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Chronic Pelvic Pain

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Fawaz Edris MD, RDMS, FRCSC, FACOG, AAACS Introduction Non cyclical uterine or non-uterine pelvic pain 6/12 Gynecological GIT Urological Orthopedic Musculoskeletal ... – PowerPoint PPT presentation

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Title: Chronic Pelvic Pain


1
Chronic Pelvic Pain
  • Fawaz Edris
  • MD, RDMS, FRCSC, FACOG, AAACS

2
Introduction
  • Non cyclical uterine or non-uterine pelvic pain gt
    6/12
  • Gynecological
  • GIT
  • Urological
  • Orthopedic
  • Musculoskeletal
  • superficial (nerve entrapment, hernia,
    referred)
  • Psychological (by exclusion)

3
Introduction
  • Somatic pain
  • Visceral pain
  • Diffusely spread
  • Lack of well defined areas in the sensory cortex
  • Viscerosomatic convergence
  • No neurons in the spinal cord receives only
    visceral pain
  • Viscerosomatic neurons
  • Larger receptive field than somatic
  • Less numbers than somatic

4
History
  • Pain history and its components
  • Relationship to period, bowel movement,
    urination, intercourse and activity
  • Previous episodes
  • Other symptoms (GIT, urological, weight loss,
    etc)
  • Effect on life (social, work, family)
  • Relationship of onset to events (newly married,
    rape, lifting, chest infection, etc)
  • Hx of sexual, physical, or emotional abuse
  • What medication used
  • What investigations done
  • Other stress or psychological symptoms
    (depression, anxiety, etc) BUT!
  • Secondary gain (off work, husband to stay,
    attention, etc) BUT!
  • Full Gyn Hx (STD, PID, Infertility, dysparunia,
    surgeries including DC, etc.)
  • Full surgical Hx
  • Medical Hx (IBS, IC, IBD)

5
Examination
  • Abdominal (point, superficial, deep)
  • Pelvic (tenderness, mobility, nodularity)
  • Nerve entrapment
  • Dermatomes
  • Head raising

6
Investigations
  • Limited use
  • Scopes if symptoms suggest (GIT, Urological)
  • Imaging if symptoms suggest musculoskeletal
  • U/S although of limited use
  • Laparoscopy the ultimate but last method
  • Psychological evaluation

7
Gynecological
  • Endometriosis (30)
  • Pathogenesis
  • 20-30 missed on laparoscopy
  • Treatment is medical (may start before Dx)
  • Cont. OCP
  • Depot Provera
  • Danzol
  • GnRH analouge add back therapy
  • If no response, surgical (TAH / TAHBSO)
  • Size and location doesnt correlate with pain
  • Path0physiology of pain not well understood
  • Infertility
  • Chronic PID(25)
  • Recurrent exacerbations
  • Hydrosalpinges
  • Adhesions !!

8
Gynecological
  • Ovarian
  • Cysts are ASYMPTOMATIC, unless
  • Rapid distention
  • Bleeding
  • Torsion
  • Special cysts (Endometrioma, Dermoid)
  • Ovarian remnants retroperitonealy (with cyst)
  • Uterine
  • Adenomyosis (rarely CPP)
  • Fibroid are ASYMPTOMATIC, unless
  • Degeneration
  • Torsion
  • Prolapsed submucus fibroid
  • Retroverted uterus DOSE NOT cause CPP. Maybe
    dysparunia!

9
Gynecological
  • Pelvic Congestion Syndrome
  • Myth!
  • Non specific symptoms
  • No agreed upon diagnostic measures
  • No agreed upon therapeutic measures

10
Non-Gynecological
  • G.U.T
  • Multiple examples, the most common
  • Urethral syndrome
  • IC
  • Common 1 in 5 women
  • Urgency, frequency, nocturia, CPP
  • Diagnosis treatment
  • G.I.T
  • Multiple examples, the most common
  • IBS, IBD, Hernias.
  • Innervation of the lower intestinal tract, same
    as uterus and fallopian tubes ? pelvic pain

11
Psychological
  • 30 of CPP remains undiagnosed even after
    laparoscopy
  • Is this a primary or secondary thing!

12
Pain Perception
  • Every pain is a result of stimulus and response,
    however Chronic pain ?Acute pain.
  • Acute pain response is appropriate to stimulus.
  • Chronic pain is affected additionally by
  • Patients reaction to pain
  • Familys reaction to the patient and her pain
    (reinforce or persistence)
  • So Response to a stimulus is inappropriate,
    exaggerated, inaccurate, and may persist even
    after the stimulus is gone

13
Management
  • Therapeutic, supportive, and sympathetic
    physician-patient relationship should be
    established (only few can do it!)
  • Regular F/U rather than come back when pain
    persist
  • The latter reinforces pain behavior
  • If no pathology is found, patient should NOT be
    ignored!
  • Reassurance symptomatic treatment
  • Multidisciplinary pain clinic

14
Management
  • Multidisciplinary pain clinic
  • GYN, Psychologist, Anesthetist, others
  • If no team is in place, use referrals.
  • Psychologist
  • Techniques for stress reduction, adaptive
    strategies
  • Marital, sexual, and social counseling

15
Management
  • Treat underlying cause if found!
  • If none is found
  • Multidisciplinary team
  • NSAIDs
  • Ovulatory/menstrual suppression
  • Cont. OCP, Depot Provera, Danzol, GnRH analouge
    add back therapy
  • May work for those with pain related to the
    period (mid-cycle, premenstrual or menstrual) or
    those with ovarian causes (ovarian remnant)
  • Low dose TCA (increase inhibitory neuromodulators)

16
Management
  • Surgeries
  • If no pathology ? NOT effective
  • If no strong evidence of pathology ? thorough
    psychological evaluation before any surgery
  • Lysis of adhesions
  • NOT effective unless the site of adhesions site
    of pain.
  • Vicious cycle

17
  • Thank you
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