Chronic Pelvic Pain

What is the standard treatment length for PID and classic patient response to therapy Should respond in 72 hours, if not come back

14 days is standard regimen of treatment. Due to a growing resistance to fluoroquinolones, this class of antibiotics is no longer routinely recommended for treatment of gonorrhea and therefore cannot be a primary option for treatment of PID. Patient should respond to treatment within 72 hours. If the patient is not responding to treatment, you must reevaluate the patient.

History for Endometriosis Pain Infertility dysmenorrhea Low back and or bladder pain irregular bleeding

A complete medical, surgical, social, and family history should be collected from the patient. Symptoms may include: pain, infertility, dysmenorrhea, non-menstrual pelvic pain, dyspareunia, low back pain, bladder pain, frequency and dysuria, irregular vaginal bleeding, partial bowel obstruction, irritable bowel syndrome, perimenstrual chest and shoulder pain, abdominal wall pain, and non-pelvic pain.

S/S of PID Abdominal pain abnormal discharge intermenstraul bleeding or postcoital bleed

A patient may present with complaints of one or more of the following symptoms: abdominal pain, abnormal vaginal discharge, postcoital bleeding, intermenstrual bleeding, fever, nausea, vomiting, symptoms of a UTI, or low back pain.

Rectal Exam

A rectal exam should always be included in the pelvic examination of a woman with pelvic pain.

Diagnostics for Chronic Pelvic pain

CBC, serum chemistry, sed rate, urinalysis with microscopy culture, vaginal and endocervical swabs for microscopy, gonorrhea and chlamydia testing, stool for occult blood, RPR, pregnancy test, TSH. The TSH is important because thyroid disease affects body functions and may be found in women with bowel or bladder problems. Other diagnostics include ultrasound of the abdomen and the pelvis. An abdominal ultrasound can reveal ovarian masses, tubal dilatation, adenomyosis or endometriosis. In certain instances sigmoidoscopy and or colonoscopy, abdominal CT, small bowel radiographic series, MRI, or cystoscopy are indicated.

Chronic Pelvic Pain Most common problem in women Cyclic or non cyclic

Chronic pelvic pain is one of the most common medical problems affecting women today. It is defined as cyclic or non-cyclic pain in the lower abdomen or pelvic, lasting for six months, arising continuously or intermittently, and impacting activities of daily living.

Dyspareunia pain Pelvic Congestion Syndrome

Dyspareunia may be due to endometriosis, pelvic floor dysfunction, interstitial cystitis, and vulvodynia. Symptoms of pelvic congestion syndrome include changing location of pain, dysmenorrhea, deep dyspareunia, pain after intercourse, and dull pain worsened by standing for long periods. This pain is improved by lying down.

Risk Factors for Early recognition saves fertility

Early recognition of endometriosis is essential to preserve fertility. Risk factors for endometriosis include: increased risk with affected first-degree female relatives, history of uninterrupted prolonged menstrual cycles, increased incidence in women with uterine anomalies leading to outflow obstruction, such as transverse vaginal septum.

Endometriosis Endometrial glands and stroma outside endometrial cavity Tissue responds to estrogen by swelling Common cause of secondary: dysmenorrhea abnormal bleeding patterns fertility issue

Endometriosis is the third leading cause of gynecologic hospitalization in the United States. More likely to occur in women with menarche before age 11, cycle length less than 27 days, and heavy, prolonged cycles. Higher parity and increased length of lactation are related to decrease risk of endometriosis. Women who exercise more than four hours per week regularly are also less likely to develop endometriosis. Endometrial tissue responds cyclically to estrogen by swelling and producing local inflammation. Endometriosis is characterized by endometrial glands and stroma outside of the endometrial cavity sometimes outside of the pelvic cavity. It is the common cause of secondary dysmenorrhea, abnormal bleeding patterns, alter fertility, and dyspareunia.

Findings of lymphnodes, and systemic adenopathy with flulike symptoms

Enlarged tender lymph nodes are often a sign of the sexually-transmitted infection or a pelvic infection. Diffuse systemic adenopathy with flulike symptoms, consider possibility of primary HIV infection.

OLD CARTS continued

Gastrointestinal includes constipation, diarrhea. Genitourinary includes: dysuria, urgency, incontinency, and neurologic. R equals radiation. Does the pain moved to other areas on your body? T equals temporal. What time of day is it worse or better? S equal severity. On a scale of 1 to 10.

