BC Women’s Centre for Pelvic Pain & Endometriosis
www.womenspelvicpainendo.com
Chronic Pelvic Pain
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CPP: Objectives
At the end of today, you will be able to:
1. List 3 tools that may be useful in assessing
CPP
2. Understand nociceptive triggers to CPP and
how to decrease them
3. Describe the possible contributors to CPP
4. Know why and how to calm the central NS
5. Understand the effect of narcotic usage on CPP
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Chronic Pelvic Pain

CPP is “one of the most common
medical problems affecting women
today” (IPPS, 2012)

Affects 17%-24% of women aged
18-50 (IPPS, 2012; Zondervan, 1999)
 50% of women with CPP also have
endometriosis (10% of women
overall) … but 50% do not (Leyland et
al., 2010)
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A Case of Chronic Pelvic Pain
 27 year old G1P1 woman with a 3 year history
of CPP
 Dysmenorrhea since age 15
 Became daily CPP soon after SVD of her son
 Bilateral adnexal pain radiating to inguinal area
 Constant, with some exacerbation at menses
 Aggravated by physical activity
 Patient requesting hysterectomy because of
impact of pain on her life
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CPP: Medical History
 Bowel: Alternating constipation & diarrhea
 Bladder: No symptoms
 Vaginal: No dyspareunia
 Surgeries:
 Laparoscopy x4 (Jan/10, Aug/10, Feb/11, Sep/11); mild
endometriosis cauterized; some improvement for ~3
months
 Medications:
 Past: Trial of Depot-Lupron = intolerable side-effects and
no change in Sx
 Current: 16mg/d hydromorphone, medical marijuana,
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continuous OCPs…. Still has daily (7/10) pain and
CPP: Psychosocial History
 Self-report:
 Lives with long-term partner and their 3 year old son
 Denies alcohol or recreational drug use
 Unable to work; difficulty caring for child
 Mood is frustrated, stressed, not depressed
 Pain worse when under a lot of stress
 Childhood sexual abuse (age 6-12) by family member
 Clinical assessment:
 Sx of trauma/PTSD, anxiety, depression
 Multiple life stressors, few social supports, recent losses
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CPP: Exam
 Bilateral lower quadrant
tenderness with abdominal wall
trigger points
 No uterine or adnexal
tenderness
 No cul-de-sac tenderness or
nodularity
 Pelvic floor is tender and has
increased tone
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Assessment Tools
 High scores on pain
catastrophizing scale (PCS)
 PHQ9 – 3
 GAD7 - 10
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CPP:
Clinical Impression
 Dysmenorrhea/endometriosis
 Pelvic floor tension
 Bowel irritability; likely narcotic
side-effects
 Central sensitization of NS
 Aggravated by trauma, anxiety,
depression, many life stressors,
recent losses, few social supports
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Discussion Questions
 List 3 tools that may be useful in further
assessing this patient?
 Describe the possible contributors to her pain.
 Are there any nociceptive triggers that could be
decreased?
 How can she calm her central nervous system?
 What about her narcotic usage?
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Action Plan
• Discourage hysterectomy, as non-tender uterus
and primarily myofascial pain on exam
 Trial of progestin for suppression
of menses
 Taper off narcotics by 10% q 2
weeks
Bowel regimen;
diet modifications
• Education
on chronic
pain
– NS sensitization, calming the NS, MBSR, pacing activity
• Community pelvic floor physiotherapy
• Community psychotherapy (MBCT/CBT, grief ,
trauma)
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CPP: Summary
When working with CPP, it is important to know
that:
1. Assessment tools can be very helpful
2. There are many contributors to CPP
3. Nociceptive triggers need to be decreased
4. Calming the central nervous system is crucial
5. Narcotics usage is not always the best option
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Centre for Pelvic Pain & Endometriosis
•
Interdisciplinary
approach
•
The team:
Gynecologists
– Gynecology fellow
– Registered nurse
– Registered pelvic floor
physiotherapist
– Registered clinical
counsellor
– Clerks
–
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Questions
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