Karen C. Wang, MD Department of Obstetrics and Gynecology Director of Minimally Invasive Surgery...
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Transcript of Karen C. Wang, MD Department of Obstetrics and Gynecology Director of Minimally Invasive Surgery...
Karen C. Wang, MDDepartment of Obstetrics and Gynecology
Director of Minimally Invasive SurgeryBeth Israel Medical Center
April 22, 2010
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
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
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
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
$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
Pain is subjective A normal physical
examination does not preclude the presence of pathology
Never expect only one diagnosis or etiology
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
GYN
GU
PM&R
GI
Neurology/pain med
Gynecologic Urologic GastrointestinalMusculoskeletal/
Neurologic
• 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
• IBS• Functional Bowel
disorders• Chronic appendicitis• Inflammatory bowel
disease• Hernias• Diverticular disease• Intermittent bowel
Obstruction
• Pelvic floor myalgia• Trigger points• Idiopathic low back
pain• Disc disease• SI joint disease• Coccydynia
• Nerve entrapmentsyndromes
*excludes carcinomas
Gynecologic Urologic Gastrointestinal Musculoskeletal/Neurologic
• 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
• IBS• Functional Bowel
disorders• Chronic appendicitis• Inflammatory bowel
disease• Hernias• Diverticular disease• Intermittent bowel
Obstruction
• Pelvic floor myalgia• Trigger points• Idiopathic low back
pain• Disc disease• SI joint disease• Coccydynia
• Nerve entrapmentsyndromes
*excludes carcinomas
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.
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
Pelvic ultrasound shows a complex 5 cm right adnexal mass that is persistent on serial ultrasounds over 4 months.
Uterus
Ovary
endometriosisadhesions
Defined by the presence of endometrial glands and stroma outside of the uterus
Histological diagnosis that requires surgical evaluation
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
-None-None-Chronic non-menstrual -Chronic non-menstrual
pelvic painpelvic pain-Dysmenorrhea-Dysmenorrhea-Dyspareunia -Dyspareunia
-Pelvic mass-Pelvic mass-Dyschezia-Dyschezia-Decreased quality of life-Decreased quality of life-Infertility-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.
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
10%
30%
60%
0%0% 100%100%
reproductive aged women
subfertile
chronic pelvic pain
50% adolescent with chronic pelvic pain
ACOG practice bulletin 2000
asymptomatic2%
Prevalence of EndometriosisPrevalence of Endometriosis
1999 Joan Beck
Posterior cul-de-sac 69%Ovaries 33%Fossa ovarica 45%Anterior cul-de-sac 24%Bowel/appendix 5%
SurgicalMedical
MEDICAL NSAIDs Combination OCP Progestins
Oral Depo-Provera Mirena IUD
GnRH agonist (> 18 y.o.) Danazol Aromatase inhibitor
Treatment Route Cost/ 6 mo. Adverse Effects
Estrogen & progesterone
Pills, patch, ring
$240 Breast tenderness, spotting, headaches
Progesterone Oral, injectable
$60-400 Weight gain, mood swings, breast tenderness, edema
Danazol Oral $350 Hirsutism, acne, voice change, vaginal atrophy
GnRH agonists IM, nasal spray
$1900-3200 Hot flushes, vaginal atrophy, bone loss
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
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
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
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
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
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
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)
Sutton et al. Fertil Steril 1994; 62(4):696-700. * p=0.01, laser vs. expectant
0
1
2
3
4
5
6
7
8
9
10
Before 3 mo 6 mo
Expectant
LaserVA
S pa
in s
core
(0-1
0)
8.5
4.5
*
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%
Namnoun et al. Fertil Steril 1995; Matorras et al. Fertil Steril 2002.
Recurrent pain Reoperation for recurrent pain
Namnoun 1995
Hysterectomy 62% 31% Hysterectomy +BSO 10% 3.7%
Matorras 2002
Hysterectomy +BSO 0%
Hysterectomy +BSO +HRT 2.5% 3.7%
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….
Other sources of pain have been excluded and/or maximally treated!!!
Interstitial cystitis Fibromyalgia
Urerthral syndrome Irritable bowel syndrome
Pudendal neuralgia Levator ani myalgia
Piriformis syndrome
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.