Pelvic Exam

Inspect the external genitalia. Look for lesions, vulvar, vestibular, and urethral point tenderness. Inspect the pelvic floor muscles for painful spasm and trigger points. Pelvic floor pain may be a primary problem or the result of other pathologies such as interstitial cystitis or endometriosis. Pain elicited with deep palpation of the cervix and vaginal fornices are suggestive of endometriosis or chronic pelvic infections. A fixed retroverted uterus points to endometriosis or adhesions. Cervical motion tenderness has been associated with endometriosis, pelvic adhesions, or inflammatory bowel disease.

Diagnosis of Endometriosis Laparoscopy is diagnostic gold standard

Laparoscopy is the gold standard for diagnosing endometriosis. Ultrasound, MRI, and CT scans are useful in the presence of pelvic or adnexal mass. CA-125 is limited for the diagnosis of endometriosis. There may be elevated levels of CA-125 in patients with endometriosis. Lab tests to rule out other causes of pain include sexually-transmitted infection screen, urinalysis, hemoccult testing, and pap testing.

Laparoscopy for Chronic Pelvic pain Gold Standard for diagnosis

Laparoscopy is the gold standard in the diagnosis of chronic pelvic pain. It is the only diagnostic tool available to diagnose peritoneal endometriosis and adhesions.

Referral for Chronic Pelvic Pain

Management may include a referral to a gynecological pain specialist or gynecologist with access to a multidisciplinary pain team.

Management for PID outpatient and prompt

Most patients can be managed on an outpatient basis. 2010 CDC criteria for empiric treatment can be based on finding classic triad; urgent treatment is preferred even without specific lab results rather than risk a lifetime of chronic pelvic pain scarring and infertility.

Physical exam General

Observe the patient during the interview. Are they displaying pain? Are they sitting comfortably or moving around because of the pain? Are they sitting up straight? Leaning forward? Examine head, neck, cardiac and respiratory systems to rule out abnormalities

Physical exam of Uterus and cervix findings Fixed uterus Adnexal enlargement

On physical exam there may be fixed uterine position, adnexal enlargement, cervical motion tenderness, or tenderness in vaginal cul-de-sac.

Other Medications for Endometriosis

Other medications include: Provera tablets, danazol, GnRH agonists. However the GnRH agonists are not recommended as a primary treatment approach.

Patient education and follow up for PID Avoid intercourse until done with medications Follow up if not improving or no resolution

Patient education is very important in the treatment of PID. The patient will need to adhere to their medication. You will need to review the side effects of the medications. They will need to avoid intercourse until all antibiotics are finished and they will need to understand the risk for long-term health. The patient should avoid alcohol during treatment. Their sexual partners will need to be treated. One of the most important instructions is that the patient should be instructed on the importance of follow-up in the clinic 48 to 72 hours and then again in 10 to 14 days to monitor resolution of symptoms.

Physical exam Abdomen

Perform an abdominal exam. Inspect for scar. Palpate for masses. Determine the location of pain. Pain suggestive of organic cause will usually be localized. Watch for guarding. Assess for hernia. Assess for lymph nodes.

Referring after poor response to therapy

Refer to a gynecologist if there is a poor response to medical therapy or if fertility assistance is desired. Refer for other hormonal suppression with gonadotropin releasing hormone analogs such as Lupron or androgens as danazol. Gynecologist should be managing any follow-up required if receiving GnRH agonists or danazol to assess side effects and evaluate efficacy. After surgery or suppressive drug therapies, women may have 18 to 24 months of pain relief.

Medical Treatment for PID Ceftriaxone 250mg IM single dose Doxycycline 100 mg PO BID 14 days

Regimen A includes ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg PO b.i.d. times 14 days with or without metronidazole 500 mg PO b.i.d. times 14 days. This will give treatment for bacterial vaginosis and trichomoniasis as well as anaerobic organism coverage. Regimen B Cefoxitin 2 g IM in a single dose and probenecid 1 g orally in a single dose administered together plus doxycycline 100 mg PO b.i.d. times 14 days with or without metronidazole 500 mg PO b.i.d. times 14 days.

Interstitial Cystitis Symptoms Irritable Bowel syndrome

Subjective symptoms suggestive of interstitial cystitis are dysuria, urgency, frequency, and laboratory confirmation with many negative urine cultures. Irritable bowel syndrome consists of alternating constipation and diarrhea, abdominal bloating, mucus per rectum, relief of pain after bowel movement, and sensation of incomplete evacuation after a bowel movement. Irritable bowel syndrome is frequent in women with chronic pelvic pain with the incidence of 65 to 79%. Irritable bowel syndrome is associated with endometriosis, dyspareunia, and dysmenorrhea.

