Chronic pelvic pain resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: : Roghayeh Marandi, M.D.

Synonyms and keywords:

Overview

Chronic pelvic pain is a symptom, not a diagnosis, and is defined as persistent or recurrent pelvic pain of either men or women for longer than three to six months. It can be classified into two subgroups: specific disease-associated pelvic pain that there is a pathology to explain the pain such as pelvic inflammatory disease, infections, adnexal pathologies, endometriosis, etc., and chronic pelvic pain syndrome (CPPS), which its diagnosis often based on the history and physical examinations and imaging and laboratory findings are often inconclusive in diagnosing it, and usually, no specific etiology can be found. Ninety-nine percent of all cases of chronic pelvic pain are female. The Pathophysiology of chronic pelvic disease could be related to the somatic structure or viscera pathologies, central sensitization of pain, or both. Treatment of chronic pelvic pain is often complicated and is usually focused on the suspected etiology of the chronic pelvic pain, such as treating a comorbid mood disorder, neuropathy, or uterine dysfunction, which can exacerbate chronic pain.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Ovarian cyst
• Malignancy

Gender-specific causes classification

Women

Infection, Endometriosis, Dysmenrrhea, Dysparenia, Myofascial Pain Syndrome, Vulvodynia, Vulvitis, Cystitis,bladder pain syndrome, Ovarian Remnant Congestion, Sympathetically Mediated Pain, Pelvic Congestion, Pelvic Fibrosis, Pelvis Neurodystonica, Irritable Bowel Syndrome, Sexual/Physical Abuse, Cancer, Psychiatric Disorders, Surgical Procedures(adhesions), Pelvic floor muscle pain syndrome, Vulvodynia,Vestibular pain syndrome,Endometriosis- associated pain syndrome

Men

Prostatitis, Chronic Orchalgia, Prostadynia, Interstitial Cystitis, Ureteral Obstruction, Irritable Bowel Syndrome, bladder pain syndrome,Sexual/Physical Abuse, Cancer,Psychiatric Disorders, Proctalgia fugax, Radiation proctitis, Surgical Procedures (adhesions), Rectal pain syndrome,Pelvic floor muscle pain syndrome,Prostatic pain syndrome, Scrotal pain syndrome, Testicular pain syndrome, Epididymal pain syndrome, Penile pain syndrome, Urethral pain syndrome, Post-vasectomy scrotal pain syndrome

Common Causes

Commonly proposed etiologies of chronic pelvic pain(CCP) include:

• Endometriosis (very controversial) Deeply Infiltrative Endometriosis may be more important
• Infection or post-infectious neurological hypersensitivity
• Exaggerated bladder, bowel, or uterine pain sensitivity (also known as visceral pain)
• Ovarian cysts, uterine leiomyoma

Diagnosis

Shown below is an algorithm summarizing the diagnosis of chronic pelvic pain:

Characterize the pelvic pain ❑Duration: more than 3-6 months ❑Frequency: cyclical or non-cyclical ❑ Type: like paresthesia, numbness, burning, or lancinating pain ❑location: in the pelvis, anus, and/or genitals

Ask about associated symptoms ❑Gynecological: Painful periods painful ovulation painful intercourse heavy bleeding with periods irregular periods vaginal discharge pain during ejaculation ❑Gastrointestinal: Painful bowel movement with menses the urgency with bowel movement bloating diarrhea or constipation nausea, vomiting Abdominal pain (episodic or constant) Abdominal distension Fever Weight gain or loss Anorexia Dyspepsia ❑Musculoskeletal: Low back pain pain with certain movements ❑Urinary tract: Dysuria, polyuria ❑Psychological: Stress, depression, anxiety, anger

Inquire about ❑ Past medical history ❑Psychological disorder ❑Previous abdominal or pelvic surgery

Examine the patient ❑General Apperance: ❑ Check for weight loss ❑Abdominal and pelvic examination ❑ Check for:focal tenderness, enlargement, distortion on abdominal examination, suprapubic tenderness ❑Examination of external and internal genitalia, Q tip test ❑Rectal examination ❑check for: for fecal incontinence, tender puborectal muscles, anal or rectal prolapse ❑Musculoskeletal examination: ❑check for:Tender sacroiliac joints are suggestive of a musculoskeletal origin to the pain Full clinical examination of the spinal, muscular, nervous, and urogenital systems to detect any pathology

Order ❑ To rule out the pregnancy, chronic inflammation, or infection, mass or any pathologic cause, as the source of chronic pelvic pain, order: ❑Complete blood count with differential ❑Urine pregnancy test ❑Erythrocyte sedimentation rate ❑Urinalysis ❑chlamydia, and gonorrhea test ❑CA-125 ❑Pap smear ❑Abdominal and pelvic Ultrasound ❑Cystoscopy ❑Urodynamic studies ❑Laprascopy

