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* exaggerated bladder, bowel, or uterine pain sensitivity (also known as visceral pain)
* exaggerated bladder, bowel, or uterine pain sensitivity (also known as visceral pain)
* [[pelvic girdle pain]] (SPD or DSP)
* [[pelvic girdle pain]] (SPD or DSP)

; Urologic
* [[Interstitial Cystitis]]—Painful bladder syndrome characterized by urinary frequency, urgency and painful urination.


; Gynecologic
; Gynecologic
* [[Adhesions]]—scar tissue that connects organs and tissues that are not normally connected
* [[Dysmenorrhea]]—pain during the menstrual period
* [[Dysmenorrhea]]—pain during the menstrual period
* [[Uterine Fibroids]]—benign tumors in the wall of the uterus
* [[Endometriosis]]—pain caused by uterine tissue that is outside the uterus
* [[Endometriosis]]—pain caused by uterine tissue that is outside the uterus
* [[Müllerian abnormalities]]
* [[Müllerian abnormalities]]
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* [[Ovarian torsion]]—the ovary is twisted in a way that interferes with its blood supply
* [[Ovarian torsion]]—the ovary is twisted in a way that interferes with its blood supply
* [[Ectopic pregnancy]]—a pregnancy implanted outside the uterus
* [[Ectopic pregnancy]]—a pregnancy implanted outside the uterus
* [[Pelvic venous congestion]]


; Abdominal
; Abdominal
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The absence of visible pathology in chronic pain syndromes should not form the basis for either seeking psychological explanations or questioning the reality of the patient’s pain. Instead it is essential to approach the complexity of chronic pain from a psychophysiological perspective which recognises the importance of the mind-body interaction. Some of the mechanisms by which the limbic system impacts on pain, and in particular myofascial pain, have been clarified by research findings in neurology and psychophysiology.<ref name="Jantos"/>
The absence of visible pathology in chronic pain syndromes should not form the basis for either seeking psychological explanations or questioning the reality of the patient’s pain. Instead it is essential to approach the complexity of chronic pain from a psychophysiological perspective which recognises the importance of the mind-body interaction. Some of the mechanisms by which the limbic system impacts on pain, and in particular myofascial pain, have been clarified by research findings in neurology and psychophysiology.<ref name="Jantos"/>

Conscious pain mapping in which the sedated but still conscious patient is able to provide feedback during a diagnostic laparoscopy has been found to be a useful tool in determining the source and cause of pelvic pain.<ref name="Howard">{{cite journal |author=Howard FM, El-Minawi AM, Sanchez RA |title=[http://www.ncbi.nlm.nih.gov/pubmed/11084181 Conscious pain mapping by laparoscopy in women with chronic pelvic pain] |journal=Obstet. Gynecol. |volume=96 |issue=6 |pages=934-9 |year=2000}}</ref>



===Treatment===
===Treatment===
Many women will benefit from a consultation with a physical therapist, a trial of anti-inflammatory medications, hormonal therapy, or even neurological agents.
Many women will benefit from a consultation with a physical therapist, a trial of anti-inflammatory medications, hormonal therapy, or even neurological agents.


⚫
A [[hysterectomy]] is sometimes performed.<ref name="pmid20177285">{{cite journal |author=Kuppermann M, Learman LA, Schembri M, ''et al.'' |title=Predictors of hysterectomy use and satisfaction |journal=Obstet Gynecol |volume=115 |issue=3 |pages=543–51 |year=2010 |month=March |pmid=20177285 |doi=10.1097/AOG.0b013e3181cf46a0 |url=}}</ref>
A variety of surgical treatments are available depending on the determined cause of the pain, including myomectomy (for removal of fibroids), ablation of endometriosis, removal of endometriomas, adhesiolysis and LUNA (Laparoscopic Uterosacral Nerve Ablation). Surgical procedures are not without risk as surgery itself may incite the formation of adhesions, thus where possible an [[Adhesion Barrier]] should be employed.
⚫
A [[hysterectomy]] is sometimes performed<ref name="pmid20177285">{{cite journal |author=Kuppermann M, Learman LA, Schembri M, ''et al.'' |title=Predictors of hysterectomy use and satisfaction |journal=Obstet Gynecol |volume=115 |issue=3 |pages=543–51 |year=2010 |month=March |pmid=20177285 |doi=10.1097/AOG.0b013e3181cf46a0 |url=}}</ref> but this should be viewed as a last resort as the pain often returns associated with other conditions.<ref name="Wiseman">{{cite journal |author=Wiseman DM |title=Disorders of adhesions or adhesion-related disorder: monolithic entities or part of something bigger--CAPPS? |journal=Semin. Reprod Med.|volume=26 |issue=4 |pages=356-68 |year=2008 |url=http://adhesions.org/Wiseman2008SeminreprodMed26p356CAPPS.pdf|PMID=18756413}}</ref>


