Chronic Pelvic Pain in Gynecological Practice

1. Chronic Pelvic Pain in Gynecological Practice Yasser Orief, M.D

2. Agenda BACHGROUND Definition of pain Nociception & innervation Innervation of urogenital system PAIN EVALUATION & MEASUREMENT Pain Evaluation Pain measurement CHRONIC PELVIC PAIN Definitions of CPC Classification of CPC syndromes

3. Background Pain is the most common symptom of any illness; the physician�s therapeutic task is twofold: to discover and treat the cause of pain and to treat the pain itself, whether or not the underlying cause is treatable.

4. PAIN �AN UNPLEASANT SENSORY AND EMOTIONAL EXPERIENCE ASSOCIATED WITH ACTUAL OR POTENTIAL TISSUE DAMAGE�* * INTERNATIONAL ASSOCIATION FOR THE STUDY OF PAIN

5. Pain Pathway

7. Actually two quite different kinds of pain exist: The first is termed nociceptive. This pain is associated with tissue damage or inflammation, so it is also called �inflammatory pain�. The second is termed neuropathic and results from a lesion to the peripheral or central nervous systems. Many pains will have a mixed neuropathic and nociceptive aetiology. Although we use the term of pain to define all sensations that hurt or are unpleasant, actually two quite different kinds of pain exist. The first is termed nociceptive. This pain is associated with tissue damage or inflammation, so it is also called �inflammatory pain�. The second is termed neuropathic and results from a lesion to the peripheral or central nervous systems. Many pains will have a mixed neuropathic and nociceptive aetiology. Although we use the term of pain to define all sensations that hurt or are unpleasant, actually two quite different kinds of pain exist. The first is termed nociceptive. This pain is associated with tissue damage or inflammation, so it is also called �inflammatory pain�. The second is termed neuropathic and results from a lesion to the peripheral or central nervous systems. Many pains will have a mixed neuropathic and nociceptive aetiology.

8. Nociceptive Pain Presumably related to ongoing activation of primary afferent neurons in response to noxious stimuli (eg, tissue injury) Pain is consistent with the degree of tissue injury Subtypes Somatic: well localized, described as sharp, aching, throbbing Visceral: more diffuse, described as gnawing or cramping Nociceptive pain is thought to be related to ongoing activation of primary afferent neurons responsive to noxious stimuli. The activation of the nociceptors is related to tissue damage, although the relation between pain and tissue damage is neither uniform nor constant. Somatic pain refers to ongoing activation of somatic afferent neurons, such as that experienced in bone pain. Visceral pain is related to activation of the primary afferent neurons that innervate viscera, for example, liver capsular pain.Nociceptive pain is thought to be related to ongoing activation of primary afferent neurons responsive to noxious stimuli. The activation of the nociceptors is related to tissue damage, although the relation between pain and tissue damage is neither uniform nor constant. Somatic pain refers to ongoing activation of somatic afferent neurons, such as that experienced in bone pain. Visceral pain is related to activation of the primary afferent neurons that innervate viscera, for example, liver capsular pain.

9. Neuropathic Pain Pain believed to be sustained by aberrant somatosensory processing in the peripheral or central nervous system (eg, nerve injury) Neuropathic pain includes many clinical entities, which vary in their presentation, pathophysiology, and treatment. Classification is based upon location of the pain generator (peripheral or central) and types of mechanisms involved. Deafferentation pain includes injury to the brain or spinal cord, phantom pain, and postherpetic neuralgia. Complex regional pain syndrome (reflex sympathetic dystrophy and causalgia) suggests a relatively higher likelihood of sympathetically-maintained pain. Neuropathic pain includes many clinical entities, which vary in their presentation, pathophysiology, and treatment. Classification is based upon location of the pain generator (peripheral or central) and types of mechanisms involved. Deafferentation pain includes injury to the brain or spinal cord, phantom pain, and postherpetic neuralgia. Complex regional pain syndrome (reflex sympathetic dystrophy and causalgia) suggests a relatively higher likelihood of sympathetically-maintained pain.

10. Idiopathic Pain Pain in the absence of an identifiable physical or psychologic cause (eg, fibromyalgia) Pain is perceived to be excessive for the extent of organic pathology If a comprehensive assessment yields insufficient evidence for a definitive diagnosis, pain is labeled idiopathic. This term does not imply that the pain is any less real for the patient or that the patient is malingering, but rather that the etiology is elusive.If a comprehensive assessment yields insufficient evidence for a definitive diagnosis, pain is labeled idiopathic. This term does not imply that the pain is any less real for the patient or that the patient is malingering, but rather that the etiology is elusive.

11. Psychogenic Pain Pain sustained by psychologic factors More precisely characterized in psychiatric terminology Patients have affective and behavioral disturbances Patients with organic component often have concurrent psychological contributions and co-morbidities The term �psychogenic pain� is used when the clinician believes that psychologic factors might be causing, maintaining, or exacerbating pain symptoms. This classification most often is used in the absence of finding physiologic causes for the pain. The term �chronic nonmalignant pain syndrome� also is used in this context to describe poorly-controlled pain associated with high levels of disability and psychologic disturbance. However, there is a danger that this label can be applied pejoratively, resulting in pain undertreatment and mismanagement. Instead, a broader classification that integrates physical, psychosocial, and behavioral components may be optimal. The term �psychogenic pain� is used when the clinician believes that psychologic factors might be causing, maintaining, or exacerbating pain symptoms. This classification most often is used in the absence of finding physiologic causes for the pain. The term �chronic nonmalignant pain syndrome� also is used in this context to describe poorly-controlled pain associated with high levels of disability and psychologic disturbance. However, there is a danger that this label can be applied pejoratively, resulting in pain undertreatment and mismanagement. Instead, a broader classification that integrates physical, psychosocial, and behavioral components may be optimal.

