Chronic Pelvic PainAnnick Poirier MD FRCSC
Erin Kelly MD FRCSC
Family Medicine Summit
March 6th, 2020
Presenter: Dr. Erin Kelly
• Speakers Bureau/Honoraria: N/A
• Consulting Fees: N/A
• Grants/Research Support: N/A
• Patents: N/A
• Other: N/A
• The Alberta College of Family Physicians has provided support in the form of a speaker fee and/or expenses.
Presenter: Dr. Annick Poirier
• Speakers Bureau/Honoraria: N/A
• Consulting Fees: N/A
• Grants/Research Support: N/A
• Patents: N/A
• Other: N/A
• The Alberta College of Family Physicians has provided support in the form of a speaker fee and/or expenses.
Disclosure
• We are not pain specialists by training
• We seek support and advocate for our pain program and its patients
• There is very little evidence supporting our practice
Outline & Learning Objectives
1. Differentiate the underlying causes of dyspareunia and chronic pelvic pain
2. Identify the initial investigations for patients with dyspareunia and chronic pelvic pain
3. Discuss management options for dyspareunia/CPP
4. Recognize when to refer
What we are hoping you take home…
• To recognize some elusive causes of chronic pelvic pain, when other causes have been ruled out
• To gain skill performing a pelvic exam for chronic pelvic pain- as it is the single best diagnostic tool!
• To develop an approach to chronic pelvic pain, from diagnosis to simple initial treatment plans and other resources
• When to refer to chronic pelvic pain program, and what we provide to our patients
What we are not going to cover…
Definition
Chronic Pelvic PainNoncyclical pain of 3- 6 or more months’ duration that is perceived to be in the pelvic area and is unrelated to pregnancy and of sufficient severity to cause functional disability or lead to medical care.
American College of Obstetricians and Gynaecologists
Chronic Pain SyndromeInitial source of pain
Pelvic fracture
Delivery
Bladder infection
Painful menstruation
MSK
Surgery
Myofascial dysfunction
Peripheral nerve dysfunctionCentral sensitization
Causes of Chronic Pelvic Pain
What we are not going to cover…
Myofascial Pelvic Pain
Common painful condition
…trigger points may be identified in as many as 85 % of patients suffering from urological, colorectal and gynaecological pelvic pain syndromes… can be responsible for some, if not all, symptoms related to these syndromes…
Robert M. Moldwin and Jennifer Yonaitis Fariello. Myofascial Trigger Points of the
Pelvic Floor: Associations with Urological Pain Syndromes and Treatment Strategies
Including Injection Therapy. Curr Urol Rep (2013) 14: 409-417.
Myofascial Pelvic Pain
• Short, tight, tender pelvic floor muscles (hypertonic pelvic floor)
• Myofascial trigger point• Focus of hyperirritability and pain in a muscle.
Persistent fibre contraction
• Twitch response
• Refers pain on direct compression
• Referred autonomic phenomena
Hoffman B. L. et all. William Gynecology. 3rd edition. Chapter 11: Pelvic Pain
Myofascial trigger point
Vulvodynia
• vulvar pain of at least 3 months duration that has no identifiable cause
• further subdivided by:
• Location – The symptoms can be localized, generalized, or mixed
• Provocation – Provoked, spontaneous, or mixed
• Onset – Primary or secondary
• Temporal pattern – Intermittent, persistent, constant, immediate
Vulvodynia: Theories, Pathogenesis
Vulvodynia
Neurologic Proliferation
and sensitization
Chronic inflammation
Chronic Infection
Genetics
allergy
Hormonal
myofascial
Psychological
Vaginismus
• Involuntary contraction of the pelvic musculature surrounding the outer third of the vagina
• Vaginismus• lifelong (primary)
• acquired (secondary)
• complete, partial
• situational
No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain. J Obstet Gynaecol Can
2018;40(11):e747−e787 https://doi.org/10.1016/j.jogc.2018.08.015
Vaginismus
• Difficult to differentiate vaginismus from provoked vulvodynia and it is likely that both occur on a continuum with some women having more of a prominence of pelvic floor muscle tightness symptoms and other women having a predominance of pain symptoms
Pudendal Neuralgia
Pudendal Neuralgia• Cardinal symptoms of neuropathic pain:
• Hyperalgesia• Allodynia• No sensory deficit
• The diagnosis is made on the basis of characteristic clinical findings that include:• Pain in the anatomical territory of the pudendal nerve
• Pain worsened by sitting
• Pain does not wake the patient at night
• Pain without superficial sensory deficit
• Pain relieved by diagnostic pudendal nerve block
Pelvic Examination-the single best diagnostic tool!