==Male==
==Male==
Line 71: Line 61:


==Epidemiology==
==Epidemiology==
Chronic pelvic pain is a common condition beleived to affect over 10 million women in the US, with rate of [[dysmenorrhoea]] between 16.8—81%, [[dyspareunia]] between 8—21.8%, and noncyclical pain between 2.1—24%.<ref>{{cite journal |author=Latthe P, Latthe M, Say L, Gülmezoglu M, Khan KS |title=WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity |journal=BMC Public Health |volume=6 |issue= |pages=177 |year=2006 |pmid=16824213 |pmc=1550236 |doi=10.1186/1471-2458-6-177 |url=}}</ref>
Chronic pelvic pain is a common condition with rate of [[dysmenorrhoea]] between 16.8—81%, [[dyspareunia]] between 8—21.8%, and noncyclical pain between 2.1—24%.<ref>{{cite journal |author=Latthe P, Latthe M, Say L, Gülmezoglu M, Khan KS |title=WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity |journal=BMC Public Health |volume=6 |issue= |pages=177 |year=2006 |pmid=16824213 |pmc=1550236 |doi=10.1186/1471-2458-6-177 |url=}}</ref>

==Relationship to Other Conditions==
Patients with an initial diagnosis of Chronic Pelvic Pain whose condition remains unresolved often develop a set of bladder, bowel, genital and other symptoms that make them indistinguishable in many respects from long-standing patients whose diagnoses may have started out as [[Interstitial Cystitis]] (IC), [[Adhesion]]s and Adhesion Related Disorder (ARD), [[Irritable Bowel Syndrome]] (IBS), [[endometriosis]], [[dyspareunia]] or [[vulvodynia]]. A number of studies attest to the co-prevalence between various abdominal and pelvic disorders including adhesions, dyspareunia, endometriosis, interstitial cystitis, painful bladder syndrome, chronic prostatitis/chronic pelvic pain syndrome, vulvodynia, irritable bowel syndrome, pudendal neuralgia, and even fibromyalgia, chronic fatigue syndrome, temporomandibular joint and muscle disorders. <ref name="Zondervan">{{cite journal |author=Zondervan KT, Yudkin PL, Vessey MP, et al. |title=Chronic pelvic pain in the community--symptoms, investigations, and diagnoses. |journal=Am. J. Obstet. Gynecol. |volume=184 |issue= |pages=1149-55 |year=2001 |url=|PMID=11349181}}</ref> <ref name="Stanford">{{cite journal |author=Stanford EJ, Koziol J, Feng A |title=The prevalence of interstitial cystitis, endometriosis, adhesions, and vulvar pain in women with chronic pelvic pain. |journal=J. Minim. Invasive. Gynecol.|volume=12 |issue=1 |pages=43-9 |year=2005 |url=|PMID=15904598}}</ref>
<ref name="Rodríguez">{{cite journal |author=Rodríguez MA, Afari N, Buchwald DS |title=Evidence for overlap between urological and nonurological unexplained clinical conditions |journal=J. Urol.|volume=182 |issue=5 |pages=2123-31 |year=2009 |url=|PMID=19758633}}</ref> <ref name="Wiseman"/>

