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8/18/2019 Chronic Pelvic Pain.pptx
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CHRONIC PELVIC PAIN
Dr. Javardo McIntoshIntern
Department of Obstetr cs and !"neco#o$"Pr ncess Mar$aret Hosp ta#%&th March '(%)
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Overv e*
Introd+ct on
Ep dem o#o$"
Et o#o$"
C# n ca# Presentat on
H stor"E,am nat on
Invest $at ons
Mana$ement
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Introd+ct on
Chron c pe#v c pa nInterm ttent or constant pa n n the #o*er abdomen or pe#v s of a *oman of at#east ) months n d+rat on-not occ+rr n$ e,c#+s ve#" * th menstr+at on or nterco+rse and not assoc ated* th pre$nanc"s+ c ent sever t" to ca+se f+nct ona# d sab # t" or re/+ re med ca# care
It s a s"mptom not a d a$nos s.
Ma" s $n 0cant#" mpact on a *oman1s ab # t" to f+nct on
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Ep dem o#o$"
Frequency
A2ects % n 3 *omen
Most common n *omen of reprod+ct ve a$e espec a##" those a$ed ')45("ears.
Of a## referra#s to $"neco#o$ st %(6 are for pe#v c pa n
Mortality/Morbidity
CPP ma" #ead to pro#on$ed s+2er n$- mar ta# and fam #" prob#ems- #oss ofemp#o"ment or d sab # t"- and var o+s adverse med ca# react ons from# fe#on$ therap".
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Et o#o$"
7he pathoph"s o#o$" of CPP s not *e## +nderstood.
A de0n t ve d a$nos s s not made for )% percent of *omen * th CPP.
Man" persons ass+me that a## chron c pe#v c pa n res+#ts from a $"neco#o$ cso+rce.
One st+d" n the 8n ted 9 n$dom fo+nd that d a$noses re#ated to the+r nar" and $astro ntest na# s"stems *ere more common than $"neco#o$ cd a$noses.:
7he fo+r most common#" d a$nosed ca+sesendometr os s- adhes ons- rr tab#e bo*e# s"ndrome ;I- and nterst t a# c"st t s
*Zondervan KT, Yudkin PL, Vessey MP, Dawes MG, Barlow DH, Kennedy SH. Pa erns o! dia"nosis and re!erral in wo#en $onsul in" !or $%roni$ &elvi$ &ain in 'K
$are. Br J Obstet Gynaecol . ())) (+ -(( /((0 1(( ( .
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Ca+ses of CPP
SYSTEM DIFFERENTIAL DIAGNOSES
Gyne$olo"i$ 2d%esions, adeno#yosis, adne3al $ys s, $%roni$ endo#e ri idys#enorr%ea, endo#e riosis, "yne$olo"i$ #ali"nan$ies,leio#yo#a a &elvi$ $on"es ion syndro#e, &elvi$ in!la##adisease
Gas roin es inal 4elia$ disease, $oli is, $olon $an$er, in!la##a ory 5oweldisease, irri a5le 5owel syndro#e
Mus$uloskele al De"enera ive disk disease, !i5ro#yal"ia, leva or ani syndro#e#yo!as$ial &ain, &eri&ar u# &elvi$ &ain syndro#e, s ress!ra$ ures
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Ca+ses of CPP
SYSTEM DIFFERENTIAL DIAGNOSES
Psy$%ia ri$6neurolo"i$ 25do#inal e&ile&sy, a5do#inal #i"raines, de&ression, nerveen raen , neurolo"i$ dys!un$ ion, slee& dis ur5an$esso#a i7a ion
'rolo"i$ Bladder #ali"nan$y, $%roni$ urinary ra$ in!e$ ion, in ers$ys i is, radia ion $ys i is, uroli %iasis
8 %er 9a#ilial Medi erranean !ever, %er&es 7os er, &or&%yria
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H stor"
Characteristics of painNat+re
7hrobb n$- Ach n$- Interm ttent- =harp-Co# c?"