12. Levels of pain Pathology at the site of origin. Referred Pain. Trigger points . Action of the Brain. It is important to remember that all of these 4 levels of pain must be treated together for CPP therapy to be successful. Pathology at the site of origin. There is or was an injury (pathology) at the place (site of origin) where the pain first started. This injury might be endometriosis, ovarian Referred Pain. Your body has two types of nerves. Visceral nerves carry impulses from the organs and structures within your abdomen and chest (stomach, intestines, lungs, etc.). Somatic nerves bring messages from the skin and muscles. Both types of nerves travel to the same sites on the spinal cord. When your visceral nerves are stimulated for long periods with chronic, ongoing pain, some of this stimulation may spill over into the somatic nerves, which then carry the pain back to the muscles and skin. In CPP, the somatic nerves may carry the pain back to your pelvic and abdominal muscles and skin. That means that your pain Trigger points are specific areas of tenderness occurring in the muscle wall of the abdomen. Trigger points may start out as just one symptom of your pelvic pain or they may be the major source of pain for you. For this reason, treating the trigger points, for some women, may significantly reduce the pain. Action of the Brain. Your brain influences your emotions and behavior. It also interacts with your spinal cord and affects how you feel the visceral and referred pain. For instance, if you are depressed, your brain will allow more pain signals to cross the gates of the spinal cord cord, and you will feel more pain. This influence or modulation by the brain must treated. Treatment can also be include psychological counseling, physical therapy and medications. It is important to remember that all of these 4 levels of pain must be treated together for CPP therapy to be successful. Pathology at the site of origin. There is or was an injury (pathology) at the place (site of origin) where the pain first started. This injury might be endometriosis, ovarian Referred Pain. Your body has two types of nerves. Visceral nerves carry impulses from the organs and structures within your abdomen and chest (stomach, intestines, lungs, etc.). Somatic nerves bring messages from the skin and muscles. Both types of nerves travel to the same sites on the spinal cord. When your visceral nerves are stimulated for long periods with chronic, ongoing pain, some of this stimulation may spill over into the somatic nerves, which then carry the pain back to the muscles and skin. In CPP, the somatic nerves may carry the pain back to your pelvic and abdominal muscles and skin. That means that your pain Trigger points are specific areas of tenderness occurring in the muscle wall of the abdomen. Trigger points may start out as just one symptom of your pelvic pain or they may be the major source of pain for you. For this reason, treating the trigger points, for some women, may significantly reduce the pain. Action of the Brain. Your brain influences your emotions and behavior. It also interacts with your spinal cord and affects how you feel the visceral and referred pain. For instance, if you are depressed, your brain will allow more pain signals to cross the gates of the spinal cord cord, and you will feel more pain. This influence or modulation by the brain must treated. Treatment can also be include psychological counseling, physical therapy and medications. It is important to remember that all of these 4 levels of pain must be treated together for CPP therapy to be successful.

13. Viscerosomatic Convergence and Pelvic Floor Myalgia Viscero Muscular Reflex ! Pelvic Floor Tension Myalgia Viscero Muscular Reflex ! Pelvic Floor Tension Myalgia

14. Viscerovisceral Hyperalgesia Visceral Hyperalgesia Visceral Sensitization e.g. IBS, IC Viscerovisceral Hyperalgesia ! Referral Sensitization to second viscera e.g. IC with IBS, endometriosis Visceral Hyperalgesia Visceral Sensitization e.g. IBS, IC Viscerovisceral Hyperalgesia ! Referral Sensitization to second viscera e.g. IC with IBS, endometriosis

15. Abdominal Wall Trigger Points Tenderness over the �ovarian point� Suggests pelvic congestion syndrome Pain thought to be due to compression of ovarian veins Tenderness over the �ovarian point� Suggests pelvic congestion syndrome Pain thought to be due to compression of ovarian veins

16. Pain Evaluation & Measurement

17. � Take a detailed history of the pain including an assessment of the pain intensity and character � Evaluate the psychological state of the patient, including an assessment of mood and coping responses � Perform a physical examination emphasizing the neurologic examination � Appropriate diagnostic workup to determine the cause of the pain which may include tumour markers, radiologic studies, scans etc. � Re-evaluate therapy. Systematic evaluation of the pain involves the following;

18. The initial evaluation of pain should include a description of pain using PQRST criteria P: Palliative or Provocative factors, �what makes it less intense?� Q: Quality, �what is it like?� R: Radiation, �does it spread anywhere else?� S: Severity, �how severe is it?� T: Temporal factors, �is it there all the time, or does it come and go?�

19. Pain measurement A number of different rating scales have been devised. They all rely on a subjective assessment of the pain and therefore make inter-individual comparisons difficult. Additionally, pain is a multidimensional complex phenomenon and is not adequately described by unidimensional scales Pain measurement A number of different rating scales have been devised to attempt to methodically measure pain. These have been used in research, audit and in clinical practice. Additionally, pain is a multidimensional complex phenomenon and is not adequately described by unidimensional scales, however there is value in making some sort of an assessment to aid clinical practice. Pain measurement A number of different rating scales have been devised to attempt to methodically measure pain. These have been used in research, audit and in clinical practice. Additionally, pain is a multidimensional complex phenomenon and is not adequately described by unidimensional scales, however there is value in making some sort of an assessment to aid clinical practice.

