Chapter 54 Pelvic Pain

Question 1

Chronic
pelvic pain (CPP) is defined as

Answer 1

nonmenstrual-related

pain below the umbilicus that has continued for more than 6 months.

Question 2

Common causes of

CPP in men are similar to those in women and often include chronic (nonbacterial)

Answer 2

prostatitis, chronic orchalgia, and prostatodynia

Question 3

Of patients who undergo exploratory laparoscopy, clinical

diagnosis findings include the following:

Answer 3

endometriosis accounts for one-third of patients, adhesions another third, and no pathology for the remaining third.

Question 4

When assessing the pelvic pain patient, it is important to approach these patients

Answer 4

in a multidisciplinary fashion. Both diagnosis and management of these patients require good
integration and knowledge of all pelvic organ systems and other systems including musculoskeletal, neurologic, and psychiatric.

Question 5

Gender-Specific Causes for Pelvic Pain- Women

Answer 5

Infection, endometriosis, dysmenorrhea (primary: menstruation, middleshmurtz;
secondary: fibroids, adenolysis, IUD), dyspareunia, mononeuropathies, myofascial
pain, vulvitis, cystitis, ovarian remnant syndrome, sympathetically mediated pain,
pelvic congestion, pelvic fibrosis, pelvis neurodystonia, pelvagia
Irritable bowel syndrome and other gastrointestinal disorders
Sexual/physical abuse
Cancer pain
Psychiatric disorders
Surgical procedures (adhesions)

Question 6

Gender-Specific Causes for Pelvic Pain- Men

Answer 6

Prostatitis, chronic orchalgia, and prostatodynia,
interstitial cystitis, ureteral obstruction
Irritable bowel syndrome and other gastrointestinal
disorders
Sexual/physical abuse
Cancer pain
Psychiatric disorders
Surgical procedures (adhesions)

Question 7

vascular hypothesis

Answer 7

It has been noted that pain may be related to dilated pelvic veins in which blood flow is markedly reduced. Pelvic venous incompetence is likely seen in 10% of women, and up to 60% of patients with this abnormality can develop pelvic congestion syndrome (PCS).

Question 8

vascular hypothesis patients can find relief when the dilation is treated, such as with

Answer 8

foam sclerotherapy followed by coil embolization to within a centimeter of vein origin. Positive results
have also been documented with medroxyprogesterone
acetate 30 to 50 mg daily.

Question 9

Organ-Specific Causes for Pelvic Pain

Reproductive

Vascular

Answer 9

Reproductive
-Visceral: uterus, ovaries, bladder, urethra,
-Somatic: skin, vulva, clitoris, vaginal canal
Adhesions, endometriosis,
salpingo-oophoritis, neoplasm
Vascular : Dilated pelvic vein/pelvic congestion theory

Question 10

Organ-Specific Causes for Pelvic Pain

Musculocutaneous

Spinal

Answer 10

Musculocutaneous: Ligamentous structures, muscular (iliopsoas,
piriformis, quadrates lumborum, sacro-iliac
joint, obturator internus, pubococcygeus)
Skeletal (referred pain)
Myofascial syndrome
Pelvic floor muscle tension/spasm

Spinal:
Degenerative joint disease, disc herniation,
spondylosis, neoplasm of spinal cord/sacral
nerve, coccydynia, degenerative disease

Question 11

Organ-Specific Causes for Pelvic Pain

Neurologic

Gastrointestinal

Answer 11

Neurologic: Neuralgia/cutaneous nerve entrapment
(surgical scar in the lower part of the
abdomen), iliohypogastric, ilioinguinal,
genitofemoral, lateral femoral cutaneous
nerve, shingles (herpes zoster infection),
spine-related nerve compressions

Gastrointestinal: Irritable bowel syndrome, abdominal
epilepsy, abdominal migraine, recurrent
small bowel obstruction, hernia

Question 12

Organ-Specific Causes for Pelvic Pain

Urologic

Psychological
(psychosocial/
sexual)

Answer 12

Urologic: Bladder dysfunction, chronic (nonbacterial)
prostatitis, chronic orchalgia, and
prostatodynia

Psychological
(psychosocial/ sexual):
Anxiety, depression, somatization, physical
or sexual abuse, drug addiction, dependence,
family problems, sexual dysfunction

Question 13

History Assessment

Answer 13

Pattern of onset
Inciting event
Quality (burning, aching, dull, sharp, cramping)
Duration and progression of complaints
Constant or intermittent nature
Exacerbating factors (position,
eating, urination, defecation,
valsalva)
Alleviating factors

