Rosiebel Candido Esguerra, M.D

Rosiebel
Candido Esguerra
Rosiebel Candido Esguerra, M.D.
•  Introduc*on
•  Defini*on of Chronic Pelvic Pain (CPP)
•  Mechanisms of CPP
•  Causes / contributors of Pain
•  Evalua*on of Pa*ents with CPP
•  Management of CPP
•  Conclusion
2017 PGH Annual Postgraduate Course, June 26-‐28, Marrio= Conven?on Center
PAST PRESENT
-‐ focused on iden*fying a single pathology, e.g. Chronic Pelvic Pain
infec*on or inflamma*on
-‐ now recognized as a specific neurological
-‐ this approach showed to be insufficient and
disease en?ty resul*ng from a maladap&ve
resulted in a number of inappropriate
func&onal and structural transforma&on
outcomes:
occurring over &me
•  Over-‐inves*ga*on of the end-‐organ as the
-‐ oKen associated with nega*ve cogni*ve,
source of pain
behavioral, sexual and emo*onal
•  Inappropriate treatment of the end-‐organ consequences
e.g. overuse of an*bio*cs
removal of the organ -‐ a single trigger may not be iden*fied
Noncyclic pain > 6 months dura?on
localizes to the: anatomic pelvis

anterior abdominal wall
at or below the umbilicus
lumbosacral back or bu=ocks
Of sufficient severity to cause func?onal

disability or lead to medical care
American College of Obstetricians and Gynecologists (ACOG)
Ongoing acute pain Nocicep*ve pain
mechanisms
inflammatory pain
Chronic pain mechanisms neuropathic pain
Emo*onal, cogni*ve,
behavioral and sexual
responses and mechanisms
•  Based on pathophysiology

Nocicep*ve Pain Ac*va*on of nociceptors in response to noxious s*muli

Inflammatory Pain Ac*va*on of inflammatory process
S*mula*on of “silent nociceptors”
Neuropathic Pain Central sensi*za*on or neuronal pain

Psychogenic Pain Results from the physical manifesta*on of unresolved
emo*onal or psychological conflict.

Mixed Pain
Idiopathic Pain unexplained
•  Based on dura*on
Type Pathophysiology Characteris?cs
Acute Pain Ac*va*on of peripheral Lasts for few seconds to hours
nociceptors,
Release of COX enzymes and
prostaglandins
Chronic Pain Sensi*za*on at the level of Lasts for ≥ 6 months
spinal neurons via mul*ple
mechanisms
Stage 4
PERCEPTION
Coluzzi F., et al. From acute to chronic

pain: tapentadol in the progressive stages
of this disease en*ty. European Review
Ascending
for Medical and Pharmacological
Sciences. 2017; 21: 1672-‐1683 Pathways
Stage 1
TRANSDUCTION
Stage 3
MODULATION
Stage 2
TRANSMISSION
SUBSTANCE P
CGRP
Dureja, GP., et al. Evidence and consensus recommenda*ons for the pharmacological
management of pain In India. Journal of Pain Research. 2017:10 709–736
Dureja, GP., et al. Evidence and consensus recommenda*ons for the pharmacological
management of pain In India. Journal of Pain Research. 2017:10 709–736
Reduced ac*va*on threshold in the nociceptors leading to
increased sensi*vity and responsivity
Modifica*on of the peripheral *ssue, which may result in

the transducers being more exposed to peripheral
s*mula*on
Recruitment of the "silent nociceptors" increasing input to

the DH (hyperalgesia)
Ac*va*on of local immunocytes and mast cells with NGF

releaseing
Dureja, GP., et al. Evidence and consensus
recommenda*ons for the pharmacological
management of pain In India. Journal of Pain
Research. 2017:10 709–736

expansion of the recep*ve field
increased signal transmission to CNS
amplifica*on of pain percep*on
ALLODYNIA AND HYPERALGESIA
Dureja, GP., et al. Evidence and consensus
recommenda*ons for the pharmacological
management of pain In India. Journal of Pain
Research. 2017:10 709–736

