Female Chronic Pelvic Pain

Female Chronic Pelvic Pain Colleen M. Fitzgerald, MD, MS

Disclosure  Nothing to Disclose

Learning Objectives  Describe the causes and key elements of history and physical exam in the evaluation of pelvic pain  Explain the anatomy and physiology of pelvic pain syndromes  Review the principles underlying various modalities to manage pelvic pain  Describe the role of specialist physicians in evaluation and treatment of pelvic pain disorders

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Introduction Pelvic pain has multifactorial etiology Multiple stakeholders Precision of diagnosis limited by converging somatic & visceral pain afferents Economic pressure Inadequate training Lack of evidence for effective, durable treatments

Primary Care

GYN

Neurology

GI/GU

Physical Medicine & Rehabilitation (PM&R)

Definition of Chronic Pelvic Pain (CPP)  “ noncyclic pain of 6 or more months' duration that localizes to the anatomic pelvis, anterior abdominal wall at or below the umbilicus, the lumbosacral back, or the buttocks. To meet criteria, the pain should be severe enough to cause some disability.”  Most studies fail to even describe location/duration of symptoms  Pelvic Pain (Regional, visceral) versus Pelvic Girdle Pain (musculoskeletal) Howard FM et al , Ob Gyn 2003 Vleeming A et al, Eur Spine J, 2008

CPP Epidemiology  25% of women aged 18 to 50 years have CPP lasting  > 6 months  40% of listed indications for laparoscopy  10-18% of hysterectomies  Only 25% of UK women surveyed had sought medical evaluation in the last year  Point Prevalence of musculoskeletal pain – 20% Howard FM et al , Ob Gyn Surv 1993 Zondervan K, et al Br J Gen Prac 2001 Tu FF, AJOG 2006

Known risk factors for CPP  40 studies (12040 women), 48 factors evaluated with meta-analysis  Drug/alcohol abuse  Miscarriage  Pelvic inflammatory disease  Previous C-section  Pelvic pathology  Abuse  Psychological comorbidity Latthe P et al, BMJ 2006

Differential diagnosis/comorbidities

Jarrell JF et al, Journal of Obst Gyn Canada 2005

Suggested red flags for CPP  Bleeding per rectum  New bowel symptoms over 50  New pain after the menopause  Pelvic mass  Suicidal ideation  Excessive weight loss  Irregular vaginal bleeding over 40  Post coital bleeding

Royal College of Obstetrics and Gynecology (RCOG) 2005

Peripheral Neurobiology of the Pelvis  Autonomic: sympathethic and parasympathetic (vagina) plus Somatic (vulva)  Nerve density is greater in the distal vagina  Nocioceptive information arriving from the vulva, vagina, and cervix is conveyed to widespread regions of the CNS  Hormonal status influences innervation Berkeley KJ et al , Brain Res 1995

Neuroanatomy of Pain Pathways Somatosensory cortex Limbic forebrain system

Intralaminar thalamic nucleus

Periaqueductal gray area

Ventroposterolateral thalamic nucleus Rostroventral medulla Descending pathway

Peripheral nerves

Hyman SE et al, Sc Amer Med 1996

Ascending pathways

Epidemiology of Interstitial Cystitis(IC)/ Painful Bladder Syndrome (PBS)  9x prevalence in women  67 to 230 per 100,000 women having clinically confirmed disease  Mean age of diagnosis in 40’s  Comorbid with fibromyalgia, vulvodynia, endometriosis  3 antecedents: female hormone use, h/o fewer pregnancies, total number of non bladder syndromes Curhan GC et al, J Urol. 1999 Leppilahti M, et al, J Urol. 2005 Warren JW Urology 2011; Chung MK et al, J Soc Laparoendosc Surg. 2002, 2005 Clemons JL et al., Obstet Gynecol 2002

Bladder Health Conditions Present With Similar Symptoms OAB Urinary Urgency, Frequency, ± Incontinence

UTI Urinary Urgency, Frequency, Dysuria, ± Suprapubic Pain

PBS Urinary Urgency, Frequency, ± Pelvic Pain

PBS = interstitial cystitis; OAB = overactive bladder; UTI = urinary tract infection.

