Egyptian Society Of Chronic Pelvic Pain In Women 

( Established 2003 )

Road Map of Chronic Pelvic

Pain For Wome

By

Dr.  Nasr Said Nassar

Founder and President Of  Egyptian Society Of
Chronic Pelvic Pain For Women 

Consultant Obstetrics and Gynecology
Head Department Of Ob.&Gyn,
Monira General Hospital, Cairo Egypt

 


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1 - What is chronic female pelvic pain?

2 - What are possible causes of chronic pelvic pain?

3 - What are common symptoms?

4 -What  increases  the  risk  of  chronic  pelvic   pain?

5 - When to call a doctor?

6 - How is chronic pelvic pain in women diagnosed?
               ** Taking complete history :

               ** Tests and diagnosis

7 -  How is the prevention?


 8 - How is chronic pelvic pain treated ?


     ** Home Treatment
     ** Medication Choices
     ** Surgery Choices :
     ** Other treatment :


         -   Alternative medicine
         -   Lifestyle and home remedies                                                          

    

                                                            ...................................

 

                                         
1 - What is chronic female pelvic pain?


Chronic pelvic pain, refers to pain in female pelvic region, i.e.  pain, below a woman’s belly button ( umbilicus ), or pain in the region between both hips, below the belly button. In order to be considered chronic, the pain must last for at least six months or longer. The type of pain varies from woman to woman. The pain may be enough to interfere with normal daily activities, i.e. difficult to sleep, work or enjoy life.
The pain may comes in attacks and disappears or be constant. It may severe, moderate or mild.
The pain takes different forms like sharp, dull ache, heaviness, pressure, colicky or stitch pain. If the patient asked to locate  pain, she  might sweep her  hand over that entire area rather than point to one spot. 
The pain may indicate that the lesion or the pathology is in the same the site of pain, or it may be referral pain indicates that the lesion or the pathology in another place different of the site of pain..  

2 - What are possible causes of chronic pelvic pain?


The cause of chronic pelvic pain is often hard to find. Like many women, your patient never receives a specific diagnosis that explains her pain. But  you have to tell your patient that doesn't mean  her pain isn't real and treatable.
If the source of your chronic pelvic pain is found, treatment focuses on that cause. If no cause can be found, treatment for chronic pelvic pain focuses on managing the pain.
Some of the more common causes of chronic pelvic pain include:
 Endometriosis. This can lead to painful cysts and adhesions (fibrous bands of scar tissue).
 Tension in pelvic floor muscles. Spasms or tension of the pelvic floor muscles can lead to recurring pelvic pain.
 Chronic pelvic inflammatory disease. This can occur if a long-term infection, often sexually transmitted, causes scarring involving pelvic organs.
 Pelvic congestion syndrome. This condition may be caused by enlarged, varicose-type veins around uterus and ovaries.
 Ovarian remnant. During a complete hysterectomy — surgical removal of the uterus, ovaries and fallopian tubes (salpingo-oophorectomy) — a small piece of ovary may be left inside, which can later develop tiny, painful cysts.
 Fibroids. These non-cancerous uterine growths may cause pressure or a feeling of heaviness in lower abdomen. They rarely cause sharp (acute) pain unless they become deprived of nutrients and begin to die (degenerate).
 Irritable bowel syndrome. Symptoms associated with irritable bowel syndrome — bloating, constipation or diarrhea — can be a source of uncomfortable pelvic pain and pressure.
 Interstitial cystitis. Chronic inflammation of the bladder and a frequent need to urinate characterize interstitial cystitis. The patient may experiences  pelvic pain as the bladder fills, which may improve temporarily after emptying  the bladder.
 Psychological factors. If the patient is depressed, experiences chronic stress or has been sexually or physically abused, she may be more likely to experience chronic pelvic pain.
Emotional distress makes pain worse, and likewise living with chronic pain makes emotional distress worse. So chronic pain and emotional distress frequently get locked into a vicious cycle.
Detection of the cause of chronic pelvic pain in women is often very difficult, lengthy process, frustrated, and not found in many cases. Up to 61 % of chronic pelvic pain in women sufferers will never be specifically diagnosed, i.e.  61 %  of these patients are with unknown  etiology.
Sometimes, after a disease has been treated or an injury has healed, the affected nerves keep sending pain signals. This is called neuropathic pain. It may help explain why it can be so hard to find the cause of chronic pelvic pain.