Descending
Pathways
•  Several neurotransmikers
and neuromodulators are
involved in descending
pain:
•  inhibitory
•  Opioids
•  5-‐hydroxytryptamine
•  norepinephrine
•  facilitatory
•  Serotonin (pro-‐nocicep*ve)
Coluzzi F., et al. From acute to chronic
pain: tapentadol in the progressive stages
of this disease en*ty. European Review
for Medical and Pharmacological
Sciences. 2017; 21: 1672-‐1683

CNS structural
Plas?city
(neuronal atrophy
and death,
decrease in brain
volume and size)
HPA axis
Psychological
Changes
Pain dysfunc?on
(decreased
(depression,
anxiety)
chronifica*on cor*sol,
increased pain)
ANS Dysfunc?on
(increased
sympathe*c and
decreased
parasympathe*c) Brawn etal. Central changes associated with chonic
pelvic pain and endometriosis. Human Reproduc*on
Updates Vol 20(5)pp 737-‐747, 2014
Brawn, J. et al. Centralchangesassociatedwithchronic pelvicpainandendometriosis. 2014
HumanReproduc*onUpdate,Vol.20,No.5pp.737–747
Central changes
Exacerba*on of
symptoms
predisposi*on to other

chronic condi*ons
•  Decreased glucocor*coids can exacerbate infec*on/
inflamma*on leading to pain intensifica*on
•  Pain can aggravate even if the nocicep*ve input stays
constant
•  Pain genera*on occurs even without a peripheral noxious
input
Brawn, J. et al. Centralchangesassociatedwithchronic

pelvicpainandendometriosis. 2014
•  Chronic pain condi*ons tend to cluster, involving mul*ple
organ systems.
•  Share common predisposing factors such as gene*cs,
psychological/cogni*ve state, or similar neural mechanisms
•  The central changes secondary to one chronic pain condi*on
could predispose to the development of another ex.
Endometriosis is associated with other autoimmune diseases
like SLE, hypothyroidism
Brawn, J. et al. Centralchangesassociatedwithchronic
pelvicpainandendometriosis. 2014
nature, frequency and dura*on, chronology, and site of pain
History
pain pakern during ac*vi*es

rela*onship to precipita*ng/relieving factors, including its rela*on to movement
and posture, and the menstrual cycle (pain diary of 2-‐3 cycles)
pa*ent’s and family’s ideas about the causes of and future for her pain
review the effects of previous treatments
associated gynecological, urogenital and bowel symptoms
level of func*oning and symptoms rela*ng to overall well-‐being such as
psychological and social factors
*history of sexual abuse or physical abuse

•  Iden*fy the exact anatomic loca*ons of tenderness and
correlate these with areas of pain
•  Should be done in a systema*c and methodical manner,
proceeding from the least tender to the most tender
•  Should include musculoskeletal, gastrointes*nal, urinary, and
psychoneurological examina*on
•  Examina*on done in standing, sirng, supine, and lithotomy
posi*ons


LITHOTOMY POSITION POSSIBLE PROBLEMS DIAGNOSED

Visual inspec*on of the external genitalia Inflammatory and infec*ous diseases; vulvar abscess; trauma; fustula; ulcera*ve disease;
pigmented lesions (neoplasias); condylomata; atrophic changes; fissure
Basic sensory tes*ng to sharpness, dullness, and light touch Nerve entrapment; neuropathy; spinal cord lesion
Cokon-‐*pped swab evalua*on of the ves*bule Vulvar ves*buli*s
Single-‐digit palpa*on of vulva and pubic arch Trigger points

