Chronic Pelvic Pain in Women: An Evidence based approach

1. Aboubakr Elnashar
Chronic Pelvic Pain in
Women
An Evidence based approach
Aboubakr Elnashar
Prof Ob Gyn, Benha Universiy Hospital, Egypt

2. Aboubakr Elnashar
ACOG (2004).
RCOG (2005)
Cochrane Library. Syt Review: copyright (2010)
Interventions for treating chronic pelvic pain in
women. Stones W, Cheong YC, Howard FM, Singh S

3. Aboubakr Elnashar

4.  Diagnostic dilemmas.
 : Frustration for both the physician and the
patient.
 Disability and distress
 Significant costs to health services.
CPP
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OBJECTIVES
 DEFINITIONS.
 CAUSES.
 PATHOGENESIS
 DIAGNOSIS.
 TREATMENT.
CONCLUSION

6. DEFINITION
ACOG (2004).
 Noncyclic pain that lasts 6 months or more;
 localized to the pelvis, the anterior abd wall at or
below the umbilicus, or the buttocks
 sufficient severity to cause functional disability or
require medical care
Other definitions
do not require that the pain be noncyclic.
Aboubakr Elnashar

7. RCOG (2005)
 Intermittent or constant pain for at least 6
months
 lower abdomen or pelvis.
 Not occurring exclusively with menstruation or
intercourse
 Not associated with pregnancy.
Aboubakr Elnashar

8. Aboubakr Elnashar
PREVALENCE
 1 in 6 of the adult female.
(RCOG ; 2005)
15%
(Mathias et al, 1999)
 common in women in the reproductive and
older age groups

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PATHOGENESIS
Often laparoscopy reveals no obvious cause
Possible explanations in absence of cause
1. undetected IBS
(Prior 1989).
2. central sensitisation of the nervous system
(Rapkin 1995)
3. vascular hypothesis
(Taylor, 1949; Beard 1984)
pain arises from dilated pelvic veins in which blood
flow is markedly reduced.
{pathophysiology is not well understood}: tt is often
unsatisfactory and limited to symptom relief.

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CAUSES
Definitive diagnosis is not made for 61%
(Zondervan et al, 1999)
Many patients & physicians incorrectly
assume that all CPP results from a
gynecologic source.
One study in the UK:
Urinary&GIT: more common than gynecologic.

11.  25-50%: more than one cause.
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12. Gastrointestinal:
IBS
celiac disease
Colitis
colon cancer
inflammatory bowel disease
Urologic:
Interstitial cystitis
bladder malignancy
chronic urinary tract infection
radiation cystitis
urolithiasis
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13. Aboubakr Elnashar
•Gynecologic
Extrauterine
oAdhesions
oChronic PID
oEndometriosis
oAdnexal cysts
oOvarian remnant syndrome
Uterine
oAdenomyosis
oChronic endometritis
oFibroids
oIntrauterine device
oPelvic congestion syndrome
oGyn malignancy

14. Pelvic congestion syndrome:
Pain:
consistent dull aching pelvic
accentuated before menses
associated with low backache, dyspareunia,
postcoital aching,
Discomfort on prolonged sitting and standing and
often associated with variable degree of
premenstrual tension.
The patient
usually multipara
in her 30s-
60% have some sort of psychopathology.

15. Diagnosis:
Transuterine venography is the standard for
diagnosis.
U/S, doppler and laparoscopy may reveal
varicosities. '

16. Treatment
I. Medical
1. Suppressive therapy:
Low estrogen- high gestagen OCs,
GnRHa or
continuous high dose progestogen, MPA (Provera)
50-300mg/day for up to 18 months, have achieved
promising results

17. 2. Venoactive drugs
Micronised purified flavonoid fraction (Daflon 500
mg twice daily for 6 months
protective and tonic effect on the venous and
capillary wall: increase in venous tone, improvement
in lymphatic drainage and a reduction in capillary
hyperpermeability: ameliorate venous stasis.
(Simsek et al.2007)
statistically significant improvement in pelvic pain
scores without any side effects.
Dihydroergotamine (DHE) (Migranal): Is a selective
venoconstricting agent which increases venous tone
and mobilizes blood which is present in capacitance
vessels.

