L21: Chronic Pelvic Pain (CPP) Flashcards
What is pain?
EXAM QUESTION
A subjective phenomenon described as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage Just because one person has pain –> not every one will have that pain
Protective
- I don’t want to do this because it might cause me pain
What is acute pelvic pain?
local damage to tissue resulting in pain and dysfunction ( normal tissue healing guidelines) 4-6 weeks?
- Eg. 2nd degree perineal tear post SVD
- Eg. Post surgical hysterectomy
- Eg. Ectopic Pregnancy
- Eg. Ovarian cyst
- Eg. I sprained by ankle and its going to get better
What are 4 chronic pelvic pain?
- Persistent pain lasting > 6months
- Recurrent episodes of abdomino-perineo-pelvic pain.
- Hypersensitivity of tissue / muscle / nerve (Eg. to light touch)
- Sexual dysfunction (pain) often in the absence of organic etiology. (Dyspareunia • Very undereducated) I have pain and this is not getting better –> Vicious cycle
CPP accounts for ________% of referrals to women’s health services ( ie. O&G, WH Physio)
20
What are 5 etiological characteristics of CPPS?
- Urological ( eg.bladder / urethral)
- Gynaecological (eg. endometriosis)
- Neurogenic ( eg. pudendal nerve)
- Musculoskeletal (eg. pelvic floor)
- Rheumatic (eg.auto-immune diseases) -RARE
What are 3 things pain is modulated by?
- Cognition (If not cognitively aware = less pain)
- Emotions
- If you are really emotional = more pain (catastrophizing
- Stress = more painful
- memory / attention
- Poor experience with pain in the past = more pain (catastrophizing)
What are 5 impacts that chronic pelvic pain has?
- daily life,
- mood
- sleep
- relationships
- activities.
CPP is ______
bio-psycho-social
What are the characteristics of CPP as a bio-psycho-social?
- Biological causes ( eg. Gynaecological) are important to diagnose if relevant –O&G
- Local tissue pain ( eg. Pelvic floor myalgia) are important to diagnose if relevant –WH Physio However……..
- Attention to the psychological / social aspects of pain is an important part of effective assessment and treatment !
Why do patients get hesitant about treatment with pain?
- Poor treatment
- Painful treatment
What are 5 activities do pain during pelvic involve?
- Empty bladder/bowel
- Sitting
- Intercourse
- Childbirth
- Wearing tight pants/jeans (causes too much pain)
- Due to the rubbing
- Usually wear flowly skirts, recurrent rubbing dermatitis (but don’t actually)
Who does the Multidisciplinary approach to CPP involve?
Very difficult to Ax / Rx CPP if no further training in ______ examinations (VE) –post graduate.
vaginal
- Must build trust and rapport
- Getting them to give a good subjective –> sometimes scared of pelvic exam
- Understand the signs and symptoms in the subjective Ax refer to an experienced WH physio.
- Or, reassess your MSK patient if no progress
What are 4 common complaints of pain in CPP?
- abdomino-pelvic pain
- pain with sitting or with movement or with change of posture
- with sexual activit
- unilateral or bilateral pain.
- Possible pain with voiding or bowel evacuation
- Sitting pain
- Burning groin pain
- Pain with intercourse
- No pain at night (this is not back neuropathic pain)
What are 5 structures that MSK pain can originate from?
Musculoskeletal pain may originate from
- muscle
- fascia
- ligaments
- joint
- bones
What are the 6 types of MSK sources of CPP?
- Pelvic Floor Muscle Pain (Pelvic Floor Myalgia) pain in the muscles of the pelvic floor, perineal or levator ani),
- Intra-pelvic Muscle
- Pain in the pelvic side wall muscles (obturator internus, piriformis, coccygeus)
- Was a trigger –> no trigger is gone –> becomes over protective(contracting due to fear of pain or body is trying to protect as it thinks there is something wrong)
- Pelvic/Lower Abdominal Muscle Pain
- pain in the rectus abdominus, oblique or transverse abdominus muscles, described below the umbilicus
- Posterior Pelvic/Buttock Muscle Pain pain in the gluteal muscles
- Coccyx Pain
- Pelvic Joint, Ligament, or Bony Pain
- Joint pain
- Sacroiliac or pubic symphysis joint
- Ligament pain
- Sacro-spinous or Sacro-tuberous ligament
- Bony pain
- pubic ramus, ilium, ischial spine or ischial tuberosity
- Joint pain
What is provoked pain?