Physical Exam ComponentsComponents description
General appearance, demeanor Gait, mobility, posture, guarding, eye contact…
Abdominal exam abdominal wall trigger points
Hand-held mirrorHand-held mirror education/validation, helps decrease anxiety of any contact, facilitate how to apply topical etc
Cotton-swab test Palpation of genital areas with cotton-tipped applicatorEvidence of allodyniaCan be performed on any area of the body as well
Single digit exam if speculum or bimanual not tolerable
Assess pelvic floor musclesResponse to pressure/stretch applied to: Transverse perneii ,Bulbocavernosus + ishiocavernosus, Pubococcygeus, iliococcygeus, cocygeus, Obturator internus
Assess pelvic floor tone PFM strength and relaxation
Physical Exam
Physical Exam ComponentsComponents description
General appearance, demeanor Gait, mobility, posture, guarding, eye contact…
Abdominal exam abdominal wall trigger points
Hand-held mirrorHand-held mirror education/validation, helps decrease anxiety of any contact, facilitate how to apply topical etc
Cotton-swab test Palpation of genital areas with cotton-tipped applicatorEvidence of allodyniaCan be performed on any area of the body as well
Single digit exam if speculum or bimanual not tolerable
Assess pelvic floor musclesResponse to pressure/stretch applied to: Transverse perneii ,Bulbocavernosus + ishiocavernosus, Pubococcygeus, iliococcygeus, cocygeus, Obturator internus
Assess pelvic floor tone PFM strength and relaxation
Physical Exam
Initial Treatments and Resources
Rule out other causes of pelvic pain…
Then focus on education and expectations
… it should be made clear that pelvic pain syndromes are chronic conditions in which symptoms are managed but are likely to be ongoing, characterized by periods of remission and symptom flare. Improvements may be slow, as there is not a treatment that is one size fits all, finding the correct treatment for a patient may take some trial and error, time and patience…
Then focus on education and expectations
• Realistic goals and expectations
• Stress management
• Pacing
• Body posture
• Voiding and defecation techniques
Vulvar Hygiene
Pelvic floor Physiotherapy
• Primary treatment of myofascial pelvic pain
• Manual myofascial release
• Stretching
• Strengthening
• Physical therapy works!
• A small trial comparing PFPT and trigger point injections in women with MPPS reported >50 % improvement in symptoms for each group
• A retrospective review of 146 women with MPPS who received PFPT, 63 % of patients reported significant improvement in pain scores
Available in the community
Other Important Therapies
• Acupuncture
• Hypnosis
• Transcutaneous Electrical Nerve Stimulation (TENS)
• Dilators, self massage
• Yoga, stretching
• Sexual Health Counselling/Psychotherapy/Cognitive Behavioral Therapy
• Mindfulness Cognitive Behavioral Therapy
Web Resources
• https://www.retrainpain.org/
• https://www.pelvicpain.org/IPPS/Patients/Patient-Resources/IPPS/Content/Professional/Patient-Resources.aspx?hkey=19cefdcc-cf5e-49f7-9508-68f450a207a3
• https://palousemindfulness.com/index.html
• Acetaminophen
• NSAIDS: Voltarensuppositories
• Opium & Belladonna suppositories
• Gabapentin suppositories
• Vaginal diazepam
Local Medications
Topical Medications• Lidocaine 2 or 5% ointment
• Topical /Local estrogen (vagifem, estragyn vs. Premarin cream)
• Gabapentin compounded ointment/cream 2 to 10%
• Amitriptyline compounded ointment/cream 2 to 10% with baclofen or ketamine
• Capsacin
• Corticosteroids
• Cromolyn
• Enoxaparin
• Cutaneous Fibroblast Lysate
• Meloxicam
Oral Medications
• Antidepressants
• SNRIs: venlafaxine, duloxetine, Milnacipran
• SSRIs: no controlled studies
• TCAs: Amitriptyline
• Anticonvulsants
• including gabapentin
• pregabalin Therapies used in other pain syndrome are appropriate
When to refer to our program, and what we provide to our
patients
Lois Hole Chronic Pelvic Pain Program
• Multi-disciplinary team• Tertiary level care for
refractory cases• Intensive program
• Goal setting• Education classes• Exercises classes• Mindfulness classes
Referral process
• Compulsory gynecology consultation
• Referral information and form available through Alberta Referral Directory
• Patient are triage according to clinical criteria
• Currently long waiting list