MANAGEMENT OF CHRONIC PELVIC PAIN By Tim Chang
o pain >6 months duration, o below the umbilicus o affecting daily activities
accounts for 10% gynaecology visits 20% hysterectomies primary indication CPP 40% all laparoscopies performed fro CPP 40% cases there is NO obvious pathology in an adolescent there is increased likelihood of pathology∴ need to assess more aggressively Aetiology: Gynaecological
1. Endometriosis 2. Chronic Pelvic Inflammatory Disease 3. Ovarian causes: eg:
cysts (recurrent) ovarian tumours residual ovaries
5. Pelvic venous congestion 6. Adhesions 7. Physiological
• IBD • IBS • diverticular disease • malignancy
• stone • infection • interstitial cystitis • urethral syndrome • cancer
• levator syndrome • abdominal myofascial pain from trigger points
Psychological 1. Depression 2. somatoform disorders 3. Anxiety disorders History HPI 1.
o dysmenorrhoea o mid cycle o non cyclic
disturbance with life style (include use of analgesia)
Other factors 1.
o LMP o menorrhagia o PCB/IMB/premenstrual spotting
O & G History 1.
contraception history esp. use IUCD / OCP, etc.
Medical History Family History
Psychosocial history 1. Examination: General demeanor and affect, especially initial entrance into the office. Vital signs General assessment eg.
Vaginal examination (single finger and bimanual) map pain exact location
uterine size / orientation / tenderness ⇒ adenomyosis
anterior vaginal wall palpation for urethral / bladder inflammation etc.
Investigations • always exclude pregnancy
definitive pathology found in 60% ie: 40% have a negative laparoscopy
pelvic venography / venous Doppler ovarian vessels
Management of chronic pelvic pain. Management depends on
• cause e.g endometriosis / PID • severity of pain • philosophy of Patient/ Doctor
1) Empiric symptomatic treatment of the most likely cause after History, examination and
basic investigations e.g OCP + NSAIDS for dysmenorrhoea likely endometriosis
2) Specific treatment of the cause after thorough investigations, including surgery 3) Non specific Analgesic treatment of pain
• symptomatic • ovarian suppression e.g OCP / Danazol / GnRHa • antibiotics
• laparoscopy 30% placebo effect • excision of endometriosis • salpingectomy • removal adnexa / ovary • hysterectomy
Management of CPP with negative laparoscopy Multi-disciplinary approach:
• medical including TENS / nerve stimulators • psychological • non medical e.g acupunture
1) counselling and explanation is critical in the management.
Explain that there is no serious pathology
Referral to other specialists if significant symptoms -
3) Ovarian suppression (esp. if related to menstrual cycle)
• monophasic OCP continuous • Primolut / Provera continuous • DMPA 150mg 3 monthly • GnRHa
very little role as a primary procedure but may be doen laparoscopically in addition to excisional surgery of Pouch of Douglas endometriosis Presacral neurectomy useful if
technically challenging procedure needs to be done by an experienced surgeon Hysterectomy ±
80%-95% have relief of pelvic pain in selected patients, but recurrence rates up to 40% Causes of pelvic pain after pelvic clearance 1.
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