18. II. Surgical
III. Embolization
IV. Psychotherapy:
explanation, reassurance that she is normal, with
some sedative drugs.

19. Musculoskeletal:
Degenerative disk disease
Fibromyalgia
levator ani syndrome
myofascial pain
peripartum pelvic pain syndrome
stress fractures
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20. Psychiatric/neurologic
Abdominal epilepsy
abdominal migraines
Depression
nerve entrapment
neurologic dysfunction
sleep disturbances
Somatization
Other
Familial Mediterranean fever
herpes zoster
porphyria
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Most commonly diagnosed causes
 IBS
 Interstitial cystitis
 Endometriosis
 Pelvic adhesions.

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DIAGNOSIS
I. History
II. Physical examination
III. Investigations

24. I. HISTORY
Characteristics of the pain
 Quality, duration, modifying factors
 its association with menses, sexual activity, urination,
defecation
History of pelvic infections, or previous surgeries.
Urinary complaints:
Dysuria, Urgency, Frequency
Bowel complaints:
Constipation, flatulance, Diarrhea.
History of physical or sexual abuse
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Red flag symptoms
 unexplained weight loss
 New bowel symptoms over 50
 New pain after the menopause
 Pelvic mass
 Bleeding per rectum
 Irregular vaginal bleeding over 40
 Post coital bleeding
Rule out malignancy or serious systemic
disease.

26. Possible significance
Hematochezia:
Gastrointestinal malignancy/bleeding
History of pelvic surgery, pelvic infections, or use of
intrauterine device:
Adhesions
Nonhormonal pain fluctuation:
Adhesions, interstitial cystitis, IBS, musculoskeletal
causes
Pain fluctuates with menstrual cycle:
Adenomyosis or endometriosis
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27. II. PHYSICAL EXAMINATION
Abdominal:
 Slowly & gently {abdominal & pelvic components of
the examination may be painful}.
 Palpation of the outer pelvis & back: trigger points:
myofascial cause
 Tenderness
 masses or
 other anatomical findings
 Lack of findings does not rule out intra-abdominal
pathology
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Trigger points on abdominal wall
Ultrasound showing hydrosalpinx - circled in red
Ovary stuck up high in scar tissue - circled in blue

29. Tenderness over the
“ovarian point”
Suggests pelvic
congestion syndrome.
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30. Pelvic examination:
Single-digit, one-handed examination.
Bimanual examination:
Nodularity
point tenderness
cervical motion tenderness, or
lack of mobility of the uterus.
A moistened cotton swab:
point tenderness in the vulva & vagina
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31. Rectal examination
Rectal or posterior uterine masses,
nodularity, or
pelvic floor point tenderness.
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32. Carnett’s sign
Placing a finger on the painful, tender area of the
patient’s abdomen
patient raise both legs off the table while lying in the
supine position
Positive test: pain increases
Myofascial cause
Abdominal wall cause. e.g., fibromyalgia or trigger
point.
Visceral pain should not worsen during the
maneuver.
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III. INVESTIGATIONS
If the history & physical examination do not lead to a
diagnosis: {C}
 Cancer screenings appropriate to age & risk factors.
 β-hCG: rule out pregnancy
 CBC:
Infection, systemic illness, or malignancy
(elevated/decreased WBC or anemia)
 Urinalysis & urine culture:
Bladder malignancy, infection
 ESR:
Infection, malignancy, systemic illness
 Vaginal swabs:
gonorrhea & chlamydia: PID

35. TVS:
Adenomyosis
endometriosis/endometrioma
malignancy {B}
MRI & CT
should not be used routinely, but can help assess
any abnormalities found on TVS {B}.
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36. Laparoscopy
 in the past: ‘gold standard’.
 2nd line of investigation if other therapeutic
interventions fail {C}
(RCOG, 2005).
 Indication:
Diagnosis remains elusive after the initial
workup
Confirm or treat, suspected endometriosis,
adhesions, or both.
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TREATMENT
Types of interventions
Lifestyle:
exercise, dietary, substance use.
Psychological:
cognitive behaviour therapy, psychotherapy,
counselling, meditation, biofeedback, US as
reassurance, hypnosis.
Physical therapy.

