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Chronic Pelvic Pain (CPP)

Chronic Pelvic Pain (CPP)

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Chronic Pelvic Pain (CPP)

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  1. Chronic Pelvic Pain (CPP) Khaled Zeitoun, M.D. Assistant Clinical Professor Columbia University

  2. Chronic Pelvic Pain: Definition • An unpleasant Sensory and Emotional experience associated with actual or potential tissue damage or described in terms of such damage • Symptom and always Subjective

  3. Chronic Pelvic Pain: Definition • Temporal characteristics • Severity • Location

  4. Chronic Pelvic Pain: Definition • Noncyclic pain of at least 6 months duration • Menstrual pain /Intermittent pain

  5. Chronic Pelvic Pain: Definition • Anatomic pelvis • Anterior abdominal wall at or below the umbilicus • Lumbosacral back and buttock region • Vulvar pain ???

  6. Chronic Pelvic Pain: Definition • Causes functional disability • Medical care

  7. Chronic Pelvic Pain: Definition • Acute pain occurs in conjunction with autonomic reflex responses, and associated with signs of inflammation and infection. • Chronic pain is characterized by physiological, affective and behavioral responses that differ from acute pain.

  8. Chronic Pelvic Pain: Theories Classic medical or Cartesian model • Pain perception results directly from and is related to the extent of local tissue destruction • Pain in the absence of tissue injury is psychogenic

  9. Chronic Pelvic Pain: Theories The gate-control theory of pain • Somatic and psychogenic factors can potentiate or modify response to pain • Failing to recognize the many social factors believed to affect a patient's responses to pain and to therapy

  10. Chronic Pelvic Pain: Theories The biopsychosocial theory of pain • Most comprehensive model for dealing with chronic pelvic pain • Integrates all the factors that contribute to a patient's perception of pain: nociceptive stimuli, psychological state, and social determinants • Explains symptom "shifting"

  11. Chronic Pelvic Pain: Population • Women of all ages are affected • Studies focused on women between 18 and 50 years old

  12. Chronic Pelvic Pain: Demographic Variables • No difference in age, race, socioeconomic status, education, ethnic background, education or employment. • More common in divorced / separated women than single and married women (Mathias et al, 1996)

  13. Chronic Pelvic Pain: Prevalence • 15% to 20% of women between 18 and 50 years old have chronic pelvic pain of more than one year’s duration • CPP accounted for 2% to 10% of all outpatient gynecologic consultations annually ( Reiter, 1990)

  14. Chronic Pelvic Pain: Health Impact • General health scores are lower • Associated disturbances of mood and energy levels (>50%) • Depression is common • Quality of life is decreased • Restricted activity and decreased productivity

  15. Chronic Pelvic Pain: Health Impact • 90% of women with CPP complain of dyspareunia

  16. Chronic Pelvic Pain: Health Care • 20% see a gynecologist • 10% other physician • 1% mental health evaluation • Rest see no one????

  17. Chronic Pelvic Pain: Health Care • Very few are seen and evaluated by clinicians in more than one specialty • 75% of women who report CPP have not seen a healthcare provider for 3 month despite persistent pain affecting daily activities

  18. Chronic Pelvic Pain: Health Care • 56% take one or more nonprescription drugs • 25% take medications prescribed by a provider • 12% oral contraceptives

  19. Chronic Pelvic Pain: Health Care • 61% no diagnosis given by physician • 39% diagnosis given 25% endometriosis 49% a non-cycle related gynecologic disorder (e.g. yeast infection or chronic PID) 10% non-gynecologic disorder 16% other

  20. Chronic Pelvic Pain: Health Care • 10% to 35% of laparoscopies are for CPP • 9% to 80% of laparoscopies report abnormalities

  21. Chronic Pelvic Pain: Health Care • Up to 70% of laparoscopies report endometriosis • Even if pathology is found it might not be the reason for the pain

  22. Chronic Pelvic Pain: Health Care • between 10% to 12% of hysterectomies are done for CPP Mortality 0.1% ( 70 women a year) Not always beneficial Detrimental effect of castration on heart disease, bone and Alzheimer’s

  23. Chronic Pelvic Pain: Economic Impact • Direct medical costs • Loss of productivity

  24. Chronic Pelvic Pain: Causes Gynecologic causes: • Cyclic • Noncyclic

  25. Chronic Pelvic Pain: Causes Gynecologic causes: • Endometriosis • Adhesions (?) • Adenomyosis • Chronic pelvic infection • Hydrosalpinx • Pelvic congestion (?) • Leiomyomata(?) • Malignancies • Primary dysmenorrhea

