Presentation (EUS definitions)
Definition: Chronic pelvic pain (CPP) is chronic or persistent pain perceived* in structures related to the pelvis of either men or women. It is often associated with negative cognitive, behavioural, sexual and emotional consequences as well as with symptoms suggestive of lower urinary tract, sexual, bowel, pelvic floor or gynaecological dysfunction.
(*Perceived indicates that the patient and clinician, to the best of their ability from the history, examination and inves- tigations (where appropriate) has localised the pain as being perceived in the specified anatomical pelvic area.)
Definition: Chronic pelvic pain syndrome (CPPS) is the occurrence of CPP when there is no proven infection or other obvious local pathology that may account for the pain. It is often associated with negative cognitive, behavioural, sexual or emotional consequences, as well as with symptoms suggestive of lower urinary tract, sexual, bowel or gynaecological dysfunction. CPPS is a subdivision of CPP.
Epidemiology
- Chronic pelvic pain affects ∼15% of women.
Pathophysiology
Differential diagnosis
GYNAECOLOGICAL CAUSES Pelvic inflammatory disease
PID causing CPP is likely related to scarring, tissue damage, and adhesions.
The nerves to the intra-abdominal pelvic organs and contiguous structures can be damaged or the structures can adhere in such a way that painful stretching is produced by activities such as exercise, sexual intercourse, or passage of food through the bowel.
A study conducted by Heisterberg found that women with previous PID complained more of dyspareunia (14% versus 3% respectively) and CPP (6% versus 0.4% respectively) compared with controls.
Pelvic congestion syndrome Pelvic congestion syndrome --> dilated pelvic veins with delayed disappearance of dye
Can be a common finding in women with no apparent cause for their pelvic pain
If congestion severe --> ? pain
Prolonged standing increases pelvic congestion and increases pain
30% reduction in pain can be achieved with IV selective vasoconstrictor dihydroergotamine
Pelvic congestion mainly in reproductive years so ovarian hormones, probably oestrogen, may contribute
Endometriosis
Endometriosis is presence and proliferation of functional endometrial tissue containing both glands and stoma, in sites outside the endometrial cavity (primarily pelvic viscera and peritoneum).
Adenomyosis is endometrial glands within the myometrium causing chronic pain, especially dysmenorrhoea.
Endometriosis is common between the ages of 30 and 45 years
The symptoms include deep dyspareunia, dysmenorrhoea, and constant pelvic pain
The mechanism of chronic pain from this condition is unclear
Chemical: Likely prostaglandins release to peritoneal surfaces
Mechanical: Swelling and stretching of the tissue as well as nerve damage secondary to scarring that occurs around the implants.
Peritoneal adhesions
Pelvic peritoneal adhesions are often asymptomatic
A single adhesion band which is under tension is likely to cause pain in certain positions or during movement particularly when they are extensive and involve sensitive structures like the ovary
Adhesions are usually a complication of PID, endometriosis, appendicitis, peritonitis, and/or previous pelvic surgery.
Other gynaecological causes such as ovarian remnant syndrome, ovarian cyst, and retroverted uterus Ovarian remnant syndrome is sometimes seen in patients following hysterectomy and bilateral salpingo-oophorectomy for severe endometriosis or pelvic inflammatory disease.
Ovarian remnant syndrome results from residual ovarian cortical tissue that is left in situ after difficult surgical dissection during oophorectomy.
The patient usually has had multiple pelvic operations with the uterus and adnexa removed sequentially.
Ovarian cysts can also cause unilateral pelvic pain.
An acutely retroverted uterus can sometimes contribute to the pelvic pain syndrome.
(However, there is still no convincing evidence that ventrosuspension is effective in relieving such symptoms.)
