Chronic pelvic pain | Dr N Layyous

Chronic pelvic pain

This is a very complex topic due to many conditions and diseases that can cause pelvic pain.

WHAT DEFINES CHRONIC PELVIC PAIN?

Chronic pelvic pain: pain of at least six months’ duration in lower abdomen and severe enough to affect quality of life or require treatment.

HOW COMMON IS CHRONIC PELVIC PAIN?

15 % of women report chronic pelvic pain, and 4% report the pain to be severe enough to miss work. Chronic pelvic pain leads to hysterectomy in 20% and laparoscopy in 40 %.

WHAT ARE THE GYNECOLOGIC CAUSES OF CHRONIC PELVIC PAIN?

Gynecologic causes account for approximately 20% and include:

• Endometriosis: is the presence of endometrial tissues outside uterine cavity. This is the most common cause and is present in about 70 %of women with chronic pelvic pain.
• Pelvic Inflammatory Disease (PID): PID is infection of the upper genital tract (tubes, ovaries, and uterus) and is caused by an untreated sexually transmitted infection. 30% of women with PID will develop chronic pelvic pain due to the scar tissue caused by the infection.
• Pelvic adhesions: Dense adhesions, fibrous bands from infection, endometriosis, or prior surgery can cause chronic pelvic pain. Mild adhesions may not be the cause of the pain. Adhesions involving the bowel can cause abdominal bloating, constipation, and pain. Adhesions involving the uterus and the bladder are found in patients with multiple cesarean deliveries.
• Pelvic Congestion Syndrome: This condition is dilated uterine and ovarian veins found on a pelvic ultrasound or pelvic MRI. Dilated veins can be found in asymptomatic women.
• Adenomyosis: This condition is the presence of endometrial glands in myometrium due to increased parity that causes heavy bleeding and pain with menstruation. Pain is due to bleeding and enlargement of endometrial glands in the uterine muscle.
• Pelvic Mass: The pain can be caused by torsion or pressure of the mass on adjacent organs.
• Fibroids: Fibroids can cause pressure symptoms. Acute pain can occur due to degeneration, twisting, or expulsion of the fibroid through the cervix.

WHAT ARE THE UROLOGIC CAUSES OF CHRONIC PELVIC PAIN?

Interstitial cystitis painful bladder syndrome

Recurrent urinary tract infection

Urethral diverticulum

Bladder cancer.

WHAT ARE THE GASTROINTESTINAL CAUSES OF CHRONIC PELVIC PAIN?

• Irritable Bowel Syndrome (IBS): This syndrome is characterized by chronic or intermittent abdominal pain that is associated with bowel function or dysfunction. About 10 % of the general population has symptoms compatible with IBS; women are diagnosed more than twice as often as men.
• Inflammatory Bowel Disease:

Crohn’s disease and Ulcerative colitis cause fatigue, diarrhea, abdominal cramps, weight loss, fever, and rectal bleeding

Diverticulitis

Colon cancer

Chronic constipation

Celiac disease.

WHAT ARE THE MUSCULOSKELETAL CAUSES OF PELVIC PAIN?

• Fibromyalgia: This is a disorder in which the patient has at least 11 areas throughout the body that are tender to touch (knees, shoulders, elbows, neck).
• pelvic floor muscle spasms
• chronic abdominal wall pain
• inflammation of the pubic bone
• Hip joint and muscle tendon abnormalities.

WHAT ARE THE MENTAL HEALTH ISSUES THAT CAN CAUSE CHRONIC PELVIC PAIN?

Drug seeking and opiate dependency

Physical and sexual abuse experience

Depression and somatization disorders.

SYMPTOMS of Chronic pelvic pain

Nature of pelvic pain can be acute (sudden), chronic, intermittent, or cyclic

Cyclical pain is usually associated with the period.

Pain can also be associated with voiding, bowel motion, physical activity or intercourse.

DIAGNOSIS of Chronic pelvic pain

Medical history

Physical examination

Psychological assessment and counseling.

RADIOLOGIC imagings ARE USED FOR DIAGNOSIS OF PELVIC PAIN?

Pelvic ultrasound detects pelvic masses and fibroid.

It is not used to distinguish between benign and malignant masses and diagnose adenomyosis.

MRI is better to identify pelvic masses and for diagnosis of adenomyosis.

CT scan can detect diverticular disease and pelvic masses.

LABORATORY STUDIES ARE USED FOR DIAGNOSIS OF PELVIC PAIN.