colposcopic evalua*on of the vulva and pubic arch Neoplasia
Sims retractor or single-‐blade speculum examina*on of vagina and pelvic Enterocele; cystocele; rectocele; uterine descensus trigger points
muscles
Cokon-‐*pped swab evalua*on of cervical os and paracervical and Trigger points
cervical *ssues
Cokon-‐*pped swab evalua*on of vaginal cuff Trigger points; neuroma
Single-‐digit pelvic examina*on of introitus Vulvar ves*buli*s; vaginismus; trigger points
Single-‐digit pelvic examina*on of levator ani Pelvic floor pain syndrome; trigger points
Single-‐digit pelvic examina*on of coccygeus Pelvic floor pain syndrome; trigger points
Single-‐digit pelvic examina*on of pyriformis with and without abduc*on Piriformis syndrome
Single-‐digit pelvic examina*on of anterior vaginal urethral Chronic urethral syndrome; urethri*s; cys**s; inters**al cys**s; trigoni*s; urethral
diver*culum; vaginal wall cyst syndrome
Single-‐digit pelvic examina*on of cervix, paracervical areas, and vaginal Trigger points; endometriosis; cervici*s; repeated cervical trauma; pelvic infec*on;
fornices ureteral pain
Single-‐digit pelvic examina*on of uterus Adenomyosis; pelvic conges*on syndrome; pelvic infec*on; premenstrual syndrome;
adhesions
Single-‐digit pelvic examina*on of coccyx Coccydynia

Single-‐digit pelvic examina*on of adnexa Pelvic conges*on syndrome; endometriosis
Bimanual pelvic examina*on
NEUROLOGICAL
GYNECOLOGICAL •  Triggered points
•  Endometriosis •  Nerve entrapment
•  Adenomyosis •  Damaged nerves
•  Chronic pelvic inflammatory disease (PID) •  Pudendal neuralgia
•  Pelvic venous conges*on •  Perineal pain syndrome
•  Adhesions, including residual and trapped ovary
syndromes
•  Pelvic organ prolapseGynecological malignancy MUSCULOSKELETAL
•  Fibromyalgia
•  Osteoporosis
GASTROINTESTINAL •  Scoliosis
•  Piriformis syndrome
•  Irritable bowel syndrome (IBS) •  Levator ani spasm or injury
•  Inflammatory bowel disease
•  Coeliac disease
•  Hernia PSYCHOLOGICAL
•  Mesenteric venous thrombosis •  Depression, including postnatal depression
•  Previous trauma*c experience
URINARY
UNKNOWN ETIOLOGY
•  Bladder pain syndrome (inters**al cys**s)
•  Urethral syndrome
•  Chronic pelvic pain syndrome
Complete blood count with differen?al count
Screening for gonorrhea and chlamydia ,Cervical swab

culture
Urinalysis, microscopy, and culture
*Urinary, bowel, and Fcalysis with occult blood

endometrial biomarkers

-‐ insufficient evidence
Serum CA 125
to allow clinical
recommenda*on for
use at present
FSH ,estradiol
Transvaginal Sonography
•  to iden*fy and assess adnexal masses
•  likle value for posi*ve iden*fica*on of other causes of CPP, e.g. pelvic
endometriosis
•  Accuracy in diagnosing adenomyosis:
65-‐68% sensi*vity and 65-‐98% specificity (two prospec*ve blinded studies)
82.5% sensi*vity and 84.6% specificity (systema*c review of 14 trials)
MRI
•  comparable to TVS in diagnosing adenomyosis
70 – 78% sensi*vi*es, 86-‐93% specifici*es
•  lacks the sensi*vity in the detec*on of endometrio*c deposits
•  reserved as 2nd line inves*ga*on if
other therapeu*c inves*ga*ons
failed
•  no longer considered ‘gold
standard’ for inves*ga*ng chronic
pelvic pain
RCOG. The ini*al Management of Chronic Pelvic Pain May 2012
SOGC Consensus Guidelines for Management of Chronic Pelvic Pain JOGC Aug 2005