PBS Can Be a Significant Detriment to Quality of Life if Left Untreated  25% may be unable to work full time  63% report dyspareunia  5-fold increase in treatment for emotional problems  PBS patients scored significantly worse on quality-of-life evaluations than patients on renal dialysis  The average time between development of IC symptoms to a confirmed diagnosis is 5 years Held PJ et al. In: Interstitial Cystitis. Springer-Verlag,1990 Driscoll A et al, J Urol. 2001

PBS History  Assess risk factors for bladder visceral sensitivity – prior instrumentation as child, recurrent UTIs, abuse  Query urinary habits  Rule out urinary tract infection, nephrolithiasis  In older patients, history of smoking, rule out bladder cancer (cytology, cystoscopy)

PBS Physical Examination  Suprapubic tenderness  Anterior vaginal wall/ bladder base tenderness  Levator muscle spasm  Rectal spasm

Definition of Endometriosis     

Presence of endometrial glands and stroma outside the endometrial cavity and uterine musculature Location – unclear association with pain Appearance – unclear association with pain Proximity to nerve fibers related to pelvic pain as well Generalized, not just regional pain sensitivity

Berkley K, Science, 2005 Bajaj P et al, J Pain 2003

Endometriosis History  Extremely painful (or disabling) menstrual cramps; pain may get worse over time  Chronic pelvic pain (includes lower back pain and pelvic pain)  Pain during or after sex  Intestinal, or bladder voiding pain  Painful bowel movements or painful urination during menstrual periods  Heavy menstrual periods  Premenstrual spotting or bleeding between periods  Infertility

Diagnostic laparoscopy for Endometriosis (Gynecology)  Role: r/o endometriosis or pelvic adhesions  30-50% of these will be negative  Laparoscopic excision of implants with histological confirmation* (PPV visual diagnosis only 45%)  In selected populations, worse outcomes compared with initial multi-disciplinary therapy Peters AA et al, Ob Gyn 1991 Howard FM et al, Ob Gyn 2000 Walter A, AJOG 2001

Irritable Bowel Syndrome (IBS)  Rome criteria: at least 3 months of continuous recurrent symptoms – Pain relieved with defecation – And/or associated with change in frequency of stool – And/or associated with change in consistency of stool (Constipationpredominant, Diarrhea-predominant)

 Functional gastrointestinal disorder

– No structural or biochemical abnormality currently available explains symptoms – 3-15% of the general population in Western countries – Symptoms suggestive of IBS present in 50-80% of women with CPP

IBS Symptoms       

Abdominal pain Bloating Belching Excessive flatus Bloating Painful defecation Sensation of incomplete evacuation

   

Pelvic pain “Crampy” pain Sharp shooting intermittent pain Does not usually radiate (rarely to the back)

History and Physical Exam in IBS  Ask about travel history  Workup rectal bleeding, unexplained anemia, other RFs for colon CA  50% of IBS patients have psychological symptoms at time of presentation  7-13% of IBS patients recall an antecedent gastroenteritis  Usually normal physical exam – – – – –

Bloating common Generalized pain, left lower quadrant Rule out masses Evaluate presence of scars Don’t ignore possibility of acute abdomen Mayer EA, NEJM 2008 Drossman DA et al, Gut 1999

Vulvodynia Definition  Focal chronic non-malignant urogenital pain syndrome in women characterized by chronic vulvar discomfort with no visible abnormalities

 Bachmann GA, J Reprod Med 2006

Vulvodynia  16% lifetime prevalence  61% onset in reproductive years 21-50 y/o, 25% post menopause  Oral contraceptives may contribute to development  Primary had higher systemic pain perception, autonomic abnormalities (low diastolic BP) and higher anxiety traits  Comorbidities of IBS, Fibromyalgia, and IC  Hansen A, J Reprod Med 2002  Granot M et al, AJOG 2004

History and Physical Examination in Vulvodynia – Itching, burning, stinging or stabbing in the area around the opening of the vagina – Provoked/Unprovoked, pain with attempt at penetration – Localized/ Generalized vulvar dysesthesia (perimenopausal) – Primary versus secondary – Q tip test

Pelvic Congestion Syndrome Ovarian vein varicosities CPP, dull pelvic aches 10-38% prevalence Pelvic Magnetic resonance venograpy (MRV), confirmed by transfemoral venography  No valid diagnostic test studies  Treatment studies show ovarian suppression to be most helpful  Embolectomy?    

