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Chronic pelvic pain

Chronic pelvic pain. Karen C. Wang, MD Department of Obstetrics and Gynecology Director of Minimally Invasive Surgery Beth Israel Medical Center April 22, 2010. Objectives. Define and review the impact of chronic pelvic pain (CPP) Discuss the potential etiologies of CPP

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Chronic pelvic pain

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  1. Chronic pelvic pain Karen C. Wang, MD Department of Obstetrics and Gynecology Director of Minimally Invasive Surgery Beth Israel Medical Center April 22, 2010

  2. Objectives • Define and review the impact of chronic pelvic pain (CPP) • Discuss the potential etiologies of CPP • Review current treatment modalities for common gynecologic causes of CPP • Emphasize the importance of a multidisciplinary approach to the management of CPP

  3. Chronic Pelvic Pain (CPP) • Non-cyclic pain • Duration > 6 months • Localized to: anatomic pelvis, anterior abdominal wall, lumbrosacral back or buttocks • Sufficient severity to cause functional disability or lead to medical care American College of Obstetricians and Gynecologists Practice Bulletin No. 51, March 2004

  4. Epidemiology • 15-20% of women between the ages of 18-50 years have pelvic pain lasting more than one year during their lifetime • Primary indication for: • 10% outpatient gynecology visits • 12% hysterectomy • 40% diagnostic laparoscopy Howard FM, Ob Gyn Surv 1993, Lee NC et al AJOG 1984, Zondervan K, et al Br J Gen Prac 2001, Tu FF, AJOG 2006

  5. Social Impact of CPP • Among women with CPP • Use 3x more medications • Have 4x more GYN surgeries • Are 5x more likely to have a hysterectomy • 58% reduce normal activity >1 day/month • 26% stay in bed >1 day/month • 15% report lost time from work • 48% report reduced work productivity Mathias SD et al Obstet Gynecol 1996, Reiter R et al. Obstet Gynecol 1990

  6. Economic impact of CPP • $300-500 million/year in laparoscopic evaluations • $881 million/year in direct costs • $2 billion/year in indirect costs Tu FF & Beaumont, JL AJOG 2006, Mathias SD et al Ob/Gyn 1996

  7. Important Considerations • Pain is subjective • A normal physical examination does not preclude the presence of pathology • Never expect only one diagnosis or etiology

  8. Important Considerations Neurology/pain med • Simultaneously evaluate and treat all contributing factors (collaboration) • Treatment is challenging due to the lack of effective durable treatments • Economic pressures often hinder extensive workup GI GYN PM&R GU

  9. Common etiologies of CPP* Musculoskeletal/Neurologic Gynecologic Urologic Gastrointestinal • Pelvic floor myalgia • Trigger points • Idiopathic low back • pain • Disc disease • SI joint disease • Coccydynia • Nerve entrapment • syndromes • IBS • Functional Bowel • disorders • Chronic appendicitis • Inflammatory bowel • disease • Hernias • Diverticular disease • Intermittent bowel • Obstruction • Endometriosis • Adenomyosis • Adhesions • Chronic PID • Uterine fibroids • Pelvic congestion • Ovarian remnant • Residual ovarian • syndrome • Vaginal apex pain • Vestibulodynia • Interstitial Cystitis • Urethral syndrome • Chronic UTI • Bladder stones *excludes carcinomas

  10. Common etiologies of CPP* Musculoskeletal/Neurologic Gynecologic Urologic Gastrointestinal • Pelvic floor myalgia • Trigger points • Idiopathic low back • pain • Disc disease • SI joint disease • Coccydynia • Nerve entrapment • syndromes • IBS • Functional Bowel • disorders • Chronic appendicitis • Inflammatory bowel • disease • Hernias • Diverticular disease • Intermittent bowel • Obstruction • Endometriosis • Adenomyosis • Adhesions • Chronic PID • Uterine fibroids • Pelvic congestion • Ovarian remnant • Residual ovarian • syndrome • Vaginal apex pain • Interstitial Cystitis • Urethral syndrome • Chronic UTI • Bladder stones *excludes carcinomas

  11. Endometriosis

  12. Case Study 1 • 26 year-old G0 presents with complaints of crampy intermittent shooting pelvic pain for the past four years. +dysmenorrhea since menarche, previously controlled with NSAIDs. Now with daily pelvic pain worse shortly before and during menses. +deep dyspareunia and +dyschezia. Never been on oral contraceptives.

  13. Case Study 1 • Examination • Abdomen diffusely tender • Cervix deviated to the left on speculum examination • Uterus retroverted and minimally mobile • Thickening and tenderness of the left uterosacral ligament • Fullness and tenderness of the right adnexa

  14. Case Study 1 Pelvic ultrasound shows a complex 5 cm right adnexal mass that is persistent on serial ultrasounds over 4 months.