3 - What are common symptoms?


Chronic pelvic pain exhibits many different characteristics. Among the signs and symptoms are:
 Severe and steady pain, extreme and constant pain.
 Pain that comes and goes (intermittent)
 Dull aching
 Sharp pains or cramping
 Pressure or heaviness deep within the  pelvis
In addition, the patient  may experience:
 Pain during intercourse
 Pain while having a bowel movement
 Pain when she sit down
The discomfort may intensify after standing for long periods and may be relieved when she lie down. The pain may be mild and annoying, or it may be so severe that she miss work, can't sleep and can't exercise.
The type of pain of chronic pelvic pain can vary widely, can include:
• Pain that ranges from mild to severe.
• Pain that ranges from dull ( vague) to sharp.                                                                            
• Severe cramping during periods.
• Pain during sex.
• Pain when you urinate or have a bowel movement.
• Chronic pain can lead to depression.
• Depression can cause the patient to feel sad and hopeless, eat and sleep poorly, and move slowly.
Also,
• Severe menstrual cramps (dysmenorrhea).
• Low backache 1 or 2 days before the start of the menstrual period (or earlier), subsiding during the period.
• Painful urination.
• Rectal pain.
• Pain during bowel movements.
Symptoms that can accompany pelvic pain, depending on the cause, include:
• Blood in the urine or stool.
• Vaginal bleeding after intercourse.
• Heavy or irregular vaginal bleeding.

4 - What  increases  the  risk  of  chronic  pelvic   pain?


Factors that increase a woman's risk of developing female pelvic pain that becomes chronic include:
• Pregnancy and childbirth that have stressed the back and pelvis, including delivery of a large baby, a difficult delivery, or a forceps or vacuum delivery.
•  A history of childhood or adult physical or sexual abuse. About half of women with chronic female pelvic pain report abuse in their past.
• A history of pelvic inflammatory disease (PID).
• A history of radiation therapy or surgery of the abdomen or pelvis (including some surgeries for urinary incontinence).
• Past or current diagnosis of depression. Pain sensation and depression seem to be interrelated.
• Alcohol or drug abuse.
• An abnormal structure (congenital abnormality) of the uterus, cervix, or vagina.


5 - When to call a doctor?


General advice to all women, to call doctor if she got one of the following:
• Her periods have changed from relatively pain-free to painful.
• Pain interferes with daily activities.
• She begins to have pain during intercourse.
• She has painful urination, blood in your urine, or an inability to control the flow of urine.
• She has blood in the stool or a significant, unexplained change in your bowel movements.


6 - How is chronic pelvic pain in women diagnosed?


** Taking complete history :

Many helpful questions are important specially about the past and present health, and about illness or health-related problems in patient`s family. She should be asked to describe the kind of pain she has, where it is and how strong it is. She should be asked about  anything can causes the pain to get better or worse.
Also, some leading questions should be asked as :
• Is the pain related to your menstrual cycle?
• Is it related to bowel movements?
• Does it hurt during urination or sexual activity?
• Have you had an infection?
• Have you had surgery in your pelvic area?