There is a sound basis for explaining why a patient with only one organ affected initially, may develop a problem in another. Once pain persists for 3-6 months and becomes “chronic”, biochemical changes in the spinal chord and dorsal root ganglia <ref name="LaBerge">{{cite journal |author=LaBerge J, Malley SE, Zvarova K, Vizzard MA |title=Expression of corticotropin-releasing factor and CRF receptors in micturition pathways after cyclophosphamide-induced cystitis |journal=Am. J. Physiol. Regul. Integr. Comp. Physiol.|volume=291 |issue= |pages=R692-703|year=2006 |url=|PMID=16614059}}</ref> cause unsolicited and inappropriate activation of the brain’s pain centers. Pain itself becomes a disease in its own right rather than indicating a local problem. Removing the initiating triggers such as endometriosis or adhesions may arrest the pain temporarily, but the pain is likely to return because the neural changes themselves have not been addressed. The reason why patients develop multiple pelvic or abdominal symptoms may be rooted in the complex neuroanatomy of sacral, lumbar, hypogastric and pelvic plexi.<ref name="Wesselmann">{{cite journal |author=Wesselmann U, Burnett AL, Heinberg LJ |title=The urogenital and rectal pain syndromes |journal=Pain|volume=73|issue= |pages=269-94|year=1997|url=|PMID=9469518}}</ref> “Cross talk” is believed to occur between the nerves of abdominal and pelvic tissues.<ref name="Pezzone">{{cite journal |author=Pezzone MA, Liang R, Fraser MO |title=A model of neural cross-talk and irritation in the pelvis: implications for the overlap of chronic pelvic pain disorders. |journal=Gastroenterology.|volume=128|issue= |pages=1953-64|year=2005|url=|PMID=15940629}}</ref> Impulses from one organ (e.g. bladder) may set off impulses in a nearby pathway, deceiving the brain into believing that they have also originated elsewhere (e.g. bowel). Even inflammation in one organ (e.g. uterus, bladder, bowel) may induce actual pathological changes or hypersensitivity in another.<ref name="Giamberardino">{{cite journal |author=Giamberardino MA, Berkley KJ, Affaitati G, et al. |title=Influence of endometriosis on pain behaviors and muscle hyperalgesia induced by a ureteral calculosis in female rats |journal=Pain|volume=95|issue= |pages=247-57|year=2002|url=|PMID=11839424}}</ref> <ref name="Bielefeldt">{{cite journal |author=Bielefeldt K , Lamb K, Gebhart GF |title=Convergence of sensory pathways in the development of somatic and visceral hypersensitivity |journal=Am J Physiol Gastrointest Liver Physiol.|volume=291|issue= |pages=G658-65|year=2006|url=|PMID=16500917}}</ref> <ref name="Ustinova">{{cite journal |author=Ustinova EE, Fraser MO, Pezzone MA |title=Colonic Irritation in the Rat Sensitizes Urinary Bladder Afferents to Mechanical and Chemical Stimuli: An Afferent Origin of Pelvic Organ Cross-Sensitization |journal=Am. J. Physiol. Renal Physiol.|volume=290|issue=6 |pages=F1478-87|year=2006|url=|PMID=16403832}}</ref> <ref name="Winnard">{{cite journal |author=Winnard KP, Dmitrieva N, Berkley KJ |title=Cross-organ interactions between reproductive, gastrointestinal, and urinary tracts: modulation by estrous stage and involvement of the hypogastric nerve |journal=Am. J. Physiol. Regul. Integr. Comp. Physiol.|volume=291|issue=6 |pages=R1592-601|year=2006|url=|PMID=16946082}}</ref>