Question 14

History Assessment

Answer 14

Efficacy and toxicity of previous
medications
Association with menstrual cycle
Incontinence
Pregnancy
Sexual activity
Sudden weight loss or weight gain
Breast or endocrinologic
difficulties
Family history of ovarian,
uterine, or breast cancer

Question 15

multidisciplinary team represents both the referral basis as well as the combined perspective

Answer 15

for sources of pain and
sources of treatment approaches: gynecologists, psychologists, physiotherapists, uro-gynecologists, gastrointerologists,
neurologists, psychiatrists, social workers, internal
medicine physicians, general surgeons, and pain medicine physicians are all involved in caring for these patients

Question 16

The history must consist of a systematic review of systems assessments including

Answer 16

gastrointestinal, musculoskeletal,

vascular, genito-urinary, neurologic, and psychological

Question 17

The physical examination must include

Answer 17

abdominal, pelvic,

musculoskeletal, neurologic, and psychiatric assessments

Question 18

core component

of any physical exam, and especially important in the assessment of pelvic pain

Answer 18

The focused abdominal examination. Auscultation for sounds, bruits,
organomegaly, and palpations in four quadrants are all
components of an abdominal exam.

Question 19

A pelvic examination

Answer 19

An experienced physician should
participate in a thorough examination of gynecologic,
urologic, and overall pelvic health

Question 20

psychiatric assessment

Answer 20

A thorough psychosocial or psychosexual history is needed when organic diseases are excluded or coexisting psychiatric disorders are suggested.
Sufficient history must be obtained to evaluate depression, anxiety disorder, somatization, physical or sexual abuse, drug abuse or dependence, and family, marital, or sexual problems.

Question 21

DIAGNOSTIC STUDIES

Answer 21

These exams include blood work, cultures, pregnancy testing, ultrasonography, x-rays, computed tomography (CT) scans, magnetic
resonance imaging (MRI), and diagnostic blocks.

Question 22

Iliopsoas

Answer 22

Innervation: L1-L4
Referral Pattern: Lower abdomen, groin, anterior thigh, low back, and lateral trunk
Symptoms: Pain with hip extension and weight-bearing, especially at heel strike

Question 23

Piriformis

Answer 23

Innervation: L5- S3
Referral Pattern: Buttock, pelvic floor, and low back
Symptoms: Pain on standing, walking, and sitting

Question 24

Quadratus Lumborum

Answer 24

Innervation: T12-L3
Referral Pattern: Lower abdomen, anterior lateral trunk, anterior thigh, buttock, and sacroiliac joint
Symptoms: Pain in lateral low back with standing and walking

Question 25

Sacroiliac Joint

Answer 25

Innervation: L4-S3 Referral Pattern: Posterior thigh buttock, pelvic floor, low back Symptoms: Pain on standing and walking and a possible “catch” on one side with bending

Question 26

Obturator Internus

Answer 26

Innervation: L3-S2 Referral Pattern: Pelvic floor, buttock, posterior thigh, and coccyx Symptoms: “Pressure” in pelvic floor

Question 27

Pubococcygeus

Answer 27

Innervation: S1-S4 Referral Pattern: Pelvic floor, vagina, rectum, buttock Symptoms: Pain on sitting, dyspareunia

Question 28

Types of Pain

Answer 28

Nociceptive/somatic: Afferent A d and C-fibers Visceral: Solid or hollow organs Sympathetic: After a nerve or limb injury, diffuse burning, allodynia, hyperpathia, sudomotor dysfunction, impaired blood flow Neuropathic: Sharp lancinating pain

Question 29

Nociceptive pain

Answer 29

arises from stimulation of specific pain receptors. It can be thermal (responds to heat or cold), mechanical (responds to stretching or crushing) or chemical.

Question 30

Somatic pain

Answer 30

can originate in the musculoskeletal system. It can be defined as a sharp and well localized pain; moreover, it can often be reproduced

Question 31

Visceral pain

Answer 31

usually dull and vague in | location and can be difficult to locate

Question 32

Neuropathic pain

Answer 32

has distinct characteristics of “burning,” “tingling,” and or “shooting.” It can originate from the peripheral nervous system or from the central nervous system. Neuropathic pain can be sympathetically mediated as well. An example of sympathetically mediated pain is complex regional pain syndrome.

Question 33

This “viscero-somatic convergence” | is based on a principle that

Answer 33

visceral innervations converge terminally in the spinal cord at the same level as overlying somatic structures. Thus, it is difficult to distinguish between somatic and visceral origins, resulting in “referred pain.

