Fawaz EdrisMD, RDMS, FRCSC, FACOG, AAACS

IntroductionNon cyclical uterine or non-uterine pelvic

pain > 6/12GynecologicalGITUrologicalOrthopedicMusculoskeletal“superficial” (nerve entrapment, hernia,

referred) Psychological (by exclusion)

IntroductionSomatic painVisceral pain

Diffusely spread Lack of well defined areas in the sensory cortex Viscerosomatic convergence

No neurons in the spinal cord receives only visceral pain

Viscerosomatic neurons Larger receptive field than somatic Less numbers than somatic

HistoryPain history and its componentsRelationship to period, bowel movement, urination, intercourse

and activityPrevious episodesOther symptoms (GIT, urological, weight loss, etc)Effect on life (social, work, family)Relationship of onset to events (newly married, rape, lifting, chest

infection, etc) Hx of sexual, physical, or emotional abuseWhat medication usedWhat investigations doneOther stress or psychological symptoms (depression, anxiety, etc)

BUT!Secondary gain (off work, husband to stay, attention, etc) BUT!Full Gyn Hx (STD, PID, Infertility, dysparunia, surgeries including D&C, etc.)Full surgical HxMedical Hx (IBS, IC, IBD)

Examination Abdominal (point, superficial, deep)Pelvic (tenderness, mobility, nodularity) Nerve entrapment

DermatomesHead raising

InvestigationsLimited useScopes: if symptoms suggest (GIT,

Urological)Imaging: if symptoms suggest

musculoskeletal U/S: although of limited use Laparoscopy the ultimate but last methodPsychological evaluation

Gynecological Endometriosis (30%)

Pathogenesis20-30% missed on laparoscopyTreatment is medical (may start before Dx)

Cont. OCP Depot Provera Danzol GnRH analouge + add back therapy

If no response, surgical (TAH / TAH+BSO)Size and location doesn’t correlate with painPath0physiology of pain not well understoodInfertility

Chronic PID(25%)Recurrent exacerbations HydrosalpingesAdhesions !!

Gynecological Ovarian

Cysts are ASYMPTOMATIC, unless Rapid distention Bleeding Torsion Special cysts (Endometrioma, Dermoid)

Ovarian remnants retroperitonealy (with cyst)Uterine

Adenomyosis (rarely CPP)Fibroid are ASYMPTOMATIC, unless

Degeneration Torsion Prolapsed submucus fibroid

Retroverted uterus DOSE NOT cause CPP. Maybe dysparunia!

Gynecological Pelvic Congestion Syndrome

Myth! Non specific symptoms No agreed upon diagnostic measures No agreed upon therapeutic measures

Non-Gynecological G.U.T

Multiple examples, the most common: Urethral syndrome IC

Common: 1 in 5 women Urgency, frequency, nocturia, CPP Diagnosis & treatment

G.I.TMultiple examples, the most common:

IBS, IBD, Hernias.Innervation of the lower intestinal tract, same as

uterus and fallopian tubes pelvic pain

Psychological 30% of CPP remains undiagnosed even after

laparoscopy Is this a primary or secondary thing!

Pain Perception Every pain is a result of stimulus and response,

however: Chronic pain ≠Acute pain.Acute pain: response is appropriate to stimulus.Chronic pain is affected additionally by:

Patient’s reaction to painFamily’s reaction to the patient and her pain

(reinforce or persistence) So: Response to a stimulus is inappropriate,

exaggerated, inaccurate, and may persist even after the stimulus is gone

Management Therapeutic, supportive, and sympathetic

physician-patient relationship should be established (only few can do it!)

Regular F/U rather than “come back when pain persist”The latter reinforces pain behavior

If no pathology is found, patient should NOT be ignored!Reassurance + symptomatic treatment Multidisciplinary pain clinic

Management Multidisciplinary pain clinicGYN, Psychologist, Anesthetist, othersIf no team is in place, use referrals.Psychologist

Techniques for stress reduction, adaptive strategies Marital, sexual, and social counseling

Management Treat underlying cause if found!If none is found:

Multidisciplinary teamNSAIDsOvulatory/menstrual suppression

Cont. OCP, Depot Provera, Danzol, GnRH analouge + add back therapy May work for those with pain related to the period

(mid-cycle, premenstrual or menstrual) or those with ovarian causes (ovarian remnant)

Low dose TCA (increase inhibitory neuromodulators)

Management Surgeries

If no pathology NOT effectiveIf no strong evidence of pathology thorough

psychological evaluation before any surgery Lysis of adhesions:

NOT effective unless the site of adhesions = site of pain.

Vicious cycle

Thank you