Medical and surgical management of chronic pelvic pain

Chronic pelvic pain (CPP) affects over 1 million women in the UK, with subsequent impact on ability to work and the economy. It is often debilitating and can be difficult to treat. Gynaecologists have traditionally focussed on the organ-specific approach to the diagnosis of pain. Endometriosis is common as is chronic pelvic inflammatory disease and adenomyosis. Some causes are non-gynaecological such as irritable bowel syndrome and interstitial cystitis. However, as many as 55% of women presenting with CPP will have no obvious underlying pathology following completion of all investigations.This review focuses on the appropriate investigations, diagnosis and management of women with identified pathological causes of pelvic pain. It also considers the holistic approach to the management of the woman with chronic pelvic pain syndrome. Careful prescribing, assessment, interaction and support from a multidisciplinary team are required.     

Chronic pelvic pain in women: etiology,pathogenesis and diagnostic approach

Chronic pelvic pain (CPP), defined as non-cyclic pain of 6 or more months, is a frequent disorder that may negatively affect health-related quality of life. In women several causes are recognised, although in a not negligible proportion of patients a definite diagnosis cannot be made. Different neurophysiological mechanisms are involved in the pathophysiology of CPP. Pain may be classified as nociceptive or non-nociceptive. In the first case the symptom originates from stimulation of a pain-sensitive structure, whereas in the second pain is considered neuropatic or psychogenic. Patients history is crucial and is generally of utmost importance for a correct diagnosis, being sometimes more indicative than several diagnostic investigations. The main contributing factors in women with CPP can still be identified by history and physical examination in most cases. Many disorders of the reproductive tract, urological organs, gastrointestinal, musculoskeletal and psycho-neurological systems may be associated with CPP. Excluding endometriosis, the most frequent causes of CPP are: post-operative adhesions, pelvic varices, interstitial cystitis and irritable bowel syndrome. CPP is a symptom, not a disease, and rarely reflects a single pathologic process. Gaining women's trust and developing a strong patient-physician relationship is of utmost importance for the long-term outcome of care.     

节育术后慢性盆腔痛

女性节育术后可发生慢性盆腔痛（CPP）。输卵管绝育术后CPP的主要原因有盆腔炎性疾病、大网膜粘连综合征、盆腔淤血综合征,神经官能症也是病因之一。妇科检查、影像学检查和腹腔镜检查可明确诊断;宫内节育器（IUD）放置后的CPP主要与IUD位置异常有关,X线与B超联合检查、腹腔镜检查是重要的检查方法。CPP治疗前首先要明确诊断,针对病因治疗是关键。     

The role of laparoscopy as a diagnostic tool in chronic pelvic pain.

More than 40% of laparoscopies are performed for the diagnosis of chronic pelvic pain (CPP). Although laparoscopic evaluation is sometimes considered a routine part of the evaluation, ideally the decision to perform a laparoscopy should be based on the patient's history, physical examination and findings of non-invasive tests. About 65% of women with CPP have at least one diagnosis detectable by laparoscopy and it is common to attribute causality to this diagnosis. Endometriosis is diagnosed in one-third of laparoscopies for CPP. Endometriosis requires histological confirmation to assure an accurate diagnosis. Adhesions are diagnosed in about one-quarter of laparoscopies. Ovarian cysts, hernias, pelvic congestion syndrome, ovarian remnant syndrome, ovarian retention syndrome, post-operative peritoneal cysts and endosalpingiosis are other diagnoses that can be made laparoscopically in some cases. Laparoscopic conscious pain mapping has the potential to improve the accuracy of laparoscopy as a diagnostic tool in CPP.     

