Chronic pelvic painDr: Abir Moheidin Said

Chronic pelvic painThe pelvic pain that persists for

aperior of 3 months or more to be considered chronic

Differentiating between acute & chronic pain is important in understanding chronic pelvic pain syndromes

Acute pain is most commen after experienced by patients after surgery or other soft tissue traumas, it tendes to be immediate, sever & short

CPPCPP is a common problem presenting a

major challenge to healthcare professionals. This is partly due to understanding of the etiology & natural history of the disease.

CPP is a serious problem affecting the lives of many women during their child bearing years

The differential diagnosis of the underlying etiology often involves both psychological & organic factors

DifinitionInternational Association for the

Study of Pain (IASP)defines CPP as chronic or recurrent pelvic pain that has a gynaecological origin but for which no definite lesion or cause is found, absence of pathology

3-6 months duration which is not relieved by narcotic analgesia

Incidence13-20% of gynaecological

consultations 52% of diagnostic laparoscopyIn the United States 12-16% of

hysterectomies were performed for CPP

CPPWomen with symptoms of pain may

want to see a gynecologist if problems don‘t go away after a few days, should take a carful history & examination, followed by a pregnancy test. The absence of visible pathology in chronic pain syndromes should not form the basis for either seeking psychological explanations or questioning the reality of the patient‘s pain.

CPP

Instead it is essential to approach the complexity of chronic pain from a psychophysiological perspective which recognizes the importance of the mind-body interaction. Some of the mechanisms by which the limbic system impacts on pain, & in particular myofascial pain, have been clarified by research findings in neurology & psychophysiology

Gynaecological causesPID ( cervicitis, endometritis, salpingo-

oophoritis)Most cases of PID are caused by sexually

transmitted organisms, such as Chlamydia trachomatis & neisseria gonorrhoeae

Chlamydia infection may be asymptomatic & the resulting salpingitis is often referred to as (silent pelvic inflammatory disease)

The mechanism of CPP following PID is likely to be related to the scarring, tissue damage & adhesions

Pelvic congestion syndromeDilated pelvic veins with delayed

disappearance of dye & is a common finding in women with no apparent cause for their pelvic pain

Is largely confined to women in their reproductive years ( ovarian hormones, probably estrogen)

Standing for long period of time will increase pelvic congestion & pain

EndometriosisPresence & proliferation of endometrial

tissue outside the endometrial cavity The most frequent sites of implantation

are the pelvic viscera & peritoniumAdenomyosis cause CPP , especially

dysmenorrhoea,dyspareunia & CPPMechanism by swelling, stretching of

the tissue as well as nerve damage secondary to scarring

Other gyn. causesOvarian remnant syndrome following

hysterectomy & BSO for sever endometriosis or PID, because of residual ovarian cortical tissue that is left in situ after difficult surgical dissection during oophorectomy

Ovarian cysts can causes unilateral pelvic pain

Retroverted uterus can sometimes contribute to Pelvic pain syndrome, however, there is still no convincing evidence that ventrosuspension is effective in relieving such symptoms

Peritoneal adhesionsResponsible for pelvic pain although they

are often asymptomaticA single adhesion band which is under

tension is likely to causes pain during certain position or during movement

Peritoneal adh. Can cause pain , particularly when they are extensive & involve sensitive structures like the ovary

Usually a complication of PID, endometriosis, appendicitis, peritonitis & previous pelvic surgery

Gastroenterological causesIrritable bowel syndrome ( 60%

of referrals to gynaecologist for CPP)

Chronic appendicitisChronic diverticulitisColitis

Urological causesUrethral syndrome is a complex

of various symptoms such as dysuria, frequency & urgency, suprapubic pelvic discomfort & dyspareunia

Interstitial cystitis is a chronic non-bacterial inflammation of the bladder ( hypersensitivity or hyperalgsia has been postulated as the cause of the pain

Neurological & musculoskeletalNerve entrapment usually follows an

abdominal cutaneous nerve injury spontaneously or after incisions

Myofascial syndrome about 15% of CPP, injection of local anesthetic can temporarily obliterate the pain

Low back pain syndrome, underlying aetiology can involve vascular, neuralgic, psychogenic or musculoskeletal causes

Psychosocial causesDepression & pain can be closely

linked togetherHistories of sexual & physical

abuseSomatization disordersAnxiety

CPP

ManagementGood historyOrganic & psychological aspectsInvestigation & treatment of organic

diseaseClinical psychological &/or

psychiatric inputDifferent healthcare professionals

may play in the management , depending on the underlying etiology

Vaginal & cervical swabs

ManagementPelvic ultrasound ( peritoneal free

fluid, dilated fallopian tubes, tubo-ovarian abscess,ect)

Endometrial biopsy can sent for microbiological as well as histopathological

Hysteroscopy Laparoscopy

( adhesion,leimyoma,hernia,ect)Urin analysis / C&S

Management

Sigmoidoscopy for irritable bowel syndrome or diverticulitis

Radiological imaging studies to exclude any pathology

Cystoscopy, IV pyelogrampsychotherapy

TreatmentPain clinics can offer for women in whom

organic pathology has been excludedAlternative treatment such as

acupunture,transcutaneous electrical stimulation, hypnosis, exercise .

psychotherapy have been shown to achieve 71% reduction in pain

Anxiety & depression can also be reduced with psychosocial functioning improved, including return to work, increased social activities & improved sexual activity

TreatmentMany women will benefit from a

consultation with a consultation with a physical therapist, a trial of anti inflammatory medications, hormonal therapy or even neurological agents

A hysterectomy is sometimes performed

ManagmentManagement of CPP is a major

challenge for health service, both physical & psychological management offered by various medical & non medical health professionals, gynaecologist, psychologist, anaesthesiologist, urologist 6 gastroenterologists

THANKS