Only sore when you do an exam and push on the muscles
What is unprovoked pain?
Pain constantly –> referred pain
What are 8 characteristics of pelvic floor pain (myalgia)?
- History of Childbirth injuries, POP, pelvic organ malignancy, pelvic surgery
- Urinary/defecatory dysfunction
- Dyspareunia
- Pain with intercourse
- Pain with sitting
- Leading type of pain and is highest diagnostic activity (can feel like they are sitting on something –> due to the nerves (pedundal nerve) –> referred
- Bulge
- Vaginal discharge, bleeding
- Organ and/or nerve injury related to surgery
- Sometimes they think that there is something there but it isn’t there –> just because they are contracting
Where can pain come from in CPP in joint pain?
Sacroiliac or pubic symphysis joint
Where can pain come from in CPP in ligament pain?
Sacro-spinous or Sacro-tuberous ligament
Where can pain come from in CPP in bony pain?
pubic ramus, ilium, ischial spine or ischial tuberosity
When pain causes the brain to think there is a threat, what happens?
- Stores and cnetralises pain
- Starts to protect their pain –> contract the muscle (overocnrtact) –> unable to stop (but contributes to pain) –> nerve pain and centralises
What are the 2 Urological Sources of CPP?
- Bladder Pain
- Common complaints: urgency, frequency, nocturia, pain, pressure, discomfort, hesitancy, intermittency, incomplete emptying, incontinence, dysuria
- Urethra Pain
- Pain usually with voiding, with/ night frequency.
- Feeling of dull pressure,
- Radiating to groin, sacral and perineal area ?
What are the common complaints of bladder pain in CPP?
urgency, frequency, nocturia, pain, pressure, discomfort, hesitancy, intermittency, incomplete emptying, incontinence, dysuria
What are the common complaints of urethra pain in CPP?
- Pain usually with voiding, with/ night frequency.
- feeling of dull pressure,
- Radiating to groin, sacral and perineal area ?
What are vulval sources of CPP?
- Vulva, Vestibular and Clitoral Pain Pain externally
- Eg. can’t wear tight pants, sitting for prologned time
- Pain in the vagina or the external genital organs. (chronic vaginal/vulvar pain syndrome)
- Pain is described as sharp, burning, aching and/or stabbing in nature
- Due to chronic nerve pain
- Vulva tissue –> outside
- Sitting
- Wearing tight pant
- Idiopathic –> Cause unknown Vagina –> inside
What are 8 GIT sources of CPP?
- Gastro-Intestinal Pain
- Constipation / diarrhea and
- Dyssynergic defecation
- Pain with defecation
- Bleeding / discharge
- Cramping abdominal pain,
- Recurrent rectal pain / rectal pressure
- Burning sensation or aching episodes
How is the diagnosis of CPP done?
Neurologial Pain
- Common complaints: Burning, throbbing, stabbing, electrical, tingling, stinging and paresthesia pain in the pelvis and/or perineal region.
- There may be a change in skin color and temperature.
- Hand in Hand with PFM Myalgia
- Eg. Pudendal nerve, sacral nerve
- See ICS review of CPP for exact nerve referral patterns.
What are the 6 common complaints in neurological pain in CPP?
- Burning
- throbbing
- stabbing
- electrical
- tingling
- stinging and paresthesia pain in the pelvis and/or perineal region.
What does the anatomy of pudendal nerve look like?
How do you diagnose pudendal nerve pain?
