Stump the Gynecologist: Differential Diagnosis of Chronic Pelvic Pain

Jennifer K. McDonald DO F.A.C.O.G.October 10, 2008

ACOG Definition

“Non-cyclic pain of 6 or more months duration that localizes to the anatomic pelvis, abdominal wall at or below the umbilicus, lumbosacral back or the buttocks and is of sufficient severity to cause functional disability or lead to medical care.”

Background

10% out-patient gynecologic visits 20% of laparoscopies

15% of hysterectomies $2.8 billion annually

15% of American women

61% of CPP will have no definitive diagnosis !!

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enPrevalence

CPP Migraine

Asthma Back Pain

Age Prevalence

Features

Present for six months or more Conventional treatments have yielded little or

no relief Degree or pain perceived seems out of

proportion to the degree of tissue damage detected by conventional means

Physical appearance of depression is present Physical activity is increasingly limited Emotional roles in the family are altered

Distinction

Acute painPain is symptom of

underlying tissue damage

Chronic painPain itself becomes the

disease

Females - Unique Design• Structural changes during

development

• Pelvis widens after menarche

• Gluteal stretching

• Internal rotation of the femurs/lateral displacement

of the patella

• Ligamentous laxity

• Decreased muscular tone increases lumbar lordosis and exaggerated anterior

pelvic tilt

• Pelvic organs connected through shared common

nerve pathways

Gynecologic - extra-uterine

Gynecologic - uterine

Urologic

Gastrointestinal

Musculoskeletal

Neurologic

Where do we look?

Ovary T10 umbilical area

Uterus T12 lower abdominal wall

Vagina L1 skin over groin

Referred Pain

Most common culprits

Endometriosis Adenomyosis

Interstitial cystitis Irritable bowel

Pelvic Adhesions

Endometriosis Presence of endometrial glands and stroma

outside the uterus No difference among ethnic groups or

socioeconomic status Genetic predisposition 6-10% increased risk

with history of first degree relative

Dysmenorrhea Abnormal bleeding

Dyspaurenia GI complaints

Infertility Urinary complaints

Low back pain

The many faces of endometriosis

Location Location

76% ovaries69% posterior & anterior cul de sac47% posterior broad

ligament36% uterosacral ligaments11% uterus6% fallopian tubes4% sigmoid colon

Interstitial Cystitis

Prevalence of bladder origin chronic pelvic pain/interstitial cystitis is much

greater than previously believed

IC is a chronic inflammatory condition of the bladder characterized by irritable voiding

symptoms of urgency and frequency in the absence of objective evidence of another disease that could cause the symptoms

Pathogenesis of IC:Defective Urothelial Barrier

IrritatingSolutes

GAGLayer

Urothelium

IrritatedNerve

Inflammation

InitialDevelopment of

IC SymptomsDiagnosis of IC

See at least 5 physicians

before diagnosis

May have unnecessary hysterectomy

Significant suffering and reduced QOL

2-7 years

IC is Typically Diagnosed Late in Disease Continuum

Average Time Between Initial Development of

Symptoms and Diagnosis is 5 Years

IC Concurrent with Endometriosis

Clinicians should consider the bladder to be the source of CPP, even when endometriosis is present

10%IC Alone 20%20%

Endometriosis Endometriosis AloneAlone

70% IC and

Endometriosis

Diagnosis of Patients With CPP byCystoscopy and Hydrodistention & Laparoscopy1

1

Identifying Patients Is ImportantA New Screening Questionnaire for

Pelvic Pain and Urgency/Frequency (PUF)

Identifying Patients Is ImportantA New Screening Questionnaire for

Pelvic Pain and Urgency/Frequency (PUF)Circle the answer that best describes how you feel for each question.

SymptomScore

BotherScore

SYMPTOM SCORE (1, 2a, 4a, 5, 6, 7a, 8a)BOTHER SCORE (2b, 4b, 7b, 8b)

b. If you get up at night to void, to what extent does it usually bother you?

b. Has pain or urgency ever made you avoid sexual intercourse?

b. How often does your pain bother you?

b. How often does your urgency bother you?

TOTAL SCORE (Symptom Score + Bother Score) =

How many times do you void during waking hours?1

4

20+

4+a. How many times do you void at night?2

YES _____ NO_____Are you currently sexually active?3

ever had pain or urgency to urinate during or aftersexual intercourse?

a. If you are sexually active, do you now have or have you4

your pelvis, vagina, lower abdomen, urethra, perineum, testes, or scrotum?

Do you have pain associated with your bladder or in5

0

3-6

0

None

Never

Never

Never

Never

Never

NeverDo you still have urgency shortly after urinating?6

a. When you have urgency, is it usually—?8

1

7-10

1

Mild

Occasionally

Occasionally

Occasionally

Occasionally

Occasionally

Occasionally

Mild

Mild

2

11-14

2

Moderate

Usually

Usually

Usually

Usually

Usually

Usually

Moderate

Moderate

3

15-19

3

Severe

Always

Always

Always

Always

Always

Always

Severe

Severea. When you have pain, is it usually—?7

PUF is a constellation of symptoms identified by IC experts as characteristic of interstitial cystitis. The more symptoms a patient experiences, the more likely it is that they’re caused by interstitial cystitis.

PUF is a constellation of symptoms identified by IC experts as PUF is a constellation of symptoms identified by IC experts as characteristic of interstitial cystitis. characteristic of interstitial cystitis. The more symptoms a patient experiences, the more likely it isThe more symptoms a patient experiences, the more likely it is that they’re caused by interstitial cystitis. that they’re caused by interstitial cystitis.

Parsons 2000

Pelvic Adhesions

Distort normal blood/nerve supply

Decreased mobility of organs/hypoxia

Pelvic inflammatory disease (PID)

Most common Chlamydia Inflammatory reaction

Secretion of prostaglandins

Fibromyalgia Tender Points

11 or more TP sensitivity of

88% and specificity of

81%

Abdominal Wall Tenderpoints

Irritable Bowel

12% US population 2:1 women

Peak age 30-40 Increased GI

motility and sensitivity to stimulants

Pelvic Pain Assessment Forms

www.pelvicpain.org

Pain Diarieswww.reliefinsite.com

Keys to Treatment

Pain and its perception are located in the nervous system so its treatment must encompass a Mind and Body approach

Multiple interactive problems are most likely with CPP so it isn’t which treatment is best but

which treatments It usually took time for things to get to where they are so it will be take time to get them back

to normal as well Chronic pain affects a family not just an

individual patient

How can chiropractic help

Manipulation increases spinal mobility and improves blood

supply by influencing the autonomic nervous system

The patient with CPP needs a multidisciplinary approach … are you ready?