Chronic pelvic pain

1. Chronic pelvic pain Prof.ssa Elisabetta Costantini Clinica Urologica e Andrologica Università degli studi di Perugia

2. Definition of chronic pelvic pain (CPP) Chronic pelvic pain is chronic or persistent pain perceived in structures related to the pelvis of either men or women. It is often associated with negative cognitive, behavioural, sexual and emotional consequences as well as with symptoms suggestive of lower urinary tract, sexual, bowel, pelvic floor or gynaecological dysfunctions

3. Definition of chronic pelvic pain (CPP) • A conditions with well-defined classical pathology (such as infection or cancer) Specific disease-associated pelvic pain • A conditons with no obvious pathology Chronic pelvic pain syndrome

4. Definition of chronic pelvic pain syndrome (CPPS) Chronic pelvic pain syndrome is the occurrence of CPP when there is no proven infection or other obvious local pathology that may account for the pain.It is often associated with negative cognitive, behavioural, sexual or emotional consequences, as well as with symptoms suggestive of lower urinary tract, sexual, bowel or gynaecological dysfunction CPPS is a subdivision of CPP

5. Pain perception in CPPS may be focused… • A single organ • More than one pelvic organ, even associated with systemic symptoms such as chronic fatigue syndrome (CFS), fibromyalgia (FM) or Sjögren’s syndrome

6. When pain is localised to a single organ Urologicalpainsyndroms • Prostate Pain Syndrom (PPS) • Bladder Pain syndrome (BPS) • Urethral Pain Syndrome • Scrotal Pain Syndrome • Testicular pain syndrome • Epididymal pain syndrome • Penile pain syndrome

7. When pain is localised to a single organ Gynaecologicalpain syndroms • Vulvar Pain Syndrom • Vaginal Pain syndrome • Clitoral Pain Syndrome

8. When pain is localised to a single organ • Chronic Anal Pain Syndrom • Intermittent anal Pain syndrome Gastrointestinal pain syndroms

9. Epidemiology • Incidence: No adequate data on Incidence were found. • Prevalence: In a large study in Europe (2004) it was found that chronic pain of moderate to severe intensity occurs in 19% of adult

10. Influence in QOL • Pelvic pain syndromes do have an impact on the QoL: • Depression • Anxiety • Impaired emotional functioning and fatiguenes Addressing co-morbidities will help in further improving the QoL

11. CPP and mechanisms • CPP mechanisms are well defined and involve mechanisms of neuroplasticity and neuropathic pain • The mechanisms of neuroplasticity and neuropathic pain result in increased perception of afferent stimuli which may produce abnormal sensations as well as pain. • End-organ function can also be altered by the mechanisms of neuroplasticity so that symptoms of function can also occur.

12. Risk Factors and underlying causes Risk factors include many different factors from various areas, including genetic, psychological state, recurrent somatic trauma and endocrine factors.

13. Myofascialpainsyndromes The relationship between muscular dysfunction (especially overactivity) and pelvic pain has been found in several studies This relationship has been found in chronic prostatitis ,BPS and vulvar pain

14. Diagnosis • History • Physical Evaluation • Supplemental evaluation • Laboratory • Image

16. History History is very important for the evaluation of patients with CPP. • Type of pain • Duration • Localization • Urinary dysfunctions • Sexual dysfunctions • Gastrointestinal dysfunctions

17. Supplementalevaluation Determination of the severity of disease, its progression and treatment response can be assessed only by means of a reliable symptom-scoring instrument A 5 point verbal scale: none, mild, moderate, severe, very severe pain A VAS score from 1 to 10

18. Supplementalevaluation • Prostate pain syndrome NIH-CPSI International Prostate Symptom Score (I-PSS) • Bladderpainsyndrome InterstitialCystitisSymptom Index (ICSI) • Gastrointestinalquestionnaire IBSSymptomSeverity Scale (IBS-SSS) • Sexualfunctionassessment International index of erectile function (IIEF) The femalesexualfunctionindex (FSFI)

19. Focusedmyofascialevaluation • Trigger points

20. Image • Ultrasound • MRI • MRIdefecating proctogram

21. Treatment • Consevative therapy • Medical therapy • Transurethral resection (TUR), coagulation and laser • Open Surgery for BPS • Neuromodulation • Nerve blocks

22. CONSEVATIVE THERAPY

23. The physiotherapist is part of the pain management team, together with the pain doctor and the psychologist

24. Physiotherapists can either specifically treat the pathology of the pelvic floor muscles, or more generally treat myofascial pain if it is part of the pelvic pain syndrome

25. Pelvicfloormusclepain Treating pelvic floor overactivity and myofascial trigger points should be considered in the management of CPP.