Onset
=+dden vs $rad+a#
Intens t"
M #d- Moderate- =evere
D+rat on
Interm ttent vs constant
@re/+enc"
Rad at on
A##ev at
post+re
mea#s
bo*e# movements
vo d n$
menstr+at on
nterco+rsemed cat ons
Menstr+a# c"c#e before- d+r
Interco+rse D+r n$ and or
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H stor"
Associated SymptomsAnore, a
@at $+e
!astro ntest na# s"mptoms
D arrhea- Const pat on- Hematoche a-!as
8ro#o$ c s"mptoms
@re/+enc"- Hes tanc"- 8r$enc"-Incont nence- D"s+r a
!8
Non menstr+a# va$ na# b#eed n$
PV d schar$e
Method of contracept on
Va$ na# Dr"ness
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H stor"
Past Medical/Surgicalhistory
Pe#v c Infect ons
Infert # t"
Prev o+s =+r$er es
8se of I8D
Ab+se
Ps"cho#o$ ca#-
Ph"s ca#
=e,+a#
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H stor"
RED F A!S"MP#$MS
8ne,p#a ned *e $ht #oss
Hematoche a
Per menopa+sa# rre$+#ar b#eed n$-
Postmenopa+sa# va$ na# b#eed n$
Postco ta# b#eed n$
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H stor"
H stor" of pe#v c s+r$er"- pe#v cnfect ons- or +se of ntra+ter ne
dev ce
Adhes ons
Non4hormona# pa n F+ct+at on Adhes ons- nterst t a# c"st t s- rr tab#e bo*e#s"ndrome- m+sc+#os?e#eta# ca+ses
Pa n F+ct+ates * th menstr+a# c"c#e Adenom"os s or endometr os s
Per menopa+sa# or postmenopa+sa#rre$+#ar va$ na# b#eed n$
Endometr a# cancer
Postco ta# b#eed n$ Cerv ca# cancer or cerv c t s ;e.$.- ch#am"d a or$onorrhea>
8ne,p#a ned *e $ht #oss ="stem c ##ness or ma# $nanc"
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Ph"s ca# E,am nat on
Can dent f"
Areas of 7enderness
Presence of masses
Other anatom ca# 0nd n$s
Norma# ph"s ca# e,am nat on does not r+#e o+t ntraabdom na# patho#o$"
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Ph"s ca# e,am nat on
L thotom" e,am nat on +s+a##" nc#+desthe fo##o* n$
V s+a# nspect on of the e,terna#$en ta# a
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Ph"s ca# E,am nat on
Co#poscop c eva#+at on of the v+#va-
vest b+#e and cerv ,
= ms retractor or s n$#e4b#adespec+#+m e,am nat on of the va$ naand pe#v c m+sc#es
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Ph"s ca# E,am nat on
Pe#v c e,am nat on
< man+a# Pe#v c e,am nat on Pa#pate for nod+#es- masses- orpo nt tenderness a#on$ the b#adderor other m+sc+#os?e#eta# str+ct+res .
Rectova$ na# e,am nat on
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Ph"s ca# E,am nat on
Carnett s s $n for pat ents * th pe#v c pa n.
7he e,am ner p#aces h s or her 0n$er on thetender area of the pat ent s abdomen and as?sthe pat ent to ra se both #e$s o2 the tab#e.
An ncrease n the pat ent s pa n d+r n$ th smane+ver s cons dered a pos t ve test.
Ind cates a m"ofasc a# ca+se of the pa n.
7h s ma" a#so nd cate that the ca+se of the pa n s* th n the abdom na# *a## ;e.$.- 0brom"a#$ a or tr $$erpo nt>.