20. Scaling systems Categorical scales e.g., verbal rating scales: mild, moderate, severe pain Visual analogue scale (VAS) Complex pain assessment Brief Pain Inventory (BPI), McGill Pain Questionnaire. � Categorical scales e.g., verbal rating scales: mild, moderate, severe pain � Visual analogue scale (VAS), e.g., a line is drawn with numbers from 0 (no pain)-10 (severe pain), pain severity is indicated by marking along the line 0 �����������������������������������������- 10 � The BPI consists of several visual analogue scales grouped together assessing pain at rest, on movement, and other aspects of the pain including interference with function and effect on work. � Categorical scales e.g., verbal rating scales: mild, moderate, severe pain � Visual analogue scale (VAS), e.g., a line is drawn with numbers from 0 (no pain)-10 (severe pain), pain severity is indicated by marking along the line 0 �����������������������������������������- 10 � The BPI consists of several visual analogue scales grouped together assessing pain at rest, on movement, and other aspects of the pain including interference with function and effect on work.

22. Chronic Pelvic Pain (CPP)

23. ACOG Definition of CPP �Non-cyclic pain of 6 or more months duration that localizes to the anatomic pelvis, abdominal wall at or below the umbilicus, lumbosacral back or the buttocks and is of sufficient severity to cause functional disability or lead to medical care.�

24. Definition of Chronic Pelvic Pain Duration 3months if continues 6 months if cyclic Location Anatomic pelvis Abdominal wall below the umbilicus Lower back Non-cyclic � Dysmenorrhea � Dyspareunia Severity Medical or surgical therapy required Functional impairment CPP may be defined by its duration and location. Most authorities consider pelvic pain chronic when it has lasted six or more months, although this is arbitrary and three months may be as appropriate. Pain may be considered pelvic if it is located deep within the anatomic true or false pelvis, on the anterior abdominal wall, or on the lower lumbar or sacral area of the back.CPP may be defined by its duration and location. Most authorities consider pelvic pain chronic when it has lasted six or more months, although this is arbitrary and three months may be as appropriate. Pain may be considered pelvic if it is located deep within the anatomic true or false pelvis, on the anterior abdominal wall, or on the lower lumbar or sacral area of the back.

25. Why is Chronic Pelvic Pain so Different?

26. ACUTE vs CHRONIC PAIN ACUTE PELVIC PAIN: symptom of underlying tissue injury and disease CHRONIC PELVIC PAIN: pain becomes the disease (etiology not found or treatment of presumed etiology fails)

27. CPP Syndrome Is the occurrence of persistent or recurrent episodic pelvic pain associated with symptoms suggestive of lower urinary tract, sexual, bowel or gynaecological dysfunction. There is no proven infection or other obvious pathology. (adopted from ICS 2002)

28. CPP Syndrome Bladder pain syndrome Urethral pain syndrome Penile pain syndrome Prostate pain syndrome Scrotal pain syndrome Testicular pain syndrome Post vasectomy pain syndrome Epididymal pain syndrome Endometriosis associated pain syndrome Vaginal pain syndrome Vulvar pain syndrome Generalized vulvar pain syndrome Localized vulvar pain syndrome Vestibular pain syndrome Clitorial pain syndrome Anorectal pain syndrome Anismus pain syndrome Pudendal pain syndrome Perineal pain syndrome Pelvic floor muscle pain syndrome

29. There is currently no ideal classification for those conditions that may be considered under chronic pain syndrome. The major controversy within this area is that a pain may involve multiple sites, aetiologies and mechanisms. An individual using the above classification should start on the left of the table and proceed to the right only if they can truly and confidently confirm the pathology in the appropriate system and organ. In many cases, it may not be possible to progress further than labelling a condition as pelvic pain syndrome.There is currently no ideal classification for those conditions that may be considered under chronic pain syndrome. The major controversy within this area is that a pain may involve multiple sites, aetiologies and mechanisms. An individual using the above classification should start on the left of the table and proceed to the right only if they can truly and confidently confirm the pathology in the appropriate system and organ. In many cases, it may not be possible to progress further than labelling a condition as pelvic pain syndrome.