26. Pelvicfloormusclepain For patients with CPP and dysfunction of the pelvic floor muscles, it is very helpful to learn how to relax the muscles when the pain starts The circle of pain-spasm-pain can be interrupted

27. Myofacial trigger point release (MTrP’s) Treatment of MTrP’s can be done by manual therapy, dry needling and wet needling. The evidence for all the different treatments is weak, with most studies showing no significant difference between these techniques

28. Physiotherapy in BPS General muscular exercise may be beneficial in some BPS patients

29. Physiotherapy in BPS Transvaginal manual therapy of the pelvic floor musculature (Thiele massage) in BPS patients with high-tone dysfunction of the pelvic floor significantly improved several assessment scales

30. Biofeedback improves the outcome of myofascial therapy. In patients with an overactive pelvic floor, biofeedback is recommended as therapy adjuvant to muscle exercises.

31. Multimodalapproach

32. Sexualdysfunctions

33. Chronicpelvicfloorhypertonus It may also be the factor connecting certain urological, urogynecologic, and anorectal conditions with sexual dysfunction.

34. Pelvicfloorhypertonus is a component of conditionssuchas: • Constipation • Irritablebowelsyndrome • Vaginismus • Pseudyssinergia o dyssinergia

35. PelvicFloorMuscleAssessment Physical therapists’ evaluation of muscles includes assessment of both strength and tone.

36. Strength It is defined as the maximal force a muscle can generate, and is often referred to as the weight that the muscle can lift once or the one repetition maximum

37. Pelvicfloorstrength It is defined by the recruitment of muscle fibers in a maximum voluntary contraction Intra-vaginal and inter-anal palpation are therefore considered the most sensitive method to evaluate pelvic floor muscle strength

38. Tonus Hypotonus describes weakness, whereas hypertonus describes muscle contraction,or tightne . Vaginal and anal hypertonus have also been referred to as “spasm”; however, spasm refers to a reactionary condition, usually in response to acute pain, rather than a constant one. There currently exists no standardized method for grading pelvic floor muscle tone, nor has inter-therapist reliability been assessed.

39. Male sexualdysfunctions

40. Male Sexual Function and Dysfunction The phases of male sexual function include desire, mediated by testicular androgens, erection, ejaculation, orgasm, and detumescence

41. Prevalence • Extremely prevalent in the general population • Simons & Carey (2001) • 3% orgasmic disorder • 5% erectile disorder • 3% hypoactive sexual desire disorder • 5% premature ejaculation

42. Erection Erection is a neurovascular event that relies on interplay between the autonomic and somatic innervation of the penis, the smooth and striated musculature of the corpora cavernosa and pelvic floor, and the arterial inflow supplied by the paired pudendal arteries

43. Anatomy of the penis • Tunica Albuginea • Corpora Cavernosa -- Sinusoid • Corpus Spongiosum -- Sinusoid • Glans Penis • Artrial supply • Venous drainage • Nerve

44. Arterial Supply • Internal iliac artery • internal pudendal artery [main] • Dorsal artery • Bulbourethral artery • Cavenous artery • External iliac, Obturator, vesical and femoral artery. [accessory]

45. Venous drainage • Emissary veins, transformed from peripheral sinusoids • Deep dorsal vein Bulbourethral vein, Cavernous vein

46. Mechanism of erection : • Dilatation arterioles&arteries • Expanding of sinusoids • Compression of subtunical venular plexuses • Emissary veins enclosed • Increasing of intracavernous pressure to raise the penis

48. Mechanism of Detumescence Transient intracorporeal pressure increase [smooth muscle contraction] Pressure decrease slowly [slow reopening of the venous channels] Pressure decrease fast [venous outflow capacity is fully restored]

49. Neuroanatomy of penile erection • Peripheral pathways • autonomic [ C. Cavenosa & C. Spongiosum] • somatic [ Glans Penis & C. Spongiosum] Sympa, - NE release Parasym, + NO & Ach release Somatic, +Ach release

50. Pelvicfloor muscle function • It may be involved in the enhancement of blood flow to the penis. • While the ischiocavernous muscle facilitates erection, the bulbocavernous may be involved in maintaining the erection. • Contraction of the bulbocavernous muscles blocks the blood from escaping by pressing on the deep dorsal vein of the penis.