Chronic pelvic pain

كلية الطب ? جامعة بابل المرحلة الخامسة
د-نسرين مالك
Gynaecology
Chronic pelvic pain:-

Definition:- Intermittent or constant pelvic pain in the lower abdomen or pelvis of at least 6mths’ duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy.
Chronic pelvic pain (CPP) is a symptom, not a diagnosis.
Prevalence:-
• Annual prevalence in women aged 15–73 is 38/1000
• Many women do not receive a diagnosis even after many years and multiple investigations.
Classification of causes of chronic pelvic pain.
1-Inflammatory:-
? Infective: chronic salpingitis.
? Inflammatory, non -infective: endometriosis, adenomyosis, vulvodynia with dermatosis.
2- Mechanical:- uterine retroversion, adhesions, (Trapped ovary syndrome) after hysterectomy the ovary becomes trapped within dense adhesions at the pelvic side wall
3-Functional: -
? Pelvic venous congestion:-Dilated pelvic veins, believed to cause a cyclical dragging pain, worst premenstrually and after prolonged periods of standing and walking.
? Irritable bowel syndrome.
4-Neuropathic:- post surgical, dysesthetic vulvodynia, vulval vestibulodynia ( ‘vestibulitis’)
5-Musculoskeletal:- pelvic floor myalgia, abdominal and pelvic trigger points, postural muscle strain



Diagnosis :-
History including:-
A detailed history of the pain, including events surrounding its onset, site, nature, radiation, time course, exacerbating and relieving factors,and any cyclicity.
1-LMP.
2-Contraception.
3-Recent unprotected sexual intercourse (UPSI).
4- Vaginal discharge or bleeding.
5-Bowel symptoms.
6- Urinary symptoms.
7-Precipitating factors (physical and psychological).
8-A sexual history and future fertility wishes should be explored (it maybe possible to discuss abuse at this point).
Examination: • Abdomen: does she have an masses?
• Pelvic: are discharge, cervical excitation, adnexal tenderness, masses present?
• Speculum may not be appropriate if history of vaginismus or pain.

Investigations:- Be careful not to over investigate initially.the investigation required are:-
1-Mid stream urine examination.
2- Triple swabs (high vaginal, cervical, and endocervical for Chlamydia).
3- FBC, CRP.
4- Pelvic US(transvaginal or abdominal as appropriate).
5- Abdominal X-ray (+/– contrast), CT, MRI as appropriate.
6-Diagnostic laparoscopy.
7-Therapeutic trial of GnRH analogues:-With clearly cyclical pain, a trial of a GnRH analogue (GnRHa) can be a useful diagnostic tool:-
• Women requesting hysterectomy with bilateral salpingooopherectomy
can be reassured that it may be a successful treatment if their pain is relieved with a GnRHa.
• If their pain persists on GnRHa treatment, they should be counseled that hysterectomy is unlikely to remove their pain and other causes for it should be explored.

Treatment:-
1-Analgesia:-
• Pre-emptive analgesia may prevent emergency admissions.
• Opiates may be required for severe, acute exacerbations, but if needed regularly, referral to a dedicated pain clinic should be made.
• Neuropathic treatments such as amitriptyline, gabapentin, and pregabalin can be useful.

2-Hormonal treatments:-
The COCP, progestagens, and GnRH analogues can be effective. If pain is improved with a GnRHa then this can be combined safely with low-dose HRT for at least 2yrs.
Progesteron:- medroxy progesterone acetate (MPA) was effective after 4 months treatment as reflected in pain score.

3-Complementary therapy:-
A variety of complementary therapies can produce good results and should be encouraged if the woman suggests them. Static magnetic therapy ,the effect of wearing small magnets as therapy for chronic pelvic pain versus placepo were assessed as there is significant differences appeared after 4 weeks.Acupuncture has a place in the management of chronic pelvic pain in general.. Support groups can also give reassurance.

4-Surgery:-This has a limited role to play, but hysterectomy can be helpful, as above. Adhesiolysis may be benefit for those with sever adhesions.