Question 34

Treatment Modalities

Answer 34

Medication: NSAIDs, antidepressants, anticonvulsants, opioids Interventional: Trigger point injection, nerve blocks, sympathetic blocks, epidural steroid injections Surgical: Spinal cord stimulator, intrathecal opioid pump

Question 35

Nonsteroidal Anti-Inflammatory Drugs

Answer 35

These drugs reduce overall prostaglandin production throughout the body, and can be effective in the treatment of pelvic pain. As prostaglandins can protect the stomach and support platelets and blood clotting, NSAIDs may cause ulcers in the stomach and promote bleeding.

Question 36

NSAIDs Drug interactions of concern

Answer 36

include blood thinners, such as warfarin, which can increase potential serious bleeding risks.

Question 37

Adverse Effects of NSAIDs

Answer 37

NSAIDs reduce blood flow to kidneys and can affect kidney function. NSAIDs also may increase blood pressure and may antagonize antihypertensive medications.

Question 38

Oral contraceptives (OCPs)

Answer 38

Some women may have cyclic pelvic pain related to ovulation, Mittelschmirtz, endometriosis, or even premenstrual dysphoric disorder (PMDD), a severe form of premenstrual syndrome (PMS). By using hormonal regulation to block ovulation, this type of pain may be decreased.

Question 39

The analgesic effect of antidepressants has | a postulated mechanism of action related to

Answer 39

inhibition of monoamine reuptake, increase in the serotonin (5HT) and norepinephrine (NE) availability in descending inhibitory spinal pathways, with an increase in descending inhibitory tone, and decrease in ascending nociceptive transmission

Question 40

Temporary but consistent responses to nerve blocks | may lead to more lasting procedures such as

Answer 40

pulsed radiofrequency | neuromodulation or neurolytic nerve blocks.

Question 41

Procedures may be performed for diagnostic reasons, therapeutic reasons, or both

Answer 41

l Trigger-point injection/botulinum toxin l Peripheral nerve block (ilioinguinal/genitofemoral/ pudendal) l Epidural steroid injection (thoracic/lumbar/caudal) l Sympathetic nerve block (hypogastric/ganglion of impar) l Spinal cord stimulator l Intrathecal pump

Question 42

Trigger-Point Injections

Answer 42

These injections are used mostly for localized specific areas of tenderness related to myofascial pain or neuroma. These can be effective techniques for myofascial pain using various agents; local anesthetics, saline, and even simple needling have been found to be effective techniques for pain relief

Question 43

Trigger-Point Injections | Adverse Effects

Answer 43

myofascial trigger points have also been considered a source of pain and voiding symptoms as well as a trigger for neurogenic bladder inflammation for patients with interstitial cystitis and urethral syndromes.

