Case Study in Chronic Pelvic Pain
Jennifer McDonald DO F.A.C.O.G
61% of CPP will have no definitive
diagnosis !!
Definition of Chronic Pelvic Pain (CPP)
Non-cyclic
 6 months or more in duration
 Localized to pelvis, anterior abdominal wall
below the umbilicus, lumbosacral area, or
buttocks
 Causes significant enough impairment to
cause them to seek treatment

Case
C.A. is a 26 year old white female who has been
treated 12 times in the last two years for recurrent
urinary tract infections.
She presents with
symptoms of urinary frequency, urgency, pelvic pain,
and dyspaurenia. She also describes alternating
diarrhea and constipation especially around the time
of her menstrual cycle. She reports she is in a long
term, monogamous relationship but is afraid to
commit to marriage as her problem with painful
intercourse is worsening. She admits that she voids
18-20 times per day and awakens 3-5 times each
night. She is a non-smoker and her menstrual cycles
are painful but regular.
Important Questions for CPP patients
Where is your pain?
 When did it start?
 What makes it better?
 What makes it worse?
 Are your cycles
painful?
 Pain with urination?
Frequency?
 Is intercourse painful?
 Do you have pain in
other parts of your
body?

What diagnostic studies
have been done?
 What were the results?
 What treatments have
been tried? How
successfully?
 How do you sleep?
 How is your family life?
Job?
 Any bowel symptoms?
 Have you seen other
doctors?

Physical Exam



C.A. is a healthy appearing female who is
height/weight appropriate
Supra-pubic and perineal tenderness as
well as tenderness across the bladder base
No evidence of vaginitis or a sexually
transmitted disease
Where do we look?
Gynecologic - extra-uterine
Gynecologic - uterine
Urologic
Musculoskeletal
Gastrointestinal
Neurologic
Pelvic Pain Assessment
www.reliefinsite.com
www.pelvicpain.org
Lab Evaluation
Urinalysis
• Nitrite negative
• Leukocyte esterase
negative
• Trace blood
• Bilirubin negative
Urine Culture
• No organisms
Cystoscopy/
Hydro-distension
(Not always necessary)
C.A. has Interstitial Cystitis





CPP syndrome of bladder origin estimated to
affect as many as 1 in 4.5 women
Often misdiagnosed as endometriosis, recurrent
UTI’s, or overactive bladder
Typically white women of reproductive age (90%)
Symptoms first noticed in their 30s but usually a
delay of 5-8 years before accurate diagnosis
making average age 42-46
Women have consulted 5-8 healthcare
professionals before receiving a correct diagnosis
Pathogenesis of IC
K+ and Urea
GAG
Layer
Irritated
Nerves
Identifying Patients Is Important
A New Screening Questionnaire for
Pelvic Pain and Urgency/Frequency (PUF)
PUF
Screening
Circle the answer that best describes how you feel for each question.
0
1
2
3
4
1 How many times do you void during waking hours?
3-6
7-10
11-14
15-19
20+
2 a. How many times do you void at night?
0
1
2
3
4+
None
Mild
Moderate
Severe
Never Occasionally
Usually
Always
Never Occasionally
Usually
Always
5 Do you have pain associated with your bladder or in
your pelvis, vagina, lower abdomen, urethra, perineum,
testes, or scrotum?
Never Occasionally
Usually
Always
6 Do you still have urgency shortly after urinating?
Never Occasionally
Usually
Always
Moderate
Severe
Usually
Always
Moderate
Severe
Usually
Always
b. If you get up at night to void, to what extent does
it usually bother you?
3
Symptom Bother
Score
Score
> 10 points
74% likelihood
of IC
Are you currently sexually active?
YES _____ NO_____
4 a. If you are sexually active, do you now have or have you
ever had pain or urgency to urinate during or after
sexual intercourse?
b. Has pain or urgency ever made you avoid sexual intercourse?
7 a. When you have pain, is it usually—?
b. How often does your pain bother you?
8 a. When you have urgency, is it usually—?
b. How often does your urgency bother you?
Mild
Never Occasionally
Mild
Never Occasionally
5-10 points
55% likelihood
of IC
Healthy women
< 2 points
SYMPTOM SCORE (1, 2a, 4a, 5, 6, 7a, 8a)
BOTHER SCORE (2b, 4b, 7b, 8b)
TOTAL SCORE (Symptom Score + Bother Score) =
PUF
PUF isisaa constellation
constellationofof symptoms
symptoms identified
identified by
by ICIC experts
experts as
as characteristic
characteristic ofof interstitial
interstitial cystitis.
cystitis.
The
The more
more symptoms
symptoms aapatient
patient experiences,
experiences, the
the more
more likely
likely itit isis that
that they’re
they’re caused
caused by
by interstitial
interstitial cystitis.
cystitis.
Parsons 2000
1
C.A.’s PUF
= 18
Potassium Sensitivity Test (PST)
80% patients with IC have a +PST
 Instillation of 40mL of room temperature sterile
water. Pain rated 0-5
 Water removed after 5 minutes and replaced with
40 mL of KCl. Pain re-evaluated
 Any increase of 2 or more points is a + result

• 91% patients with PUF > 20 will have + PST
• 76% patients with PUF 15-19
• 55% of patients with PUF 5-9
• Allows us to reserve PST for women with suggestive
symptoms but lower PUF scores
Obstacles to Diagnosis
IC relatively “new” or at least newly
understood
 Definition of IC not uniformly agreed upon
 Lack of education in medical profession
 No definitive test
 Often misdiagnosed for long periods
because of overlapping symptom complex
 Variation in severity of symptoms

Treatments
• Elmiron  only drug FDA
approved for treatment
• Resembles naturally
occurring GAGs
• Reduces painful symptoms
• 2 to 4 months women with
mild disease and 6-12
months in women with
severe disease
Non-Pharmacologic Treatment
Dietary manipulation is mandatory
Alcohol
Apples
Bananas
Citrus fruits
Coffee
Carbonated beverages
Chocolate
Mayonnaise
Most nuts
Pineapple
Onions
Soy sauce
Yogurt
Sour cream
Beans
• Chiropractic care
• Biofeedback/Bladder training
• Pelvic floor relaxation exercises
Keys to Treatment
Pain and its perception are located in the nervous
system so its treatment must encompass a Mind
and Body approach
 Multiple interactive problems are most likely with
CPP so it isn’t which treatment is best but which
treatments
 It usually took time for things to get to where
they are so it will be take time to get them back
to normal as well
 Chronic pain affects a family not just an individual
patient

The patient with CPP needs a multidisciplinary
approach … are you ready?