==Treatment of Patients with Overlapping Conditions==
Without an understanding of the relationship between these various conditions, a patient is subject to the peculiarities of compartmentalized medical practice. The most dominant of the seemingly unrelated symptoms will determine the specialty to which the patient is initially referred where they will be given the default diagnosis for that specialty's unexplained condition. Unexplained pelvic pain will no doubt receive a gynecological diagnosis of adhesions, PID or endometriosis. Unexplained bowel disturbances will be assigned a diagnosis of IBS by a gastroenterologist, mysterious bladder voiding issues will be labeled by the urologist as IC and a neurologist may well view the problem as one of pudendal neuralgia. The patient will locked into a treatment determined by that specialty's diagnostic paradigm and usually only in terms of end-organ rather than systematic pathology. To free the patients from the constraints imposed by this specialty-specific terminology, a term is proposed<ref name="Wiseman"/> to describe these overlapping and coalescing conditions and to allow for their integrated and multidisciplinary treatment:

'''[http://www.iscapps.org CAPPS]: Complex Abdomino-Pelvic and Pain Syndrome:''' ''a syndrome of nonmalignant origin consisting of a complex of symptoms of the abdomen or pelvis that includes pain, bowel, or bladder dysfunction of at least 6 months duration.''

In addition to being able to address condition-specific issues, multidisciplinary teams should include surgeons, nurses, pharmacists, nutritionists, pain medicine specialists, psychologists, physical therapists, neurologists, gastroenterologists, gynecologists, urogynecologists, urologists, psychiatrists and social workers. Such a “biopsychosocial” approach has been introduced, advocated, and to some degree validated in a number areas of pain medicine, including pelvic pain. <ref name="Steege">{{cite journal |author=Steege JF, Stout AL, Somkuti SG |title=Chronic pelvic pain in women: toward an integrative model |journal=Obstet. Gynecol. Surv.|volume=48|issue= |pages=95-110|year=1997|url=|PMID=8437777}}</ref> <ref name="Pearce">{{cite journal |author=Pearce C, Curtis M |title=A multidisciplinary approach to self care in chronic pelvic pain |journal=Br. J. Nurs.|volume=16|issue=2 |pages=82-5|year=2007|url=|PMID=17353816}}</ref> <ref name="Jarrell">{{cite journal |author= Jarrell JF, Vilos GA, Allaire C, Burgess S, Fortin C, Gerwin R, Lapensee L, Lea RH, Leyland NA, Martyn P, Shenassa H, Taenzer P , Abu-Rafea B |title=Consensus guidelines for the management of chronic pelvic pain. |journal=J. Obstet. Gynaecol. Can.|volume=27|issue=9 |pages=869-910year=2005|url=|PMID=19830953}}</ref> <ref name="Daniels ">{{cite journal |author=Daniels JP, Khan KS |title=Chronic pelvic pain in women |journal=BMJ|volume=341|issue= |pages=772-775|year=2010|url=|PMID=20923840}}</ref><ref name="Messelink">{{cite journal |author=Messelink EJ |title=The pelvic pain centre |journal=World J. Urol.|volume=19|issue=3 |pages=208-12|year=2001|url=|PMID=11469609}}</ref>

The importance of further research and training regarding these interrelated conditions has been recognized by the establishment of the [http://www.iscapps.org International Society for Complex Abdomino-Pelvic & Pain Syndrome], [http://www.overlappingconditions.org/ Chronic Pain Research Alliance (CPRA)] and [http://www.mappnetwork.org/ Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP)].


==References==
==References==
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* [http://www.pelvicpain.org International Pelvic Pain Society]
* [http://www.pelvicpain.org International Pelvic Pain Society]
* [http://www.ampainsoc.org American Pain Society]
* [http://www.ampainsoc.org American Pain Society]
* [http://www.adhesions.org International Adhesions Society]
* [http://www.iscapps.org International Society for Complex Abdomino-Pelvic & Pain Syndrome]
* [http://www.overlappingconditions.org/ Chronic Pain Research Alliance (CPRA)]
* [http://www.mappnetwork.org/ Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP)]
* [http://www2.med.umich.edu/departments/obgyn/index.cfm?fuseaction=Obgyn.pelvicPainClinic University of Michigan Pelvic Pain Program]
* [http://www2.med.umich.edu/departments/obgyn/index.cfm?fuseaction=Obgyn.pelvicPainClinic University of Michigan Pelvic Pain Program]
* [http://www.med.unc.edu/obgyn/services_algs.html University of North Carolina Pelvic Pain Program]
* [http://www.med.unc.edu/obgyn/services_algs.html University of North Carolina Pelvic Pain Program]