Blood test

Urine test

Cervical swab to check Chlamydia and gonorrhea infection are necessary when infection is suspected

Pregnancy test should be obtained if ectopic pregnancy is suspected.

WHY IS LAPAROSCOPIC SURGERY USED FOR PELVIC PAIN?

To diagnosed pelvic adhesion and endometriosis.

Laparoscopic evaluation of the pelvis is necessary to make the correct diagnosis and for treatment at the same time. One large study revealed the following findings during laparoscopy in women with chronic pelvic pain:

35 % had no visible abnormalities, 33 % had endometriosis, 24 % had adhesions, 5 % had PID, and 3 % had ovarian cysts.

WHEN WOULD ADDITIONAL SURGERY BE NECESSARY?

There is recurrence in the cases of endometriosis, pelvic adhesions, ovarian cysts, and fibroids so patient may complain of recurrent pelvic pain, requiring a repeat laparoscopy for treatment.

WHAT IF LAPAROSCOPY DOES NOT SHOW ANY ABNORMALITIES?

If no abnormality is detected by laparoscopy, it is necessary to perform cystoscopy and colonoscopy to rule out urologic and gastrointestinal causes of pain.

Cystoscopy: This procedure to detect a bladder tumor and interstitial cystitis. Colonoscopy: This procedure to detect colon tumors and inflammatory bowel disease.

TREATMENT of Chronic pelvic pain

IS TREATMENT BEFORE DIAGNOSIS (EMPIRIC TREATMENT) APPROPRIATE?

Empiric treatment can be used in cases of suspected endometriosis, especially if the patient does not want to undergo a surgical procedure but the satisfactory response does not confirm the diagnosis

Prolonged treatment may be necessary to evaluate improvement in symptoms.

May not be effective in cases of moderate and severe endometriosis.

WHAT CONDITIONS ARE TREATED WITH MEDICATIONS?

• PID: This condition is treated with a combination of broad-spectrum antibiotics In some instances, admission to hospital is needed for IV antibiotics.
• UTI: Oral antibiotics. A simple cystitis can be treated with three to five days. Recurrent cystitis sometimes require daily antibiotic therapy for suppression. Hospitalization and IV antibiotic therapy are required in cases of complicated renal infections.
• Irritable Bowel Syndrome: Modifications in diet, behavioral changes, medications, and psychotherapy are used.
• Interstitial Cystitis/Painful Bladder Syndrome: No curative therapy. Ongoing physical and pharmacologic therapies are used to control the symptoms.
• Pelvic Congestion Syndrome: This diagnosis is controversial, progesterone injections have shown effectiveness

WHAT CONDITIONS ARE TREATED WITH SURGERY?

• Adhesions: Laparoscopic adhesiolysis is most effective in patients with dense adhesions and adhesions involving the bowel.
• Adenomyosis: Laparoscopic hysterectomy is the treatment of choice.
• Endometriosis: Laparoscopic resection of endometriosis implants. In cases of severe endometriosis and women who have, completed childbearing removal of the uterus and ovaries is an effective option.
• Pelvic/Ovarian Mass: This includes the removal of a mass with or without the removal of the ovary. The preservation of the ovary depends on several factors.
• Pelvic congestion syndrome: Surgical treatment options include the hysterectomy and oophorectomy, embolization of the ovarian veins, sclerotherapy, and surgical ligation of the ovarian veins.
• Fibroids: myomectomy or hysterectomy is surgical treatment option.

LAPAROSCOPIC UTEROSACRAL NERVE ABLATION (LUNA)

LUNA is resection of about 2 cm segment of the uterosacral ligament to destroy the uterine nerve fibers located in the uterosacral ligament .Success rates of this procedure decline rapidly over several years.

LAPAROSCOPIC PRESACRALNEURECTOMY (LPSN)

LPSN is resection of the sacral nerve plexus. This is risky because of the presence of large vessels and ureters near the area of dissection. This is effective for central pelvic pain and menstrual pain. Success rates decline over many years.

ALTERNATIVE TREATMENT OPTIONS FOR CHRONIC PELVIC PAIN

Physical therapy

Trigger-point injections

Local anesthetic patches

Acupuncture

Psychotherapy

Behavioral and relaxation feedback therapies

Nerve stimulation

Dr Najeeb Layyous F.R.C.O.G

Consultant Obstetrician, Gynecologist and Infertility Specialist