Positive test of pudendal nerve block test
- Inject –> have pain relief
Pain is modulated by _____, _____, ____, ___ and _____.
cognitive, emotional, experience, memory and attention
Pain has an impact on many aspects of daily life, affecting ______, _____, ____ and _____.
mood, sleep, relationships; activities
Attention to the _______ aspects of pain is an important part of effective assessment and treatment
psychological
People with ______ are more likely to develop chronic pain
depression
Possible sexual abuse –> can be a risk factor for chronic pelvic pain
What are 5 things that can be done in assessment for CPP?
- Posture ( slumped / poor tone / pain?)
- Sitting to one side –> can’t sit due to pain (try to deload)
- Gait ( listing)
- Favouring one leg while walking
- Lumbar spine or pelvic joint tests ( diff diagnosis)
- Superficial palpation ( abdominals, inner thigh, pubic bone
- Lumbar spine, pelvic joints, muscles)
- Neural Tests ( if applicable)
What is done in a vaginal examination?
- Visual inspection of vulva ( redness / skin conditions/ scar tissue)
- Palpation vulval tissue ( sensitivity / pain/ lesions ?) (Is light touch becoming sharp burning nerve pain?)
- Perineal body palpation ( pain / over toned?)
- Vaginismus ( spasm opening of vagina- Repetitively contracting / small introitus)
What are the 5 pelvic floor muscles to look at in the vaginal examination?
- Pubococcygeus
- Puborectalis
- Obturator Internus
- Coccygeus
- Urethra / bladder sensitvity
How should tone be graded in the vaginal exam?
0: normal
+1: some tone
+2: significant tone
How are VEs done?
One or two fingers
How are rectal exminations (PR) done?
- 1 Finger exam in sidelying
- VE before PR –infection control
- Ax:
- Coccygeus (bimanual) –left and right for pain and tone
- Coccyx pain / deviation / #
- Dyssynergia –poor timing of EAS with bearing down
What is the 3 assessment purposes in the Rectal Examinations (PR)?
- Coccygeus (bimanual) –left and right for pain and tone
- Coccyx pain / deviation / #
- Dyssynergia (Muscle doesn’t know what to do anymore (doing something odd due to the pain))–poor timing of EAS with bearing down
What is the best outcome measure for CPP?
What are the 2 questionnaires for outcome measure in CPP?
- Pelvic Floor Distress Inventory (PFDI)- Very validated –> give a rating
- Prolapse and Incontinence Sexual Questionnaire (PISQ)
Validated outcome measures due to psychosocial impact of CPP
What is treatment based on?
Based on an accurate diagnosis / questionnaires / recognition of chronic pain / and multi disciplinary opinions!
What are 10 treatments of CPP?
- Breathing awareness / pelvic floor down training (How to relax pelvic floor again)
- Abdominal wall relaxations
- Relaxation!
- Medication
- Eg. Tri-cyclic anti-depressants (neuropathic pain)) / surgery
- Neural stretches
- Trigger point therapy (VE, PR, and superficial)
- TENS (perineal / vaginal)
- Bladder and bowel function
- De-sensitising techniques (self trigger point / dilators)
- Chronic pain management
What is important when treating CPP?
- Educate your patient -very important.-create rapport
- Communicate / referrals to multidisciplinary team
What are 5 characteristics of the technique of breathing awareness as treatment for CPP?
- Shallow breathing pattern
- Sympathetic NS
- Abdominal wall relaxation = to help relaxation of pelvic floor
- Decrease PFM tone / overactivity
- Any position
Why is the technique of breathing awareness at treatment for CPP helpful?
Big tool to help with pain
What are the 3 types of medication for CPP?
- Endep -Amitriptyline
- Lyrica -Pregalbin
- Gabapentin -Neurontin
What are 8 Indication for use for medication in CPP?
- Not pain medication
- Neuropathic pain
- Small doses / long periods
- Bladder pain / PBS
- Hypersensitivity / vulva
- Allodynia / vulva
- Poor sleep
- Adjunct to Physiotherapy
What are 3 types of surgery done as treatment for CPP?
