chronic%20pelvic%20pain%20in%20women
CHRONIC PELVIC PAIN IN WOMEN
Chronic pelvic pain (CPP) is a persistent, distressing, & severe pain of >6 month duration.
It occurs intermittently, cyclically, or situationally.
Localized to the pelvis, anterior abdominal wall at or below the umbilicus, the lumbosacral back, or the buttocks.
It is severe enough to cause functional disability or need medical care.
In women, CPP is not restricted to intercourse or menstruation & is not associated w/ pregnancy.
It is a symptom w/ a number of contributory factors & not a diagnosis; pathophysiology is complex & not well understood.
It is assumed that in the development of chronic pain, the nervous system is affected among others by inflammatory & chemical mediators & hormones.
A complex problem that is both multifactorial & multidimensional.

Diagnosis

  • A subdivision of chronic pelvic pain (CPP), chronic pelvic pain syndrome (CPPS) is pain localized to >1 organ site
    • Patients may perceive the pain as coming from 1 organ or from systemic symptoms 
  • It is the occurrence of CPP without an obvious ongoing disease process that can account for the pain, often associated with negative behavioral, cognitive, emotional or sexual consequences in addition to symptoms that are suggestive of a bowel, lower urinary tract, gynecological, or sexual dysfunction
  • CPPS is also suggested by the following: Pain persistence >6 months, incomplete pain reduction from prior therapies, pain is not consistent with tissue damage, loss of function and signs of depression are present, changes in the relationship and family dynamics
  • The term CPPS may also be used when pelvic pain is poorly localized or specific pathology is unidentified
  • CPPS mechanisms include neuroplasticity and neuropathic pain mechanisms
  • CPPS should be subdivided according to its corresponding phenotype based on the classification proposed by the European Association of Urology (EAU) if with adequate evidences  
    • Based on the axis system recommended by the International Association for the Study of Pain (IASP)

Gastrointestinal Aspect

Chronic Anal Pain Syndrome (Chronic Proctalgia)

  • The following criteria should be met for the past 3 months with onset of symptoms at least 6 months before diagnosis: Chronic or recurrent rectal pain or aching, episodes lasting at least 20 minutes, other causes of rectal pain are excluded eg coccygodynia, cryptitis, hemorrhoids, inflammatory bowel disease, intramuscular abscess and fissure, ischemia
  • Also demonstrates severe tenderness on posterior traction of the puborectalis muscle
  • Intermittent chronic anal pain syndrome (proctalgia fugax) may be considered a subgroup of the chronic anal pain syndromes
    • The following diagnostic criteria should be met for the past 3 months with onset of symptoms at least 6 months before diagnosis: Recurring episodes of pain localized to the anus or lower rectum, episodes lasting from several seconds to minutes, absence of anorectal pain between episodes
  • Workup: Endoscopy, anorectal manometry, rectal balloon expulsion test, magnetic resonance imaging (MRI) defecography, pelvic floor muscle testing
  • Treatment: Biofeedback is the preferred treatment, Botulinum toxin A injection, electrogalvanic stimulation (less effective than biofeedback), percutaneous tibial nerve stimulation
    • May consider sacral neuromodulation; inhaled Salbutamol for intermittent anal pain syndrome

Gynecological Aspect

  • Pain that is predominantly cyclical is likely to have a gynecological cause
  • Pain associated with gastrointestinal and urinary symptoms must be assessed carefully
    • Symptoms suggestive of irritable bowel syndrome (IBS) or interstitial cystitis are frequently seen in women with CPP and these may be a primary cause or a component of CPP or a secondary effect brought about by the efferent neurological dysfunction of CPP
Dysmenorrhea 
  • May be considered as a chronic pain syndrome if persistent and associated with negative behavioral, cognitive, emotional or sexual effects
Endometriosis-associated Pain Syndrome
  • Patients with laparoscopically-confirmed endometriosis with chronic or recurrent pain despite appropriate therapeutic strategies and associated with negative behavioral, cognitive or emotional effects, or sexual, urological or bowel dysfunction

