Mx 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

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 Non-gynaecological
• 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

o dysmenorrhoea o mid cycle o non cyclic disturbance with life style (include use of analgesia)
Other factors
o LMP o menorrhagia o PCB/IMB/premenstrual spotting
O & G History
contraception history esp. use IUCD / OCP, etc. Medical History
Family History

Psychosocial history

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
Medical management
• symptomatic • ovarian suppression e.g OCP / Danazol / GnRHa • antibiotics
Surgical management
• 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 - avoid opiates
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



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