  15. Normal Pelvis

  16. Endometriosis adhesions endometriosis Uterus Ovary

  17. Endometriosis • Defined by the presence of endometrial glands and stroma outside of the uterus • Histological diagnosis that requires surgical evaluation

  18. Etiology of Endometriosis • Implantation Theory • Retrograde menstruation • Direct transplantation Theory • Post-surgical (cesarean section, myomectomy, episiotomy) • Lymphatic or vascular dissemination • Coelomic metaplasia • Peritoneal cavity has cells that can de-differentiate into endometrial tissue

  19. Symptoms of Endometriosis -None -Chronic non-menstrual pelvic pain -Dysmenorrhea -Dyspareunia -Pelvic mass -Dyschezia -Decreased quality of life -Infertility • Severity of symptoms do not correlate with severity of anatomic disease except for depth of infiltration • Co-occurrence with: interstitial cystitis, irritable bowel syndrome, temperomandibular disorder, migraine, fibromyalgia, vulvodynia.

  20. Diagnosis of Endometriosis • Histological confirmation after surgical exploration • Ultrasound • Adnexal mass • MRI • Adnexal mass • Adenomyosis • Infiltrating endometriosis of uterosacrals or cul de sac • CA-125 • Nonspecific. May be elevated with benign or malignant disease

  21. 10% 30% 60% 50% Prevalence of Endometriosis 2% asymptomatic reproductive aged women subfertile chronic pelvic pain adolescent with chronic pelvic pain 100% 0% ACOG practice bulletin 2000

  22. Location of endometriosis Posterior cul-de-sac 69% Ovaries 33% Fossa ovarica 45% Anterior cul-de-sac 24% Bowel/appendix 5% 1999 Joan Beck

  23. trEATment options Medical Surgical

  24. Treatment for Endometriosis • MEDICAL • NSAIDs • Combination OCP • Progestins • Oral • Depo-Provera • Mirena IUD • GnRH agonist (> 18 y.o.) • Danazol • Aromatase inhibitor

  25. Hormonal Treatments

  26. Levonorgestrel-IUD for endometriosis • Advantage – low maintenance, minimal side effects • 5 year lifespan • Systemic and local effects • RCT LNG-IUD vs. Lupron • 6 month follow-up • Significant improvement from baseline in both groups • No difference between groups • 3 year follow-up data in observational series (n=34) • 56% continuation rate at end • VAS dropped from 7.7 -> 2.7 • (average pain, previous month) Petta, Hum Rep 2005; Lockhat F et al, Hum Rep 2005

  27. Levonorgestrel-IUD for endometriosis • Decrease lesion size and pain symptoms in rectovaginal nodules • Equivalent to GnRH agonist (Lupron) in randomized controlled trial • Decrease in recurrence of pain after surgery for endometriosis • Over 50% of women choose to retain IUD after 3 years Petta, Hum Rep 2005; Lockhat F et al, Hum Rep 2005

  28. Efficacy of medical therapy • Most treatment decrease symptoms in 70-85% of users • Choose treatment based on patient preference, cost, and side-effects • Recurrence is common after discontinuation of medical therapy

  29. Treatment for Endometriosis • SURGICAL • Conservative • Laparoscopy* • Excision/ablation • LUNA/presacral neurectomy • Adnexal mass • Oophorectomy • Hysterectomy + BSO • Resection of lesions (rectovaginal, small bowel, extrapelvic) *Sutton CJ et al, Fertil Steril 1997

  30. Indications for surgery • To establish a diagnosis • To improve or relieve symptoms • To normalize anatomy for sub-fertility • To investigate a mass • To evaluate pain that is refractory to other treatments

  31. Conservative Surgical Management • Recurrence rate is correlated with disease severity • 37% mild disease • 74% severe disease • 67% within two years of surgery • Use of GnRH agonist for 3 months delays recurrence

  32. Laparoscopy for pelvic pain associated with endometriosis (RCT) • Sutton et al. 1994 • Study design • RCT, double blinded • N=63 ♀ stage I-III endometriosis • [Laparoscopic laser ablation + LUNA] vs. expectant management • Results • No difference at 3 months (48% of expectant group with improved pain) • Significant improvement with laser ablation at 6 months (63% vs. 23%, p<0.01) 8.5 * VAS pain score (0-10) 4.5 Sutton et al. Fertil Steril 1994; 62(4):696-700. * p=0.01, laser vs. expectant

  33. Hysterectomy ± BSO • Touted as “definitive treatment” • No RCTs to evaluate efficacy • Endometriosis &/or pelvic pain may recur, even if BSO performed • Incidence unknown, estimates vary widely ~2-60%

  34. Hysterectomy is not definitive for all endometriosis or chronic pelvic pain Namnoun et al. Fertil Steril 1995; Matorras et al. Fertil Steril 2002.