Vaginal and Vulvar Pain Syndrome

  • Pain persisting for >6 months in the vagina or the female external genitalia (vulva which includes the labia, clitoris, and vaginal entrance) with no known cause; also called vulvodynia
  • Causes of vulvodynia include history of chronic antibiotic use or sexual abuse, hormonal changes, injury or irritation to the nerve or muscle, hypersensitivity to yeast infections or allergies to chemicals or other substances, abnormal inflammatory response to trauma or infection
  • Workup: Complete gynecological examination, ultrasound, laparoscopy
  • Treatment: Hormonal treatments [combined oral contraceptives, progestins, gonadotropin-releasing hormone (GnRH) agonists, or Danazol] should be considered for pain that seems to be cyclical in nature
    • Laparoscopy for treatable causes
    • Other therapies include a multidisciplinary approach for persistent diseases and psychological treatment for refractory chronic vulvar pain

Musculoskeletal Aspect

Coccyx Pain Syndrome (Coccygodynia)

  • Pain at the coccyx elicited by its manipulation that is due to pelvic floor hypertonicity and reduced coccyx mobility
  • Usually related to prolonged sitting or trauma and is worsened by arising, bending, sitting, defecation, or intercourse
  • Workup: Local anesthetic injection produces pain relief
  • Treatment: Anti-inflammatory drugs, physical therapy, massage, neuroablation
    • Consider local injection if coccyx is unstable

Pelvic Floor Muscle Pain Syndrome

  • A dull pressure or ache that worsens with sitting or lying down and is frequently associated with incomplete evacuation
  • CPP can be a form of myalgia due to misuse of the pelvic floor muscles; pelvic floor overactivity and myofascial trigger points may also be involved
  • Workup: Test for pelvic floor function and myofascial trigger points, pelvic floor muscle electromyography (EMG)
  • Treatment: First-line treatment is pelvic floor muscle therapy in patients with CPPS
    • Use biofeedback as adjuvant to muscle exercises
    • Treatment by pressure or needling is recommended for myofascial trigger points
    • May consider Botulinum A toxin injection for trigger points and pelvic floor muscle overactivity
    • Management of pain will involve a physiotherapist, a pain doctor, and a psychologist

Neurological Aspect

Pudendal Neuralgia

  • Burning, crushing or electric pain perceived in the perineum from the anus to clitoris or penis
  • Related features include allodynia (pain on light touch), dysesthesia (unpleasant sensory perceptions usually but not necessarily due to provocation), hyperalgesia (heightened pain perception after a painful stimulus), and paresthesia (pins and needles)
  • Associated with history of pelvic surgery, prolonged sitting, and postmenopausal older women; rarely in trauma (eg birth trauma, fractures, falls), cancer, or cycling
  • Patient’s immobility and disability develop muscular aches and pain that lead to involvement of the musculoskeletal system
  • Workup: Imaging and neurophysiology may aid in the diagnosis, but investigations are often normal
    • Gold standard is an image and nerve locator-guided local anesthetic injection
  • Treatment: Refer to a specialist if a peripheral nerve problem is suspected
    • Treat as for any other nerve injury; utilize available standard regimens to neuropathic pain management

Psychological Aspect

  • Majority of patients meet the diagnostic criteria for a persistent somatoform pain disorder in which pain is associated with psychosocial problems or emotional conflict
  • Evaluating the link between psychiatric diseases and CPP is difficult; while chronic pain can result in a psychopathology, an existing psychopathologic condition may also affect pain perception and encourage the development of chronic pain
  • Women with CPP often have comorbid conditions eg anxiety, depression, substance abuse, or sexual problems
    • Anxiety may be related to the patient’s fears of an undiagnosed pathology as the cause of pain, eg cancer, and to uncertainties regarding treatment possibilities and the probable prognosis if treated or not
    • Depression may be attributed to pain or its impact
  • Workup: Assess patient’s psychological history and pain-related beliefs and behavior
    • Asking the patient’s perception about pain gives the chance for appropriate information and reassurance
  • Treatment: Offer psychological interventions in combination with other modalities eg medical and surgical treatments
    • Psychologically-informed physical therapy results in improved pain and function
    • Exercise and cognitive behavioral therapy combined with Medroxyprogesterone acetate reduces pelvic pain in majority of women

