Chapter 54 Pelvic Pain Flashcards
KEY POINTS 1. Chronic pelvic pain (CPP) usually persists for more than 6 months. Even after a thorough evaluation, the etiology of the pain may remain obscure, and inconsistency remains in the pathology of various disorders and pain. 2. The prevalence of female pelvic pain is estimated to be one in seven women of reproductive age. Internationally, the prevalence of CPP is equivalent to that of asthma, back pain, or migraine. 3. Both diagnosis and management of these patients require good in
Chronic pelvic pain (CPP) is defined as
nonmenstrual-related
pain below the umbilicus that has continued for more than 6 months.
Common causes of
CPP in men are similar to those in women and often include chronic (nonbacterial)
prostatitis, chronic orchalgia, and prostatodynia
Of patients who undergo exploratory laparoscopy, clinical
diagnosis findings include the following:
endometriosis accounts for one-third of patients, adhesions another third, and no pathology for the remaining third.
When assessing the pelvic pain patient, it is important to approach these patients
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.
Gender-Specific Causes for Pelvic Pain- Women
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)
Gender-Specific Causes for Pelvic Pain- Men
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)
vascular hypothesis
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).
vascular hypothesis patients can find relief when the dilation is treated, such as with
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.
Organ-Specific Causes for Pelvic Pain
Reproductive
Vascular
Reproductive
-Visceral: uterus, ovaries, bladder, urethra,
-Somatic: skin, vulva, clitoris, vaginal canal
Adhesions, endometriosis,
salpingo-oophoritis, neoplasm
Vascular : Dilated pelvic vein/pelvic congestion theory
Organ-Specific Causes for Pelvic Pain
Musculocutaneous
Spinal
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
Organ-Specific Causes for Pelvic Pain
Neurologic
Gastrointestinal
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
Organ-Specific Causes for Pelvic Pain
Urologic
Psychological
(psychosocial/
sexual)
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
History Assessment
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
History Assessment
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
multidisciplinary team represents both the referral basis as well as the combined perspective
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
The history must consist of a systematic review of systems assessments including
gastrointestinal, musculoskeletal,
vascular, genito-urinary, neurologic, and psychological
The physical examination must include
abdominal, pelvic,
musculoskeletal, neurologic, and psychiatric assessments
core component
of any physical exam, and especially important in the assessment of pelvic pain
The focused abdominal examination. Auscultation for sounds, bruits,
organomegaly, and palpations in four quadrants are all
components of an abdominal exam.
A pelvic examination
An experienced physician should
participate in a thorough examination of gynecologic,
urologic, and overall pelvic health
psychiatric assessment
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.
DIAGNOSTIC STUDIES
These exams include blood work, cultures, pregnancy testing, ultrasonography, x-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI), and diagnostic blocks.
Iliopsoas
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
Piriformis
Innervation: L5- S3
Referral Pattern: Buttock, pelvic floor, and low back
Symptoms: Pain on standing, walking, and sitting
Quadratus Lumborum
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
Sacroiliac Joint
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
Obturator Internus
Innervation: L3-S2
Referral Pattern: Pelvic floor, buttock, posterior thigh, and coccyx
Symptoms: “Pressure” in pelvic floor
Pubococcygeus
Innervation: S1-S4
Referral Pattern: Pelvic floor, vagina, rectum, buttock
Symptoms: Pain on sitting, dyspareunia
Types of Pain
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
Nociceptive pain
arises from stimulation of specific pain receptors. It can be thermal (responds to heat or cold), mechanical (responds
to stretching or crushing) or chemical.
Somatic pain
can originate in the musculoskeletal system. It can be defined as a sharp and well localized pain; moreover, it can often be reproduced
Visceral pain
usually dull and vague in
location and can be difficult to locate
Neuropathic pain
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.
This “viscero-somatic convergence”
is based on a principle that
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.