More details:
• When did you first begin experiencing pelvic pain?
• Has your pain changed or spread over time?
• How often do you experience pelvic pain?
• How severe is your pain, and how long does it last?
• Where is your pain located? Does it always occur in one place?
• Would you describe your pain as sharp or dull?
• Does your pain come in waves or is it constant?
• Can you anticipate when the pain is coming?
• Is your pain usually triggered by a specific event, such as intercourse or exercise?
• Do you feel pain during urination or a bowel movement?
• Does your menstrual cycle affect your pain?
• Does anything make your pain better or worse?
• Does your pain limit your ability to function? For example, have you ever had to miss school or work because of your pain?
• Is your pain causing difficulty in your marriage or other important personal relationships?
• Have you recently felt down, depressed or hopeless?
• Have you recently lost interest in things you once enjoyed?
• Have you ever had pelvic surgery?
• Have you ever been pregnant?
• Have you ever been treated for a urinary tract or vaginal infection?
• Have you ever been touched against your will?
• What do you think is causing your pain?
• What treatments have you tried so far for this condition? How have they worked?
• Are you currently being treated or have you recently been treated for any other medical conditions?


** Tests and Diagnosis
Possible tests or exams are include:
 Pelvic examination. This can reveal signs of infection, abnormal growths or tense pelvic floor muscles. The doctor will check for areas of tenderness and changes in sensation. This pelvic examination may be more extensive than what used to be during a routine gynecologic examination. It's important to the doctor to know if she feels any pain during this exam, especially if the pain is similar to the discomfort the patient has been experiencing.
 A digital rectal exam may be conducted in a slower, more thorough manner than a routine pelvic exam, carefully checking for tender areas.
 Cultures. Samples can be taken from the cervix or vagina to check for infection, including sexually transmitted diseases, such as chlamydia, herpes and gonorrhea.
 A Pap test, which detects cervical cancer and cervical precancer (dysplasia).
 A pregnancy test (human chorionic gonadotropin, or hCG). If you test positive for pregnancy, you will also have an ultrasound to check for signs of a tubal (ectopic) pregnancy.
 A complete blood count (CBC), which can detect signs of infection, anemia, and blood cell abnormalities.
 An erythrocyte sedimentation rate (ESR), which can indicate infection if elevated.
 Tests for sexually transmitted diseases, such as chlamydia, gonorrhea, and genital herpes.
 Urinalysis and urine culture, which can detect signs of infection and kidney stones.
 Stool analysis, to check for signs of blood.
 Abdominal ultrasound and/or transvaginal ultrasound of the pelvic area using a small ultrasound device (transducer) inserted into the vagina. Ultrasound plays a major role in looking for causes of pelvic pain. It is useful for detecting endometrial hyperplasia; pelvic inflammatory disease; and cancerous or noncancerous (benign) growths such as fibroids, cysts, and tumors on the ovaries, uterus, cervix, or fallopian tubes.
 Intravenous pyelogram (IVP), which uses an injected dye combined with X-rays to create pictures of the kidneys, bladder, ureters, and urethra.
 Computed tomography (CT) urogram, which uses X-rays to create pictures of the kidneys and urinary tract.
 Laparoscopy, look inside the pelvis for causes of pain, including scar tissue (adhesions), abnormal growths, cysts, tumors, and pelvic inflammatory disease. Laparoscopy is the only way to confirm the presence of endometriosis. If needed, a growth or adhesion can also be removed during the procedure.
 Computed tomography (CT) scan of the pelvis, which uses X-rays to create pictures of organs and bones.
 Magnetic resonance imaging (MRI) of the pelvis, which uses a magnetic field and pulses of radio wave energy to create pictures of organs and bones.
 Cystoscopy, which uses a viewing instrument inserted through the urethra into the bladder. This allows a doctor to see signs of inflammation, growths, or kidney stones in the bladder.
 Urodynamic studies, which test bladder function and whether bladder spasms are causing pelvic pain.
 Evaluation for irritable bowel syndrome.
 Evaluation of abdominal wall for "trigger points."

7 - How is the prevention?

