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:

❑Sexological: erectile dysfunction, ejaculatory function, post-orgasmic pain

Characterize the pelvic pain ❑Duration: more than 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 ❑Neurological:sensory loss, dysaesthesia ❑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, pelvic floor muscles and gluteal muscles 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 ❑Neurolgical examination: Sacral reflexes, muscular function

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 ❑Semen culture ❑chlamydia, and gonorrhea test ❑CA-125 ❑Pap smear ❑Stool culture ❑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 ❑Endometrial polyps ❑Endometriosis ❑Mittelschmerz pain ❑Mullerian abnormalities ❑Ovarian cysts ❑Pelvic inflammatory disease ❑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

Shown below is an algorithm summarizing the treatment of chronic pelvic pain including: CPP and CPPS

Treatment of Chronic pelvic pain: ❑ Treatment is based on the origin of chronic pelvic pain. Treatments include pain relievers, oral contraceptive pills, pelvic floor therapy, cognitive behavioral therapy, nutrition counseling, neuromodulatory procedures, and surgery

Treatment of CPP(with an underlying pathology ❑Pain management: Usually, the first step in the treatment of CPP is analgesic drugs. ❑ Specific treatment for the identified cause, for example: ❑ in endometriosis, there are therapeutic options, including oral contraceptives, NSAIDS, GNRH agonists and laparscopy are available

Treatment of CPPS( without underlying pathology ❑Pain management: Usually, the first step in the treatment of CPPS is analgesic drugs. ❑Pain education: education about the causes of pain ❑Physical therapy: if there is a pathology of the pelvic floor muscles, or treat myofascial pain if it is part of the pelvic pain syndrome. ❑Biofeedback treatment: for Anal pain syndrome ❑Microwave thermotherapy ❑Extracorporeal shockwave therapy ❑Posterior tibial nerve stimulation ❑Transcutaneous electrical nerve stimulation ❑Psychological therapy ❑Dietary treatment ❑Pharmacological management ❑NSAIDS,α-blockers, Antibiotic therapy, Pregabalin for prostate pain syndrome ❑Anti-histamines, Amitriptyline, Pentosane polysulphate, Intravesical Treatments, Local anesthetics for bladder pain syndrome ❑Botulinum toxin. injected in trigger points might be helpful in Pelvic Floor, Abdominal and Chronic Anal Pain ❑Antidepressants, especially when there is a mood disorder ❑Acupuncture

Do's

• Managing chronic pelvic pain syndrome requires an interprofessional team of healthcare professionals that includes a physical therapist, psychologist, pharmacist, and several physicians in different specialties. The importance of multi-disciplinary treatment is emphasized by several reviews.
• Depending on the severity of the patient's pain, prescription analgesics may be necessary for adequate analgesia. A pharmacist helps coordinate care and helps aid in patient understanding, including proper usage and side effects.
• A cognitive-behavioral therapist helps in the coping and understanding of a patient's pain.

Don'ts

• Zafirlukast and prednisone in two low-power placebo-controlled studies failed to show a benefit in prostate pain syndrome.

References

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