Treatment Modalities
Medication: NSAIDs, antidepressants, anticonvulsants, opioids
Interventional: Trigger point injection, nerve blocks, sympathetic
blocks, epidural steroid injections
Surgical: Spinal cord stimulator, intrathecal opioid pump
Nonsteroidal Anti-Inflammatory Drugs
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.
NSAIDs Drug interactions of concern
include blood thinners, such as warfarin, which can increase potential
serious bleeding risks.
Adverse Effects of NSAIDs
NSAIDs reduce blood flow to kidneys and can affect kidney function. NSAIDs also may increase blood pressure and may antagonize antihypertensive medications.
Oral contraceptives (OCPs)
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.
The analgesic effect of antidepressants has
a postulated mechanism of action related to
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
Temporary but consistent responses to nerve blocks
may lead to more lasting procedures such as
pulsed radiofrequency
neuromodulation or neurolytic nerve blocks.
Procedures may be performed for diagnostic reasons, therapeutic
reasons, or both
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
Trigger-Point Injections
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
Trigger-Point Injections
Adverse Effects
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.
Botulinum Toxin
botulinum toxin type A (Botox) effectively treats CPP and the associated spasm of pelvic floor muscles in women.
Epidural Steroid Blocks and Facet Joint Injections
Epidural
steroid injections and facet joint injections are targeted
therapy procedures used as dermatomal-directed therapy.
Neural Blockade and Neurolysis.
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.
Complications from neurolysis include
possible neuroma formation, deafferentation pain, permanent motor or sensory deficits, orthostatic hypotension,
diarrhea, sexual dysfunction, and bowel or bladder incontinence.
in neurolysis Neuroma formation is more likely with
surgical or radiofrequency ablation than with alcohol, phenol, or cryolysis, because cutting or burning destroys the neural sheath
Peripheral Nerve Blocks
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.
Pelvic Organs Innervations
Fallopian tubes, superior portion of uterine segment, ureters
and bladder, appendix, broad ligament, proximal large bowel
Spinal Innervation: T9–12, L1
Sympathetic and Peripheral Nerves: Celiac plexus, hypogastric plexus
Pelvic Organs Innervations
Abdominal wall
Spinal Innervation: T12–L1, L1–L2
Sympathetic and Peripheral Nerves: Ilioinguinal, genitofemoral
Pelvic Organs Innervations
Inferior portion of uterine segment, ureters and bladder, superior vagina, distal colon, rectum, uterosacral ligaments
Spinal Innervation: S2–S4 Sympathetic and Peripheral Nerves: Inferior hypogastric plexus, inguinal, genitofemoral
Pelvic Organs Innervations
Lower vagina, vulva, perineum
Spinal Innervation: S2–S4 Sympathetic and Peripheral Nerves: Ganglion impar, pudendal, genitofemoral, inguinal
Superior Hypogastric Nerve Block (Presacral Nerve)
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.
Ganglion Impar
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
Ganglion Impar (Ganglion of Walther) Block use
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.
Ganglion Impar (Ganglion of Walther) Block technique
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.
Ganglion Impar (Ganglion of Walther) Block complications
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.
Intrathecal and Epidural Block and Neurolysis.
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.
Neuromodulation: Spinal Cord Stimulation
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
Neurolysis/Neurosurgical Ablative Techniques
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)
Various surgical procedures may
be considered to treat CPP. Surgical procedures include
presacral neurectomy (superior hypogastric plexus excision), paracervical denervation (laparoscopic uterine nerve ablation [LUNA]), and uterovaginal ganglion excision (inferior hypogastric plexus excision).
Presacral Neurectomy
This is the surgical removal of the presacral plexus, a group of nerves that conducts pain signals
from the uterus to the brain.
Presacral Neurectomy Potential risks can include
injury of the vena cava and thus an available vascular surgeon should be available for consultation.
Laparoscopic Uterine Nerve Ablation (LUNA)
LUNA can allow for interruption of the nerves to the uterus and pelvis
ALTERNATIVE/COMPLEMENTARY
PAIN MEDICINE
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.
Transcutaneous Electrical Nerve
Stimulation (TENS) unit
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.
Acupuncture
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.