1.  Treat diseases or disorders
that might be a cause of or a •  CPP has a mul*factorial nature
contributor to CPP o  An integrated, mul*disciplinary program
should be adopted:
q  Hormonal
2.  Treat chronic pelvic pain, itself q  Medical
q  Surgical
as a diagnosis (CPPS) q  Psychological interven*ons
q  Emo*onal support
Interven?on Adverse Effects Evidence of benefit
Hypo-‐estrogenic effects; vasomotor Significant symptom relief compared to
GnRH Agonists symptoms, vaginal dryness, loss of bone no treatment (PR 3.93 95% CI1.37 to
mineral density, sleep disturbances, mood 11.28)
swings, loss of libido
Acne, headache, depression, breast Similar efficacy as GnRH agonists
COCPs symptoms, breakthrough bleeding, fluid (goserelin) at relieving pain associated
reten*on, increased risk of venous with endometriosis ( data from one small
thromboembolism trial)
As above for COCP; par*culatly fluid One study showed benefit in reducing
Vaginal contracep?ve reten*on/weight gain, headaches
pain, however 36% of ring users and 61%
ring or transdermal
Endometriosis oestrogen/proges?n
patch users withdrew from the study for
various reasons including side-‐effects and
treatment inefficacy
Medical treatment patch
Menstrual irregulari*es, abdominal pain, No significant difference in pain scores
LNG-‐IUS expulsion, depression, PID, peripheral edema between LNG-‐IUS and GnRH agonist
Weight gain, bloa*ng, irregular menstrual Limited evidence however available

Prostagens bleeding, sore breasts, headache
evidence does suggest con*nuous
progestagens are effec*ve therapies
Simpson LR,Mahmood T, (similar in efficacy to other treatments)
Medical and surgical
Androgenic effects: acne, edema, weight Relieves pain from endometriosis more
management of Pain.Obstetrics , Danazol gain, hirsu*sm, voice changes (irreversible?); effec*vely than placebo (mean difference
Gynecology and ReproducBve
Medicine
vaginal sporng, muscle cramps
-‐3.4 95% CI -‐4.8 to -‐1.8) similar
effec*veness to GnRH agonists; Use no
(2016)

longer supported due to the undesirable
Cochrane Review 2007 side effects
Aromatase Inhibitors Limited evidence. Can be used in
combina*on with COCP, progestagens,
G n R H a g o n i s t s i n r e c t o v a g i n a l
endometriosis
SERMs, SPRMs Insufficient data to support use
Goals: 1. to remove areas of peritoneal, ovarian and
deep infiltra*ng endometriosis
2. to restore anatomy by division of adhesions
Based on 2014 Cochrane Review
Simpson LR,Mahmood
T, Medical and surgical management of Pain.Obstetrics , Gynecology and ReproducBve Medicine
DISEASE RECOMMENDED TREATMENT
Adenomyosis Medical Management:

•  NSAIDs
•  Hormonal therapy: COCP, high dose progestagens (MPA, norethisterone)
GnRH agonists, danazol, LNG-‐IUS, aromatase inhibitors
Others: endometrial abla*on and resec*on, magne*c resonance-‐guided
focused ultrasound, uterine artery abla*on, hysterectomy

Ongoing Cochrane Review

Uterine artery abla*on is efficacious in the short and medium term for control
of symptom.
NICE Guidelines 2012

Adhesions There is no evidence to support the division of fine adhesions to support CPP.
However, it is generally accepted that dense and vascular adhesions may cause
CPP, and that division of such adhesions may improve pain and should be
considered.
DISEASE RECOMMENDED TREATMENT
Pelvic venous conges?on Hormonal Therapy (progestagens and GnRH agonists: limited data
Hysterectomy
Pelvic vein liga*on
Pelvic vein emboliza*on: significant reduc*on in pain scores. Few
data available on its impact on menstrua*on and fer*lity

Na&onal Ins&tute for Health Research

Irritable Bowel Symptoms (IBS) Dietary modifica*on is the mainstay of therapy. Exclusion of
lactose, sorbitol, fructose, caffeinated products, and grains
An*-‐spasmodics
Dietary Modifica*ons:


Bladder Pain Syndrome/ Referral to Urology
Inters??al cys??s
A mul*disciplinary, integrated approach is recommended.
The team should include gynecologists, pain specialists,

physiotherapists, clinical or health psychologists
The management plan should address any concern

regarding their condi*on, including beliefs or anxie*es.
The goal of treatment is find strategies that afford more
func*onal living than complete eradica*on of pain.
Neuromodulatory Psychological
medica?ons Hormonal Therapy therapies Complementary
(anxiolyBcs, (cogni*ve-‐behavioral Strategies (yoga,
neurolepBcs, (prostagens, GnRH therapy, pain acupuncture,
analgesics, agonists) mindfulness based
psychoterapy, sexual
anBdepressants) counselling) medicine)
ANTIDEPRESSANTS NEUROLEPTICS
ANALGESICS tricyclic an*depressants: gabapen*n
NSAIDs amitriptyline
pregabalin
Opioids nortriptyline
desipramine lamotrigine
ANXIOLYTICS HORMONAL
alprazolam Therapy
Management op*ons in CPPS based on a Cochrane review (2014)
TREATMENT ASSESSED CONCLUSION