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
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
~ 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
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 1994El-Mowafi Prog Obstet Gynecol 2000
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
Swank D et al. Lancet 2003
Pain scores
hrQOL scores
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
0
10
20
30
40
50
60
70
80
90
Chan '85 Daniell '89 Sutton '90 Steege '91
42 42
6520
One Year Follow-up
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
Involuntary spasm of the pelvic floor muscles
Etiology Inflammation Childbirth Pelvic surgery Trauma
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
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
Only 2 RCTs identified in systematic review extremely limited focus (pregnancy-related pelvic
pain and botulinum toxin for myofascial pain) Small n (44, 30 respectively) Methodological issues: no power analysis and
mixture of myofascial pain conditions in botulinum toxin study
For now: individualized therapeutic approach – goal is desensitization
Tu FF et al Ob Gyn Surv 2005
Manual therapy muscle core
strengthening (pelvic/lumbar stabilization)
muscle re-education joint mobilization myofascial release
Modalities Biofeedback electrical stimulation
(TENS)
Orthotic devices pelvic stability belt gait assistance vaginal cones
Must refer to physical therapist with expertise in pelvic pain and intravaginal pelvic floor modalities!
Medications analgesics/NSAIDs tricyclic antidepressants and antiepileptic agents muscle relaxants topical analgesics (camphor, menthol, xylocaine,
lidoderm patch) trigger point injections (botulinum toxin, local
anesthetics, steroids) Psychotherapy, education, work evaluation
Chronic pelvic pain: 89% of 122 women treated had significant symptom
improvement (> 3 months follow-up)
Interstitial cystitis: 70% of 10 patients treated with both injections and
manual therapy had >50% improvement on global symptom severity (mean follow-up 20 months)
Slocumb JC AJOG 1984 Weiss J, J Urol, 2001
Design Double-blinded, RCT of botulinum toxin A 80U vs.
placebo (30 per arm) bilateral injections into puborectalis, pubococcygeus
Outcomes 26 month follow-up no group differences in nonmenstrual pelvic pain (VAS
40 vs. 22) Improvements from pretreatment in both groups
Botox (VAS 51 v. 22 p <0.01), placebo (VAS 47 v. 40, p > 0.05)
Abbott JA et al Ob Gyn 2006
Diagnose endometriosis and/or pelvic adhesions Evaluate an adnexal mass Keep in mind that:
30-50% of diagnostic laparoscopies for pelvic pain are negative
Initial multi-disciplinary therapy is superior to diagnostic laparoscopy and unidimensional therapy
Adhesion removal is no better than sham surgery
Chronic pelvic pain is generally multifactorial, often with multiple organ systems involved
expand differential diagnosis to include GI, GU, musculoskeletal, and central nervous system causes of pain
Begin with “gold-standard” therapies for contributing factors Ex. Hormonal suppression for cyclic pain or chronic pain
with cyclic exacerbation Ex. Physical therapy for abdominal wall and pelvic floor
myofascial pain Ex. Laparoscopy for excision/ablation of endometriosis
When standard treatments fail, then reconsider the diagnosis, re-evaluate comorbid psychosocial variables
Hysterectomy should be considered last resort for treatment of chronic pelvic pain Depending on population surveyed and whether BSO
performed, 3-62% of women will report persistent or recurrent pain
Women with pelvic pain and depression are more likely to report persistent pain and decreased QOL following hysterectomy than women with either condition alone
Patients & physicians should have reasonable expectations
Anecdotally, women with chronic daily pain, diffuse abdominal &/or pelvic floor pain are more likely to report recurrent or persistent pain following surgery
Namnoun et al. Fertil Steril 1995. Matorras et al. Fertil Steril 2002. Hartmann et al. Obstet Gynecol 2004.
Abnormalities in pain processing are a common mechanism in many chronic pain disorders (IBS, IC, fibromyalgia, etc.) It is likely to be an underlying mechanism in at least some
women with CPP Consider adding centrally-acting medication when
standard “gynecology” treatments fail Antidepressants for pain Antiepileptics for pain
Consider using centrally-acting medication as part of first-line therapy Chronic pelvic pain with negative laparoscopy Chronic pelvic pain with diffuse abdominal and pelvic floor
tenderness with no or minimal endometriosis Pelvic nerve entrapment syndromes (ex. Pudendal nueralgia)