Tu FF Obstet Gynecol Survery 2010

Pudendal Neuralgia  Perineal pain aggravated by sitting, reduced by standing, not present when recumbent, relieved sitting on a toilet seat when compression of nerve is minimized  Sites of impingement: sacrospinous ligament, sacrotuberous ligament, Alcock’s canal  Pudendal nerve block, high anatomic variability (Fluoroscopic/CT guided)  Pudendal Nerve Release

Hibner M et al, J Min Invasive Gyne 2010

Pelvic Girdle Pain (Musculoskeletal)  Pain experienced between the posterior iliac crest and the gluteal fold, particularly in the region of the sacroiliac joint  Pain may radiate in the posterior thigh and can also occur in conjunction with/or separately in the symphysis  Diminished capacity for standing, walking and sitting  Arises in relation to pregnancy, trauma, or reactive arthritis  Exclude lumbar causes  Pain must be reproducible by specific clinical tests

Pelvic Floor Muscles Slow Twitch Type 1 Endurance Fibers – 70%, Fast Twitch Type 2 Fibers – 30% Continence, Support, Sexual appreciation, Pain Pain Floor of the Core Fitzgerald CM, J Reprod Med, 2011

Differential Diagnosis Category

Diagnoses

Muscular/fascia

Pelvic floor myofascial pain/levator ani syndrome/tension myalgia Myofascial pain syndromes of associated extrinsic muscles (ilipsoas, adductor, piriformis) Dyssynergia of the pelvic floor muscles Vaginismus/ dyspareunia

Skeletal/joint

Pelvic insufficiency/stress fracture Sacroiliac joint dysfunction/Servilities Pelvic obliquity or derangement, pelvic asymmetry Pubic symphysitis/Osteitis pubis/Pubic symphysis separation Coccydynia Lumbar degenerative disc disease/spondylosis or listhesis (with referral to posterior pelvis (L4 -L5-S1)) Hip osteoarthritis/Hip fracture /Acetabular labral tears/Chondrosis/Developmental hip dysplasia /Femoral acetabular impingement/Avascular necrosis of the femoral head Bony Metastasis

Neurologic

Radiculopathy Plexopathy Peripheral neuropathy – Pudendal neuropathy

Viscerosomatic (presumed)

Endometriosis Irritable Bowel Syndrome Bladder Pain Syndrome Dysmenorrhea

PM&R Pelvic Girdle Pain (PGP) Provocation Tests  Posterior Pelvic Pain Provocation test  Patrick’s Faber  Modified Trendelenburg Test

Pelvic Girdle Palpation and Function Tests  Long Dorsal Ligament  Pubic Symphysis  Active Straight Leg Raise

Pelvic Floor exam (Urogynecology/PM&R/Physical Therapy) Assess for tenderness, quality and coordination of contraction and relaxation, voluntary and involuntary, and strength (Modified Oxford scale) CPP = Poor relaxation and tenderness

Musculoskeletal Pelvic Imaging Plain xray: acute blunt trauma: r/o fracture/symphyseal separation or Osteoarthritis of the hip or pubic symphysis (osteitis pubis), Sacroiliitis MRI Lumbar spine: bowel or bladder or lower extremity neurologic change Pelvic MRI: Stress fracture, mass, tendinopathy, muscle tear, hip or other bony pathology

Goals for Rehabilitation Education and Behavioral Management Address Biomechanical factors Pelvic joint Motor control Awareness Function

Pelvic floor muscle physical therapy Manual therapy: soft tissue/joint mobilization Biofeedback

–Surface electromyography (sEMG) –Realtime ultrasound –Manual

Electrical Stimulation Weighted cones Pressure biofeedback Weiss, J Urol 2001

Pelvic Floor Biofeedback

At home Adjunctive Pelvic Floor treatment Vaginal dilators Electrical Stimulation Vaginal Cones

Core stability training

Overall Treatments for CPP  Medroxylprogesterone acetate (MPA 50mg once daily)  Counseling (after negative US)  Multidisciplinary approach (PT, psychotherapy, diet and environmental factors)  Lysis of deep adhesions  Treat organ cross talk

 Stones W et al, Cochrane Database Syst Rev 2005

Treatment options for Cyclic CPP  NSAID (inconclusive)

