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Consensus Guidelines For The Management of Chronic Pelvic Pain
Consensus Guidelines For The Management of Chronic Pelvic Pain
Disclaimer: This guideline has been reaffirmed for use and approved by Board of The Society of Obstetricians and Gynaecologists of
Canada. A revision is underway.
This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be
construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these
opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior
written permission of the publisher.
All people have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In order to
facilitate informed choice, patients should be provided with information and support that is evidence-based, culturally appropriate and tailored to
their needs.
This guideline was written using language that places women at the centre of care. That said, the SOGC is committed to respecting the rights of
all people - including transgender, gender non-binary, and intersex people - for whom the guideline may apply. We encourage healthcare
providers to engage in respectful conversation with patients regarding their gender identity as a critical part of providing safe and appropriate
care. The values, beliefs and individual needs of each patient and their family should be sought and the final decision about the care and
treatment options chosen by the patient should be respected.
Evidence: Medline and the Cochrane Database from 1982 to 2004 CPP; (b) general clinical assessment; (c) practical assessment of
were searched for articles in English on subjects related to CPP, pain levels; (d) myofascial pain; (e) medications and surgical
including acute care management, myofascial dysfunction, and procedures; (d) principles of opiate management; (f) increased use
medical and surgical therapeutic options. The committee reviewed of magnetic resonance imaging (MRI); (g) documentation of the
the literature and available data from a needs assessment of surgically observed extent of disease; (h) alternative therapies;
subjects with CPP, using a consensus approach to develop (i) access to multidisciplinary care models that have components
recommendations. of physical therapy (such as exercise and posture) and
psychology (such as cognitive-behavioural therapy), along with
Values: The quality of the evidence was rated using the criteria other medical disciplines, such as gynaecology and anesthesia;
described in the Report of the Canadian Task Force on the Periodic G) increased attention to CPP in the training of health care
Health Examination. Recommendations for practice were ranked professionals; and (k) increased attention to CPP in formal, high-
according to the method described in that report (Table 1). calibre research. The committee recommends that provincial
ministries of health pursue the creation of multidisciplinary teams
Recommendations: The recommendations are directed to the
to manage the condition.
following areas: (a) an understanding of the needs of women with
Disclaimer: This guideline has been reaffirmed for use Chapter 4: Investigations
and approved by Board of The Society of Obstetri-
cians and Gynaecologists of Canada. A revision is 1. Patient-assisted laparoscopy should be subjected to
underway. clinical trial (Ill-C).
This guideline was developed by the Chronic Pelvic Pain Chapter 5: Sources of Chronic Pelvic Pain
Working Group and approved by the Executive and
Council of the Society of Obstetricians and Gynaecolo- 1. Hysterectomy for endometriosis or adenomyosis with
gists of Canada. ovarian conservation can be an acceptable alternative.
The patient should be informed of the possible conse-
Chapter 2: Scope, Definition, and Causes of Chronic Pelvic quences (residual ovary syndrome, persistent pain,
Pain and reactivation of endometriosis) (II-2A).
2. Ovarian cystectomy, rather than oophorectomy,
1. Because of the complex nature and multifactorial devel-
should be an individual decision, based on the
opment of its common state, CPP should be increas-
patient's age and wishes, fertility issues, and surgical
ingly incorporated into the educational curricula of
feasibility (11-38).
health professionals (medical students, residents, nurses,
3. The management of symptomatic uterine fibroids
physiotherapists, specialists) (111-B).
should follow the clinical practice guidelines of the
Chapter 3: History-taking, Physical Examination, and Psy- Society of Obstetricians and Gynaecologists of
chological Assessment Canada (11-38).