Sexual Aspect

  • Sexual dysfunction is prevalent in patients with pelvic pain syndrome, is multifactorial, and may be related to depression, use of antidepressants, relationship satisfaction, and many others
    • In women, dysfunctions that are most reported are sexual avoidance, dyspareunia, and vaginismus
  • Patients with symptoms suggesting CPPS should be screened for sexual abuse
  • Workup: Inquire regarding psychiatric history and history of relationship, sexual functioning, and negative experiences eg abuse
    • May use the Female Sexual Function Index (FSFI) questionnaire
  • Treatment: Refer to a specialist for management of sexual dysfunction
    • Utilize a biopsychosocial approach in pain treatment
    • Offer partner treatment and behavioral strategies for coping with sexual dysfunction
    • Refer for pelvic floor muscle physical therapy

Urological Aspect

Bladder Pain Syndrome

  • Pain, discomfort, or pressure perceived to be related to the bladder with at least daytime and/or nighttime increase in urinary frequency, aggravated by food or drink, relieved by voiding but returns soon, and other well-defined pathologies excluded
  • Workup: Urinalysis, urine culture, uroflowmetry, general anesthetic rigid cystoscopy with hydrodistention, bladder biopsy, pelvic floor muscle testing, potassium chloride (KCl) sensitivity test, micturition diary, Interstitial Cystitis Symptom Index (ICSI) score list
  • Treatment: Hydroxyzine, Amitriptyline, Nortriptyline, Pentosan polysulfate, Cimetidine, Cyclosporin A
    • Intravesical therapies: Pentosan polysulfate sodium (PPS), Dimethyl sulfoxide (DMSO), Botulinum toxin A plus hydrodistention, Hyaluronic acid, Chondroitin sulfate, Heparin, Lidocaine with Sodium bicarbonate 
    • Other therapies include neuromodulation, bladder training, physical therapy, psychological therapy, sacral or pudendal nerve stimulation

Urethral Pain Syndrome

  • Episodic pain that is chronic or recurrent, perceived in the urethra, and is without obvious local pathology
  • May be a part of bladder pain syndrome; urethral pain may be a neuropathic hypersensitivity after a urinary tract infection
  • Workup: Uroflowmetry, pelvic floor muscle testing, micturition diary
  • Treatment: There is no specific treatment for urethral pain syndrome; patients are recommended to be treated in a multidisciplinary and multimodal program
    • For distressed patients, may consider a pain-relevant psychological therapy

History

  • A complete and detailed history should include organ-specific inquiries on gastroenterologic, gynecologic,musculoskeletal, urologic and neurologic symptoms including a thorough review of systems of infectious,endocrine, psychiatric and sexual disorders
    • Ask for previous radiation or medical treatment, recent pregnancy, history of pelvic surgery or infections or use of intrauterine device (IUD), history of physical or sexual abuse, history of alcohol and drug abuse
      • A history of sexual abuse as a child may lead to the development of depression, anxiety or somatization which makes patient vulnerable to developing chronic pelvic pain (CPP)
    • Rule out malignancy or other severe systemic diseases by noting “red flag” symptoms eg rectal bleeding, pelvic mass, weight loss, suicidal ideation, new bowel symptoms at >50 years of age, postcoital bleeding, new pain after menopause, irregular vaginal bleeding >40 years of age
  • Characterize pain according to its quality, duration, location, intensity, timing, aggravating or alleviating factors,trigger situation, relation to movement and posture, association with menses, sexual activity, urination, defection,effect on quality of life
    • Visceral pain is dull, crampy, or poorly localized, somatic pain may be dull or sharp, and neuropathic pain maybe burning, stabbing, electrical, or paresthesia-like
  • CPP often has more than one component and goal of assessment is to investigate contributing factors related to CPP including environmental, social (social isolation, family problems), cognitive (pain assessment, pain control perception), emotional (symptoms of anxiety or depression), behavioral (level of activity and medication use), and physical (tiredness, sexual dysfunction, sleep problems)
    • May make use of the history and physical examination forms from the International Pelvic Pain Society
    • Psychological comorbidities may also be detected using other validated symptom-based tools