30. Epidemiology

31. Magnitude of CPP >9 million women in the United States1 20% of women had pelvic pain >1 year in duration2 CPP accounts for 10% of referrals for OB/Gyn visits3 Over 20% of laparoscopies4 12 -18 % of hysterectomies5 Patients with CPP have significantly lower general health scores compared with patients without CPP1 CPP Is a Significant and Common Disorder in Women CPP Is a Significant and Common Disorder in Women In fact, a Gallup poll of 5263 eligible women found that 14.7% had CPP for at least 3 months.1 This is equivalent to more than 9 million women in the United States. In another survey of 581 women in 5 OB/Gyn and family medicine practices, it was found that 20% of women had pelvic pain for over 1 year.2 Some of these women also reported that their condition limited their home activity (11%) and sexual activity (12%). Sixteen percent indicated taking medication for pain.2 CPP accounts for 10% of patient referrals to OB/Gyns,3 over 40% of laparoscopies,4 and 18% of hysterectomies.5 Patients with CPP have significantly lower general health scores compared with patients without CPP.1 In addition, 61% of women with CPP reported that the cause was unknown. CPP Is a Significant and Common Disorder in Women In fact, a Gallup poll of 5263 eligible women found that 14.7% had CPP for at least 3 months.1 This is equivalent to more than 9 million women in the United States. In another survey of 581 women in 5 OB/Gyn and family medicine practices, it was found that 20% of women had pelvic pain for over 1 year.2 Some of these women also reported that their condition limited their home activity (11%) and sexual activity (12%). Sixteen percent indicated taking medication for pain.2 CPP accounts for 10% of patient referrals to OB/Gyns,3 over 40% of laparoscopies,4 and 18% of hysterectomies.5 Patients with CPP have significantly lower general health scores compared with patients without CPP.1 In addition, 61% of women with CPP reported that the cause was unknown.

32. Prevalence of CPP is Comparable to Other Common Medical Problems Cross-sectional analysis by UK Mediplus Primary Care database.

33. Medical costs for CPP Direct outpatient medical costs for CPP: $881.5 million/year1 Total annual direct costs $2.8 billion/year 15% of women with CPP missed >1 hr paid work/month1 Cost of work time lost for CPP $555.3 million/year

34. Etiology

35. Introduction Pelvic pain has multifactorial etiology Overlapping cerebral representation for somatic and visceral structures Multiple stakeholders involved in evaluation and management Many people in my field, gynecology, equate pelvic pain with endometriosis Clinical experience and epidemiological studies suggest the pathophysiology is far more complicated than this one-to-one concordance. Endometriotic implants is only one observation associated with symptoms of pain in the female pelvic/abdominal region. This classic elephant and blind men metaphor is an appropriate metaphor for the patchwork approach to pelvic pain workup that results from our specialist dominated workup. By the time painful stimuli from the periphery reach the thalamus, considerable integration of inputs (which may represent both somatic and visceral input) can occur. At the sensory cortex, even more integration can occur, which is how psychological state can further modulate the pain experience. Unfortunately for the suffering patient, they don�t necessarily get a interdisciplinary evaluation at first. Urology, gynecology, neurology, PM&R-PT, GI, anesthesia, psychiatry-psychology all may lay claim to the patient who presents with persistent abdominal-pelvic pain symptoms. Clinicians need to recognize when treatment isn�t effective that prompt initiation for multidisciplinary mgt is needed, with a humble understanding that our historical labels for pain disorders (endometriosis, interstitial cystitis, or adhesions) are inadequate. Many people in my field, gynecology, equate pelvic pain with endometriosis Clinical experience and epidemiological studies suggest the pathophysiology is far more complicated than this one-to-one concordance. Endometriotic implants is only one observation associated with symptoms of pain in the female pelvic/abdominal region. This classic elephant and blind men metaphor is an appropriate metaphor for the patchwork approach to pelvic pain workup that results from our specialist dominated workup. By the time painful stimuli from the periphery reach the thalamus, considerable integration of inputs (which may represent both somatic and visceral input) can occur. At the sensory cortex, even more integration can occur, which is how psychological state can further modulate the pain experience. Unfortunately for the suffering patient, they don�t necessarily get a interdisciplinary evaluation at first. Urology, gynecology, neurology, PM&R-PT, GI, anesthesia, psychiatry-psychology all may lay claim to the patient who presents with persistent abdominal-pelvic pain symptoms. Clinicians need to recognize when treatment isn�t effective that prompt initiation for multidisciplinary mgt is needed, with a humble understanding that our historical labels for pain disorders (endometriosis, interstitial cystitis, or adhesions) are inadequate.

36. Systems Based Evaluation Gastrointestinal Skeletal Muscular Vascular Reproductive Urinary Neurologic Don�t forget the most important extra-abdominal organ! Psychiatric evaluation

37. EtiologyPhysical vs. Psychiatric

38. ACOG Practice BulletinNumber 51; March 2004 CPP is common in women and presents a diagnostic challenge Most common disorders that cause CPP are endometriosis, interstitial cystitis and irritable bowel syndrome 38-85% of women presenting to a gynecologist for CPP may have IC

39. Pelvic Pain Assessment Forms

40. International Pelvic Pain Society Assssment Form

41. History Detailed Focused Pelvic Review of systems Biopsychosocial Model A detailed medical history is an essential starting point because the nature, frequency and site of the pain, as well as its relationship to precipitating factors and the menstrual cycle, may provide vital clues to the aetiology. A detailed menstrual and sexual history, including any history of sexually transmitted diseases and vaginal discharge is mandatory. Discrete inquiry about previous sexual trauma may be appropriate. A detailed medical history is an essential starting point because the nature, frequency and site of the pain, as well as its relationship to precipitating factors and the menstrual cycle, may provide vital clues to the aetiology. A detailed menstrual and sexual history, including any history of sexually transmitted diseases and vaginal discharge is mandatory. Discrete inquiry about previous sexual trauma may be appropriate.

