Pelvic Pain

Question 1

Explain how the pathophysiology of chronic pelvic pain syndrome is different from that of painful gynecologic diseases (eg. endometriosis). How does this impact management?

Answer 1

Chronic pelvic pain may begin with a painful disease, but over time the pain impacts the patient’s lifestyle and relationships, leading to affective disorders (anxiety, depression) which worsen the pain in turn

Multidisciplinary approach to CPP is necessary since simply treating the painful disease is not enough to break the cycle

Question 2

What simple physical exam maneuver could you use to distinguish an abdominal wall trigger point from an intraperitoneal source of pain?

Answer 2

Head raise test - if pain decreases this suggests an intraperitoneal source (since tension of the rectus on head raise protects the painful area), if pain increases this suggests an abdominal wall trigger point

Question 3

What is the relationship between history of sexual abuse and current pelvic pain?

Answer 3

Abuse rarely directly causes pelvic pain, but abuse can make coping with pelvic pain much more difficult (25-50% of women with chronic pelvic pain have a history of abuse)

Question 4

You perform a TLH BSO for treatment of symptomatic endometriosis in a 42-year-old woman. Afterwards, your patient’s pain is significantly improved, but she is bothered by severe menopausal symptoms. She is curious about HRT. How would you counsel her about the effect of HRT on recurrence of her pain?

Answer 4

Recurrence of endometriosis with HRT is extremely low, therefore HRT is not contraindicated in this situation

Question 5

Define endosalpingiosis. What is its relationship to chronic pelvic pain?

Answer 5

Endosalpingiosis: ectopic fallopian tube-like ciliated epithelium (without stroma)
May be found more frequently in women undergoing laparoscopy for chronic pelvic pain (gross appearance i similar to endometriosis), but seems to be associated with rather than a cause of pelvic pain

Question 6

What is the etiology of pelvic peritoneal pockets? How should they be managed?

Answer 6

Peritoneal invasion by endometriosis leads to scarring and retraction of peritoneal tissue, resulting in the appearance of a pocket

Symptoms can be ameliorated by laparoscopic excision of the pocket

Question 7

List four risk factors for development of chronic pelvic pain following an episode of PID.

Answer 7

Non-black race
Multiple previous episodes of PID
Older age
Married
Less education
More than 3 days between onset of symptoms and treatment of acute PID

(Condom use following PID protects against development of PID)

Question 8

Define ovarian remnant syndrome. What historical featues would lead you to suspect this, and what investigations could you order? What treatments exist?

Answer 8

Ovarian remnant syndrome: presence of functional ovarian tissue following the intended removal of the ovary (either incomplete removal of the ovary or implantation and growth of ovarian tissue displaced during oophorectomy)

Suspect if patient has pelvic pain but no vasomotor symptoms after oophorectomy

Workup: pre-menopausal level of FSH, cystic structure seen on pelvic US

Tx: GnRH agonist w/ add-back or surgical excision

Question 9

What are the characteristic symptoms of interstitial cystitis?

Answer 9

Pelvic pain, irritative voiding symptoms (frequency, urgency, nocturia)
Pain may radiate to pelvis, supra-pubic area, perineum, vulva, vagina, low back, medial thighs …
Pain may be increased by eating spicy foods, drinking carbonated/caffeinated/alcoholic drinks, stress, exercise
Pain may be relieved by voiding a small amount, but recurs as the bladder fills
Pain may flare prior to menses - in general, symptoms often overlap with those of other pelvic disease (associated with endometriosis, IBS, fibromyalgia, pelvic floor dysfunction …)

Question 10

What would you expect to see on cystoscopy of a patient with interstitial cystitis? On urodynamics?

Answer 10

Cysto:
Petechiae, submucosal hemorrhages, ulcers of bladder mucosa
Could consider a KCl sensitivity test - mucosal permeability is increased in IC therefore KCl will cause intense pain compared with water

UDS:
Decreased bladder capacity & compliance

Question 11

True or false: myofascial pelvic pain is typically localized to superficial tissues (eg. patients will report vaginismus rather than deep dyspareunia).

Answer 11

False - while trigger points may be superficial, the pain they cause can still be referred deep into the pelvis

Question 12

Describe two treatment options for myofascial pelvic pain.

Answer 12

Trigger point injection - dry or with local anesthetic or electrical stimulus
Physio (massage, stretching, heat can be useful adjuncts)
High-frequency TENS, ultrasound stimulation
Analgesics (acetaminophen, NSAIDs)

Question 13

What are the first- and second-line medical treatments of chronic gynecologic pelvic pain?

Answer 13

First-line: CHCs, NSAIDs

Second-line: Progestins, danazol, GNRH agonist & add-back hormones

Question 14

What is the evidence for laparoscopic adhesiolysis in patients with chronic pelvic pain?

Answer 14

Very weak - RCTs comparing laparoscopy & adhesiolysis to no treatment have not shown benefit
Studies showing benefit have primarily been observational