– Hopewell AC Cochrane Database Syst Rev 2009 Apr

 GnRHa

– Brown J et al. Cochrane Database Syst Rev 2010 Dec

 Combine OCP, LNG-IS, Progestagens

– Surgery – Won HR, Abbott J. Int J WH 2010 – Jacobson TZ et al. Cochrane Database Syst Rev 2009

 Aromatase Inhibitors for endometriosis pain

– Ferrero S et al. Reprod Biol Endocrinol 2011 June

Selected medication options  Analgesics (Naproxen, diclofenac, acetaminophen, tramadol)  Tricyclic antidepressant (amitriptyline 10-25 qHS)  Antiepileptics (gabapentin 300mg TID, pregabalin 75mg BID)  Benzodiazepine (Diazepam 2mg BID)  Anticholinergics (Oxybutynin 5mg BID, tolterodine 204mg daily)  Antispasmodics (Pinaverin 50mg BID)  Ovarian cycle Inhibitors  Other (Pentosan polysulphate) Vercellini P etal. Gyne Endo, April 2009

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Surgical Treatments for CPP  Hysterectomy (40% will have persistent pain)  Percutaneous transcatheter embolotherapy (relief in 50-80% with varicosities  Denervating Procedures (Presacral Neurectomy) Adhesiolysis (Not RECOMMENDED) Vercellini P etal. Gyne Endo, April 2009

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Treatment for IC/PBS  AUA Guidelines 2011: 86 articles – First line: General relaxation, stress/pain management, patient education, self-care – Second line: manual PT, Oral: amitriptyline, cimetidine, hydroxyzine, PPS; Intravesical: DMSO, heparin, lidocaine; pain management – Third line: Cystoscopy under anesthesia with hydrodistension; tx of hunner’s ulcers, pain management – Fourth line: Neuromodulation, pain management – Fifth line: Cyclosporine A, Intradetrusor BTX, pain management – Sixth line: Diversion with or without cystectomy

Dietary Guidelines for PBS AVOID •citrus, chocolate, aged cheeses •Sodas, alcohol, caffeinated drinks •heavy seasoned foods •? nitrite/nitrate containing meats, as well as canned, cured meats •? foods containing preservatives •Look for exacerbation in 8-12 hr period Shorter B et al, 2007 J Urol

Medical Treatments for IBS

Mayer EA NEJM 2008

Vulvodynia Treatments  Vestibulectomy (fair evidence 30-50% improve, effect size unclear, placebo effect may be as high as 35%)  Dietary modifications  Physical therapy  Vulvar care measures – Topical (lack of benefit: xylocaine 5%, cromolyn, nifedipine) – Oral (lack of benefit: fluconazole, desipramine); Recommended future RCTs in neuropathic agents – Injectable (lack of benefit: botulinum toxin)

Landry T et al. Clin J of Pain 2008 24:155-171 Andrews J Obstet and Gyne Survey 2011 4

Medical Pelvic floor Treatments  Vaginal diazepam (5-10 mg TID, 10mg qHS)  Topical compounded ointments (vaginal or transabdominal) – Baclofen, amitryptiline, gabapentin, ketamine, ketorolac Oyama, Rejba et al. Urology, Nov;64(5):862-5 2004; – Rogalski MJ IUJ 2010

Therapeutic Injections  Trigger Point Injections  Sacroiliac joint injections (SIJ) under fluoroscopy  Nerve Blocks (Ilioinguinal, genitofemoral, pudendal)  Neurolysis  Chemodenervation with botulinum toxin – Abbott et al. Obst Gynecol 2006

Other Treatments for CPP  Acupuncture, acupressure, transcutaneous electrical nerve stimulation (TENS)  Chinese herbal medicine (endometriosis)  Psychological therapies

Flower A et al, Cochrane Database Rev 2009

Champaneria et al, Acta Obstet Gynecol Scand 2012

Sacral Neuromodulation for CPP – 10/12 studies in IC, 7 report treatment outcome – 51-77% respond to test stimulation – f/u 5-87 mo.

– Mean reduction in pain scores: 40-72% – Median reoperation rate: 27-50% – Success rate 60-77% with mean f/u 9-36 mo

Marcelissen T et al J Urol 2011 Aug

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Conclusions  Large differential diagnosis for CPP  Peripheral and central contributing factors  Multimodal treatment should be the rule, given poorly understood etiology – including consideration of musculoskeletal targets