Chronic pelvic pain

1. Chronic pelvic pain Karen C. Wang, MD Department of Obstetrics and Gynecology Director of Minimally Invasive Surgery Beth Israel Medical Center April 22, 2010

2. Objectives • Define and review the impact of chronic pelvic pain (CPP) • Discuss the potential etiologies of CPP • Review current treatment modalities for common gynecologic causes of CPP • Emphasize the importance of a multidisciplinary approach to the management of CPP

3. Chronic Pelvic Pain (CPP) • Non-cyclic pain • Duration > 6 months • Localized to: anatomic pelvis, anterior abdominal wall, lumbrosacral back or buttocks • Sufficient severity to cause functional disability or lead to medical care American College of Obstetricians and Gynecologists Practice Bulletin No. 51, March 2004

4. Epidemiology • 15-20% of women between the ages of 18-50 years have pelvic pain lasting more than one year during their lifetime • Primary indication for: • 10% outpatient gynecology visits • 12% hysterectomy • 40% diagnostic laparoscopy Howard FM, Ob Gyn Surv 1993, Lee NC et al AJOG 1984, Zondervan K, et al Br J Gen Prac 2001, Tu FF, AJOG 2006

5. Social Impact of CPP • Among women with CPP • Use 3x more medications • Have 4x more GYN surgeries • Are 5x more likely to have a hysterectomy • 58% reduce normal activity >1 day/month • 26% stay in bed >1 day/month • 15% report lost time from work • 48% report reduced work productivity Mathias SD et al Obstet Gynecol 1996, Reiter R et al. Obstet Gynecol 1990

6. Economic impact of CPP • $300-500 million/year in laparoscopic evaluations • $881 million/year in direct costs • $2 billion/year in indirect costs Tu FF & Beaumont, JL AJOG 2006, Mathias SD et al Ob/Gyn 1996

7. Important Considerations • Pain is subjective • A normal physical examination does not preclude the presence of pathology • Never expect only one diagnosis or etiology

8. Important Considerations Neurology/pain med • Simultaneously evaluate and treat all contributing factors (collaboration) • Treatment is challenging due to the lack of effective durable treatments • Economic pressures often hinder extensive workup GI GYN PM&R GU

9. Common etiologies of CPP* Musculoskeletal/Neurologic Gynecologic Urologic Gastrointestinal • Pelvic floor myalgia • Trigger points • Idiopathic low back • pain • Disc disease • SI joint disease • Coccydynia • Nerve entrapment • syndromes • IBS • Functional Bowel • disorders • Chronic appendicitis • Inflammatory bowel • disease • Hernias • Diverticular disease • Intermittent bowel • Obstruction • Endometriosis • Adenomyosis • Adhesions • Chronic PID • Uterine fibroids • Pelvic congestion • Ovarian remnant • Residual ovarian • syndrome • Vaginal apex pain • Vestibulodynia • Interstitial Cystitis • Urethral syndrome • Chronic UTI • Bladder stones *excludes carcinomas

10. Common etiologies of CPP* Musculoskeletal/Neurologic Gynecologic Urologic Gastrointestinal • Pelvic floor myalgia • Trigger points • Idiopathic low back • pain • Disc disease • SI joint disease • Coccydynia • Nerve entrapment • syndromes • IBS • Functional Bowel • disorders • Chronic appendicitis • Inflammatory bowel • disease • Hernias • Diverticular disease • Intermittent bowel • Obstruction • Endometriosis • Adenomyosis • Adhesions • Chronic PID • Uterine fibroids • Pelvic congestion • Ovarian remnant • Residual ovarian • syndrome • Vaginal apex pain • Interstitial Cystitis • Urethral syndrome • Chronic UTI • Bladder stones *excludes carcinomas

11. Endometriosis

12. Case Study 1 • 26 year-old G0 presents with complaints of crampy intermittent shooting pelvic pain for the past four years. +dysmenorrhea since menarche, previously controlled with NSAIDs. Now with daily pelvic pain worse shortly before and during menses. +deep dyspareunia and +dyschezia. Never been on oral contraceptives.

13. Case Study 1 • Examination • Abdomen diffusely tender • Cervix deviated to the left on speculum examination • Uterus retroverted and minimally mobile • Thickening and tenderness of the left uterosacral ligament • Fullness and tenderness of the right adnexa

14. Case Study 1 Pelvic ultrasound shows a complex 5 cm right adnexal mass that is persistent on serial ultrasounds over 4 months.