Revision as of 15:22, 2 May 2012

Pelvic pain

Pelvic pain is a symptom that can affect both women and men. The pelvic pain that persists for a period of 3 months or more to be considered chronic while less than this duration is considered acute. The pain may indicate the existence of poorly-understood conditions that likely represent abnormal psychoneuromuscular function. Differentiating between acute and chronic pain is important in understanding chronic pelvic pain syndromes. Acute pain is most common, often experienced by patients after surgery or other soft tissue traumas. It tends to be immediate, severe and short lived however, pain that extends beyond a normal recovery period and lasts longer than 3–6 months constitutes chronic pain.[1]

Female

Most women, at some time in their lives, experience pelvic pain. As girls enter puberty, pelvic or abdominal pain becomes a frequent complaint.

Chronic pelvic pain (CPP) accounts for 10% of all visits to gynecologists. In addition, CPP is the reason for 20—30% of all laparoscopies in adults.[citation needed]

Cause

Many different conditions can cause pelvic pain including:

  • exaggerated bladder, bowel, or uterine pain sensitivity (also known as visceral pain)
  • pelvic girdle pain (SPD or DSP)
Gynecologic
Abdominal

Internal hernias are difficult to identify in women, and misdiagnosis with endometriosis or idiopathic chronic pelvic pain is very common. One cause of misdiagnosis that when the woman lies down flat on an examination table, all of the medical signs of the hernia disappear. The hernia can typically only be detected when symptoms are present, so diagnosis requires positioning the woman's body in a way that provokes symptoms.[2]

Workup

The diagnostic workup begins with a careful history and examination, followed by a pregnancy test. Some women may also need bloodwork or additional imaging studies, and a handful may also benefit from having surgical evaluation.

The absence of visible pathology in chronic pain syndromes should not form the basis for either seeking psychological explanations or questioning the reality of the patient’s pain. Instead it is essential to approach the complexity of chronic pain from a psychophysiological perspective which recognises the importance of the mind-body interaction. Some of the mechanisms by which the limbic system impacts on pain, and in particular myofascial pain, have been clarified by research findings in neurology and psychophysiology.[1]

Treatment

Many women will benefit from a consultation with a physical therapist, a trial of anti-inflammatory medications, hormonal therapy, or even neurological agents.

A hysterectomy is sometimes performed.[3]

Male

Main article: Chronic prostatitis/chronic pelvic pain syndrome

Chronic pelvic pain in men is referred to as Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) and is also known as chronic nonbacterial prostatitis. Men in this category have no known infection, but do have extensive pelvic pain lasting more than 3 months.[4] There are no standard diagnostic tests; diagnosis is by exclusion of other disease entities. Multimodal therapy is the most successful treatment option,[5] and includes α-blockers,[6] phytotherapy,[7][8] and protocols aimed at quieting the pelvic nerves through myofascial trigger point release with psychological re-training for anxiety control.[9][10] Antibiotics are not recommended.[11][12]

Differential diagnosis

In men, chronic pelvic pain (category IIIB) is often misdiagnosed as chronic bacterial prostatitis and needlessly treated with antibiotics exposing the patient to inappropriate antibiotic use and unnecessarily to adverse effects with little if any benefit in most cases. Within a Bulgarian study, where by definition all patients had negative microbiological results, a 65% adverse drug reaction rate was found for patients treated with ciprofloxacin in comparison to a 9% rate for the placebo patients. This was combined with a higher cure rate (69% v 53%) found within the placebo group.[13]

Epidemiology

Chronic pelvic pain is a common condition with rate of dysmenorrhoea between 16.8—81%, dyspareunia between 8—21.8%, and noncyclical pain between 2.1—24%.[14]