Question 44

Botulinum Toxin

Answer 44

``` botulinum toxin type A (Botox) effectively treats CPP and the associated spasm of pelvic floor muscles in women. ```

Question 45

Epidural Steroid Blocks and Facet Joint Injections

Answer 45

Epidural steroid injections and facet joint injections are targeted therapy procedures used as dermatomal-directed therapy.

Question 46

Neural Blockade and Neurolysis.

Answer 46

General principles for neural blocks include the diagnostic value of local anesthetic injection, and many physicians have observed improved pain in response to a series of local anesthetic injections (with or without steroids) in patients with chronic neuropathic nonmalignant pain. Once the nociceptive pathways have been identified, neurolysis may be of long-term benefit.

Question 47

Complications from neurolysis include

Answer 47

possible neuroma formation, deafferentation pain, permanent motor or sensory deficits, orthostatic hypotension, diarrhea, sexual dysfunction, and bowel or bladder incontinence.

Question 48

in neurolysis Neuroma formation is more likely with

Answer 48

surgical or radiofrequency ablation than with alcohol, phenol, or cryolysis, because cutting or burning destroys the neural sheath

Question 49

Peripheral Nerve Blocks

Answer 49

These blocks are valuable for neuropathic pain or neuroma of somatic nerves of the pelvis, muscles, and bone. Neurolysis should be cautiously considered for severe nonmalignant pain that is refractory to conservative measures.

Question 50

Pelvic Organs Innervations Fallopian tubes, superior portion of uterine segment, ureters and bladder, appendix, broad ligament, proximal large bowel

Answer 50

Spinal Innervation: T9–12, L1 | Sympathetic and Peripheral Nerves: Celiac plexus, hypogastric plexus

Question 51

Pelvic Organs Innervations Abdominal wall

Answer 51

Spinal Innervation: T12–L1, L1–L2 | Sympathetic and Peripheral Nerves: Ilioinguinal, genitofemoral

Question 52

Pelvic Organs Innervations Inferior portion of uterine segment, ureters and bladder, superior vagina, distal colon, rectum, uterosacral ligaments

Answer 52

Spinal Innervation: S2–S4 Sympathetic and Peripheral Nerves: Inferior hypogastric plexus, inguinal, genitofemoral

Question 53

Pelvic Organs Innervations Lower vagina, vulva, perineum

Answer 53

Spinal Innervation: S2–S4 Sympathetic and Peripheral Nerves: Ganglion impar, pudendal, genitofemoral, inguinal

Question 54

Superior Hypogastric Nerve Block (Presacral Nerve)

Answer 54

The plexus is located anterior to the L5 vertebral body and sacrum at the bifurcation of the common iliac vessels. The visceral afferents that travel through this plexus have their cell bodies located in the dorsal root ganglia from T10 to L2.

Question 55

Ganglion Impar

Answer 55

The ganglion impar is the termination of the paired paravertebral sympathetic chains. This terminal end is a single ganglion located anterior to the sacrococcygeal junction

Question 56

Ganglion Impar (Ganglion of Walther) Block use

Answer 56

Ganglion impar block and neurolysis has been reported to achieve 70% to 100% pain relief for perineal pain caused by cancer of the cervix, colon, bladder, rectum, or endometrium.

Question 57

Ganglion Impar (Ganglion of Walther) Block technique

Answer 57

The procedure is performed by inserting a needle directly through the sacrococcygeal ligament. The position is confirmed with injection of contrast medium under fluoroscopy. Local anesthetic or neurolytic solution is then injected, usually with a volume of 4 to 6 ml.

Question 58

Ganglion Impar (Ganglion of Walther) Block complications

Answer 58

can lead to further painful dysfunction, including possible neuroma formation, neuritis, deafferentation pain, permanent motor and sensory losses, hypotension, diarrhea, sexual dysfunctional, and bowel and bladder incontinence.

Question 59

Intrathecal and Epidural Block and Neurolysis.

Answer 59

Intractable pelvic cancer pain with somatic involvement may be alleviated by destruction of the appropriate somatic sensory fibers. Intrathecal neurolysis is preferred for unilateral pain and carries a reduced risk of motor fiber destruction.

Question 60

Neuromodulation: Spinal Cord Stimulation

Answer 60

Spinal cord stimulation (SCS) is an advanced treatment option for patients who have failed conservative management. Studies have shown positive responses for many patients with long-term CPP

Question 61

Neurolysis/Neurosurgical Ablative Techniques

Answer 61

``` Neuroablation of selected nerves can be performed by using different techniques, including thermocoagulation (radiofrequency ablation), cryoablation, or injection of chemical agents (alcohol, hypertonic saline, phenol) ```

Question 62

Various surgical procedures may | be considered to treat CPP. Surgical procedures include

Answer 62

``` presacral neurectomy (superior hypogastric plexus excision), paracervical denervation (laparoscopic uterine nerve ablation [LUNA]), and uterovaginal ganglion excision (inferior hypogastric plexus excision). ```

Question 63

Presacral Neurectomy

Answer 63

This is the surgical removal of the presacral plexus, a group of nerves that conducts pain signals from the uterus to the brain.

Question 64

Presacral Neurectomy Potential risks can include

Answer 64

injury of the vena cava and thus an available vascular surgeon should be available for consultation.

Question 65

Laparoscopic Uterine Nerve Ablation (LUNA)

Answer 65

LUNA can allow for interruption of the nerves to the uterus and pelvis

Question 66

ALTERNATIVE/COMPLEMENTARY | PAIN MEDICINE

Answer 66

Physical therapy, psychological counseling, behavioral relaxation, massage, therapeutic heat, ice, electrical stimulation, acupuncture, magnesium, vitamin B1, counseling, and orthotic devices can be useful and require further exploration by the care team involved.

Question 67

Transcutaneous Electrical Nerve | Stimulation (TENS) unit

Answer 67

The TENS unit is a pulse generator with an amplifier and electrodes are used to deliver continuous or varying duration of electrical nerve stimulation to relieve pain. The stimulation causes myelinated afferents to activate segmental inhibitory circuits with a cumulative effect. Induction time can be cumulative but typical recommendations include 30 min to 2 hr BID, depending on the severity of the pain. Usually, the patient controls a modulated frequency between 0 and 100 Hz for pain control.

Question 68

Acupuncture

Answer 68

Acupuncture involves the use of metallic needles to penetrate the skin at specific points in the body; analgesia involves neurohumoral mechanisms via release of endogenous opiates and monoamines with evidence of sustained depression in spinal cord dorsal horn neurons.