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Medical:
NSAIDs, OCP, oral and non-oral progestogen,
danazol, GnRH analogues (alone or with ’add-back’
oestrogen), progestogen-releasing intra-uterine
contraceptive devices (IUCD), drugs affecting blood
vessels, antidepressants, anticonvulsants,
analgesics, combined analgesic and caffeine
preparations, local anaesthetic infiltration alone or
in combination with corticosteroids.

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Surgical:
diagnostic laparoscopy, adhesiolysis,
ventrosuspension, presacral neurectomy,
laparoscopic uterine nerve ablation (LUNA), ovarian
vein ligation (via surgery or radiology),
hysterectomy, oophorectomy, ovarian drilling,
wedge resection, endometrial ablation.
Other:
Transcutaneous nerve stimulation, complementary
medicine, referral to standard versus
multidisciplinary clinic setting

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Cochrane analysis, 2010: Few RCT
Of the cause: IBS, interstitial cystitis, endometriosis,
PID, dysmenorrhea,
No cause:
 Multidisciplinary approach{A}:
Dietary
Social
Environmental
Psychological factors in addition to
medication therapy)
improve outcomes over medication therapy alone {B}.

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Counseling supported by ultrasound
scanning {B}
Social problems
Depression
Sexual abuse
Personality disorder
Troubled marriage
Family crisis.

42. Aboubakr Elnashar
I. Non surgical therapies:
 Excluded: endometriosis,primary dysmenorrhea,
PID,IBS, interstitial cystitis
Only the following tts have shown benefit:
 Oral MPA (Provera) 50 mg/d {B}
 GnRHa Goserelin (Zoladex) for 3-6 m before
laparoscopy {A}
 Progestogen (MPA): reduction of pain during tt while
goserelin gave a longer duration of benefit.

43. Aboubakr Elnashar
Cyclic pain: hormonal treatments
(continuous or cyclic low-dose COC {A}, progestins,
or GnRHa) should be considered, even if the
cause is thought to be IBS, interstitial cystitis, or
pelvic congestion syndrome {these conditions may
also respond to hormone tts}
Although selective serotonin reuptake inhibitors
have not been shown to be effective for treating
CPP, they may be used to treat concomitant
depression
Writing therapy and static magnetic field therapy
showed some evidence of short-term benefit.

44. Trigger point injections of the abdominal wall for
myofascial causes: some benefit
(Langford et al, 2007).
Botulinum toxin type A injections into the pelvic
floor muscles: some benefit
(Abbott et al, 2006)
Oral analgesics:
Acetaminophen
NSAID {C}
opioid analgesics: commonly used to treat
moderate pain
No RCT
Gabapentin (Neurontin)
alone or in combination with amitriptyline:
significant pain relief in women with CPP
(Sator-Katzenschlager et al, 2005, RCT)

45. Aboubakr Elnashar
II. Surgical Therapies
 Benefit was not demonstrated for
adhesiolysis (apart from where adhesions were severe)
uterine nerve ablation
LUNA
sertraline or photographic reinforcement after
laparoscopy.
 Total abdominal hysterectomy: some benefit in
observational & cohort studies.

46. History, Examination
Warning signs
No: History`&Exam suggestive of IBS,
IC, endometriosis, myofacial
No:CBC, urine, BHCG
ESR,STD,TVS
Normal
Address comorbid
(pschosocial,
enviromental, dietary)
Reassurance
Abnormal
Evaluate &TT specific abnormality
Yes: Evaluate &
TT
Yes: Exclude
malignancy or
serious disease
ACOG, 2005
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47. NSAID or Acetaminophen
Inadequate relief
Cyclic pain
Provera,COC, Depoprovera,GNRHa, Mirena
Inadequate relief
Noncyclic pain
Gabapentin &Amitrytlyline
Inadequate relief
Laparoscopy
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48. Aboubakr Elnashar
Conclusion
Main approaches to treatment include
Counselling or psychotherapy,
Attempts to provide reassurance using laparoscopy
to exclude serious pathology,
Progestogen therapy such as with MPA and
Surgery to interrupt nerve pathways.

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