Early diagnosis and treatment of acute pelvic pain may help prevent chronic female pelvic pain from developing.
One cause of chronic pelvic pain is pelvic inflammatory disease (PID).
 Protection from sexually transmitted diseases (STDs) should be emphasized .
Preventing an STD is easier than treating an infection after it occurs.
• Remember that it is quite possible to be infected with an STD without knowing it. Some STDs, such as HIV, can take up to 6 months before they can be detected in the blood.
o Avoid all sexual contact with anyone who has symptoms of an STD or who may have been exposed to an STD.
• Avoid having more than one sex partner at a time. The risk for an STD increases if woman has several sex partners at the same time.
Abstaining from sexual contact is the only certain way to avoid exposure to STDs.                                                                                                                                                     ( Practice safe sex or abstinence)


8 - How  is  chronic  pelvic  pain  treated ?


** Home Treatment

Home treatment may help ease female pelvic pain and can be used  with simple medical treatment plan.
To relieve your pain:
• Try nonprescription medicine, such as ibuprofen (for example, Advil or Motrin) or acetaminophen (for example, Tylenol).
o Start taking the recommended dose of pain medicine as soon as the feeling of uncomfortable.
If the patient has painful periods, she should start taking the medicine one day before menstrual period is scheduled to start.
o She should take the medicine in regularly scheduled doses to keep the pain under control. Pain medicine works better if she takes it at regularly scheduled times.
o She should not take more than the recommended dose.
o She should not take aspirin if she is younger than 20 unless doctor tells you.
•           She should not take any medicine if she is or could be pregnant.
• Apply a heating pad, hot water bottle, or warm compress to the lower belly, or take a warm bath. Heat improves blood flow and may relieve pain.
• To relieve back pain, the patients lie down and elevate the legs by placing a pillow under the knees. When lying on the side, bring the knees up to the chest.
•           She should try relaxation techniques, such as meditation, yoga, breathing exercises, and progressive muscle relaxation.
•           She should try exercise regularly. It improves blood flow, increases pain-relieving endorphins naturally made by the body, and reduces pain.
•           She should try sexual activity, which may relieve pelvic cramping and backache. If the pain is related to endometriosis, however, sex may make it worse.

**Medication Choices

The following may help relieve symptoms:
• Prescription nonsteroidal anti-inflammatory drugs (NSAIDs), taken on a regular schedule, help relieve pain caused by inflammation or menstruation. If one type doesn't work for the patient, the doctor may recommend that the patient try at least one other before stopping NSAID therapy.
• Birth control pills (oral contraceptives) are commonly prescribed to reduce painful menstruation. Oral contraceptives are often prescribed for endometriosis-related pain, though there is little research that shows them to be effective.
• High-dose progestin is sometimes prescribed to relieve pain related to endometriosis.
• Gonadotropin-releasing hormone agonists (GnRH-As) can relieve endometriosis-related pain by stopping production of the hormones that make endometriosis worse.
GnRH-A treatment may also relieve cyclic pelvic pain not related to endometriosis, as well as pelvic pain related to irritable bowel syndrome.1 However, this short-term treatment induces menopause, with side effects such as hot flashes and loss of bone density, for as long as the patients take it.
• Tricyclic antidepressant medications (TCAs) are sometimes used to treat chronic pain in other areas of the body. Limited research suggests that TCA therapy decreases chronic pelvic pain intensity for some women.
• Narcotic pain medication is only recommended as a last-resort treatment for severe pelvic pain because of the risk of addiction.
• No single medication successfully treats chronic pelvic pain in all women.
• Treating chronic pelvic pain with medication is usually preferable to using a surgical option. Surgery is only recommended when a correctable cause of pain is clearly known. Even in these cases, there are no guarantees that surgery will relieve pain or that it will not cause further problems.
• Chronic pelvic pain symptoms sometimes stop naturally when menopause occurs. If the patients are close to menopausal age (usually around age 50) and the symptoms are likely related to hormones, the best option may be home treatment and medication until menopause occurs.

