Chronic Pelvic Pain

Question 1

What is the Neuro-biological causes of Chronic Pelvic Pain?

Answer 1

• Multifactorial (Gynae, Urological, GI, MSK, neurological)
• Combination:

End organ conditions (likely to have disappeared)

+

Stressors: increasing pain sensitivity.

• early life stressors (sexual/childhood abuse)
• physical trauma (MVA)
• catastrophic events (war)
• Psychological stress/distress (verbal/psychological abuse, bullying).
• Genetic polymorphisms.

RESULT:

• Neuroplasticity (new synaptic connections)
• Central sensitization (increased excitability of spinal neurons)
• Peripheral sensitization (increased excitability of peripheral nociceptors).

(numerous theories)

CNS assesses the pain on 3 levels:

• Sensory
• Cognitive (what we think of the pain)
• Affective: emotional valence of the pain (fertility, sexuality, shame etc).

–> CPP becomes a diagnosis itself. Origin of pain no longer causes the pain.

Question 2

What investigations are done to investigate chronic pelvic pain?

Answer 2

Thorough history

• explore psychological cause and effect as much as physical.

Question 3

What is the management of chronic pelvic pain? When should you refer to a specialist?

Answer 3

HOLISTIC

• Management > cure
• Recognition that severity is not nec proportional to extent of trauma.
• Treat identifiable symptoms + concurrent psychological morbidity.
• Restore normal function, improve QOL
• Prevent recurrence and disability.

MULTIDISCIPLINARY

Non-‘medical’:

• education
• aerobic exercise
• CBT

‘Medical’

• avoid repeated end organ investigations.
• avoid opiod (high LT effects)
• avoid chronic pain medication
• Blocks (pudendal, superior hypogastric, sacro iliac)
• Botox: pelvic floor muscles: painful spasms
• Sacral neuro stimulation

Question 4

What is the definition of chronic pelvic pain (CPP)/ Persistent Pelvic Pain (PPP)?

Answer 4

Non cancer pain, lasting greater than 3 or 6 months, perceived to be related to structures in the pelvis.

Question 5

What are the potential causes of persistent pelvic pain?

Answer 5

GYNAE

• adenomyosis
• endometriosis
• ovarian cysts
• PID

UROLOGIC

• Chronic UTI
• Interstitial Cystitis
• Bladder dysfunction (ie, overactive bladder)
• Bladder stones
• Neoplasms.

GI

• Chronic appendicitis
• Diverticulitis
• IBS
• IBD
• Hernia
• Chronic obstruction
• Neoplasms.

MSK

• Myofascial syndrome
• Pelvic floor myalgia
• Nerve entrapment