Chronic Pelvic Pain

1. Chronic Pelvic Pain

2. Objectives When working with CPP, you will be able to: • Identify and address the nociceptive aggravators • Explore any other possible contributors to CPP • List 3 assessment tools that may be useful • Encourage patient education on chronic pain including sensitization of the nervous system • Explain the effects of narcotic usage on CPP • Develop an Action Plan for treatment

3. A Case of Chronic Pelvic Pain • “Kate”, 27 year old G1P1 woman, presenting with a 3 year history of CPP • Dysmenorrhea since age 15 • Became daily pain soon after vaginal delivery of son 3 years ago, rated 7/10 on pain scale • Bilateral adnexal pain radiating to inguinal area • Constant, with exacerbation at menses and aggravated by physical activity and stress • Requesting hysterectomy because of impact of pain on her quality of life

4. Medical History • What would you look for? We found: • Alternating constipation/diarrhea; No bladder symptoms • Dyspareunia • Surgeries: • Laparoscopy x4 (Jan & Aug/10, Feb & Sep/11) with cautery of mild endometriosis, “some” improvement in pain for ~3 months • Medications: • Past trial of Depot-Lupron led to intolerable side-effects, no change in symptoms • On 16mg/d hydromorphone, medical marijuana, continuous OCPs • Daily pain continues at 7/10, aggravated by frequent breakthrough bleeding

5. Psychosocial History • What would you want to know? We found: • Lives with husband and 3 year old son in Lower Mainland • High school education, works in office administration • Enjoyed job, but now unable to work • Difficulty caring for child and home • Mood is “frustrated, stressed, not depressed” • Multiple life stressors, pain worse when stressed • Few social supports, several recent losses • Sexual abuse (age 6-12) by family member • Denies alcohol or recreational drug use • No prior mental health diagnoses or counselling

6. Physical Exam • What would you look for? We found: • Bilateral lower quadrant tenderness with abdominal wall trigger points • No uterine or adnexal tenderness • No cul-de-sac tenderness or nodularity • Pelvic floor is tender and has increased tone

7. Assessment Tools • What assessment tools might be useful for this patient? We used: • Pain Diagram • PHQ-9: Patient Health Questionnaire • GAD-7: Generalized Anxiety Disorder • PCS: Pain Catastrophizing Scale • ACE: Adverse Childhood Experiences

8. Assessment Tools: Pain Diagram

9. Assessment Tools: PHQ-9 (Spitzer, et al., 2001) 1 + 8 + 0 = 9/27

10. Assessment Tools: GAD-7 (Spitzer, et al., 2006)

11. Assessment Tools: PCS (Sullivan, et al., 1995)

12. Assessment Tools: ACE (Felitti, et al., 1998)

13. Discussion Questions • What nociceptive triggers can be identified/ addressed? • Stopping menses • Bowel (constipation) • Pelvic floor tension • Are there any other possible contributors? • Breakthrough bleeding while on OCPs • Narcotics usage • Pelvic floor dysfunction • Psychosocial: stress, trauma, anxiety, grief

14. Clinical Impression • Dysmenorrhea and endometriosis • Myofascial pain with pelvic floor tension and pain on palpation • Bowel irritability, likely narcotic side-effect related • Anxiety, history of trauma • Central sensitization of nervous system, exacerbated by stress

15. Discussion Questions • What about her narcotic usage? Request for surgery? • Narcotics likely making symptoms worse • Pain primarily myofascial on exam • How can she calm the nervous system and reduce sensitization? • Pain education • Physiotherapy • Counselling

16. Action Plan • What would you do? Our Plan: • Encourage patient’s wish to improve quality of life, via: • Trial of progestin for suppression of menses • Education on chronic pain and sensitization • Taper off narcotics by 10% every 2 weeks • Bowel regimen; diet modifications • Pelvic floor physiotherapy • Counselling/psychotherapy • Discourage patient’s goal of hysterectomy: • Uterus is non-tender, pain is primarily myofascial

17. Summary When working with CPP, it is important to: • Identify and address the nociceptive triggers • Look for any other possible contributors to CPP • Identify assessment tools that may be helpful • Promote patient education on chronic pain and sensitization • Explain to the patient why narcotics are not always the best option • Make an Action Plan for treatment in collaboration with patient using an interdisciplinary approach

18. References • Felitti, V.J., Anda, R.F., Nordenberg, D., et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The adverse childhood experiences (ACE) study. American Journal of Preventative Medicine,14, 245–258. • Spitzer, R.L., Kroenke, K., Williams, J.B.W., Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166, 1092-1097 • Spitzer, R.L., Williams, J.B.W., Kroenke, K., et al. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16, 606-613. • Sullivan, M.J.L., Bishop, S., & Pivik, J. (1995). The pain catastrophizing scale: Development and validation. Psychological Assessment, 7, 524-532.

19. Thank You