  26. Chronic Pelvic Pain: Causes Gynecologic causes: • Ovarian remnant syndrome • Ovulatory pain • Adnexal cysts • Cervical stenosis • Chronic endometritis • Endometrial polyps • Chronic ectopic pregnancy • Pelvic relaxation • IUD

  27. Chronic Pelvic Pain: Causes Nongynecologic disorders: Psychiatric and psychological • Depression • Physical or sexual abuse • Somatization • Hypochondriasis • Opiod seeking • Factitious

  28. Chronic Pelvic Pain: Causes Nongynecologic disorders: Pain processing disorder • Fibromyalgia

  29. Chronic Pelvic Pain: Causes Nongynecologic disorders: Gastrointestinal • Functional bowl syndrome • Inflammatory bowl disease • Cancer • Chronic appendicitis (?) • Diverticulitis

  30. Chronic Pelvic Pain: Causes Nongynecologic disorders: Urinary • Interstitial cystitis • Urethral syndrome • Detrusor instability • Chronic calculi

  31. Chronic Pelvic Pain: Causes Nongynecologic disorders: Musculoskeletal • Hernia • Disc disease • Arthritis • Scoliosis and posture related disorders

  32. Nongynecologic disorders:Psychiatric and psychological • In depression pain is not an uncommon presentation • Mood is an important modifier of pain • The relationship between depression and pain may involve neurotransmitter abnormalities

  33. Nongynecologic disorders:Psychiatric and psychological • Physical and sexual abuse history is obtained in 25% to 40% of CPP patients • Trauma of abuse event can kindle a depressive or pain processing disorder in a genetically susceptible individual

  34. Nongynecologic disorders:Psychiatric and psychological • Somatization disorder patients have multiple physical complaints not explained by a known medical condition • DSM-IV criteria: Four different pain sites, two GI complaints, one neurologic symptom and one sexual or reproductive symptom

  35. Nongynecologic disorders:Psychiatric and psychological Somatization disorder • Emotional distress • Common abnormality of sensation processing

  36. Nongynecologic disorders:Psychiatric and psychological • Hypochondriasis patients are preoccupied with fear of having a serious disease • Obsessive • Visit many health care providers

  37. Nongynecologic disorders:Psychiatric and psychological • Drug-seeking behavior patients often request opioids for pain relief • Women with CPP may become addicted if they use opioids for pain relief • Abdominal pain due to withdrawal leads to further drug use

  38. Nongynecologic disorders:Problematic substance abuse • Impaired control of substance use • Guilt or regret about use, efforts to cut down, complaints or concerns from others • Recent substance use with resultant neurologic or cardiovascular symptoms, confusion, anxiety, or sexual dysfunction • Psychosocial dysfunction • Tolerance

  39. Nongynecologic disorders:Psychiatric and psychological • Factitious disorder patients intentionally feign disease with the purpose of assuming the role of a sick person • Malingering patients have external incentive to appear sick

  40. Nongynecologic disorders:Pain Processing Disorder • Fibromyalgia • occurs in 2% to 4% of individuals, 80% are women • Abnormal pain processing associated with neuroendocrine and autonomic disorders

  41. Nongynecologic disorders:Fibromyalgia • Criteria for diagnosis: • Pain involving all 4 quadrants of body and axial skeleton • Tenderness at 11 of 18 defined “tender points” • Tenderness due to amplification of pain signals

  42. Nongynecologic disorders:Fibromyalgia • Abnormal CNS processing of pressure • Visceral sensations can also be abnormally processed • Associated motility disorder of abdominal viscera • Disordered sleep

  43. Nongynecologic disorders:Gastrointestinal • Irritable bowel syndrome (IBS) • Abdominal pain for at least 3 month duration in the last year • Relieved by bowl movement • Altered bowl habits (frequency and appearance)

  44. Nongynecologic disorders:Gastrointestinal • Irritable bowel syndrome (IBS) • Abnormal gastrointestinal motility • Augmented sensation of visceral stimuli as pain • Consistent with abnormal pain processing and autonomic dysfunction disorders

  45. Nongynecologic disorders:Gastrointestinal • Inflammatory Bowel Disease • Pain from inflammation of bowel or adjacent structures • Nonspecific symptoms (pain, gas, distention, etc.) • Fever and diarrhea