GASTROENTEROLOGICAL CAUSES A significant proportion of woman with CPP can subsequently be found to have a gastrointestinal disorder, either pathogenic or functional. The location of the referred pain from the gastrointestinal tract overlaps that of the reproductive organs. Irritable bowel syndrome This is one of the most common causes of lower abdominal pain and may account for up to 60% of referrals to the gynaecologist for CPP.11 The exact cause of irritable bowel syndrome is still unknown although visceral hypersensitivity or hyperalgesia has been postulated as a possible cause for the pain.12 Patients with this syndrome have pain which is associated with smaller bower distention volume compared with controls.13 Other gastrointestinal causes such as chronic appendicitis, diverticulitis Chronic inflammatory conditions involving the gastrointestinal tract such as appendicitis with an atypical presentation and diverticulitis can also occasionally present as CPP.14 UROLOGICAL CAUSES Urethral syndrome
Urethral syndrome is a complex of various symptoms such as dysuria, frequency and urgency of urination, suprapubic pelvic discomfort, and dyspareunia. The diagnosis is usually made by excluding any abnormality in the urethra or bladder. The cause of urethral syndrome is uncertain but it has been attributed to subclinical infection, urethral obstruction, cold, stress, and psychogenic and allergic factors. Interstitial cystitis Interstitial cystitis is a chronic non-bacterial inflammation of the bladder. Hypersensitivity or hyperalgesia has been postulated as the cause of the pain although the underlying aetiology remains unclear.15 NEUROLOGICAL AND MUSCULOSKELETAL CAUSES Nerve entrapment Nerve entrapment usually follows an abdominal cutaneous nerve injury. Entrapment may occur spontaneously or within weeks to years after transverse suprapubic or laparoscopic skin incisions.16 The ilioinguinal or iliohypogastic nerves may become trapped between the transverse and the internal oblique muscles, especially during muscular contractions. Alternatively, the nerve may be ligated or traumatised during surgery. The clinical picture is usually suggestive of long term postoperative symptoms with an onset following surgery. Myofascial pain Myofascial syndrome has been documented in approximately 15% of patients with CPP.17 Slocumb has termed certain spots in the abdominal wall as “trigger points.”18 Trigger points are believed to be initiated by pathogenic autonomic reflex of visceral or muscular origin and can sometimes be observed during examination. The sites of the referred pain from trigger points are in a dermatome section and are the result of nerves from the muscle or deeper structures sharing a specific neuron in the spinal cord. Injections of local anaesthetics into these painful points can temporarily obliterate the pain. Trigger points are often present in woman with CPP, irrespective of the presence or type of the underlying pathology. In a conducted study by Slocumb,18 trigger points were present on the abdomen in 89%, vagina in 71%, and sacrum in 25% of cases. Other aetiological factors may also contribute to this symptom. These include psychological, hormonal, and biomechanical factors which are believed to predispose the patient to chronic myofascial syndrome when pathology is absent. Low back pain syndrome Low back pain may accompany gynaecological pathology and pelvic pain. The underlying aetiology can involve vascular, neuralgic, psychogenic, or musculoskeletal causes. NON-ORGANIC (PSYCHOSOCIAL) CAUSES There are many observational studies suggesting that women with pelvic pain are significantly more likely to have histories of depression, somatisation, sexual and physical abuse, and chronic psychological distress compared with controls.19 Childhood sexual and physical abuse have also been shown to subsequently lead to somatisation, anxiety, and depression. The intensity of these psychosocial sequelae also appears to be correlated with the duration and severity of the abuse.20 When organic disease has been excluded, these patients often have a characteristic psychological pattern: sad childhood, lack of parental interest and affection. Resentment is generally directed primarily against the patient's mother who is often perceived as having a negative attitude towards sexuality.21 The patient's marital and/or sexual relationship has often been unsuccessful with various psychosexual dysfunctions such as loss of libido, lack of orgasm, and dyspareunia. Russo et al22 have shown that the number of non-organic causes of pelvic pain is linearly correlated with both the number of lifetime anxiety disorders, agoraphobia, and the degree of neuroticism. Walker et al23 highlighted the importance of recognising that medically unexplained physical symptoms may be a proxy for psychiatric distress. They emphasised that a simple review of various medical systems may be a convenient tool to provide an estimate of the degree of psychopathology which would provide a balance of the medical and psychological therapy offered to these patients. The following psychological and/or psychiatric conditions are not uncommonly found. Depression Pain and depression can be closely linked together. Both may be mediated by the same neurotransmitters such as noradrenaline (norepinephrine), serotonin, and endorphine.24 They also give rise to similar behaviour, such as behavioural and social withdrawal with limited interaction. Depression was found to predate the symptom of pain in 75% of cases.24 Nolan et al25 found that 51 (72%) out of 71 patients with pelvic pain reported sleep disorders and 37 (51%) out of 72 patients were clinically depressed as determined by the Beck Depression Inventory. Slocumb et al26 found gynaecological patients with pelvic pain to be more anxious, depressed, hostile, and had more somatic symptoms than controls. Although there appears to be an association between chronic pelvic pain and depression, in many cases it is still unclear as to whether the depressive symptoms precede the development of pain or result from it. Somatisation disorders Patients with CPP have an increased incidence of upper abdominal pain, diarrhoea, constipation, low back pain, dyspareunia, dysmenorrhoea, nausea, bloating, breathlessness, dizziness, weakness, and menstrual irregularity.27 There is also an association between somatisation and a history of sexual trauma in women with non-somatic pelvic pain.19 Physical and sexual abuse Childhood physical and sexual abuse has been noted to be more prevalent in women with CPP compared with those with other types of pain and control groups (52% versus 12% respectively).28 There is a specific association between major sexual abuse and CPP and a more general association between physical abuse and chronic pain.19 Walker et al29,30 found that women with pelvic pain who had a previous history of sexual abuse had a significantly higher risk for having a current diagnosis of major depression and somatiform pain disorder compared with those with no abuse or less severe abuse. Toomey et al31 also found that 19 (53%) out of 36 patients with CPP reported previous abuse and that sexual abuse was reported more frequently than physical abuse. Moreover, other forms of abuse need to be identified since there was a significantly greater incidence of childhood physical abuse in patients with CPP compared with patients with other pain or with controls.32 Rapkin et al19 reported that 39% of patients with CPP had been physically abused during childhood and in this study physical abuse was more common than sexual abuse in the majority of these cases. However, many studies have failed to adopt comparative groups of patients with pain of equivalent chronicity. It is therefore difficult to exclude the possibility that psychological disturbances may have arisen from long term experiences of pain. Furthermore, the possibility of selection bias being operative cannot also be ruled out in these studies.
