Chronic pelvic pain Presented by: DR Afsar tabatabai
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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.
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;
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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
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Endometriosis Treatment: First line NSAIDs,OCP Danazol,GnRH
agonists No response to conservative treatment surgery
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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.
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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
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Pelvic Varicosity Pain Syndrome worsen throughout the day
Dyspareunia Post coital pain Mechanism: Increasing in vein
diameters substance P and calcitonin gene-related peptide
Treatment: GnRH agonists Medroxiprogesteron acetate surgery
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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 anesthesia
Treatment: diet, exercise, smoking cessation, transcutaneous
electrical nerve stimulation, bladder training, medications,
bladder distention, or bladder instillation.
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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.
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Irritable bowel syndrome Mechanism: visceral hyperalgesia
infection imbalance of neurotransmitters psychologic factors
Treatment: Treating symptoms In pain prodominance: tricyclic
antidepressants, NSAIDs, anticholinergics, calcium channel
blockers, and in some cases opioids.
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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.)
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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 exam Treatment: Bilateral
oophorectomy
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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
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.)?