15. Normal Pelvis

16. Endometriosis adhesions endometriosis Uterus Ovary

17. Endometriosis • Defined by the presence of endometrial glands and stroma outside of the uterus • Histological diagnosis that requires surgical evaluation

18. Etiology of Endometriosis • Implantation Theory • Retrograde menstruation • Direct transplantation Theory • Post-surgical (cesarean section, myomectomy, episiotomy) • Lymphatic or vascular dissemination • Coelomic metaplasia • Peritoneal cavity has cells that can de-differentiate into endometrial tissue

19. Symptoms of Endometriosis -None -Chronic non-menstrual pelvic pain -Dysmenorrhea -Dyspareunia -Pelvic mass -Dyschezia -Decreased quality of life -Infertility • Severity of symptoms do not correlate with severity of anatomic disease except for depth of infiltration • Co-occurrence with: interstitial cystitis, irritable bowel syndrome, temperomandibular disorder, migraine, fibromyalgia, vulvodynia.

20. Diagnosis of Endometriosis • Histological confirmation after surgical exploration • Ultrasound • Adnexal mass • MRI • Adnexal mass • Adenomyosis • Infiltrating endometriosis of uterosacrals or cul de sac • CA-125 • Nonspecific. May be elevated with benign or malignant disease

21. 10% 30% 60% 50% Prevalence of Endometriosis 2% asymptomatic reproductive aged women subfertile chronic pelvic pain adolescent with chronic pelvic pain 100% 0% ACOG practice bulletin 2000

22. Location of endometriosis Posterior cul-de-sac 69% Ovaries 33% Fossa ovarica 45% Anterior cul-de-sac 24% Bowel/appendix 5% 1999 Joan Beck

23. trEATment options Medical Surgical

24. Treatment for Endometriosis • MEDICAL • NSAIDs • Combination OCP • Progestins • Oral • Depo-Provera • Mirena IUD • GnRH agonist (> 18 y.o.) • Danazol • Aromatase inhibitor

25. Hormonal Treatments

26. Levonorgestrel-IUD for endometriosis • Advantage – low maintenance, minimal side effects • 5 year lifespan • Systemic and local effects • RCT LNG-IUD vs. Lupron • 6 month follow-up • Significant improvement from baseline in both groups • No difference between groups • 3 year follow-up data in observational series (n=34) • 56% continuation rate at end • VAS dropped from 7.7 -> 2.7 • (average pain, previous month) Petta, Hum Rep 2005; Lockhat F et al, Hum Rep 2005

27. Levonorgestrel-IUD for endometriosis • Decrease lesion size and pain symptoms in rectovaginal nodules • Equivalent to GnRH agonist (Lupron) in randomized controlled trial • Decrease in recurrence of pain after surgery for endometriosis • Over 50% of women choose to retain IUD after 3 years Petta, Hum Rep 2005; Lockhat F et al, Hum Rep 2005

28. Efficacy of medical therapy • Most treatment decrease symptoms in 70-85% of users • Choose treatment based on patient preference, cost, and side-effects • Recurrence is common after discontinuation of medical therapy

29. Treatment for Endometriosis • SURGICAL • Conservative • Laparoscopy* • Excision/ablation • LUNA/presacral neurectomy • Adnexal mass • Oophorectomy • Hysterectomy + BSO • Resection of lesions (rectovaginal, small bowel, extrapelvic) *Sutton CJ et al, Fertil Steril 1997

30. Indications for surgery • To establish a diagnosis • To improve or relieve symptoms • To normalize anatomy for sub-fertility • To investigate a mass • To evaluate pain that is refractory to other treatments

31. Conservative Surgical Management • Recurrence rate is correlated with disease severity • 37% mild disease • 74% severe disease • 67% within two years of surgery • Use of GnRH agonist for 3 months delays recurrence

32. Laparoscopy for pelvic pain associated with endometriosis (RCT) • Sutton et al. 1994 • Study design • RCT, double blinded • N=63 ♀ stage I-III endometriosis • [Laparoscopic laser ablation + LUNA] vs. expectant management • Results • No difference at 3 months (48% of expectant group with improved pain) • Significant improvement with laser ablation at 6 months (63% vs. 23%, p<0.01) 8.5 * VAS pain score (0-10) 4.5 Sutton et al. Fertil Steril 1994; 62(4):696-700. * p=0.01, laser vs. expectant

33. Hysterectomy ± BSO • Touted as “definitive treatment” • No RCTs to evaluate efficacy • Endometriosis &/or pelvic pain may recur, even if BSO performed • Incidence unknown, estimates vary widely ~2-60%

34. Hysterectomy is not definitive for all endometriosis or chronic pelvic pain Namnoun et al. Fertil Steril 1995; Matorras et al. Fertil Steril 2002.