Adolescent pelvic pain

Chronic pelvic pain is a frequent complaint in adolescent females. It is a complex disorder with multiple causes. The assessment must attempt to differentiate between gynaecological and non-gynaecological sources of pain. An understanding of the physical, cognitive and environmental factors associated with the pain are essential. Laparoscopy has been used in the assessment of CPP but a significant number of patients will have no obvious aetiology at the time of laparoscopy. For the young patient with CPP, a multidisciplinary approach may be essential to facilitate diagnosis and management. Although the symptoms may not always be curable, management that allows the young female to obtain normal or near normal function may be possible. This chapter focuses on the various causes of pelvic pain in the adolescent female with a focus on the assessment, diagnosis and treatment of the different causes.     

Causes of chronic pelvic pain.

Chronic pelvic pain (CPP) is a common and debilitating condition, and yet remarkably little is known about what causes the pain. In this chapter we present a model of CPP which emphasizes the multifactorial nature of the problem. A range of physical causes are discussed, including endometriosis, pelvic inflammatory disease (PID), adhesions, irritable bowel syndrome, interstitial cystitis, musculo-skeletal factors and nerve-related pain. The role of the nervous system in the genesis and moderation of pain is explored. The importance of psychological factors is discussed, both as a primary cause of pain and as a factor which affects the pain experience. As with other chronic syndromes, the biopsychosocial model offers a way of integrating physical causes of pain with psychological and social factors.     

Making a joint decision: Cannabis as a potential substitute for opioids in obstetrics and gynecology

There is a growing body of evidence that cannabis may be effective as an analgesic with potential to reduce opioid usage in chronic pain. This review synthesizes the available literature to elucidate the possible role that cannabis might play in reducing opioid use in gynecological disorders that may potentially lead to a recommendation of substituting opioids with cannabis. With reports of a decrease in opioid use after cannabis initiation, an opioid-sparing effect has been seen in gynecologic malignancies such as ovarian, uterine, endometrial, and cervical cancers, in addition to chronic pelvic pain (CPP). Though many studies have found an association between cannabis and various adverse maternal and neonatal outcomes, there is a lack of randomized controlled trials making it difficult to claim a directly causal relationship between cannabis and these adverse outcomes. Additionally, with increased use of cannabis during pregnancy, the evidence of possible benefits and risks to mothers and fetuses is examined.     

Mucinous adenocarcinoma in an ovarian remnant

The ovarian remnant syndrome, a complication of bilateral salpingo-oophorectomy, is progressively receiving more attention in the gynecological surgery literature. The syndrome is manifested by pelvic pain and a palpable or sonographic finding of a pelvic mass. However, in rare cases, patients can present with large masses and radiographic suggestion of malignancy. We present the case of a 76-year-old white female, 23 months after bilateral salpino-oophorectomy at the same institution, complaining of 3.5 months of right flank and abdominal pain. Clinical and radiological evidence of a right ovarian remnant was discovered. Subsequent laparoscopic resection was consistent with a well-encapsulated mucinous adenocarcinoma in a right ovarian remnant. Curiously, this patient had no history of endometriosis, dense pelvic adhesions, pelvic inflammatory disease, or difficulty encountered during the original hysterectomy. This is the seventh published case report in the international literature about carcinoma developing in an ovarian remnant. However, this case differs in that the patient had no preexisting gynecologic conditions at the time of hysterectomy and bilateral salpingo-oophorectomy to account for residual ovarian tissue. Additionally, the oophorectomy was performed vaginally, in contrast to multiple previous case reports.     

Does pelvic venous congestion syndrome exist and can it be treated?

Chronic pelvic pain (CPP) is a common and costly health problem in gynecology. Operative pathological findings are often absent. In some women with CPP, pelvic venous congestion has been reported; however, this observation has also been made in asymptomatic women. Thus, it is not clear whether pelvic venous congestion causes CPP and, if it does, whether it is a direct or indirect cause. Venography and non-invasive imaging methods are used for the diagnosis, but scoring systems have not been validated. The current mainstay of treatment is venography-controlled embolization, which is less invasive than surgical interventions. However, the only evidence on effectiveness comes from uncontrolled case series. A systematic review of causation evidence is needed to prove whether pelvic venous congestion causes CPP and whether embolization treatment is effective. In addition, if causation is established, good-quality primary randomized controlled trials on embolization may be required.     