**  Surgery  Choices :

Surgery may be used in the diagnosis or treatment of chronic pelvic pain. It is most likely to be effective when it is performed for a specific condition, such as fibroids or endometriosis.
There is no evidence that surgical removal of the reproductive organs relieves chronic pelvic pain. It can even make the pain worse.  When surgery, such as hysterectomy or cutting of specific pelvic-area nerves, is done for pain with no known cause, there is a risk of persistent pain or pain that is worse after surgery as well as surgery-related side effects.
Either laparoscopic surgery through a small incision or laparotomy through a larger abdominal incision can be used for procedures to treat pelvic pain.
Laparoscopy to diagnose chronic pelvic pain may be done before treatment with medications (other than birth control pills) or surgery. Sites of endometriosis (implants) or scar tissue (adhesions) may be removed or destroyed during the laparoscopy.
  
Hysterectomy, the surgical removal of the uterus, is sometimes used as a last-resort treatment for chronic, severe pelvic pain. Depending on the cause, hysterectomy may relieve pain for some women.
Hysterectomy is only a good treatment choice for chronic pelvic pain when a documented disease or surgically correctable condition of the pelvic organs is present.
When hysterectomy is performed solely for relief of pelvic pain, the results may be disappointing.
Studies have shown that surgery to remove scar tissue adhesions from previous surgery or from pelvic inflammatory disease does not relieve pain unless the adhesions are severe (referred to as stage IV adhesions).

Surgery may lead to complications that cause added pain, discomfort, or other problems such as infection or scar tissue.
Symptoms caused by chronic pelvic pain often go away without treatment when menopause occurs and hormone fluctuations settle down. Controlling symptoms with home treatment or medications until menopause may be an option. Symptoms Laparoscopy to diagnose chronic pelvic pain may be done before treatment with medications (other than birth control pills) or surgery. Sites of endometriosis (implants) or scar tissue (adhesions) may be removed or destroyed during the laparoscopy.

**Other treatment :
Female pelvic pain treatment can be enhanced with counseling, mental skills training, relaxation, and physical therapy treatment.
Counseling and mental skills training help you learn the mental and emotional tools for managing chronic pain and the stress that makes it worse. Commonly recommended approaches include:
 
Cognitive-behavioral therapy focused on changing the way patient`s think about and mentally manage pain. This approach is a proven chronic pain treatment.
( See a psychologist, licensed counselor, or clinical social worker who specializes in pain management skills.)
Biofeedback, which is the conscious control of body function that is normally unconsciously controlled.
Biofeedback, this alternative therapy is based on the idea, confirmed by scientific studies, that you can use your mind to control your body. Working with a biofeedback therapist, you'll use special monitoring equipment that beeps or flashes when your body is sending cues that pain is on the way. As you recognize these cues, you can train your body to respond differently and decrease the sensation of pain.
Interpersonal counseling, focused on best managing your life events, stressors, and relationships.
Physical therapy can help you learn specific exercises to stretch and strengthen certain muscle groups. Physical therapy helps you to improve posture, gait, and muscle tone.
Alternative medicine
Alternative pain treatments for chronic female pelvic pain are not well studied but are considered helpful for managing stress and building mental mastery over pain.
Several types of alternative therapies may reduce pain associated with certain medical conditions.
Acupuncture and trans-cutaneous nerve stimulation (TENS) have shown some success in relieving painful menstrual periods.
Acupuncture has also been used as a treatment for non-menstrual chronic pelvic pain but is not yet well studied.
During acupuncture treatment, a practitioner inserts tiny needles into the skin at precise points. Pain relief may come from the release of endorphins, the body's natural painkillers, but how this method works isn't known.
Trans-cutaneous electrical nerve stimulation (TENS).  This approach may help improve localized or regional pain. During TENS therapy, electrodes deliver electrical impulses to nearby nerve pathways — which can help control or relieve some types of pain.
 
Other low-risk alternative pain treatments that many people use to help manage pain include:
Relaxation and breathing exercises, which are a proven treatment for chronic pain.
Relaxation techniques. Deep breathing and targeted stretching exercise for the pelvic region could help minimize bouts of pain when they occur.
    Hypnosis.
    Guided imagery.
    Aromatherapy.
    Meditation.
    Yoga.
    Massage therapy.