42. Chronic Pelvic Pain: History Pain duration > 6 months Incomplete relief by most previous treatments, including surgery and non-narcotic analgesics Significantly impaired functioning at home or work Signs of depression such as early morning awakening, weight loss, and anorexia

43. Pain out of proportion to pathology History of childhood abuse, incest, rape or other sexual trauma Current sexual dysfunction Previous consultation with one or more health care providers and dissatisfaction with their management of her condition

44. Physical Examination General Examination Check for Fibromyalgia Check Abdominal Wall trigger points Systematic physical exam of abdominal, pelvic, and rectal areas, focusing on the location and intensity of the pain. Q-tip test for vestibulitis Check for Pelvic Floor Myalgia Single Digit Pelvic Exam Speculm exam Bimanual exam Rectovaginal exam Palpate the coccyx, both internally and externally Abdominal and pelvic examination will exclude any gross pelvic pathology (tumours, scarring and reduced uterine mobility), as well as demonstrating the site of tenderness if present. Abnormalities in muscle function should also be sought. Abdominal and pelvic examination will exclude any gross pelvic pathology (tumours, scarring and reduced uterine mobility), as well as demonstrating the site of tenderness if present. Abnormalities in muscle function should also be sought.

45. Patient Evaluation for Bladder Tenderness Suprapubic tenderness Anterior vaginal wall/bladder base tenderness Levator muscle spasm Rectal spasm Patient Evaluation for Bladder Tenderness When evaluating a patient for IC, there are 4 specific factors to look for during the physical exam: � Suprapubic tenderness � Anterior vaginal wall/bladder base tenderness � Levator muscle spasm � Rectal spasmPatient Evaluation for Bladder Tenderness When evaluating a patient for IC, there are 4 specific factors to look for during the physical exam: � Suprapubic tenderness � Anterior vaginal wall/bladder base tenderness � Levator muscle spasm � Rectal spasm

46. Physical Examination: Pelvic Traditional bimanual examination is the last portion of the pelvic examination Uterus Adnexa Anorectum Many layers palpated; non-specific findings likely The traditional bimanual examination is the last portion of the pelvic examination in the pelvic pain patient. The traditional bimanual examination is the last portion of the pelvic examination in the pelvic pain patient.

47. Investigations Should be selected discriminately as indicated by the findings of the history and physical exam Avoid unnecessary and repetitive diagnostic testing Vaginal smearing Cervical cultures HSG Stool analysis Ultrasound Diagnostic laparascopy Vaginal and endocervical swabs to exclude infection are mandatory, cervical cytology screening is advisable. Pelvic ultrasound scanning provides further information with regard to pelvic anatomy and pathology. Laparoscopy is the most useful invasive investigation to exclude gynaecological pathology (2) and to assist in the differential diagnosis Vaginal and endocervical swabs to exclude infection are mandatory, cervical cytology screening is advisable. Pelvic ultrasound scanning provides further information with regard to pelvic anatomy and pathology. Laparoscopy is the most useful invasive investigation to exclude gynaecological pathology (2) and to assist in the differential diagnosis

48. Dysmenorrhoea . .

49. Dysmenorrhoea Pain in association with menstruation may be primary or secondary. Primary dysmenorrhoea classically commences with the onset of ovulatory menstrual cycles and tends to decrease following childbirth Explanation and reassurance may be helpful, together with the use of simple analgesics progressing to the use of non-steroidal anti-inflammatory drugs (NSAIDs), which are particularly helpful if they are started before the onset of menstruation. Dysmenorrhoea Pain in association with menstruation may be primary or secondary. Primary dysmenorrhoea classically commences with the onset of ovulatory menstrual cycles and tends to decrease following childbirth Explanation and reassurance may be helpful, together with the use of simple analgesics progressing to the use of non-steroidal anti-inflammatory drugs (NSAIDs), which are particularly helpful if they are started before the onset of menstruation. The efficacy of NSAIDs in this condition is probably related to the effects on prostaglandin synthetase. Suppression of ovulation using the oral contraceptive pill reduces dysmenorrhoea dramatically in most cases and may be used as a therapeutic test. Because of the chronic nature of the condition, potentially addictive analgesics should be avoided. Secondary dysmenorrhoea would suggest the development of a pathological process, and the exclusion of endometriosis and pelvic infection is essentialDysmenorrhoea Pain in association with menstruation may be primary or secondary. Primary dysmenorrhoea classically commences with the onset of ovulatory menstrual cycles and tends to decrease following childbirth Explanation and reassurance may be helpful, together with the use of simple analgesics progressing to the use of non-steroidal anti-inflammatory drugs (NSAIDs), which are particularly helpful if they are started before the onset of menstruation. The efficacy of NSAIDs in this condition is probably related to the effects on prostaglandin synthetase. Suppression of ovulation using the oral contraceptive pill reduces dysmenorrhoea dramatically in most cases and may be used as a therapeutic test. Because of the chronic nature of the condition, potentially addictive analgesics should be avoided. Secondary dysmenorrhoea would suggest the development of a pathological process, and the exclusion of endometriosis and pelvic infection is essential