References

  1. ^ a b Marek Jantos (2007). "Understanding Chronic Pelvic Pain". Pelviperineology. 26 (2): 66–69.
  2. ^ Brody, Jane E. "In women, hernias may be hidden agony" The St. Louis Post-Dispatch. 18 May 2011.
  3. ^ Kuppermann M, Learman LA, Schembri M; et al. (2010). "Predictors of hysterectomy use and satisfaction". Obstet Gynecol. 115 (3): 543–51. doi:10.1097/AOG.0b013e3181cf46a0. PMID 20177285. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  4. ^ Luzzi GA (2002). "Chronic prostatitis and chronic pelvic pain in men: aetiology, diagnosis and management". Journal of the European Academy of Dermatology and Venereology : JEADV. 16 (3): 253–6. doi:10.1046/j.1468-3083.2002.00481.x. PMID 12195565.
  5. ^ Potts JM (2005). "Therapeutic options for chronic prostatitis/chronic pelvic pain syndrome". Current urology reports. 6 (4): 313–7. doi:10.1007/s11934-005-0030-5. PMID 15978236.
  6. ^ Yang G, Wei Q, Li H, Yang Y, Zhang S, Dong Q (2006). "The effect of alpha-adrenergic antagonists in chronic prostatitis/chronic pelvic pain syndrome: a meta-analysis of randomized controlled trials". J. Androl. 27 (6): 847–52. doi:10.2164/jandrol.106.000661. PMID 16870951. ...treatment duration should be long enough (more than 3 months){{cite journal}}: CS1 maint: multiple names: authors list (link)
  7. ^ Shoskes DA, Zeitlin SI, Shahed A, Rajfer J (1999). "Quercetin in men with category III chronic prostatitis: a preliminary prospective, double-blind, placebo-controlled trial". Urology. 54 (6): 960–3. doi:10.1016/S0090-4295(99)00358-1. PMID 10604689.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  8. ^ Elist J (2006). "Effects of pollen extract preparation Prostat/Poltit on lower urinary tract symptoms in patients with chronic nonbacterial prostatitis/chronic pelvic pain syndrome: a randomized, double-blind, placebo-controlled study". Urology. 67 (1): 60–3. doi:10.1016/j.urology.2005.07.035. PMID 16413333.
  9. ^ Anderson RU, Wise D, Sawyer T, Chan C (2005). "Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men". J. Urol. 174 (1): 155–60. doi:10.1097/01.ju.0000161609.31185.d5. PMID 15947608.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  10. ^ Anderson RU, Wise D, Sawyer T, Chan CA (2006). "Sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome: improvement after trigger point release and paradoxical relaxation training". J. Urol. 176 (4 Pt 1): 1534–8, discussion 1538–9. doi:10.1016/j.juro.2006.06.010. PMID 16952676.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  11. ^ Alexander RB, Propert KJ, Schaeffer AJ; et al. (2004). "Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic pain syndrome: a randomized, double-blind trial". Ann. Intern. Med. 141 (8): 581–9. PMID 15492337. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  12. ^ Nickel JC, Downey J, Clark J; et al. (2003). "Levofloxacin for chronic prostatitis/chronic pelvic pain syndrome in men: a randomized placebo-controlled multicenter trial". Urology. 62 (4): 614–7. doi:10.1016/S0090-4295(03)00583-1. PMID 14550427. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  13. ^ J. Dimitrakov. "A Prospective, Randomized, Double-Blind, Placebo-Controlled Study Of Antibiotics For The Treatment Of Category Iiib Chronic Pelvic Pain Syndrome In Men". Third International Chronic Prostatitis Network. Retrieved 4 September 2009. The results of our study show that antibiotics have an unacceptably high rate of adverse side effects as well as a statistically insignificant improvement over placebo... {{cite web}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  14. ^ Latthe P, Latthe M, Say L, Gülmezoglu M, Khan KS (2006). "WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity". BMC Public Health. 6: 177. doi:10.1186/1471-2458-6-177. PMC 1550236. PMID 16824213.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)
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