Correlation between endometriosis and pelvic pain.

STUDY OBJECTIVE: To evaluate the relationship between prevalence and severity of chronic pelvic pain (CPP) and stage, site, and type of endometriosis. DESIGN: Prospective, observational study (Canadian Task Force classification II-2). SETTING: University Hospital. PATIENTS: Of 90 consecutive women with biopsy-proved endometriosis, laparoscopy was performed in 69 for pelvic pain and in 21 for infertility or clinical and ultrasonographic suspicion of ovarian endometriosis. INTERVENTION: Preoperatively, using a 10-point visual analog scale, the severity of dysmenorrhea, CPP, and deep dyspareunia was assessed. During laparoscopy all visible endometriotic lesions were recorded and treated. MEASUREMENTS and MAIN RESULTS: Ten women (11.1%) had no pain; 72 had dysmenorrhea (mild in 13, moderate in 37, severe in 22); 55 had CPP (mild in 11, moderate in 25, severe in 19); and 39 deep dyspareunia (mild in 5, moderate in 31, severe in 3). The severity of dysmenorrhea significantly correlated with the presence and extent of pelvic adhesions (p = 0.004); the severity of CPP correlated with deep endometriosis on the uterosacral ligaments (p = 0.0001) and extent of pelvic adhesions (p = 0.02); and deep dyspareunia correlated with deep endometriosis on the uterosacral ligaments (p = 0.04). Total pain score significantly correlated with deep endometriosis on the uterosacral ligaments (p = 0.0001), peritoneal adhesions (p = 0.01), and extent of adnexal adhesions (p = 0.01). No significant correlation was found among revised American Fertility Society stage of endometriosis; presence and size of ovarian endometriomas; extent, type, and site of peritoneal lesions; and pain scores. By logistic regression analysis, the presence and intensity of total pain could be predicted simultaneously by the presence of deep endometriosis (p = 0.0001) and presence and extent of adnexal adhesions without cystic endometriosis (p = 0.01), and by the presence of ovarian endometrioma with periovarian adhesions (p = 0.03). Chronic pelvic pain was predicted by both deep endometriosis (p = 0.0001) and ovarian endometriomas with adnexal adhesions (p = 0.03). Deep dyspareunia was predicted simultaneously by deep endometriosis (p = 0.01) and an ovarian endometrioma with periovarian adhesions (p = 0. 008). Conclusion. Deep endometriosis, pelvic adhesions, and ovarian cystic endometriosis were independent predictors of pelvic pain. These data strongly suggest that it is not the size of ovarian cystic endometriosis but the association with adhesions that causes pelvic pain.     

Chronic Pelvic Pain Educational Experience Among Minimally Invasive Gynecologic Surgery Fellows and Recent Graduates: A Needs Assessment