50. Dysmenorrhoea Suppression of ovulation using the oral contraceptive pill reduces dysmenorrhoea dramatically in most cases. Because of the chronic nature of the condition, potentially addictive analgesics should be avoided. Secondary dysmenorrhoea would suggest the development of a pathological process, and the exclusion of endometriosis and pelvic infection is essential Dysmenorrhoea Pain in association with menstruation may be primary or secondary. Primary dysmenorrhoea classically commences with the onset of ovulatory menstrual cycles and tends to decrease following childbirth Explanation and reassurance may be helpful, together with the use of simple analgesics progressing to the use of non-steroidal anti-inflammatory drugs (NSAIDs), which are particularly helpful if they are started before the onset of menstruation. The efficacy of NSAIDs in this condition is probably related to the effects on prostaglandin synthetase. Suppression of ovulation using the oral contraceptive pill reduces dysmenorrhoea dramatically in most cases and may be used as a therapeutic test. Because of the chronic nature of the condition, potentially addictive analgesics should be avoided. Secondary dysmenorrhoea would suggest the development of a pathological process, and the exclusion of endometriosis and pelvic infection is essentialDysmenorrhoea Pain in association with menstruation may be primary or secondary. Primary dysmenorrhoea classically commences with the onset of ovulatory menstrual cycles and tends to decrease following childbirth Explanation and reassurance may be helpful, together with the use of simple analgesics progressing to the use of non-steroidal anti-inflammatory drugs (NSAIDs), which are particularly helpful if they are started before the onset of menstruation. The efficacy of NSAIDs in this condition is probably related to the effects on prostaglandin synthetase. Suppression of ovulation using the oral contraceptive pill reduces dysmenorrhoea dramatically in most cases and may be used as a therapeutic test. Because of the chronic nature of the condition, potentially addictive analgesics should be avoided. Secondary dysmenorrhoea would suggest the development of a pathological process, and the exclusion of endometriosis and pelvic infection is essential

51. Infection Infection A history of possible exposure to infection should be sought and it is mandatory in all cases to obtain swabs to exclude chlamydia and gonorrhoea, as well as vaginal and genital tract pathogens. Patient�s sexual contacts will need to be traced in all cases with positive cultures. If there is doubt about the diagnosis then laparoscopy may be of great assistance. The treatment of infection depends on the causative organisms. Subclinical chlamydial infection may lead to tubal pathology. Screening for this organism in sexually active young women may reduce the incidence of subsequent subfertility. Chronic pelvic inflammatory disease is no longer common in developed countries, but still poses a significant problem with chronic pain in the Third World. Infection A history of possible exposure to infection should be sought and it is mandatory in all cases to obtain swabs to exclude chlamydia and gonorrhoea, as well as vaginal and genital tract pathogens. Patient�s sexual contacts will need to be traced in all cases with positive cultures. If there is doubt about the diagnosis then laparoscopy may be of great assistance. The treatment of infection depends on the causative organisms. Subclinical chlamydial infection may lead to tubal pathology. Screening for this organism in sexually active young women may reduce the incidence of subsequent subfertility. Chronic pelvic inflammatory disease is no longer common in developed countries, but still poses a significant problem with chronic pain in the Third World.

52. Infection A history of possible exposure to infection should be sought and it is mandatory in all cases to obtain swabs to exclude chlamydia and gonorrhoea, as well as vaginal and genital tract pathogens. Patient�s sexual contacts will need to be traced in all cases with positive cultures. If there is doubt about the diagnosis then laparoscopy may be of great assistance. The treatment of infection depends on the causative organisms.

53. Infection Subclinical chlamydial infection may lead to tubal pathology. Screening for this organism in sexually active young women may reduce the incidence of subsequent subfertility. Chronic pelvic inflammatory disease is no longer common in developed countries, but still poses a significant problem with chronic pain in the Third World.

54. Gynaecological malignancy The spread of gynaecological malignancy of the cervix, uterine body or ovary will lead to pelvic pain depending on the site of spread. Treatment is of the primary condition, but all physicians dealing with pelvic pain must be fully aware of the possibility of gynaecological malignancy. The spread of gynaecological malignancy of the cervix, uterine body or ovary will lead to pelvic pain depending on the site of spread. Treatment is of the primary condition, but all physicians dealing with pelvic pain must be fully aware of the possibility of gynaecological malignancy.

55. Gynaecological malignancy The spread of gynaecological malignancy of the cervix, uterine body or ovary will lead to pelvic pain depending on the site of spread. Treatment is of the primary condition, but all physicians dealing with pelvic pain must be fully aware of the possibility of gynaecological malignancy.