Examination
Investigations
- Pelvic ultrasonography is indicated to rule out anatomic abnormalities.
- Referral for evaluation of endometriosis by laparoscopy in severe cases
- Depends on suspected organic cause initially
Treatment Options
- Requires collaborative patient-centred approach
Possible pharmacology:
- Depot medroxyprogesterone (Cochrane moderate evidence in CPP)
- Gabapentin, Pregabalin, TCA, SNRI (Though all poor evidence. Evidence only from neuropathic pain studies)
- Nonsteroidal anti-inflammatory drugs
- Gonadotropin-releasing hormone agonists (GNRH) (for endometriosis)
- Mirena can also help for endometriosis (placed at laparoscopy commonly)
- Oral contraceptives unlikely to help if pain is not cyclical
- Pelvic floor physical therapy (only if pelvic floor tenderness and evidence is not strong)
- Behavioral therapy is an integral part of treatment.
- Neuromodulation of sacral nerves (though evidence is poor and technically difficult. Quoted up to 75% success in persistent midline CPP. I am skeptical...)
- Hysterectomy = last resort (significant improvement in only about one-half of cases. 5% have worse pain after).
Prognosis:
Pain improvement possible in 85% of cases.
Pain clinics can offer an alternative approach for women in whom organic pathology has been excluded. Such alternative treatments such as acupuncture, transcutaneous electrical stimulation, hypnosis, exercise, biofeedback therapy, and intensive psychotherapy have been shown to achieve 71% reduction in pain in patients who continued to attend these clinics
Anxiety and depression can also be reduced with psychosocial functioning improved, including return to work, increased social activities, and improved sexual activity. --> multidisciplinary pain management approach is effective in relief from pain and palliative reduction in pain due to organic causes not responding to conventional therapy.
Golden pearls
References / Articles / Resources
Conditions:
Reference:
Allaire, C., Williams, C., Bodmer-Roy, S., Zhu, S., Arion, K., Ambacher, K., ... & Yong, P. J. (2018). Chronic pelvic pain in an interdisciplinary setting: 1-year prospective cohort. American journal of obstetrics and gynecology, 218(1), 114-e1. https://www.sciencedirect.com/science/article/abs/pii/S0002937817311845
Ghaly AFF, Chien PFW Chronic pelvic pain: clinical dilemma or clinician's nightmare Sexually Transmitted Infections 2000;76:419-425.https://sti.bmj.com/content/76/6/419
Essential readings:
Endometriosis - RANZCOG learning - https://www.climate.edu.au/mod/page/view.php?id=13314
Baranowski, AP. 2009. ‘Chronic pelvic pain’. Best practice & research clinical gastroenterology 23: 593–610.
Gerwin, RD. 2002. ‘Myofascial and visceral pain syndromes: visceral-somatic pain representations’. Journal of musculoskeletal pain 10 (1-1): 165–75. DD
Messelink, B, Baranowski, AP, Hughes, J. 2015. Abdominal and Pelvic Pain: From Definition to Best Practice. IASP Press.
Sikandar, S, Dickenson, AH. 2012. ‘Visceral pain: the ins and outs, the ups and downs’. Current opinion in supportive and palliative care 6 (1): 17–26. DD
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