP. Chronic pelvic pain: A patient education booklet. International Pelvic Pain Society. Available at www.pelvicpain.org. [Accessed 1998].

Codes

ICD9

  • 614.6 Pelvic peritoneal adhesions, female (postoperative) (postinfection)
  • 617.0 Endometriosis of uterus
  • 625.9 Unspecified symptom associated with female genital organs
  • 625.2 Mittelschmerz
  • 218.9 Leiomyoma of uterus, unspecified

ICD10

  • N73.6 Female pelvic peritoneal adhesions (postinfective)
  • N80.0 Endometriosis of uterus
  • R10.2 Pelvic and perineal pain
  • N83.20 Unspecified ovarian cysts
  • N94.0 Mittelschmerz
  • N94.89 Oth cond assoc w female genital organs and menstrual cycle
  • D25.9 Leiomyoma of uterus, unspecified

SNOMED

  • 237067000 chronic pain in female pelvis (finding)
  • 76376003 endometriosis of uterus (disorder)
  • 62394006 female pelvic peritoneal adhesions (disorder)
  • 79883001 cyst of ovary (disorder)
  • 43548008 Mittelschmerz (finding)
  • 39402007 pelvic congestion syndrome (disorder)
  • 95315005 uterine leiomyoma (disorder)

Clinical Pearls

  • Chronic pelvic pain (CPP) is a syndrome whose etiology remains unknown; however, uncovering a definitive diagnosis improves prognosis and treatment.
  • Evaluate all pelvis-gynecologic, urologic, gastrointestinal, neurologic, and musculoskeletal organ systems.
  • Screen for concomitant psychological disorders.
  • A team approach between the specialists and the primary provider improves patient care and outcome.
  • Establishing a supportive relationship is essential to care of the patient with CPP.
  • Even in the patient with depression, chronic pelvic pain is not "all in her head."пїЅ A combined approach of mind and body will provide optimal results.