Cause of endometriosis

The pathogenesis of endometriosis is poorly understood. Theories include retrograde menstruation, abnormal cellular process from embryogenesis, lymphatic or vascular transplantation, or autoimmune

Patients description of pain and degree of disease Predictable of severe: Painful defecation during menses and severe dyspareunia

The patient may describe gradual onset of constant, aching pain starting at or near menses, with increasing severity for a few days and relenting only when menses starts to abate. The most predictable symptoms of deeply infiltrating endometriosis are painful defecation during menses and severe dyspareunia. History of large doses of NSAID analgesics with our without narcotics can be a tip toward assessing pain severity.

IUD and PID Most will occur within 3 weeks of insertion

The risk of PID associated with IUD use is primarily confined to the first three weeks after insertion and is uncommon thereafter. No evidence suggests that IUDs should be removed in women diagnosed with acute PID. However, caution should be exercised if the IUD remains in place, and close clinical follow-up is mandatory.

Symptoms and Severity of Endometriosis Extent of pain is generally influenced by location and depth of implant. The deeper the worse 4 stages 1: no adhesions 3: Moderate and multiple 4: deep and large adhesions

The symptom severity of endometriosis varies widely. Some women with minimal disease have debilitating pain and other women with severe disease are asymptomatic. generally thought that the extent of the pain is influenced primarily by the location and depth of the endometriotic implant. Deep implants and highly innervated areas most consistently associated with pain. There are four stages of endometriosis. Stage one is considered to be minimal to have isolated implants and no significant adhesions. Stage II is mild endometriosis. There are superficial implants with less than 5 cm of total disease, no significant adhesions. Stage III is considered to be moderate there are multiple superficial and deep implants with or without peritubal and periovarian adhesions. Stage IV is severe and this includes multiple superficial and deep implants, large ovarian endometrioma with presence of adhesions.

Causes of Chronic GYN pelvic pain

These include endometriosis, adenomyosis, uterine fibroids, chronic salpingitis, adhesions, dysmenorrhea, and dyspareunia.

Causes of Non GYN pelvic Pain: Chronic

These include irritable bowel syndrome, ulcerated colitis, diverticulosis, urinary tract disease, and neuromuscular disorder.

Inpatient treatment requirements and options

When do you refer the patient that your treating for PID? Inpatient treatment is best for a very young or unreliable patient, pregnant patient, fever greater than 101, or WBCs greater than 11,000, evidence of peritonitis, suspected pelvic access, decreased bowel sounds, anorexia; for patients with escalating symptoms despite treatment; for non-resolving symptoms after 72 hours of treatment; or for severely immunocompromised patients.

If positive for G&C

Women diagnosed with gonorrhea or chlamydia should have repeat testing done at 3 to 6 months regardless of whether their sex partner has been treated. All women diagnosed with acute PID should be offered HIV testing.

Sexually transmitted infections are the cause of most PID

Women under the age of 25 are at the highest risk of developing PID, with a higher incidence in African-American women. It is most prevalent between the ages of 16 and 25. More than 100,000 women become infertile each year due to PID.

Causes of non GYN pelvic Pain: Acute

appendicitis, cystitis, diverticulitis, ureteral calculus, gastroenteritis and spastic colon, or trauma.

Risk Factors for Chronic Pelvic Pain

drug or alcohol misuse, miscarriage, menorrhagia, previous cesarean surgery, pelvic pathology, experience of sexual abuse at any age, psychological comorbidities.

Causes of Chronic Pelvic Pain Endometriosis is most common cause of CPP

endometriosis the most common causes of chronic pelvic pain postoperative adhesions, pelvic varicies, interstitial cystitis, and irritable bowel syndrome. Other causes of chronic pelvic pain include chronic pelvic inflammatory infection, pelvic congestion syndrome, musculoskeletal disorders such as lumbar lordosis, kyphosis and postsurgical pain.

History OLDCARTS

essential and generally considered central to correct diagnosis and may be more valuable than several diagnostic investigations. Subjective data, old carts. O equals onset. When and how did the pain start? L equals location specific location of the pain. D equals duration. How long does it last? C equals characteristics. What is the pain like? A equals associated symptoms. Gynecologic includes: dyspareunia, dysmenorrhea, abnormal bleeding, discharge, and fertility.