V scera# pa n sho+#d not *orsen d+r n$ the mane+ver
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Ph"s ca# e,am nat on
Ph"s ca# E,am nat on @ nd n$ Cond t on
Lac? of +ter+s mob # t" onb man+a# e,am nat on
Endometr os s- pe#v c adhes ons
Nod+#ar t" or masses onabdom na#- b man+a# pe#v c and orrecta# e,am nat on
Adenom"os s- endometr os s- hern as-ma# $nanc"- t+mors
Pa n on pa#pat on of o+ter bac?and o+ter pe#v s Abdom na# pe#v c *a## so+rce of pa n- tr $$po nts
Po nt tenderness of va$ na- v+#va-or b#adder
Adhes ons- endometr os s- nerve entrapment-tr $$er po nts- v+#var vest b+# t s
Pos t ve Carnett s s $n M"ofasc a# or abdom na# *a## ca+se of pa n
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Invest $at ons
In t a# test
Cerv ca# c"to#o$"
Endocerv ca# c+#t+resNe sser a $onorrhoeaeCh#am"d a
=too# hemocc+#t
8r ne st+d es8r na#"s s8r ne c+#t+reC"to#o$"
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Invest $at ons
Other Invest $at ons
4o#&le e 5lood $ounInfect on- s"stem c ##ness- or ma# $nanc";e#evated decreased *h te b#ood ce##co+nt or anem a>
E=R:n!e$ ion, #ali"nan$y, sys e#i$ illness
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Invest $at ons
7ransva$ na# +#traso+nd
2deno#yosis,;ndo#e riosis6endo#e rio#a,Mali"nan$y
H"sterosa#p n$o$raph"
not a 0rst4cho ce d a$nost c too#
ma" be +sef+# n pat ents * thn0#trat ve endometr os s of the +terosacra#
# $aments.
endometr a# po#"ps
Asherman s"ndrome
adenom"os s
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Invest $at ons
MRI and C7
Not ro+t ne#" +sedcan he#p assess an" abnorma# t esfo+nd on +#traso+nd.
Laparoscop" +sed *hen the d a$nos s rema ns
e#+s ve after the n t a# *or?+pcan con0rm- and poss b#" treat-
s+spected endometr os sadhes ons
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Mana$ement
Myofascial pain
Ph"s ca# therap"
7r $$er po nts can often be treated* th
In ect ons of a #oca# anesthet c ;e$-b+p vaca ne KMarca ne >-
a cort costero d
Muscle rela%ants
ma" prove +sef+# n pat ents * th$+ard n$- sp# nt n$- or react vem+sc#e spasms.
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Mana$ement
Ph"s ca# therap" techn /+es
nc#+de hot or co#d app# cat ons-
pos t on n$- stretch n$ e,erc ses-tract on- massa$e- +#traso+ndtherap"- transc+taneo+s e#ectr ca#nerve st m+#at on ;7EN=>-
Heat- massa$e- and stretch n$ canbe +sed to a##ev ate e,cess m+sc#econtract on and pa n.
Pe#v c Foor tra n n$ a#so ma" berecommended.
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Mana$ement
Pa n re#ated to the menstr+a# c"c#e
treatment a med at s+ppress n$ thec"c#e ma" he#p.
Common methods to accomp# sh th snc#+de
depot medro,"pro$esterone ;Depo4Provera>
Ora# contracept ves
< rth contro# mp#ant
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Psychophysiological therapy
Reass+ranceCo+nse## n$
Co$n t ve4behav ora# therap"
Re#a,at on therap"
=tress mana$ement
Mana$ement
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Mana$ement
Pharmacotherapy
="mptomat c abort ve therap" to stop or red+ce the sever t" of the ac+tee,acerbat ons and #on$4term therap" for chron c pa n.
In t a##"- pa n ma" respond to s mp#e over4the4co+nter ;O7C> ana#$es cs s+chas paracetamo#- b+profen- asp r n- or napro,en.
If treatment res+#ts are +nsat sfactor"- the add t on of other moda# t es orthe +se of prescr pt on dr+$s s recommended.
Am tr pt"# ne and nortr pt"# ne are the tr c"c# c ant depressants +sed mostfre/+ent#" for chron c pa n.
7he se#ect ve seroton n re+pta?e nh b tors ;==RIs> F+o,et ne- paro,et ne-and sertra# ne a#so are common#" prescr bed.
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Mana$ement
aparoscopy
hen endometr os s or pe#v c adhes ons are d scovered on d a$nost c#aparoscop"- the" are +s+a##" treated d+r n$ the proced+re.
&ysterectomy ma" be *arranted f
the pa n has pers sted for more than s , months
does not respond to ana#$es cs ; nc#+d n$ ant 4 nFammator" a$ents>
and mpa rs the *oman s norma# f+nct on.
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References