Study ObjectiveLearning to evaluate and treat chronic pelvic pain (CPP) is an established curriculum objective within the Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS). Our aim was to investigate current educational experiences related to the evaluation and management of CPP and the impacts of those experiences on FMIGS fellows and recent fellowship graduates, including satisfaction, confidence in management, and clinical interest in CPP.DesignThe AAGL–Elevating Gynecologic Surgery Special Interest Group for pelvic pain developed a 33-item survey tool to investigate the following topics: (1) current educational experiences with the assessment and management of patients with CPP, (2) satisfaction with fellowship training in CPP, (3) perceived preparedness to treat patients with CPP, (4) plans to incorporate management of CPP into clinical practice, and (5) perceived desires to expand CPP exposure. Composite scores were created to examine experiences related to diseases associated with CPP and pharmaceutical and procedural treatment options.SettingElectronic survey.PatientsNot applicable.InterventionsThe survey was distributed via AAGL email lists and offered on FMIGS social media sites from August 2017 to November 2017 to all active FMIGS fellows and individuals who graduated the fellowship during the preceding 5 years.Measurements and Main ResultsFifty-three of 82 (65%) current FMIGS fellows and 104 of 169 (62%) recent fellowship graduates completed the survey. Only 66% of current fellows endorsed working with a fellowship faculty member whose clinical work focused on CPP. Most current fellows reported having a “good amount” of experience or “extensive” experience with superficial endometriosis (39/53, 74%) and deeply infiltrative endometriosis (34/53, 64%), whereas the majority reported having “no” or “little” experience with frequently comorbid conditions like irritable bowel syndrome (68%), pelvic floor tension myalgia (55%), and interstitial cystitis/painful bladder syndrome (51%). For both current fellows and recent graduates, increased CPP Disease Experience composite scores were associated with satisfaction with CPP training (current fellows odds ratio [OR] 1.9, p =.002; recent graduates OR 1.5, p < .001), perceived preparedness to treat patients with CPP (current fellows OR 2.0, p = .0021; recent graduates OR 1.5, p <.001), and the desire to incorporate the treatment of CPP into future clinical practice (current fellows OR 1.8, p = .0099; recent graduates OR 1.3, p = .0178). More than 80% (43/53) of current fellows indicated that they believed an expanded pelvic pain curriculum should be part of the FMIGS fellowship.ConclusionThis needs assessment of FMIGS fellows and recent graduates suggests that there are gaps between FMIGS curriculum objectives and current educational experiences, and that fellows desire increased CPP exposure. Expansion and standardization of the CPP educational experience is needed and could lead to increased focus on this disease process among subspecialty benign gynecologic surgeons.     

Nonsurgical management of chronic pelvic pain: a multidisciplinary approach

Experience with multidisciplinary management of CPP has demonstrated the importance of ruling out and of treating nongynecologic conditions such as myofascial syndrome, irritable bowel syndrome, urethral syndrome, and psychogenic pain in women with CPP and normal laparoscopies. Moreover, current data suggest that availability of a multidisciplinary pelvic pain clinic can reduce the frequency of hysterectomy for this disorder.     

Ovarian remnant syndrome

Ovarian remnant syndrome (ORS) refers to a condition occurring in women who have had a bilateral salpingo-oophorectomy (BSO), with or without a hysterectomy, that leaves behind ovarian tissue. This residual ovarian tissue then results in pelvic pain or a pelvic mass. Risk factors associated with incomplete removal of an ovary and subsequent development of ORS include a history of endometriosis, pelvic inflammatory disease, multiple previous surgeries, and pelvic adhesive disease. Patients most frequently present with chronic pelvic pain, pelvic pain associated with a pelvic mass, or an asymptomatic pelvic mass. Definitive criteria for diagnosis of ORS include a history of BSO with histologic documentation of ovarian tissue obtained during subsequent surgical excision. The recommended treatment for ORS is surgical excision by laparotomy or, more recently, laparoscopy. We present the presentation and management of patients with ORS and a review of the published literature.     

Medical and surgical management of chronic pelvic pain

Chronic pelvic pain is common and is estimated to affect over one million women in the UK. It may be a symptom of a number of different conditions and is often multifactorial in nature, caused by a combination of physical, psychological and social factors. For many women, a primary cause cannot be identified. This can make both diagnosis and management difficult. Gynaecological causes of chronic pelvic pain include endometriosis, chronic pelvic inflammatory disease and adhesions. The gynaecologist must also consider non-gynaecological causes of pain related to the gastrointestinal, urinary, neurological, musculoskeletal and psychological systems if satisfactory management of the woman's pain is to be achieved.This review addresses the approach to diagnosis and management of women presenting with chronic pelvic pain. It details specific disease management but also seeks to encourage a holistic approach to all women with chronic pelvic pain, whether or not a primary diagnosis is established.     

