[41] Chronic Pelvic Pain Flashcards
What is chronic pelvic pain?
The symptom of intermittent or chronic pelvic pain the lower abdomen or pelvis, of at least 6 months duration and not associated with pregnancy
What is the prevalence of CPP in women aged 15-73?
38/1000
What are the gynaecological causes of chronic pelvic pain?
- Adenomyosis
- Endometriosis
- Adhesions
- Pelvic venous congestion
What disorders caused by adhesions exist that cause chronic pelvic pain?
- Trapped ovary syndrome
- Ovarian remnant syndrome
What happens in trapped ovary syndrome?
After hysterectomy the ovary becomes trapped within dense adhesions at the pelvic side wall
What happens in ovarian remnant syndrome?
A small piece of ovarian tissue, not removed during oophorectomy, becomes embedded within adhesions
What are the features of the pain caused by pelvic venous congestion?
- Worst premenstrually and after prolonged periods of standing and walking
- Dyspareunia often also present
What are the gastrointestinal causes of chronic pelvic pain?
- IBS
- Constipation
- Hernia
What are the urological causes of chronic pelvic pain?
- Interstitial cystitis
- Urethral syndrome
- Calculi
What are the MSK causes of chronic pelvic pain?
- Fibromyalgia
- Trigger points
What are the neurological causes of chronic pelvic pain?
- Nerve entrapment
- Neuropathic pain
What questions need to be asked in the history in chronic pelvic pain?
As for pelvic pain, but also including;
- Detailed history of pain
- Sexual history and future fertility wishes
- Patients beliefs, wishes, and concerns about the pain
What needs to be included in a detailed history about the pain in chronic pelvic pain?
- Events surrounding its onset
- Site
- Nature
- Radiation
- Time course
- Exacerbating and relieving factors
- Cyclicity
What examinations may be done in chronic pelvic pain?
- Abdominal
- Internal
- Rectal
What should be looked for on abdominal examination in chronic pelvic pain?
As for acute pelvic pain, but also altered sensation and trigger points
When might a speculum examination not be appropriate in chronic pelvic pain?
- History of vaginismus
- Pain secondary to difficult smear
- Abuse
What should be looked for on internal examination in chronic pelvic pain?
- Tension/trigger points in pelvic floor
- Adnexal tenderness/mass
- Cervical tenderness
When should a rectal examination be performed in chronic pelvic pain?
Only if indicated, e.g. strong suspicion of rectal endometriosis
What should investigations be guided by in chronic pelvic pain?
History and examination findings
Why may a pain diary be useful in chronic pelvic pain?
May help clinician and woman make connections which had not previously been noted
What can be a useful diagnostic tool with clearly cyclical chronic pelvic pain?
Trial with GnRH analogue
How can the results of a trail with GnRH analogue be useful in cyclical chronic pelvic pain?
Women requesting total abdominal hysterectomy with bilateral salpingo-oophrectomy can be reassured that it may be a successful treatment if their pain is relieved with a GnRHa, however if their pain persists, they should be counselled that TAH&BSO is unlikely to remove their pain, and other causes should be explored
What does treatment for chronic pelvic pain need to address?
Perpetuating and causative factors
In what setting is treatment for chronic pelvic pain best achieved?
Within MDT
When is success for chronic pelvic pain more likely to be successful?
It it fits within the woman own belief system
What should be used to obtain appropriate pain relief in chronic pelvic pain?
Analgesic ladder
What approach to analgesia might prevent emergency admissions with chronic pelvic pain?
Pre-emptive analgesia for predictable cyclical exacerbations
Describe the role of opiates in the management of chronic pelvic pain?
May be required for severe, acute exacerbations, but if needed regularly, referral to specialist pain clinic should be made
What analgesic options may be useful in chronic pelvic pain?
- Neuropathic treatments
- Topical capsicum on abdominal skin
What neuropathic treatments may be useful for analgesia in chronic pelvic pain?
- Amitriptyline
- Gabapentin
- Pregabalin
What hormonal treatment options can be used in chronic pelvic pain?
- COCP
- Progestagens
- Danazol
- GnRH analogues
How long can a GnRHa be combined safely with low-dose HRT?
At least 2 years
What % of women attending chronic pelvic pain clinics have MSK disorders?
75%
What can improve CPP associated with MSK disorders?
Physiotherapy
What are often perpetuating factors for CPP?
Psychosocial and psychosexual issues
What can exploring psychosocial and psychosexual issues in a non-threatening environment achieve?
Help improve pain experience and help develop pain management pain
What treatments may be useful for CPP associated with negative psychological features?
More specific treatments, such as CBT
Is surgery a first line investigation/treatment for CPP?
No, always second line
Why is surgery not a first line investigation/treatment for CPP?
Because patients with chronic pelvic pain are more likely to develop post-op pain, and negative laparoscopies reinforce abnormal health beliefs and psychological traits