56. Injuries related to childbirth Tissue trauma and soft tissue injuries occurring at the time of childbirth may lead to chronic pelvic pain related to the site of injury. Dyspareunia is a common problem leading to long-term difficulties with intercourse and female sexual dysfunction. Denervation of the pelvic floor with re-innervation may also lead to dysfunction and pain. Vulvar pain and psychosexual problems are discussed extensively in other sections of this text. Postmenopausal oestrogen deficiency may lead to pain associated with intercourse, which will respond to hormone replacement therapy. Tissue trauma and soft tissue injuries occurring at the time of childbirth may lead to chronic pelvic pain related to the site of injury. Dyspareunia is a common problem leading to long-term difficulties with intercourse and female sexual dysfunction. Denervation of the pelvic floor with re-innervation may also lead to dysfunction and pain. Vulvar pain and psychosexual problems are discussed extensively in other sections of this text. Postmenopausal oestrogen deficiency may lead to pain associated with intercourse, which will respond to hormone replacement therapy.

57. Injuries related to childbirth Tissue trauma and soft tissue injuries occurring at the time of childbirth may lead to chronic pelvic pain related to the site of injury. Dyspareunia is a common problem leading to long-term difficulties with intercourse and female sexual dysfunction. Denervation of the pelvic floor with re-innervation may also lead to dysfunction and pain.

58. Pelvic Adhesion

59. PELVIC ADHESIONS If adhesions are found adhesiolysis is beneficial in only 40% (especially in patients with chronic pain syndromes) Steege, 1991

60. Endometriosis & CPP The incidence of endometriosis is rising in the developed world. The precise aetiology is still a source of debate, but an association with nulliparity is well accepted. The condition may be suspected from a history of secondary dysmenorrhoea and often dyspareunia, as well as the finding of scarring in the vaginal fornices on vaginal examination, with reduced uterine mobility and adnexal masses. The most useful diagnostic tool is the laparoscope (9,10). Endometriotic lesions affecting the urinary bladder or causing ureteric obstructions can occur, as well as lesions affecting the bowel, which may lead to rectal bleeding in association with menstruation. 3.6.1 Treatment Analgesics and NSAIDs are helpful in ameliorating the pain at the time of menstruation, as in primary dysmenorrhoea. Hormone treatment with progestogens or the oral contraceptive pill may halt the progress of the condition, but are not curative. Luteinizing hormone releasing hormone (LHRH) analogues to create an artificial menopause will give a temporary respite, but with marked side effects due to the oestrogen deficiency. These drugs are used in preparation for surgery to improve surgical outcome and reduce surgical complications. Surgery for endometriosis is challenging, the extensive removal of all endometriotic lesions is essential. The best results are achieved laparoscopically, by highly trained and skilled laparoscopic surgeons, in specialist centres (11). A multidisciplinary team will be required for the treatment of extensive disease, including a pain management team. The pain associated with endometriosis is often not proportionate to the extent of the condition and, even after extensive removal of the lesions and suppression of the condition, the pain may continue. The incidence of endometriosis is rising in the developed world. The precise aetiology is still a source of debate, but an association with nulliparity is well accepted. The condition may be suspected from a history of secondary dysmenorrhoea and often dyspareunia, as well as the finding of scarring in the vaginal fornices on vaginal examination, with reduced uterine mobility and adnexal masses. The most useful diagnostic tool is the laparoscope (9,10). Endometriotic lesions affecting the urinary bladder or causing ureteric obstructions can occur, as well as lesions affecting the bowel, which may lead to rectal bleeding in association with menstruation. 3.6.1 Treatment Analgesics and NSAIDs are helpful in ameliorating the pain at the time of menstruation, as in primary dysmenorrhoea. Hormone treatment with progestogens or the oral contraceptive pill may halt the progress of the condition, but are not curative. Luteinizing hormone releasing hormone (LHRH) analogues to create an artificial menopause will give a temporary respite, but with marked side effects due to the oestrogen deficiency. These drugs are used in preparation for surgery to improve surgical outcome and reduce surgical complications. Surgery for endometriosis is challenging, the extensive removal of all endometriotic lesions is essential. The best results are achieved laparoscopically, by highly trained and skilled laparoscopic surgeons, in specialist centres (11). A multidisciplinary team will be required for the treatment of extensive disease, including a pain management team. The pain associated with endometriosis is often not proportionate to the extent of the condition and, even after extensive removal of the lesions and suppression of the condition, the pain may continue.

61. Endometriosis? characterized by the presence of endometrium-like tissue in ectopic sites outside the uterus, primarily on pelvic peritoneum and ovaries affects nearly 1 in 7 women of reproductive age third most common gynecologic disorder that requires hospitalization, and a leading cause of hysterectomy.

62. Commonly affected organs and structures: Ovaries and the sacral ligament

63. Endometriosis Symptoms Chronic pelvic pain Dysmenorrha Dyspareunia Infertility

64. Endometriosis and Pain Chronic pelvic pain is the most consistent symptom with a prevalence of 30-70% in adults, and 45-58% in adolescents. Dysmenorrhea is associated with endometriosis in more than 50% of adults, and up to 75% of adolescents Dyspareunia is variable ranging from 4%-55%

65. Endometriosis Treatment Medical Treatment Established Medical Treatments Experimental Treatments Surgical Treatment Conservative Vaporization Coagulation/ablation Radical

66. Role of laparoscopy Best evidence suggests that symptomatic relief can be achieved with either medical or surgical therapy for mild to moderate disease. For severe or nodular disease or for patients with endometriomas, surgical alternatives are most effective.