Chronic pelvic pain takes time to develop and can take a long time to treat. Take a time to the patients to know how to cope with pain by using one or more of the treatment choices above. Combine the treatment with the practices she prefers for keeping a positive state of mind.

Lifestyle and home remedies
One of the more frustrating aspects of chronic pain is that it can have a strong impact on the daily life. When pain strikes, the patient  may have trouble sleeping, exercising or performing physical tasks, and she may withdraw from social situations because of the pain.
Self-care measures to bolster the emotional and mental health may ease the discomfort:
 Emotional support: Chronic pain can trigger some intense, negative emotions, such as pain, grief and anger, which can affect the self-esteem and the relationships with others. Emotional support by patient`s family members and friends , by listening , show interest and sympathy , help, advise and encourage her to follow the medical instruction, accompany the patient to doctor visits ………...etc.                 
 Stress management: Becoming too anxious or stressed over certain situations may exacerbate chronic pain. Effective stress management techniques not only help reduce the patient`s  stress levels, but may also have the indirect effect of easing stress-triggered pain.

 

References :


1 - WebMD.com
2 - Written by familydoctor.org editorial staff. American Academy of Family Physicians
3 -
http://www.mayoclinic.com/health/chronic-pelvic-pain/ds00571
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2. Chronic pelvic pain. International Pain Society.
http://www.pelvicpain.org/pdf/Patients/CPP_Pt_Ed_Booklet.pdf. Accessed Jan. 8, 2009.
3. Pelvic pain. American College of Obstetricians and Gynecologists.
http://www.acog.org/publications/patient_education/bp099.cfm. Accessed Jan. 8, 2009.
4. Howard F. Evaluation of chronic pelvic pain in women.
http://www.uptodate.com/home/index.html. Accessed Jan. 8, 2009.
5. Chronic pelvic pain. Rockville, Md.: Agency for Healthcare Research and Quality.
http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=10940&nbr=5720&string=. Accessed Jan. 8, 2009.
6. Howard F. Treatment of chronic pelvic pain in women.
http://www.uptodate.com/home/index.html. Accessed Jan. 8, 2009.
7. Gallenberg MM (expert opinion). Mayo Clinic, Rochester, Minn. Jan. 16, 2009.
American College of Obstetricians and Gynecologists (2004). Chronic pelvic pain. ACOG Practice Bulletin No. 51. Obstetrics and Gynecology, 103(3): 589–605.
1. Howard FM (2003). Chronic pelvic pain. Obstetrics and Gynecology, 101(3): 594–611.
2. Hewitt GD, Brown RT (2000). Acute and chronic pelvic pain in female adolescents. Medical Clinics of North America, 84(4): 1009–1025.
3. Guidice LC, et al. (1998). Status of current research on endometriosis. Journal of Reproductive Medicine, 43(3): 252–262.
4. Mishell DR Jr, et al. (2001). Differential diagnosis of major gynecologic problems by age groups. In MA Stenchever et al., eds., Comprehensive Gynecology, 4th ed., pp. 155–176. St. Louis: Mosby.
5. Mishell DR Jr, et al. (2001). Endometriosis and adenomyosis. In MA Stenchever et al., eds., Comprehensive Gynecology, 4th ed., pp. 531–564. St. Louis: Mosby.
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Contact Info

Dr. Nasr Said Nassar
Consultant and Head of
Department of Obstetrics and Gynecology,
Monira General governmental Hospital, Cairo, Egypt.
Founder and Chairman of
" Egyptian Society of Chronic Pelvic Pain inWomen"
Tel. + 2 0100 14 35 991 Cairo, Egypt.

nasrnassar1@hotmail.com
www.nasrnassar.org

Dr. Heba Nasr Nassar
General Secretary of the society
+2 1015872447

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