Case Study in Chronic Pelvic Pain

Jennifer McDonald DO F.A.C.O.G

61% of CPP will have no definitive diagnosis !!

Definition of Chronic Pelvic Pain (CPP)

Non-cyclic 6 months or more in duration

Localized to pelvis, anterior abdominal wall below the umbilicus, lumbosacral

area, or buttocks Causes significant enough impairment

to cause them to seek treatment

CaseC.A. is a 26 year old white female who has been treated 12 times in the last two years for recurrent urinary tract infections. She presents with symptoms of urinary frequency, urgency, pelvic pain, and dyspaurenia. She also describes alternating diarrhea and constipation especially around the time of her menstrual cycle. She reports she is in a long term, monogamous relationship but is afraid to commit to marriage as her problem with painful intercourse is worsening. She admits that she voids 18-20 times per day and awakens 3-5 times each night. She is a non-smoker and her menstrual cycles are painful but regular.

Important Questions for CPP patients Where is your pain?

When did it start? What makes it better? What makes it worse?

Are your cycles painful? Pain with urination?

Frequency? Is intercourse painful?

Do you have pain in other parts of your

body?

What diagnostic studies have been

done? What were the results? What treatments have

been tried? How successfully?

How do you sleep? How is your family life?

Job? Any bowel symptoms?

Have you seen other doctors?

Physical Exam

C.A. is a healthy appearing female who is height/weight appropriate

Supra-pubic and perineal tenderness as well as tenderness across the bladder base

No evidence of vaginitis or a sexually transmitted disease

Gynecologic - extra-uterine

Gynecologic - uterine

Urologic

Gastrointestinal

Musculoskeletal

Neurologic

Where do we look?

Pelvic Pain Assessment

www.pelvicpain.org

www.reliefinsite.com

Lab Evaluation

Urinalysis

• Nitrite negative

• Leukocyte esterase negative

• Trace blood

• Bilirubin negative

Urine Culture

• No organisms

Cystoscopy/

Hydro-distension

(Not always necessary)

C.A. has Interstitial Cystitis

CPP syndrome of bladder origin estimated to affect as many as 1 in 4.5 women

Often misdiagnosed as endometriosis, recurrent UTI’s, or overactive bladder

Typically white women of reproductive age (90%)

Symptoms first noticed in their 30s but usually a delay of 5-8 years before accurate diagnosis making average age 42-46

Women have consulted 5-8 healthcare professionals before receiving a correct diagnosis

Pathogenesis of IC

GAGLayer

IrritatedNerves

K+ and Urea

1

Identifying Patients Is ImportantA New Screening Questionnaire for

Pelvic Pain and Urgency/Frequency (PUF)

Identifying Patients Is ImportantA New Screening Questionnaire for

Pelvic Pain and Urgency/Frequency (PUF)Circle the answer that best describes how you feel for each question.

SymptomScore

BotherScore

SYMPTOM SCORE (1, 2a, 4a, 5, 6, 7a, 8a)BOTHER SCORE (2b, 4b, 7b, 8b)

b. If you get up at night to void, to what extent does it usually bother you?

b. Has pain or urgency ever made you avoid sexual intercourse?

b. How often does your pain bother you?

b. How often does your urgency bother you?

TOTAL SCORE (Symptom Score + Bother Score) =

How many times do you void during waking hours?1

4

20+

4+a. How many times do you void at night?2

YES _____ NO_____Are you currently sexually active?3

ever had pain or urgency to urinate during or aftersexual intercourse?

a. If you are sexually active, do you now have or have you4

your pelvis, vagina, lower abdomen, urethra, perineum, testes, or scrotum?

Do you have pain associated with your bladder or in5

0

3-6

0

None

Never

Never

Never

Never

Never

NeverDo you still have urgency shortly after urinating?6

a. When you have urgency, is it usually—?8

1

7-10

1

Mild

Occasionally

Occasionally

Occasionally

Occasionally

Occasionally

Occasionally

Mild

Mild

2

11-14

2

Moderate

Usually

Usually

Usually

Usually

Usually

Usually

Moderate

Moderate

3

15-19

3

Severe

Always

Always

Always

Always

Always

Always

Severe

Severea. When you have pain, is it usually—?7

PUF is a constellation of symptoms identified by IC experts as characteristic of interstitial cystitis. The more symptoms a patient experiences, the more likely it is that they’re caused by interstitial cystitis.

PUF is a constellation of symptoms identified by IC experts as PUF is a constellation of symptoms identified by IC experts as characteristic of interstitial cystitis. characteristic of interstitial cystitis. The more symptoms a patient experiences, the more likely it isThe more symptoms a patient experiences, the more likely it is that they’re caused by interstitial cystitis. that they’re caused by interstitial cystitis.

Parsons 2000

> 10 points 74%

likelihood of IC

5-10 points 55%

likelihood of IC

Healthy women < 2

points

PUF Screening

C.A.’s PUF = 18

Potassium Sensitivity Test (PST)

80% patients with IC have a +PST Instillation of 40mL of room temperature

sterile water. Pain rated 0-5 Water removed after 5 minutes and replaced

with 40 mL of KCl. Pain re-evaluated Any increase of 2 or more points is a + result

• 91% patients with PUF > 20 will have + PST

• 76% patients with PUF 15-19

• 55% of patients with PUF 5-9

• Allows us to reserve PST for women with suggestive symptoms but lower PUF scores

Obstacles to Diagnosis

IC relatively “new” or at least newly understood

Definition of IC not uniformly agreed upon Lack of education in medical profession

No definitive test Often misdiagnosed for long periods

because of overlapping symptom complex Variation in severity of symptoms

Treatments

• Elmiron only drug FDA approved for treatment

• Resembles naturally occurring GAGs

• Reduces painful symptoms

• 2 to 4 months women with mild disease and 6-

12 months in women with severe disease

Non-Pharmacologic Treatment

• Chiropractic care

• Biofeedback/Bladder training

• Pelvic floor relaxation exercises

Dietary manipulation is mandatoryAlcohol Apples Bananas

Citrus fruits Coffee Carbonated beverages

Chocolate Mayonnaise Most nuts

Pineapple Onions Soy sauce

Yogurt Sour cream Beans

Keys to Treatment

Pain and its perception are located in the nervous system so its treatment must encompass a Mind and Body approach

Multiple interactive problems are most likely with CPP so it isn’t which treatment is best but

which treatments It usually took time for things to get to where

they are so it will be take time to get them back to normal as well

Chronic pain affects a family not just an individual patient

The patient with CPP needs a multidisciplinary approach … are you ready?