Chronic pelvic pain resident survival guide

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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 are 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 is 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.

Gender-specific causes classification[1][2]

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: [3] [4]

Diagnosis

Shown below is an algorithm summarizing the diagnosis of chronic pelvic pain:[1][2]

 
 
 
 
 
 
 
 
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 genitalia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
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
Sexological
Erectile dysfunction, ejaculatory function, post-orgasmic pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Specific disease-associated pelvic 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.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-Gynecologic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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: Specific disease-associated pelvic pain and CPPS[6][2][7][8][9][10][11][12][13][14]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 Specific disease-associated pelvic pain(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 laparoscopy 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

References

  1. 1.0 1.1 Hunter CW, Stovall B, Chen G, Carlson J, Levy R (March 2018). "Anatomy, Pathophysiology and Interventional Therapies for Chronic Pelvic Pain: A Review". Pain Physician. 21 (2): 147–167. PMID 29565946.
  2. 2.0 2.1 2.2 Engeler DS, Baranowski AP, Dinis-Oliveira P, Elneil S, Hughes J, Messelink EJ, van Ophoven A, Williams AC (September 2013). "The 2013 EAU guidelines on chronic pelvic pain: is management of chronic pelvic pain a habit, a philosophy, or a science? 10 years of development". Eur Urol. 64 (3): 431–9. doi:10.1016/j.eururo.2013.04.035. PMID 23684447.
  3. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
  4. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
  5. Stout AL, Steege JF, Dodson WC, Hughes CL (1991). "Relationship of laparoscopic findings to self-report of pelvic pain". Am J Obstet Gynecol. 164 (1 Pt 1): 73–9. PMID 1824741.
  6. Dydyk AM, Gupta N. PMID 32119472 Check |pmid= value (help). Missing or empty |title= (help)
  7. Fitzgerald MP, Anderson RU, Potts J, Payne CK, Peters KM, Clemens JQ, Kotarinos R, Fraser L, Cosby A, Fortman C, Neville C, Badillo S, Odabachian L, Sanfield A, O'Dougherty B, Halle-Podell R, Cen L, Chuai S, Landis JR, Mickelberg K, Barrell T, Kusek JW, Nyberg LM (January 2013). "Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes". J Urol. 189 (1 Suppl): S75–85. doi:10.1016/j.juro.2012.11.018. PMID 23234638.
  8. Loving S, Nordling J, Jaszczak P, Thomsen T (April 2012). "Does evidence support physiotherapy management of adult female chronic pelvic pain? A systematic review". Scand J Pain. 3 (2): 70–81. doi:10.1016/j.sjpain.2011.12.002. PMID 29913781.
  9. Kanter G, Volpe KA, Dunivan GC, Cichowski SB, Jeppson PC, Rogers RG, Komesu YM (February 2017). "Important role of physicians in addressing psychological aspects of interstitial cystitis/bladder pain syndrome (IC/BPS): a qualitative analysis". Int Urogynecol J. 28 (2): 249–256. doi:10.1007/s00192-016-3109-2. PMC 5292090. PMID 27581769.
  10. Chiarioni G, Nardo A, Vantini I, Romito A, Whitehead WE (April 2010). "Biofeedback is superior to electrogalvanic stimulation and massage for treatment of levator ani syndrome". Gastroenterology. 138 (4): 1321–9. doi:10.1053/j.gastro.2009.12.040. PMC 2847007. PMID 20044997.
  11. Rowe E, Smith C, Laverick L, Elkabir J, Witherow RO, Patel A (June 2005). "A prospective, randomized, placebo controlled, double-blind study of pelvic electromagnetic therapy for the treatment of chronic pelvic pain syndrome with 1 year of followup". J Urol. 173 (6): 2044–7. doi:10.1097/01.ju.0000158445.68149.38. PMID 15879822.
  12. Shoskes DA, Nickel JC, Kattan MW (June 2010). "Phenotypically directed multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome: a prospective study using UPOINT". Urology. 75 (6): 1249–53. doi:10.1016/j.urology.2010.01.021. PMID 20363491.
  13. Hanno PM, Buehler J, Wein AJ (April 1989). "Use of amitriptyline in the treatment of interstitial cystitis". J Urol. 141 (4): 846–8. doi:10.1016/s0022-5347(17)41029-9. PMID 2926877.
  14. Fritjofsson A, Fall M, Juhlin R, Persson BE, Ruutu M (September 1987). "Treatment of ulcer and nonulcer interstitial cystitis with sodium pentosanpolysulfate: a multicenter trial". J Urol. 138 (3): 508–12. doi:10.1016/s0022-5347(17)43242-3. PMID 2442416.
  15. Bates SM, Hill VA, Anderson JB, Chapple CR, Spence R, Ryan C, Talbot MD (February 2007). "A prospective, randomized, double-blind trial to evaluate the role of a short reducing course of oral corticosteroid therapy in the treatment of chronic prostatitis/chronic pelvic pain syndrome". BJU Int. 99 (2): 355–9. doi:10.1111/j.1464-410X.2007.06667.x. PMID 17313424.


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