4. The management of adnexal torsion should be deter-
1. Thorough history-taking that generates trust between mined according to the patient's age and wishes, fertil-
caregiver and patient and a pain-focused physical exami- ity issues, and surgical judgment (11-38).
nation should be part of the complete evaluation of the 5. Since the rate of recurrence of endometriosis with
patient with CPP (Ill-B). hormone replacement therapy (HRT) in women
2. Clinical measurement of pain level could be done at undergoing hysterectomy plus bilateral salpingo-
each visit for CPP (11-B). oophorectomy (8SO) is very low, HRT should not be
3. The patient can be asked two questions that are contraindicated (1-8).
simple and effective: "On a scale of 0 to 10, 0 6. In women with an intact uterus, when total hysterec-
being no pain and 10 being the worst pain imagin- tomy has not been performed because of technical
able, How is your pain today and how was your difficulties, the recurrence of endometriosis contrain-
pain 2 weeks ago?" It is important to provide a ref- dicates the use of HRT (1-8).
erence for 10 such as "pain that is so bad that you 7. Hysterectomy can be indicated in the presence of
cannot care for your children, who are in imminent severe symptoms with failure of other treatment
danger" (11-8). when fertility is no longer desired (1-8).
4. The physical examination can be conducted differently 8. Pelvic peritoneal defects (pockets) are frequently asso-
in these patients, with special attention placed on indi- ciated with endometriosis and should be treated surgi-
vidual pelvic structures, to help differentiate sources of cally (11-8).
pain. Identifying a focal area of tenderness can help tar- 9. Endosalpingiosis is an incidental histologic finding and
get specific therapy (11-8). does not appear to require specific treatment (11-28).
5. Owing to the high prevalence of mental health 10. Current evidence does not support routine adhesioly-
and other significant psychological coexisting sis for chronic pelvic pain. However, diagnostic lapa-
problems and sequelae of CPP, gynaecologists and roscopy remains of value (1-8).
family physicians should routinely screen patients
for chronic pain syndrome and refer as appropri- Chapter 6: Urologic and Gastrointestinal Causes of
ate (II-2A). Chronic Pelvic Pain
6. Access to multidisciplinary chronic pain management
should be available for women with CPP within the 1. Cystoscopy by trained specialists, with or without diag-
publicly funded health care system in each province and nostic laparoscopy, should be considered when intersti-
territory of Canada (111-8). tial cystitis (IC) is suspected (111-8).
2. Women with chronic pelvic pain will require detailed Chapter 9: Surgery-Evidence on Effectiveness
gynaecologic, urologic, gastroenterologic, and psycho-
logical assessment. Appropriate evaluation can lead to 1. The lack of robust clinical trials of the surgical manage-
optimal treatment and decrease the rate of inappropriate ment of chronic pelvic pain should be addressed. The
interventions (111-8). use of alternative epidemiologic models, including case-
J Obstet Gynaecol Can 2005;27(8):781-801 controlled and cohort-controlled trials, should be con-
sidered (III-A).
Chapter 7: Myofascial Dysfunction 2. Further delineation of the role of appendectomy and of
presacral neurectomy appears warranted in the manage-
1. Health care providers should become more aware ment of endometriosis-related pain (III-A).
of myofascial dysfunction as a cause of chronic pel-
vic pain (CPP) and the available treatment options Chapter 11: Multidisciplinary Chronic Pain Management
(IB).
2. Patients should participate in the management of CPP 1. Multidisciplinary chronic pain management should be
due to myofascial dysfunction by actively using a home available for women with chronic pelvic pain within the
stretching and exercise program (11-28). publicly funded health care system in each province and
territory of Canada (Ill-B).
Chapter 8: Medical Therapy-Evidence on Effectiveness
Chapter 14: Future Directions
1. Opioid therapy can be considered for pain control
under adequate supervision (II-3B). 1. The curriculum for professional development should be
2. Hormonal treatment of chronic pelvic pain of gynaeco- expanded to include theory and techniques in the man-
logic origin, including oral contraceptives, progestins, agement of myofascial dysfunction (A).
danazol, and gonadotropin-releasing hormone agonists, 2. Research into CPP should be encouraged, particularly in
has been studied extensively and should be considered the areas of the impact of CPP on the use of health
as the first line for many women, especially those with services, the pathophysiology of myofascial dysfunction,
endometriosis (I and II-1A). and gene therapy. Because randomized trials for qualita-
3. Adjuvant medications, such as antidepressants and anti- tive outcomes are exceedingly difficult, alternative
biotics, can be of supporting help in specific situations robust models, such as case-controlled or cohort-con-
(11-38). trolled trials, should be pursued (A).
3. Methods of improving interaction with patients should generating a great deal of electrical activity in this recep-
be explored. They might include formal contractual tor.7,8 One of the main roles of the brain in the response to
approaches to managing pain with opiates and efforts to pain is the generation of inhibitory signals, which descend
better appreciate the patient's perceived needs (A). through the cord to prevent some inappropriate actions.
J Obstet Gynaecol Can 2005;27(9): 869-887 The winding- up process may damage some of these inhib-
itory impulses. Another phenomenon that may occur is
CHAPTER 1: PHYSIOLOGICAL ASPECTS OF more diffuse dispersal of the message within the cord,
CHRONIC PAIN such that the subject appreciates the pain over several der-
matomes and not simply the one at which the signal origi-
John F. Jarrell, MD, Calgary, AB nated. Longer duration of the pain signal is responsible for
neuroplasticity, the permanent alteration of neuronal func-
his consensus statement cannot provide a complete
T summary on the physiological aspects of pain, but
the members of ttie consensus panel felt that a brief sum-
tion in the spinal cord that results in allodynia (pain from
stimuli that are not normally painful), hyperalgesia (exces-
sive sensitivity to pain), and other types of inappropriate
mary, particularly in relation to chronic pain, was war- pain.
ranted. Additional references are provided.1-4
Pain sensation begins with the stimulation of a nocicep- Therapy at the level of the cord is directed to the NMDA
tor, or nerve ending, and resultant activation of a sensory receptor. Novel neuroleptics, such as gabapentin, inhibit
nerve. A signal passes through the lightly myelinated A excessive stimulation of the secondary neurons in the spi-
delta fibres, which are responsible for the appreciation of nal cord, as do carbamazepine, phenytoin, and clonaze-
cold and mechanical stimuli that produce stinging, sharp, pam. Modulation of gamma-aminobutyric acid-receptors
fast pain. Also stimulated are the C fibres, which are may be inhibited by electric stimulation.
associated with mechanical and thermal stimuli and
transmit warm pain. Specialized bodies are responsible Therapy directed at the central processes of central inhib-
for the appreciation of texture (1vfeissner's corpuscles), ition include the use of opiates that act on the dorsal horns
vibration, tickle, and deep pressure (pacinian corpuscles) of the spinal cord and agents that increase the inhibition of
and for proprioception (Rufftni's corpuscles). The serotonin uptake, thereby increasing its availability (paroxe-
peripheral nerves use L-glutamate, substance P, and calci- tine and amitriptyline). This is an area of intense research
tonin G-related peptide as neurotransmitters. Release of activity.
chemicals (such as potassium, bradykinin, and arachi-
donic acid) from inflammatory processes is an endoge- CHAPTER 2: SCOPE, DEFINITION, AND CAUSES OF
nous source of pain sensation. CHRONIC PELVIC PAIN
Therapy directed to the peripheral nerves involves the use of Catherine Allaire, MD, Vancouver, BC
prostaglandin inhibitors, such as nonsteroidal anti-inflamma-
tory drugs and acetylsalicylic acid, as well as disruptors of
sodium channel activity, such as carbamazepine.z SCOPE
Table 2.1. Common causes of chronic pelvic pain and common coexisting conditions
Gynaecologic Urologic Gastrointestinal Musculoskeletal Psychological
Endometriosis Interstitial cystitis Irritable bowel Myofascial pain (trigger Depression
syndrome points)
Endosalpingiosis Urethral syndrome Chronic appendicitis Pelvic floor myalgia and Physical or sexual abuse
spasms (previous or current)
Adenomyosis Chronic urinary tract Constipation Nerve entrapment Sleep disturbance
infection syndromes
Pelvic adhesions Bladder stones Inflammatory bowel Mechanical low back Psychological stress
disease pain (marital, work)
Chronic pelvic infections Disc disease Substance abuse (alcohol,
narcotics, other drugs)
adequately, the patient's problem might not have pro- thorough and efficient. The pain questionnaire designed by
gressed to a chronic pain syndrome. the International Pelvic Pain Society (www.pelvicpain.org/
pdf/FRM_Pain_Questionnaire.pdf) is a useful resource
A useful model for understanding CPP is Steege's inte- and will allow data collection through a centralized data-
grated model,12 which includes the following elements: base in the future.
biological events sufficient to initiate nociception
During the initial interview, it is important to convey inter-
alterations of lifestyle and relationships over time
est, to listen with attention, and to validate the patient's
anxiety and affective disorders and
experience. Unfortunately, patients who have had pain for
circular interaction (“vicious cycle”) among these elements.
many years often feel dismissed by physicians frustrated at
their inability to cure. These physicians apply the Cartesian
There is evidence that a multidisciplinary approach to man-
model; that is, if no visible pathological condition is found,
agement (see Chapter 11 in Part two in the next issue) is
the problem must be psychological. As detailed in Chapter
more effective.
2, a biopsychosocial evaluation, which acknowledges the
possibility of multiple contributing factors, is more appro-
Recommendation priate. When the patient feels that her experience of the
Because of the complex nature and multifactorial devel- pain is believed and that the clinician will do his or her best
opment of its common state, CPP should be increas- to help, a good therapeutic relationship can be established,
ingly incorporated into the educational curricula of which will lead to better compliance with the proposed
health professionals (medical students, residents, nurses, treatment plan and perhaps to acceptance by the patient of
physiotherapists, specialists) (III-B). more realistic goals of treatment, such as improved func-
tion and quality of life, as opposed to complete resolution
of pain.
Speculum Examination
Abdomen This may not be possible if the patient has considerable
With the patient supine, look for skin lesions or hypersensi- vaginismus. Use a small specUlum. Look at the cervix, vag-
tivity, especially around scars. Examine all quadrants of the inal fornices, and vaginal walls. Cervical lesions, mucosal
abdomen for trigger points: vigorous pain responses to lesions, infections, and endometriosis implants can be iden-
light localized pressure, occasionally paired with a muscle tified. Use a long cotton swab to palpate the cervix and
twitch). Do the head-raise test: if pain is lessened with vaginal fornices, looking for localized tenderness. Post-
head-raising (and resultant tensing of the rectus muscles), hysterectomy dyspareunia may arise from localized lesions
then it is likely intraperitoneal, as the rectus protects the or nerve entrapment at the vaginal vault: palpating the
peritoneum from stretch; if, however, the pain is worsened vault with a long cotton swab may assist in identifying focal
or unrelieved by head-raising, then an abdominal wall sources of pain.
source should be suspected.
PSYCHOLOGICAL ASSESSMENT
Vulva
The patient is placed in the lithotomy position and may be Modern definitions of pain acknowledge both sensory and
offered a mirror to participate in the examination and gain affective aspects of the experience. Furthermore, particu-
more information about her body. A cotton swab is used larly when moderate or severe, CPP can have a negative
to perform a sensory examination and to identify areas of impact on the woman's capacity to function in family, sex-
tenderness. Particular attention should be given to identify- ual, social, and occupational roles. This condition is called
ing vulvar vestibulitis, as it is common in CPP patients. chronic pain syndrome. Thorough evaluation of the
This condition causes introital discomfort with intercourse woman experiencing CPP must include an assessment of
and is often felt as a tearing and burning sensation. her emotional experience and other aspects of the chronic
pain syndrome.
Single-Digit Vaginal Examination A psychosocial assessment conducted by a health psychol-
Insert one finger into the introitus and have the patient ogist or psychiatrist consists of an extensive interview and
contract and relax her perineal floor around the finger to an evaluation of the woman's response to standardized
assess tone and muscle control and whether vaginismus is pain and psychological tests that assess disability associated
present. Palpate the levator ani and coccygeus muscles and with pain (Figure 3.1 illustrates one such test, the Func-
their attachments. Palpate the vaginal side walls, looking tional Pelvic Pain Scale),13-15 emotional distress,16-18 and
for reflex sympathetic hypersensitivity. Palpate the levator quality of life.19
muscles. Palpate the pyriformis and obturator muscles (see
Chapter 7 in Part two in the next issue for details on mus- The domains covered in a psychosocial assessment include:
culoskeletal examination). Palpate the urethra and bladder (a) the woman's understanding of pain generators; (b) the
base. Gently touch the cervix and then the uterosacral liga- impact of the pain on functional roles (e.g., disability in
ments, searching for nodularity and localized tenderness. family, sexual, work, and recreational activities) and
Gently move the cervix, looking for uterine mobility and emotional functioning (e.g., anxiety about pain and depres-
motion tenderness. Palpate the adnexal areas for ovarian sion secondary to pain); (c) the woman's pain coping style
tenderness and the internal inguinal ring for inguinal ten- (e.g., ignoring the pain, becoming inactive, or going to the
derness. emergency department for injections); (d) pain modulators
Figure 3.1. Functional Pelvic Pain Scale Instructions: Please fill out this form by placing an X in the box that best
describes your pain when it is the WORST, even if it occurs at different times of your cycle. If any of these functions do not
apply to you, please write N/A (not applicable) in the box beside that function.
0 1 2 3 4
Function No pain; Some pain; Moderate pain; Severe pain; Cannot function
normal function with function with function with function because of pain
Bladder
Bowel
Intercourse
Walking
Running
Lifting
Working
Sleeping
Department of Obstetrics and Gynaecology, Foothills Provincial General Hospital, University of Calgary, Calgary AB, 1994
(e.g., stress, which exacerbates pain); (e) the woman's training and experience in working with patients experienc-
perception of the meaning of her pain with regard to her ing the psychosocial sequelae of chronic health conditions.
current and future life experience; (f) the quality of the
woman's relationships with health care providers; (g) the The following screening questions can be used in the office
woman's mental health history (past and current), espe- to identify women who would benefit from further psycho-
cially clinical psychopathological disorders (e.g., major logical evaluation. Each question is followed by an explana-
depressive disorder), abuse and neglect (sexual, physical, or tion and suggestions for how the information can be
emotional), and substance use or abuse; and (h) current evaluated.
psychosocial stress and social support, including the wom-
an's strengths. Main Concern
What concerns you most about the pain?
The data generated by the psychological assessment are
useful for determining appropriate psychosocial interven- Rationale: This open-ended question often elicits the wom-
tions directed towards alleviating the psychological and an's perception about what is most distressing about the
behavioural sequelae of chronic pain through lifestyle mod- pain, and interventions can be tailored accordingly.
ification and alterations in pain coping style. If relevant,
interventions may be aimed at treating secondary or pri- Understanding of Pain and Treatment
mary mental health disorders and reducing psychosocial Expectations
stress, which may moderate the pain experience. For What do you believe to be the cause of your pain? Do you
patients with moderate to severe pain, these interventions feel that anything has been overlooked? What do you hope
are typically critical components of a comprehensive health to gain as a result of treatment?
care plan.
Rationale: Women with CPP may have misconceptions and
Clearly, gynaecologists and family physicians cannot be fears concerning the cause of the pain (e.g., cancer), which in
expected to conduct a thorough psychosocial assessment. turn increase distress. They benefit from an accurate, physi-
However, they have an important role in identifying cal-based understanding of pain generators (e.g., disease and
patients who will likely benefit from psychosocial assess- myofascial trigger points). In contrast, psychological or psy-
ment and treatment. Women who are identified as chogenic explanations for the pain often cause more distress
experiencing considerable psychosocial impact from their and create fear that the pain will not be appropriately investi-
CPP can be referred to a mental health practitioner with gated or treated. Patient expectations for treatment outcome
(i.e., cure or elimination) may not be realistic and may con- research has not substantiated a psychological causal link
tribute to the viewing of treatment as unsuccessful. between abuse and chronic pelvic pain.
Diagnostic imaging should be performed only when indi- Findings on physical examination are not reliable predic-
cated by the history and physical findings. tors of laparoscopic findings. Up to 50% of patients with
negative results of physical examination have abnormalla-
Transvaginal ultrasonography is useful for evaluating pelvic paroscopic findings.24 In a review of 11 studies of laparo-
masses and adenomyosis and is more sensitive than trans- scopic findings in women with CPP, Howard24 found that
abdominal scanning.20 When a mass is found in the pelvis, 28% of women without CPP had abnormal laparoscopic
ultrasonography is effective in distinguishing cystic from findings adhesions and endometriosis being the most com-
solid lesions. Doppler studies evaluate the vascular charac- mon, at 17% and 5%, respectively.
teristics of the lesion.
What is Adequate Laparoscopy?
Magnetic resonance imaging (MRI) is useful for character- After laparoscopic entry, a thorough, standardized exami-
izing pelvic masses. It may be a useful, non-invasive tool in nation is performed. A panoramic view of the pelvis, with
the diagnosis of deep endometriosis, although it has limita- the patient in the Trendelenburg position and the uterus
tions in detecting small implants.21,22 Endometriomas are anteverted, allows a general survey. A manipulating instru-
readily visualized with MRI. Blood products are often seen ment is inserted, and the bowel, appendix, liver, diaphragm,
within masses. Adjacent bowel loops may be tethered to and upper abdomen are inspected. The manipulating
the mass. Differential diagnoses include cystic teratomas instrument is then used to mobilize pelvic structures to
(dermoids) and hemorrhagic cysts.22 MRI remains the visualize all peritoneal surfaces, the ovaries and ovarian
imaging test of choice for adenomyosis.22 fossae, and the cul-de-sac of Douglas, as well as the ante-
rior cul-de-sac. The instrument is used to probe areas of
A study compared the diagnostic accuracy of laparoscopy, pre- tenderness reported by the patient on pelvic examination,
operative MRI, and histologic examination of specimens in 48 as well as adhesions and pelvic deformity.
women with pelvic pain.23 MRI detected fewer endometriosis
lesions than laparoscopy or histologic examination, with sensi- Surgeons should be aware of the varied appearances of
tivity of 69% and specificity of 75% in detecting biopsy-con- endometriosis, atypical lesions being more common in
firmed endometriosis. Only 67% of lesions detected younger patients. Biopsy for histologic confirmation is rec-
laparoscopically showed histologic evidence of endometriosis. ommended. Palpation of scar tissue with the probe may
There is no consensus on the merits of preoperative In addition to a woman's desire to maintain fertility, her age,
versus postoperative medical treatment of CPP. Some the severity of her symptoms, and the site of major endo-
theoretical advantages of preoperative treatment include metriotic involvement must be evaluated when considering
decreased inflammation in the endometriotic implants definitive surgery as an option for pain management.
and decreased pelvic vascularity. Disadvantages may
include increased difficulty in diagnosis of the endome- ENDOSALPINGIOSIS
triosis and high costs of the medications and their side
Endosalpingiosis first described by Sampson45 in 1927, is
effects.
the presence of ectopic fallopian tube-like ciliated epithe-
There have been at least three randomized, placebo-con- lium without stroma. As with endometriosis, the histogene-
trolled clinical trials of surgical therapy followed by medical sis is unknown. Possible mechanisms include coelomic
management.36,38,39 Although it is not clear from these metaplasia or implantation of tubal epithelial tissue. The
studies whether postoperative medical therapy is effica- distribution and gross appearance of the lesions of endo-
cious, there is some evidence that 6 months of postopera- salpingiosis are the same as those of endometriosis. Several
tive treatment with GnRH analogues, danazol, or case studies have reported that endosalpingiosis may be
medroxyprogesterone acetate lowers pain levels at 6 associated with CPP.
months but possibly not at 12 months.
A prospective study of 1107 consecutive women undergo-
Finally, if fertility is not desired, in the face of failed medical ing laparoscopy over a year for a variety of indications
and conservative surgical therapy, hysterectomy with or found histologically proven endosalpingiosis in 7.6%,
without oophorectomy may be considered in accordance endometriosis in 27.5%, and both in 4.4%.46
with the SOGC practice guidelines.40 According to the
Endosalpingiosis was found in 7.9% of the women with
Canadian Hospital Morbidity File of Statistics Canada,
pelvic pain, 7.3% of those without pelvic pain, 11.7% of
there were 120 854 hysterectomies performed during 1988
those with infertility, and 8.3% of those without symptoms
and 1989; the listed indications included fibroids (in 37.3%
who were undergoing sterilization. The authors concluded
of cases), menstrual disorder (in 17.7%), endometriosis (in
that, in contrast to endometriosis, endosalpingiosis plays
15.7%), prolapse (in 11.4%), other (in 9.1%), and cancer
only a minor role in infertility and lower abdominal pain.
(in 8.7%).41
Another study of 16 women with endosalpingiosis who pre-
Hysterectomy with bilateral oophorectomy is generally
sented with a variety of symptoms, including pelvic pain (in
regarded as the most effective procedure for the treatment
5) and no pelvic pain (in 5), determined that endosalpingiosis
of CPP associated with endometriosis. However, after such
seems to be an incidental fmding associated with other pelvic
radical surgery, one study found a 3% rate of recurrence of
problems rather than a frequent cause of pelvic pain.47
endometriosis.42 Possible mechanisms include residual
ovarian tissue or exogenous stimulation by hormones. ADENOMYOSIS
Another study found a recurrence rate of 3.5% (0.9%
per year) among 115 women randomly assigned to receive Adenomyosis is a condition of unknown etiology and path-
hormone replacement therapy (HRT) after bilateral sal- ogenesis. It is defmed histologically as the presence of
pingo-oophorectomy (BSO) with or without hysterectomy endometrial glands and stroma deep within the myome-
but no recurrence among 57 women assigned to not trium. The uterus is usually enlarged and diffusely boggy
receive HRT after BSO.43 Among the women receiving to palpation. The adenomyotic foci may be diffusely
HRT, the recurrence rates were higher among those with distributed or be well-localized, forming adenomyomas
peritoneal involvement greater than 3 em (2.4% per year (nodules of hypertrophic myometrium and ectopic endo-
vs. 0.3%) and incomplete excision (22% among the 9 metrium). The reported incidence of adenomyosis ranges
women who underwent BSO with or without subtotal hys- from 5% to 70%.48 Most cases occur in parous women in
terectomy vs. 2% among the 106 who underwent BSO and the fourth and fifth decades of life.49 Not all women with
hysterectomy). The relative risk was 11.8 (confidence inter- adenomyosis are symptomatic. Symptoms may include pel-
val [CI] 1.4-15.6, P = 0.03). vic pain, dysmenorrhea, and menorrhagia.