Surgical Treatment for Endometriosis

excision of implants, lysis of adhesions, Reduction of ovarian tissue or hysterectomy. Uterosacral nerve ablation as an adjunct to surgical management has been found to be ineffective in treating pain associated with endometriosis. Women with total hysterectomy and bilateral salpingo-oophorectomy may need HRT. They will need both estrogen and progesterone to reduce endometrial cancer risk from residual implants.

General Treatment Guidelines for Endometriosis NSAIDS Combined oral contraceptives (To suppress bleeding)

goal of endometriosis is to reduce pain through a variety of mechanisms, including reducing inflammation, suppress the ovarian hormone production, blocking the action and production of estradiol, decreasing or completely suppressing menstrual bleeding. The treatment should be determined by the severity of symptoms, desire for fertility, degree of disease, and client's therapeutic goals. Medications used in the treatment of endometriosis include NSAIDs and combine oral contraceptives. Continuous oral contraceptives may be associated with breakthrough bleeding if taken for more than three months continuously. Patient must be informed about this possibility.

Risk factors for PID

multiple sex partners, inconsistent condom use, an infected partner, history of or concurrent STI, prior history of PID, or an IUD.

Diagnostics for PID Rule out other causes like STI, herpes syphillis

pregnancy test. If the pregnancy test is positive, an ultrasound should be considered to evaluate for ectopic pregnancy. vaginal smears and cervical cultures. Evaluate for trichomoniasis and bacterial vaginosis, gonorrhea and chlamydia. If lesions are noted, assess for herpes and syphilis. You may wish to draw CBC, ESR and CRP. Many women will have a normal CBC. CRP can help detect inflammation and the ESR are typically elevated, but are not always performed as a part of the routine workup.

Treatment options for Chronic Pelvic Pain NSAIDs are first line management SSRI and Venlafaxine: chronic with neuropathy

psychotherapy, progestogen therapy such as depo, surgery including laparoscopy, hysterectomy. Laparoscopy indications are for therapeutic as well as diagnostic purposes. The goal of treatment is to restore normal anatomy and prevent or delay recurrence of disease. Endometriotic lesions can be removed during laparoscopy. NSAIDs are usually the first line management. Antidepressants have been used in management. TCAs and venlafaxine provide pain relief for chronic pelvic pain with a neuropathic etiology. Oral contraceptives have also been used in management. Alternative treatments such as tens and acupuncture, diet, as well as treatment for any sleep disorder.

Relationship of the pain to Cyclic pain

relationship of the pain to posture meals bowel movements, voiding, menstruation, intercourse, medications. Cyclic pain suggests gynecological origin, although non-gynecological condition such as interstitial cystitis and irritable bowel syndrome may worsen premenstrually.

Subjective Data Partners relation to cycle Surgical History : adhesions Specific location: psychogenic vs organic cause

sexual history. number of partners. monogamous relationship. Relationship with the menstrual cycle. Is she having pain during her menstrual cycle? Before her menstrual cycle? After her menstrual cycle? Does the pain increase during the menstrual cycle or decrease during the menstrual cycle? Medical and surgical therapies. The surgical history is important because it provides information about the patient's risk for adhesions, peritoneal injuries, and infections. Reproductive history is important because pregnancy and childbirth can be traumatic events to the musculoskeletal system and can cause chronic pelvic pain. Women should be questioned about where the pain occurs. Women who identify specific location of pain typically have an organic cause, whereas women with psychogenic chronic pelvic pain typically move their hand around all the lower abdominal quadrants.

Pelvic Inflammatory Disease Disorder of the upper genital tract Most common cause C&G

spectrum of inflammatory disorders of the upper female genital tract including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. most common pathogens are Neisseria gonorrhea and chlamydia trachomatis. However multiple pathogens can cause pelvic inflammatory disease including: anaerobes, Gardnerella vaginalis, Haemophilus influenza, enteric gram-negative rods, staphylococci, streptococci. The presence of organisms associated with bacterial vaginosis has been seen in many cases of proven pelvic inflammatory disease.

Objective findings for PID Temp above 101 Pain with palpation over lower quadrants Cervical motion tenderness adnexal tenderness

temperature greater than 101°F. The abdominal exam may reveal guarding, rebound tenderness, pain with palpation over the lower quadrants. The speculum exam may reveal purulent cervical or vaginal discharge; and the bimanual exam may reveal cervical motion tenderness, uterine tenderness, adnexal tenderness, or fullness; adnexal masses may or may not be palpable.