35. Indications for hysterectomy in women with endometriosis • Chronic pelvic pain with significant reduction in quality of life • Does not desire fertility • Unresponsive to medical therapy and prior conservative surgical therapy • If undergoing BSO, understands and accepts negative impact of castration on other health parameters • Osteoporosis, cardiovascular disease, sexual dysfunction, menopausal symptoms, long-term risk/benefits of HRT, etc. • AND….

36. Indications for hysterectomy in women with endometriosis • Other sources of pain have been excluded and/or maximally treated!!!

37. Challenges of endometriosis • Little, if any, correlation between extent of disease and severity of pain. • Medical and surgical therapies are non-specific. ex. Lupron is an effective therapy for cyclic-IBS. • Medical and surgical therapies are inadequate for many patients. ex. Hysterectomy/BSO is not curative for all patients, 5-10% report persistent/recurrent pain. • Frequency of recurrent pain is high following medical and surgical therapies. Pain recurs often in the absence of recurrent endometriotic disease.

38. Evidence that endometriosis-associated CPP may be a central pain syndrome • High co-prevalence with other central pain disorders • Nerve fiber proliferation in endometriosis lesions • Nerve fiber proliferation in endometrial lining and myometrium in women with endometriosis and women with chronic pelvic pain • Increased generalized pain sensitivity in women with endometriosis

39. Adhesions

40. Pelvic Adhesions: Incidence • 55-100% incidence at second look laparoscopy (average 85%) • >90% incidence following major abdominal surgery • Following myomectomy, adnexal adhesions occur: • 94% with posterior uterine incisions • 56% with anterior/fundal uterine incisions Lau, Tulandi in Peritoneal Surgery 1999; Diamond, Fertil Steril 1987; Tulandi, et al. Obstet Gynecol 1993

41. Pelvic & Abdominal Adhesions • ~ 25% prevalence among CPP patients • 80% of patients undergoing pain mapping reported pain when adhesions palpated • Nerves, sensory neuron markers found in adhesions of both pain & pain-free patients Howard F, Ob Gyn Surv 1993; Sulaiman et al. Ann Surg 2002

42. Complications Associated with Pelvic Adhesions • Infertility (40%) • Chronic pelvic pain (50%) • Small bowel obstruction (49-74%) • 20% within 1 month • 40% within 1 year • Reoperation Liakakos Dig Surg, 2001; Monk et al.AmJ Obstet Gynecol 1994 El-Mowafi Prog Obstet Gynecol 2000

43. Is Adhesiolysis Effective? • RCT of laparoscopic lysis of adhesions vs. diagnostic laparoscopy • 100 participants with chronic abdominal pain (> 6 months) • Participants, assessors masked • Outcome: overall improvement in pain, function • No difference in groups at one year Pain scores hrQOL scores Swank D et al. Lancet 2003

44. Adhesions & CPP Sensory nerve fibers are present in human peritoneal adhesions • Nerve fibers were present in all the peritoneal adhesions examined • Nerve fibers expressing substance P were present in all adhesions irrespective of chronic pelvic pain • Nerves were often associated with blood vessels Sulaiman H, Annals of Surgery, 2001

45. Pain Relief After Adhesiolysis 65 20 42 42 One Year Follow-up

46. Is Adhesiolysis Effective? • Several observational studies suggest adhesiolysis may be of some benefit for women with CPP • Patients most likely to benefit: • Severe, stage IV adhesions • No endometriosis • Patients with limited psychological distress and/or comorbidities Steege 1991, Malik 2000

47. Pelvic Floor Myaglia

48. Pelvic Floor Myalgia • Involuntary spasm of the pelvic floor muscles • Etiology • Inflammation • Childbirth • Pelvic surgery • Trauma

49. Pelvic Floor myofascial syndrome • History • “heavy aching pelvic pressure, falling-out sensation,” often later in the day after prolonged sitting • dyspareunia • Diagnostic tests (unvalidated) • Contracted, painful muscles on intravaginal exam • EMG or vaginal manometry– elevated baseline tone, muscle instability, and decreased endurance contractile capacity Hetrick DC et al Neurourol Urodyn 2006

50. Pelvic floor myofascialsyndrome • Identified in over 20% of women in CPP referral clinics • Associations with IC, vulvodynia, endometriosis • Treatment includes pelvic floor physical therapy and other adjuvant therapies Weiss JM et al J Urol 2001, Glazer HI et al JRM 1998,Tu FF et al. JRM 2006, Tu et al OGS 2005