  35. Indications for hysterectomy in women with endometriosis • Chronic pelvic pain with significant reduction in quality of life • Does not desire fertility • Unresponsive to medical therapy and prior conservative surgical therapy • If undergoing BSO, understands and accepts negative impact of castration on other health parameters • Osteoporosis, cardiovascular disease, sexual dysfunction, menopausal symptoms, long-term risk/benefits of HRT, etc. • AND….

  36. Indications for hysterectomy in women with endometriosis • Other sources of pain have been excluded and/or maximally treated!!!

  37. Challenges of endometriosis • Little, if any, correlation between extent of disease and severity of pain. • Medical and surgical therapies are non-specific. ex. Lupron is an effective therapy for cyclic-IBS. • Medical and surgical therapies are inadequate for many patients. ex. Hysterectomy/BSO is not curative for all patients, 5-10% report persistent/recurrent pain. • Frequency of recurrent pain is high following medical and surgical therapies. Pain recurs often in the absence of recurrent endometriotic disease.

  38. Evidence that endometriosis-associated CPP may be a central pain syndrome • High co-prevalence with other central pain disorders • Nerve fiber proliferation in endometriosis lesions • Nerve fiber proliferation in endometrial lining and myometrium in women with endometriosis and women with chronic pelvic pain • Increased generalized pain sensitivity in women with endometriosis

  39. Adhesions

  40. Pelvic Adhesions: Incidence • 55-100% incidence at second look laparoscopy (average 85%) • >90% incidence following major abdominal surgery • Following myomectomy, adnexal adhesions occur: • 94% with posterior uterine incisions • 56% with anterior/fundal uterine incisions Lau, Tulandi in Peritoneal Surgery 1999; Diamond, Fertil Steril 1987; Tulandi, et al. Obstet Gynecol 1993

  41. Pelvic & Abdominal Adhesions • ~ 25% prevalence among CPP patients • 80% of patients undergoing pain mapping reported pain when adhesions palpated • Nerves, sensory neuron markers found in adhesions of both pain & pain-free patients Howard F, Ob Gyn Surv 1993; Sulaiman et al. Ann Surg 2002

  42. Complications Associated with Pelvic Adhesions • Infertility (40%) • Chronic pelvic pain (50%) • Small bowel obstruction (49-74%) • 20% within 1 month • 40% within 1 year • Reoperation Liakakos Dig Surg, 2001; Monk et al.AmJ Obstet Gynecol 1994 El-Mowafi Prog Obstet Gynecol 2000

  43. Is Adhesiolysis Effective? • RCT of laparoscopic lysis of adhesions vs. diagnostic laparoscopy • 100 participants with chronic abdominal pain (> 6 months) • Participants, assessors masked • Outcome: overall improvement in pain, function • No difference in groups at one year Pain scores hrQOL scores Swank D et al. Lancet 2003

  44. Adhesions & CPP Sensory nerve fibers are present in human peritoneal adhesions • Nerve fibers were present in all the peritoneal adhesions examined • Nerve fibers expressing substance P were present in all adhesions irrespective of chronic pelvic pain • Nerves were often associated with blood vessels Sulaiman H, Annals of Surgery, 2001

  45. Pain Relief After Adhesiolysis 65 20 42 42 One Year Follow-up

  46. Is Adhesiolysis Effective? • Several observational studies suggest adhesiolysis may be of some benefit for women with CPP • Patients most likely to benefit: • Severe, stage IV adhesions • No endometriosis • Patients with limited psychological distress and/or comorbidities Steege 1991, Malik 2000

  47. Pelvic Floor Myaglia

  48. Pelvic Floor Myalgia • Involuntary spasm of the pelvic floor muscles • Etiology • Inflammation • Childbirth • Pelvic surgery • Trauma

  49. Pelvic Floor myofascial syndrome • History • “heavy aching pelvic pressure, falling-out sensation,” often later in the day after prolonged sitting • dyspareunia • Diagnostic tests (unvalidated) • Contracted, painful muscles on intravaginal exam • EMG or vaginal manometry– elevated baseline tone, muscle instability, and decreased endurance contractile capacity Hetrick DC et al Neurourol Urodyn 2006

  50. Pelvic floor myofascialsyndrome • Identified in over 20% of women in CPP referral clinics • Associations with IC, vulvodynia, endometriosis • Treatment includes pelvic floor physical therapy and other adjuvant therapies Weiss JM et al J Urol 2001, Glazer HI et al JRM 1998,Tu FF et al. JRM 2006, Tu et al OGS 2005

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