CPP( with pathology to explain the pain)

CPPS (without pathology to explains the pain) ❑Painful bladder syndrome ❑Vulvodynia: Vestibular pain syndrome, Clitoral pain syndrome ❑Generalised vulvar pain syndrome ❑Rectal pain syndrome ❑Irritable bowel syndrome ❑Proctalgia fugax ❑Coccydynia ❑Pelvic floor muscle pain syndrome ❑Endometriosis- associated pain syndrome( pain remains even after endometriosis treatment) ❑Chronic prostatitis/chronic pelvic pain syndrome ❑Orchalgia ❑Perineal pain syndrome ❑Epididymal pain syndrome ❑Penile pain syndrome ❑Urethral pain syndrome ❑Post-vasectomy pain syndrome ❑Dysmenorrhea: Pain with menstruation that is not associated with well-defined pathology. Dysmenorrhoea needs to be considered as a chronic pain syndrome if it is persistent and associated with negative cognitive, behavioral, sexual, or emotional consequences.

Gynecologic ❑Adenomyosis ❑Adhesions in the pelvic area ❑Cervical polyps ❑Chronic vulvovaginitis ❑Dysmenorrhea ❑Ectopic pregnancy ❑Endometrial polyps ❑Endometriosis ❑Miscarriage ❑Mittelschmerz pain ❑Mullerian abnormalities ❑Ovarian cysts ❑Ovarian torsion ❑Pelvic inflammatory disease ❑Placental abruption ❑Retroverted uterus ❑Uterine leiomyoma

Non-Gynecologic

Gatserointestinal ❑Anal fissure ❑Appendicitis ❑Colitis ❑Colonic polyps ❑Constipation ❑Diarrhea ❑Diverticulitis ❑Gastrointestinal cancers ❑Hemorrhoids ❑Internal hernia ❑Proctitis ❑Strangulated hernia ❑Ulcerative colitis ❑Abdominal epilepsy ❑Radiation proctitis ❑Surgical Procedures (adhesions)

Genitourinary ❑Chronic bacterial prostatitis ❑Chronic bladder irritation ❑Chronic non bacterial prostatitis ❑Chronic urethritis ❑Epididymal cysts ❑Hydrocele ❑Urinary tract calculi ❑Varicocele

Musculoskeletal ❑Low back pain ❑Muscle spasm ❑Pelvic girdle malrotation ❑Tension in the pelvic floor muscles ❑Degenerative joint disease ❑Disc herniation

Co-morbidities ❑Somatization ❑Depression/Anxiety ❑Abdominal wall pain ❑Sexual/physical/psychological abuse

Treatment

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Treatment of CPP(with an underlying pathology

❑Pain management: Usually, the first step in the treatment of CPP

❑ Specific treatment for the identified cause, for example:

❑ in endometriosis, there are therapeutic options, including oral contraceptives, NSAIDS, GNRH agonists and laparscopy are available

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Treatment of CPPS( without underlying pathology

❑Pain management: Usually, the first step in the treatment of CPPS

❑Treatment of a patient with chronic pelvic pain syndromes( without any pathologies responsible for pain) is over-the-counter analgesic(acetaminophen, NSAIDs).

❑If OTC is inadequate for pain relief and the pain is cyclical, oral contraceptive pills, depot medroxyprogesterone, or an intrauterine device is recommended if the pain is cyclical.

❑If hormonal treatment is ineffective, or the pain not cyclical, or pelvic pain is suspected to be neuropathic, it is essential to evaluate the patient for an underlying mood disorder.

❑If there is a mood disorder, antidepressant therapy (SSRI) is recommended.

❑If a patient with suspected chronic pelvic pain secondary to neuropathic pain does not have an underlying mood disorder, various treatment options exist, such as antidepressants (TCAs), pregabalin, gabapentin, or SNRIs such as venlafaxine or duloxetine.

❑If pain is uncontrolled with those various treatment options, it is recommended to refer to a Pain Medicine specialist and possibly start a trial of opioid analgesics.

❑Local steroid injection can be considered in sacral nerve injury.

❑Adjunct, non-pharmacological treatments such as pelvic floor therapy for chronic pain with the musculoskeletal origin, cognitive behavioral therapy, nutrition counseling, neuromodulatory procedures are also be offered.

Treatment of Chronic pelvic pain: ❑ It depends on the underlying cause and subsequent therapy. ❑ Educating patients about pelvic anatomy, physiology

Do's

• The content in this section is in bullet points.

Don'ts

• The content in this section is in bullet points.

References

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