Physical Examination

  • If pain is intermittent, patient is best examined while in pain in order to look for pathological conditions and to be able to reproduce the pain to identify physical contributors
  • Observe for general demeanor, mobility, and posture when patient walks into the clinic
  • Check the back for trigger points, pelvic asymmetry, sacroiliac tenderness
  • Abdominal exam includes checking for skin lesions, hypersensitivity around scars, or trigger points (areas where light localized pressure elicits a vigorous pain response)
    • A positive Carnett’s sign (examiner’s finger on the tender area of the patient’s abdomen while patient raises both legs off the table) with an increase in pain indicates a myofascial cause of the pain
    • Pain lessening on the head-raise test indicates an intraperitoneal cause of pain
  • Individual pelvic structures are then examined to differentiate sources of pain and localized areas of tenderness are identified to help guide specific therapy
    • Palpation of the back, outer pelvis, and pelvic floor may show trigger points indicating a myofascial component
      • Inspect also for enlargement, distortion, prolapse, discoloration, or infectious sequelae
    • External genitalia exam, pelvic examinations with a single-digit one-hand exam followed by a bimanual exam, and a rectal exam to check for nodularity, masses, or point tenderness

Laboratory Tests

  • Initial workup includes a complete blood count (CBC), erythrocyte sedimentation rate (ESR), urinalysis with urine culture, beta-human chorionic gonadotropin (β-hCG), vaginal and endocervical swabs, and stool culture
    • Offer screening for sexually transmitted infections to sexually active patients with chronic pelvic pain (CPP)
  • Cancer screening appropriate to patient’s age and related risk factors should be done
    • A serum cancer antigen 125 (CA-125) should be measured if the following symptoms occur >12 times per month: Early satiety, bloating, pelvic pain, urinary urgency or frequency
  • The history and physical examination may point toward a specific diagnosis for which special testing may be indicated
    • Other special diagnostic tools or methods are reserved for specific questions but should not be included in the routine diagnostic workup

Imaging

  • Eg Ultrasound (US), magnetic resonance imaging (MRI), computed tomography (CT) scan
  • Should only be performed when clinically indicated
  • Transvaginal pelvic ultrasound is part of the initial diagnostic workup if history and physical exam are unrevealing of a specific diagnosis
    • Useful in evaluating pelvic masses
  • MRI and CT scans are not routinely done but can help evaluate ultrasound findings
    • MRI may be helpful if a clear cause for pain was not elicited on examination of patient
    • MRI may be used in assessing palpable nodules in the pelvis or rectovaginal disease
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Endometriosis is a common gynaecological condition affecting about 6–10% of women of reproductive age and can be a debilitating disease. It is the second most common reason for surgery in premenopausal patients. It is defined as the presence of endometrial-like tissue outside the uterine cavity, leading to a chronic inflammatory reaction. The exact aetiology is unknown, but the retrograde menstruation model is the most widely accepted theory explaining the development of pelvic endometriosis. According to this model, menstrual blood containing endometrial fragments passes through the fallopian tubes into the pelvic cavity, resulting in the formation of peritoneal endometrial deposits. There are three distinctive pathological types of pelvic endometriosis: superficial peritoneal implants, ovarian endometriomas, and deep infiltrating nodular lesions. The extent of the disease is very variable and often does not correlate with the severity of symptoms. Although it can sometimes be asymptomatic (in about 20% of cases), endometriosis is frequently associated with severe pain and infertility. Several management options exist for endometriosis and the choice depends on several factors such as age, fertility, severity of the symptoms, and extent of the disease. This review presents three different cases of endometriosis with different complexities and presentations. The diagnosis and various medical and surgical treatment options available to the clinician will be discussed.