- Pudendal Nerve Block ( local / corticosteroid)
- Trans vaginal Endometrial resection
- Gynae surgery to address local pain
What are the purposes of neural stretches in CPP?
To give a pedundal nerve a stretch and to mobilise pelvis
What are 4 muscles that trigger point therapy can be used in CPP?
- Pubococcygeus
- Puborectalis
- Coccygeus
- Obturator Internus
After down training / trigger point therapy can be useful if tolerated. –can be pain after Rx
When is trigger point therapy used for treatment?
After down training / trigger point therapy can be useful if tolerated. –can be pain after Rx
Timely treatment –> Only done when the patient is ready
How does the trigger point therapy?
Either the physio or patient can do it at home
How can TENS be used for CPP (pedundal nerve pain or bladder pain) pain relief?
Where do you place the TENS electrodes for pain relief of CPP?
- Sacrum for pedundal
- Or on posterior tibial nerve (medial to ankle)
- There is evidence to warrant that as treatment for pedendal nerve pain or bladder pain
What are 8 treatments to address bladder and bowel function?
- Address constipation ( structure vs stool form)
- Address post void residuals ( > 30 mls)
- Poor bladder habits ( positioning, straining)
- Poor bowel habits ( positioning)
- Diet (low fibre)
- Fluid intake ( over or under hydrated)
- Treat any UTI’s ( MSU / Ab’s)
- Sometimes sitting on toilet and can’t relax pelvic floor to go
What are dilators/thera-wands?
- Helps with desensitisation (can use as trigger point as well)
- If light touch is difficult for then
Why is dilator a bad word? What is used as another work?
The word –> not good for patients with pelvic pain –> dilate and stretch it out
Therawand is better
What are 7 characteristics when educating patients about CPP?
- Lorimer Mosley “ explain Pain “ –great education tool for patients
- Chronic pain vs acute pain
- Centralisation of pain
- Why MRI/ CT/ USS all NAD –they are confused!
- Why the pain is different and changes patterns
- Build trust and rapport
- Have a management plan and explain this to the patient
What are 3 things a graduate physio should know about women’s health?
- Do not perform a VE or PR without advanced training ( ie. Post grad cert, Level 1 /2/3 APA pelvic floor course, Titled / Specialist)
- Highlight subjective symptoms in your consultation –refer to a skilled WH Physio.
- Refer on if back pain / SIJ pain / ostetitis pubis etc Rx not responding –think about CPP or gynae conditions Should do a good subjective exam
What are 13 subjective signs of CPP?
- SIJ pain
- Pubic bone pain
- Inner thigh pain
- Bladder pain ( lower abdominal)
- Rectal pain
- Dysuria ( CPP vs UTI)
- Chronic constipation
- Hx sexual abuse / depression / anxiety
- Painful intercourse / VE’s –dyspareunia
- Post childbirth ( SVD/ perineal trauma) ?
- Pain on sitting
- Coccyx pain
- Pain with a PFM contraction.
What are 8 symptoms of coccydynia?
- Pain with sitting ( intermittent)
- Pain post vaginal delivery
- Pain with pelvic floor contraction
- Coccyx pain ( bilat)
- Relieved with coccyx wedge
- Localised pain on palp over coccyx
- No bladder issues
- Constipation ?
What are 9 symptoms of pudendal neuralgia?
- Pain with sitting ( constant)
- Pain post vaginal delivery
- Pain with pelvic floor contraction
- Coccyx / SIJ pain ( unilat)
- No relief with positioning
- Perineal pain /discomfort
- Pain with intercourse
- Bladder / urethral pain / sensitivity / OAB
- Lower abdominal pain / hypersensitivity
What are 5 Gynaecologial conditions ( pain > 6 months)?
- Ovarian Cysts ( often not cause of pain?)
- Endometriosis
- Adhesions ( previous surgery)
- Chronic PID ( pelvic inflammatory disease)
- Prolapse
CPP is______ and _______
complicated; multidisciplinary