Progesterone MPA more effec*ve than placebo
(medroxyprogesterone acetate, benefit up to 9 months following treatment
MPA) vs. placebo with increased side effects compared to placebo
•  Bloa*ng
•  weight gain
Moderate quality evidence

Lofexidine vs. placebo Lofexidine no beker than placebo
with increased side effects
Low to moderate quality evidence

Goserelin vs. progesterone Greater improvement in pain scores, mood, and sexual func*on with
goserelin compared with progesterone
Moderate quality evidence

Gabapen?ne vs. amitriptyline Greater improvement in pain scores shown in gabapen*n
comparable adverse effects
Low quality evidence
TREATMENT ASSESSED CONCLUSION

Reassurance ultrasound scans and •  Improved pain scores in ultrasound/ counseling group
Counseling vs.
“Watch and wait” approach •  Very low quality evidence

Wri?ng therapy •  Improved pain in wri*ng therapy group
(disclosure of pain) vs. •  Very low quality evidence
non-‐disclosure
Distension of painful pelvic structures •  Distension beker effect on pain scores than counseling
vs. Counseling •  Moderate quality evidence
Magne?c therapy No significant benefit proven

Somatocogni?ve therapy
Biofeedback /cogni?ve-‐behavioral
therapy
Psychotherapy
Chinese herbal medicine
Acupuncture
The role of surgery in CPPS remains controversial as there is no specific pathology to
treat.
Laparoscopic uterosacral nerve abla?on (LUNA)

•  ineffec*ve and should not be performed
Hysterectomy
•  remains a poten*al op*on even in the absence of
known gynecological pathology
•  considered only once all other treatments available

failed and a mul*disciplinary approach has been fully
u*lized before deciding on surgery
•  poten*al failure to achieve post-‐opera*ve pain:

•  21-‐40% will con*nue to experience pain
•  5% experience increased pain
Rosiebel Candido Esguerra

Rosiebel Candido Esguerra, M.D

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Rosiebel

localizes to the: anatomic pelvis

Of suﬃcient severity to cause func?onal

Neuropathic Pain Central sensi*za*on or neuronal pain

Coluzzi F., et al. From acute to chronic

Modiﬁca*on of the peripheral *ssue, which may result in

Recruitment of the "silent nociceptors" increasing input to

Ac*va*on of local immunocytes and mast cells with NGF

increased signal transmission to CNS

ampliﬁca*on of pain percep*on

ALLODYNIA AND HYPERALGESIA

predisposi*on to other

Brawn, J. et al. Centralchangesassociatedwithchronic

review the eﬀects of previous treatments

associated gynecological, urogenital and bowel symptoms

*history of sexual abuse or physical abuse

LITHOTOMY POSITION POSSIBLE PROBLEMS DIAGNOSED

Screening for gonorrhea and chlamydia ,Cervical swab

Urinalysis, microscopy, and culture

*Urinary, bowel, and Fcalysis with occult blood

Weight gain, bloa*ng, irregular menstrual Limited evidence however available

2. to restore anatomy by division of adhesions

Adenomyosis Medical Management:

The team should include gynecologists, pain specialists,

The management plan should address any concern

Magne?c therapy No signiﬁcant beneﬁt proven

Laparoscopic uterosacral nerve abla?on (LUNA)

• considered only once all other treatments available

• poten*al failure to achieve post-­‐opera*ve pain:

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Neuropathic Pain Central sensizaon or neuronal pain

Modiﬁcaon of the peripheral ssue, which may result in

Acvaon of local immunocytes and mast cells with NGF

ampliﬁcaon of pain percepon

•  considered only once all other treatments available

•  potenal failure to achieve post-‐operave pain: