Chronic Pelvic Pain
Pelvic Congestion Syndrome
부산백병원 산부인과
이경복
CPP Is a Significant and Common
Disorder in Women
• Magnitude of CPP
- >9 million women in the United States
- 20% of women had pelvic pain >1 year in duration
• CPP accounts for
- 10% of referrals for OB/Gyn visits
- over 40% of laparoscopies
- 18% of hysterectomies
• Patients with CPP have significantly lower general health scores
compared with patients without CPP
• CPP is associated with painful intercourse (dyspareunia)
Definition of Chronic Pelvic Pain
• Duration
- six or more months
• Location
- anatomic pelvis
- abdominal wall below the umbilicus
- lower back
• Non-cyclic
- ± Dysmenorrhea
-± Dyspareunia
• Severity
- Medical or surgical therapy required
- Functional impairment
Causes of Chronic Pelvic Pain
Neuropathology of Chronic Pelvic Pain
Visceral Silent Afferent
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Thinly or unmyelinated – easily
damaged locally
All can transmit pain - yet most are
silent
: 10% afferent are silent in skin
: 30-80% visceral afferents are
silent
Silent afferent become active with
prolonged stimulation
Many more interneunical synapses
Silent afferents play major role in
tissue sensitization
Centralization
•Despite removal of original “insult” pain
persists. The dorsal horn is still
hyperexcitable with spontaneous activity.
• Example: Phantom limb
• Spinal memory
• Barrage of nociceptive/painful stimuli to dorsal horn
; metabolic, biochemical, & electrophysiological
change
• Prolonged release of glutamate and substance P in
DH
• Decrease threshold or loss of inhibition = Allodynia
• NMDA receptor activation & increased excitability of
large pool of internuncial neurons = Expansion of
receptive fields
• Based on duration and severity, these biochemical
changes can become permanent = Centralization
; exaggerated reflex output with end organ
dysfunction and spontaneous firing of DH neurons
Neuropathic responses
•
Visceral Hyperalgesia
- visceral sensitization
: IBS, IC
• Viscerovisceral Hyperalgesia
- cross-talk
- referral sensitization to second viscera
: IC with IBS, Endometriosis with IC
•
Viscerosomatic hyperalgesia
- referral neurogenic inflammation
: IC with vulvodynia/ CPP with TP
• Visceromuscular reflex
: pelvic floor tension syndrome
• Viscerocutaneous reflex
History taking
Physical Examination
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standing examination
sitting examination
supine examination
lithotomy examination
Laboratory Evaluation
• The use of routine tests in women
with CPP is discouraged.
• Lab tests should be obtained
- the results will change the
diagnosis
- the result will change the further
evaluation
- the result will change the treatment
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blood testing
urine testing
stool testing
STD testing
hormonal assays
tumor marker
Imaging Evaluation
Endoscopic Evaluation
• routine part of evaluation of CPP
• The decision of endoscopic procedure
patient’s history & physical examination findings
avoid unnecessary risks, expense, & false expectations
Laparoscopy
• CPP as the indication for diagnostic laparoscopy
; over 40%
• Laparoscopic findings of CPP
; no visible pathology- 35%
; Occult somatic pathology
- 47% in CPP and negative laparoscopic finding
endometriosis- 33%
pelvic adhesion-24%
chronic PID-5%
ovarian cyst-3%
pelvic varicosities-<1%
myomas-<1%
others-4%
Laparoscopy
• Predominant role of laparoscopy in CPP
; diagnosis or R/O endometriosis and adhesions
• Advantages of laparoscopy in the evaluation of CPP
- patient reassurance
- differentiation between gyn and non-gyn etiology
- R/o serious or malignant disease
- increased accuracy of diagnosis
- immediate surgical treatment is often possible.
Hysteroscopy
• Hysteroscopic findings at the time of combined laproscopic and
hysteroscopic evaluation in women with CPP
; 32%(significant abnormalities laparoscopically in almost all of these
patients)
; submucosal myoma-8.9%
intrauterine polyp-6.9%
cervical stenosis-9.2%
intrauterine scarring-0.5%
hyperplasia-1.4%
uterine septum-1.1%
others-4.1%
• Role of hysteroscopy in the evaluation of CPP
Medical therapy
Oral analgesics
tricyclic antidepressants
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initial treatment option
; begin with less expensive PG
synthetase inhibitor
• scheduled rather than PRN basis;
; ‘‘As needed dosing” may
increase pain due to
‘‘attention-driven phenomenon”
• Narcotics are not recommended for
CPP
; increased dysmortility disorder due
to potent SM relaxing effect
increased sedation and altered
cognition
increased abuse and addiciton
potential
improved pain tolerance
restore normal sleep
reduced depressive symptoms
*** for patients with
sleep disturbance
mild to moderate mood
disturbance
Anxiolytics
anticonvusants
Pelvic Congestion Syndrome
• Introduction
CPP; 10% of all gynecological referrals
Pelvic migraine is associated with presence of ovarian and pelvic varicose
veins.
Up to 15% of women between the age of 20-50 years have varicose veins
in the pelvis, although not all experience symptoms( up to 60%; PCS)
Protean manifestation & limited appreciation by both clinician &
radiologists –underdaignosed cause of CPP
Pelvic Congestion Syndrome
• Anatomy
Complex network of venous structure
Plexuses surround rectum, bladder,
vagina, uterus, & ovaries
: All interconnected by anastomosis
: Essentially valveless
Major drainage into internal iliac system
Ovarian vein
left into left renal vein
right into ven cava
13-15% of women lack valves in
Lt ovarian vein(6% in Rt ovarian vein)
Normal caliber of ovarian vein: < 5
mm
Etiology
•
Hypotheses
Anatomic dysfunction
; venous overload and valvular incompetence
- Hormonal dysfunction
; relaxation of SM in the walls of pelvic veins
; ovarian hormones, possibly estrogen
- Orgasmic dysfunction
; visceral vasocongestion caused by sexual stimulation(If no orgasm)pelvic discomfort & psychic irritaion-permanent pathologic changes in the
pelvic organ(debatable)
- Psychosomatic dysfunction
; chicken-or-egg question
chronic pelvic pain-or-psychopathology dilemma
Stress actually led to chronic vascular congestion & subsequent PCS.
Absence of pain after TAH with BSO in PSC patients with psychosocial disturbance
; report return to normla lifestyles.
- Iatrogenically induced dysfunction
; interruption of the utero-ovarian circulation with functional & anatomical
changes including PCS
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Symptoms
• Pain
- dull, aching pain in the pelvis
; chronic recurring or constant pain
aching but episodes of sharp stabbing pain
worsened or brought on by lifting, walking, sitting on chair,
prolonged standing or  intra—abdominal pressure
predominantly one side, occasionally on other side
- low back ache(sacrodynia)
- sexually related pain
; post coital aching lasting hours or 1-2 days
deep thrust dyspareunia
- menstrually related pain
; congestive dysmenorrhea
Symptoms
• Menstrual disorders
; Menorrhagia and Polymenorrhea
• May have associated symptoms similar to IBS, Interstitial
Cystitis, Frequency-Urgency Syndrome
• Psychiatirc and emotional disturbances
; simple anxiety to depression with attempted suicide
; psychological evaluation & consultation
Physical Examination
abdominal Exam
- tenderness with reproduction of pain with
deep palpation over ovarian point
Pelvic examination
- cervical motion tenderness
- retrocervical and paracervical tenderness
- marked ovarian tenderness with
gentle compression
- uterine Tenderness
• Ovarian point tenderness with
history of postcoital ache
; 94% sensitive and 77%
specific for pelvic congestion
Diagnostic Testing
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USG
Laparoscopy
CT, MRI, or MRA
Venography
Diagnostic Testing
USG(standing or valsalva maneuver)
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Tortuous pelvic veins with a
diameter of greater than 6 mm.
Slow blood flow(about 3
cm/sec) or reversed caudal
flow
Dilated arcuate veins in the
myometrium that
communicate between
bilateral pelvic varicose veins
Sonographic appearances of
polycystic changes of the
ovaries.
Various change of doppler
wave forms
Left ovarian vein; 100%
aorta-ov. vein- renal vein
Right ovarian vein; 50%
ov. vein-IVC-aorta
Diagnostic Testing
laparoscopy
Diagnostic Testing
venography- selective ovarian venography
• ovarian vein diameter of >10
mm(at least more than 5 mm)
• congestion of the ovarian plexus
• uterine venous engorgement
• filling of the pelvic veins across
the midline/or filling of
vulvovaginal and thigh
varicosities
Treatment
• Medical treatment
NSAID
Oral pill
Provera
; 30-50 mg daily
reduction of pain in 80%
pain recurs upon discontinuation
GnRH agonist
; more significant improvement compared to MPA with longer
benefit
Treatment
• Surgical treatment
TAH with BSO
symptomatic improvement in 2/3
not as effective as ovarian vein
ligation
Ovarian vein ligation
73% to 78% cure or symptomatic
improvement
estabilishment of collateral channel
& recurrence of symptoms
Treatment
• endovascular treatment
73% to 78% cure or symptomatic
improvement