68. The optimal medical treatment

69. Established Medical Treatments Oral Contraceptives Progestins Danazol NSAIDs GnRH analogues

70. Pain-Medical therapy(Comparative Trials) GnRHa vs. Danazol 15 Trials No difference GnRHa vs. Progestins 2 Trials, No difference GnRHa vs. OCP 1 Trial, No difference for pelvic pain, GnRH more effective for dysmenorrhea and dyspareunia

71. Established Medical Therapy for Total Pain These drugs are equally effective in reducing the endometriotic implant mass/severity of the disease as well as reducing pelvic pain associated with endometriosis Initial treatment the choice should be based on cost and side effect profile of the drug NSAID�s appropriate and successful in many cases GnRH agonists have been proved effective after the failure of a prior medical hormonal therapy

72. Suggested approach to endometriosis-associated pain 1st line: continuous low-dose monophasic oral contraceptive with NSAIDs as needed 2nd line: progestins (start with oral dosing, consider switching to levonorgestrel intrauterine device or depo if well tolerated) 3rd line: GnRH agonist with immediate add-back therapy 4th line: repeat surgery, followed by 1, 2, or 3 May consider low-dose (100�200 mg every day) danazol if other therapies poorly tolerated.

73. Experimental Treatments RU486 (mifepristone) and SPRMs GnRH antagonists TNF-a Inhibitors Angiogenesis Inhibitors MMP Inhibitors Immunomodulators Estrogen Receptor-b Agonists Aromatase Inhibitors

74. Suggested approach to endometriosis-associated pain 1st line: continuous low-dose monophasic oral contraceptive with NSAIDs as needed 2nd line: progestins (start with oral dosing, consider switching to levonorgestrel intrauterine device or depo if well tolerated) AROMATASE INHIBITORS with OC or a Progestin 3 rd (4th) line : GnRH agonist with immediate add-back therapy AROMATASE INHIBITORS with a GnRH analogue 4th (6th) line: repeat or no surgery, followed by 1, 2, or 3 , or AIs with OC, progestin and GnRH analogue

75. Surgical Excision Aggressive Entire visible lesion should be removed. Any abnormal peritoneum is suspect (50% positive path) Appendix should go. (Lyons et al JAAGL 2002) Conservative Uterus, tubes and ovaries most often can be conserved.

76. Surgical Pearls Identify ureters & bowel first. Use the avascular spaces. Work from known to unknown. Maintain hemostasis moment to moment. Save the bowel to last if possible. Avoid hydro-dissection when possible Be patient

77. What do you consider as Endometriosis Treatment failure?

78. IC Can Appear Concurrently With Endometriosis. THE EVIL TWINS! IC Can Also Appear Concurrently With Endometriosis Studies conducted by Chung et al1,2 demonstrate that IC and endometriosis share many overlapping symptoms and thus can appear concurrently. The first study included 60 women with CPP for at least 6 months, ages 19-62. Ninety percent of the patients were diagnosed with IC, 80% were diagnosed with endometriosis, and 70% were diagnosed with both conditions.1 The second study followed 111 women with CPP, age 34-65 years, who had undergone a hysterectomy. Of them, 89% of the patients were diagnosed with IC, 75% were diagnosed with endometriosis, and 65% were diagnosed with both conditions.2 In yet another study conducted by Clemons et al3, 17/45 (38%) of women (age >18 years) scheduled to undergo laparoscopy for CPP were also diagnosed with IC. IC Can Also Appear Concurrently With Endometriosis Studies conducted by Chung et al1,2 demonstrate that IC and endometriosis share many overlapping symptoms and thus can appear concurrently. The first study included 60 women with CPP for at least 6 months, ages 19-62. Ninety percent of the patients were diagnosed with IC, 80% were diagnosed with endometriosis, and 70% were diagnosed with both conditions.1 The second study followed 111 women with CPP, age 34-65 years, who had undergone a hysterectomy. Of them, 89% of the patients were diagnosed with IC, 75% were diagnosed with endometriosis, and 65% were diagnosed with both conditions.2 In yet another study conducted by Clemons et al3, 17/45 (38%) of women (age >18 years) scheduled to undergo laparoscopy for CPP were also diagnosed with IC.

79. IC is Frequently Present Concurrently With Endometriosis

80. Consider the Bladder in Women With Unresolved CPP

81. Chronic Pelvic Pain Is Characterized by Overlapping Disease Conditions Chronic Pelvic Pain Is Characterized by Overlapping Disease Conditions A variety of common conditions have a similar clinical presentation and cause CPP. Therefore, chronic pelvic pain is frequently difficult to diagnose accurately. Some of the most common causes of CPP include: Interstitial cystitis Endometriosis Vulvodynia GI disorders Pelvic infection and adhesions Recurrent UTIChronic Pelvic Pain Is Characterized by Overlapping Disease Conditions A variety of common conditions have a similar clinical presentation and cause CPP. Therefore, chronic pelvic pain is frequently difficult to diagnose accurately. Some of the most common causes of CPP include: Interstitial cystitis Endometriosis Vulvodynia GI disorders Pelvic infection and adhesions Recurrent UTI

82. Cardinal Principles of Pain Management Believe the Patient Have Realistic Goals Institute Adequate Pain Relief Identify All Pain Generators Setup Appropriate Diagnostic Studies Explain the Reasons for Complexity

83. THANK YOU FOR YOUR ATTENTION