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

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 • PELVIC PAIN IN GYNAECOLOGICAL PRACTICE • Diagnosis • Dysmenorrhoea • Infection • Adhesions • Endometriosis • Gynaecological malignancy • Injuries related to childbirth

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

6. Complex Neuro network

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 nociceptiveaetiology.

8. 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.

9. Viscerosomatic Convergence and Pelvic Floor Myalgia Referred pain

10. ViscerovisceralHyperalgesia Referred pain

11. Abdominal Wall Trigger Points

12. Pain Evaluation & Measurement

13. Systematic evaluation of the pain involves the following; • 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.

14. 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

15. 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.

17. Chronic Pelvic Pain (CPP)

18. 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.” ACOG Practice Bulletin No. 51. American College of Obstetricians and Gynecologists.Obstet Gynecol. 2004;103:589-605.

19. 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 Definition of Chronic Pelvic Pain

20. Why is Chronic Pelvic Pain so Different?

21. 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)

22. 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)

23. CPP Syndrome • Bladder pain syndrome • Urethral pain syndrome • Penile pain syndrome • Prostate pain syndrome • Scrotal pain syndrome • Testicular pain syndrome • Post vasectomy pain syndrome • Epididymalpain syndrome • Endometriosis associated pain syndrome • Vaginal pain syndrome • Vulvar pain syndrome • Generalized vulvar pain syndrome • Localized vulvarpain syndrome • Vestibular pain syndrome • Clitorialpain syndrome • Anorectal pain syndrome • Anismuspain syndrome • Pudendalpain syndrome • Perineal pain syndrome • Pelvic floor muscle pain syndrome

25. Epidemiology

26. CPP Is a Significant and Common Disorder in Women • 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 1. Mathias SD et al. Obstet Gynecol. 1996;87:321-327. 2. Jamieson DJ, Steege JF. Obstet Gynecol. 1996;87:55-58. 3. Reiter RC. Clin Obstet Gynecol. 1990;33:130-136. 4. Howard FM. Obstet Gynecol Surv. 1993;48:357-387. 5. Carlson KJ et al. Obstet Gynecol. 1994;83:556-565.

27. Prevalence of CPP is Comparable to Other Common Medical Problems • Cross-sectional analysis by UK Mediplus Primary Care database. N=24,053 CPP Migraine Asthma Back Pain Zondervan KT et al. Br J Obstet Gynaecol. 1999:106;1149-1155.

28. 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 1. Mathias SD et al. Obstet Gynecol. 1996;87:321-327.

29. Etiology

30. Introduction Neurology/ pain med • Pelvic pain has multifactorial etiology • Overlapping cerebral representation for somatic and visceral structures • Multiple stakeholders involved in evaluation and management GI/GU GYN PM&R

31. Systems Based Evaluation The pelvis is Grand Central Station Gastrointestinal Skeletal Muscular Vascular Reproductive Urinary Neurologic Don’t forget the most important extra-abdominal organ! Psychiatric evaluation

32. EtiologyPhysical vs. Psychiatric 100% Psychiatric 100% Physical

33. 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 ACOG Practice Bulletin No. 51. American College of Obstetricians and Gynecologists.Obstet Gynecol. 2004;103:589-605.

34. Necessity of Multidisciplinary Approach

35. Pelvic Pain Assessment Forms

36. International Pelvic Pain Society Assssment Form

37. History Detailed Focused Pelvic Review of systems Biopsychosocial Model

38. 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

39. 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

40. 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

41. Patient Evaluation for Bladder Tenderness • Suprapubic tenderness • Anterior vaginal wall/bladder base tenderness • Levator muscle spasm • Rectal spasm X Howard FM, Perry CP, Carter JE, El-Minawi AM. Pelvic Pain: Diagnosis and Management. Lippincott. 2000:35-39.

42. Physical Examination: Pelvic • Traditional bimanual examination is the last portion of the pelvic examination • Uterus • Adnexa • Anorectum • Many layers palpated; non-specific findings likely

43. 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

44. Dysmenorrhoea

45. Dysmenorrhoea Pain in association with menstruation may be primary or secondary. • Primary dysmenorrhoeaclassically 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.

46. 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 dysmenorrhoeawould suggest the development of a pathological process, and the exclusion of endometriosis and pelvic infection is essential

47. Infection

48. 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.

49. Infection • Subclinical chlamydialinfection 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.

50. Gynaecological malignancy

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