Medical and surgical management of chronic pelvic pain

Chronic pelvic pain is common and is estimated to affect over one million women in the UK. It may be a symptom of a number of different conditions and is often multifactorial in nature, caused by a combination of physical, psychological and social factors. For many women, a primary cause cannot be identified. This can make both diagnosis and management difficult. Gynaecological causes of chronic pelvic pain include endometriosis, chronic pelvic inflammatory disease and adhesions. The gynaecologist must also consider non-gynaecological causes of pain related to the gastrointestinal, urinary, neurological, musculoskeletal and psychological systems if satisfactory management of the woman's pain is to be achieved.This review addresses the approach to diagnosis and management of women presenting with chronic pelvic pain. It details specific disease management but also seeks to encourage a holistic approach to all women with chronic pelvic pain, whether or not a primary diagnosis is established.     

The role of sonography in pediatric gynecology

Sonography has a major role in the evaluation of children with gynecologic disorders. The size, consistency, and origin of pelvic masses and the status of the internal genitalia can be evaluated. Sonography is useful in evaluation of children with precocious puberty because it can demonstrate adult-size ovaries in true precocious puberty, which distinguishes this from premature thelarche and adrenarche. Specific causes of precocious sexual development such as adrenal and ovarian tumors and cysts also can be diagnosed.     

The use of ultrasound-based 'soft markers' for the prediction of pelvic pathology in women with chronic pelvic pain--can we reduce the need for laparoscopy?

OBJECTIVE: To assess the accuracy of new transvaginal ultrasound-scan-based markers and to compare them to conventional ultrasound methods used in the detection of common pelvic pathology in women with chronic pelvic pain (CPP). DESIGN: A prospective observational study. SETTING: Teaching hospital. POPULATION: A total of 120 consecutive women with CPP undergoing transvaginal ultrasonography before either diagnostic or operative laparoscopy. METHODS: Anatomical abnormalities, e.g. endometrioma or hydrosalpinx (hard markers), were documented. The woman was then assessed for the presence or absence of 'soft markers' (reduced ovarian mobility and site-specific pelvic tenderness). MAIN OUTCOME MEASURE: Presence or absence of pelvic pathology noted during laparoscopy. RESULTS: Seventy women had pelvic pathology, of whom 51 had endometriosis alone, 7 both endometriosis and pelvic adhesions, 6 pelvic adhesions, 1 hydrosalpinx with endometriosis and 5 hydrosalpinx and pelvic adhesions. The likelihood ratio for the hard markers was infinity (specificity was 100%), for the soft makers 1.9 (95% CI 1.2-3.1) and for a 'normal' ultrasound 0.18 (0.09-0.34). The pre-test probability of pelvic disease in our population of women with CPP was 58%, and this probability of disease was raised to 100% with the presence of hard markers and to 73% with the presence of soft markers. The pre-test probability of 58% fell to 20% when ultrasound finding was found to be normal. CONCLUSION: This new approach improves the detection and exclusion of significant pathology in women with CPP and may lead to a reduction in the number of unnecessary laparoscopies carried out on women with CPP.     

Ultrasound evaluation of gynecologic causes of pelvic pain

Ultrasound should be considered the first-line imaging modality of choice in women presenting with acute or chronic pelvic pain of suspected gynecologic or obstetric origin because many, if not most, gynecologic/obstetric causes of pelvic pain are easily diagnosed on ultrasound examination. Since the clinical presentation of gynecologic causes of pelvic pain overlaps with gastrointestinal and genitourinary pathology, referral to CT or MRI, especially in pregnant patients, should be considered if the US examination is nondiagnostic.     

非妇科因素致慢性盆腔痛

慢性盆腔痛是影响女性健康的常见问题,疼痛的症状和病因常涉及妇科学、胃肠病学、泌尿和疼痛医学。非妇科因素导致的慢性盆腔痛的常见原因有肠易激综合征、膀胱疼痛综合征、腹部肌筋膜疼痛综合征等等。所以需要多学科共同参与诊治。