Chronic pelvic painPresented by: DR Afsar tabatabai

Definition

• Nonmenstrual pain of 6 months duration or greater, localized to the pelvis, anterior abdominal wall below the pelvis, or lower back, severe enough to result in functional disability or require medical or surgical treatment.

Putative Pelvic Pain States• Adhesions• Pelvic inflammatory disease (PID), • endometriosis• inflammatory bowel disease• prior surgery • Painful bladders syndrome• Uterian originated pains• Psychological problems

Adhesions• Pelvic inflammatory disease (PID),

endometriosis, inflammatory bowel disease, or prior surgery may cause adhesions; yet, in up to 50% of cases, there may be no significant antecedent event

• while some case series have shown benefit to adhesiolysis, others have shown no treatment benefit;

Endometriosis• little correlation between the extent of disease present and the

degree of pain• several appearances ranging from the more typical powder

burn,blue-gray lesions to atypical lesions that may be clear, red, or white.

• Associated Symptoms :• cyclic pelvic pain• dysmenorrhea.• Tenesmus involving the rectosigmoid colon.• dyspareunia or ovarian mass (endometrioma).• Pain may precede the menses, occur with menses, and

continue after menses

Endometriosis• Treatment:• First line NSAIDs,OCP• Danazol,GnRH agonists• No response to conservative treatment

surgery

Pelvic Inflammatory Disease• can be a cause of acute pain, or even

asymptomatic. mechanisms for pain:• inflammation and distension of the

fallopian tubes.• hydrosalpinx will sometimes persist for

months or years and may cause CPP.

Myofascial Pain(MFPS)• common in patients with a history of trauma

or multiple surgeries and is often overlooked as a cause for CPP.

Patterns of pain:• localized, reproducible, hyperirritable trigger

points within a muscle Treatment:• icing, stretching exercises, and injection with

local anesthesia,physical therapy

Pelvic Varicosity Pain Syndrome• worsen throughout the day• Dyspareunia• Post coital painMechanism:• Increasing in vein diameters• substance P and calcitonin gene-related peptideTreatment:• GnRH agonists• Medroxiprogesteron acetate• surgery

Painful Bladder Syndrome

characterized by urgency, frequency, or pain in the absence of a urinary tract infection or malignancy.

Diagnosis: distending the bladder cystoscopically under

anesthesiaTreatment: diet, exercise, smoking cessation, transcutaneous

electrical nerve stimulation, bladder training, medications, bladder distention, or bladder instillation.

Irritable Bowel Syndrome

(Rome III criteria): - recurrent abdominal pain or discomfort that is present for at

least 3 months - with onset at least 6 months previous and at least two of the following clinical features: (a) improvement with defecation (b) onset associated with a change in frequency of stool (c) onset associated with a change in the form (appearance) of

stools.

Irritable bowel syndromeMechanism:• visceral hyperalgesia• infection• imbalance of neurotransmitters • psychologic factorsTreatment:• Treating symptoms• In pain prodominance: tricyclic antidepressants,

NSAIDs, anticholinergics, calcium channel blockers, and in some cases opioids.

Ovarian Remnant Syndrome

• a history of extensive endometriosis or pelvic inflammatory processes resulting in a technically difficult oophorectomy

• DX:• FSH,LH are at normal range.• Ultrasonography• Treatment:• Surgery(removing all ovarian tissue….)

Residual Ovary Syndrome

Mechanism:• cyclical expansion of the ovary encased in

adhesions• chronic lower abdominal pain, dyspareunia, and

radiation of pain to the back or anterior thigh• A tender mass may be palpated on bimanual

examTreatment:• Bilateral oophorectomy

Pain of Uterine Origin

• Adenomyosis

• Chronic endometritis

• Degenerating leiomyomata

• PVPS

• Cervical stenosis

• Intrauterine contraceptive device

Hysterectomy may be indicated in the absence of pathology in patients who have concluded childbearing and who have not responded to conservative therapy

Psychological problemsConsider:• Depression• Panic attack• Anxiety

History and Physical Exam

• Characterists:What does the pain feels like? (sharp, dull, crampy, etc.)

• Onset: Was the pain onset sudden or gradual? Is it cyclic or constant?

• Location:Is the pain localized or diffuse?

• Duration:How long has the pain been present, and how has it changed over time?

• Exacerbation:What activities or movements make the pain worse?

• Relief:What medication, activities, and positions make the pain better?

• Radiation:Does the pain radiate anywhere (back, groin, flank, etc.)?

Cyclic Causes for Chronic Pelvic Pain• Adenomyosis

• Endometriosis

• IBS

• Mittelschmerz

• Ovarian remnant syndrome

• PVPS

Gastrointestinal Causes for Chronic Pelvic Pain.

• CholecystitisChronic appendicitisConstipationDiverticulitisIBSInflammatory bowel diseaseIntermittent bowel obstructionNeoplasmPseudomembranous enterocolitisUlcer (duodenal, gastric)

Urologic Causes for Chronic Pelvic Pain

• Bacterial cystitisDetrusor dyssynergiaNeoplasmPBS (interstitial cystitis)Radiation cystitisUrethral caruncleUrethral diverticulumUrethral syndromeUrolithiasis

treatment• NSAID• Anti convalsants• Anti depressents• Narcotics

thank you

thank you