A retrospective study reported that 18 (62%) of 29 women Transvaginal sonography may aid in the diagnosis of
had recurrent pain and 9 (31%) required re-operation after adenomyosis.50 The senstttvtty and specificity of prehyster-
hysterectomy with retention of the ovaries,44 ectomy ultrasonography varied from 52% to 89% and
from 50% to 99%, respectively, in 6 series (43 to 405 defects, 9 having more than one defect, and 42 (79%) also
women).51 having endometriosis. Of the 309 women, 148 had endo-
metriosis. The authors concluded that, when such defects
Several studies have shown magnetic resonance imaging are found at laparoscopy, the presence of endometriosis
(MRI) to be an excellent, minimally invasive tool for diag- should be investigated thoroughly.
nosing adenomyosis,52 with sensitivity and specificity rang-
ing from 86% to 100% in symptomatic women.53 One The defects have been postulated to result from peritoneal
recent, prospective, double-blind study of 119 consecutive irritation or invasion by endometriotic tissue, with resultant
patients undergoing hysterectomy showed endovaginal scarring and retraction of the peritoneum,45,57 Batt and
ultrasonography to be as accurate as MRI in the diagnosis Smith60 postulated that peritoneal pockets and associated
of uterine adenomyosis.54 endometriosis localized to the posterior pelvis may repre-
sent a congenital form of endometriosis that is due to rudi-
Treatment options include danazol and GnRH agonists. mentary duplication of the milllerian system during
Adenomyotic foci have been shown to contain progester- embryogenesis. Redwine61 reported that almost one-fifth
one and estrogen receptors and may undergo decidualiza- of 132 women with endometriosis had peritoneal pockets.
tion when exposed to progesterone; symptoms may then Two-thirds of the defects had endometriotic tissue around
become more apparent.55 Progestogenic agents alone or in the rim or inside, but since one-third lacked associated
combination with estrogen may therefore not be effective. endometriosis, and since fibrosis was not present as a pos-
Adenomyosis in women with infertility can be treated with sible cause, endometriosis did not seem to have been the
a variety of medications.50 likely primary cause. Redwine postulated that such perito-
neal invaginations and endometriosis may be ontologically
In one study of 15 women with MRI-diagnosed adeno- related to a separate developmental factor.
myosis (and concurrent fibroids in 12), 12 of 13 patients
reported improvement in quality of life after uterine artery Vilas and Vilos62 excised 140 pelvic peritoneal pockets
embolization.56 ranging from 0.5 to 6 em wide or deep from 106 women
15 to 50 years of age who had CPP. Of the pockets, 46%
Surgery is still the main method of diagnosing and manag- were below the uterosacral ligaments (right, 40; left, 25),
ing adenomyosis. Hysterectomy is the gold standard for 41% above the uterosacral ligaments and medial to the ure-
relief of symptoms. However, there may be a role for hys- ters (right, 20; left, 38), 6% lateral to the ureters (right, 6;
teroscopic endometrial resection if the adenomyosis has left, 2), 3% in the rectovaginal septum, and 3% anterior to
been confirmed to involve mostly the superficial 3 mm of the broad ligament (right, 3; left, 1). Associated pelvic
the myometrium. endometriosis was seen in 85% of patients. Histologic
examination of the pockets revealed endometriosis in 39%,
For a recent review of adenomyosis, see the article by Mat-
chronic inflammation-in 20%, endosalpingiosis in 12%,
alliotakis and colleagues.57
calcification in 4%, and no abnormalities in 25%. Excision
and suturing of the defects provided immediate relief of
PELVIC PERITONEAL DEFECTS (POCKETS) CPP in some 75 women. The authors postulated that the
pockets were herniations of the pelvic peritoneum over
A defect, or a pocket, in the pelvic peritoneal floor was first pelvic floor spaces and were related to the inflammatory
illustrated by Sampson45 in 1927 as he was describing effects of the various conditions.
endometriotic implants in the peritoneal cavity. In 1981,
Chatman58 reported peritoneal defects in 25 (4%) of 635 In a follow-up study of 2115 women with CPP, Vilos
consecutive patients undergoing diagnostic laparoscopy, and associates63 reported on 25 women who also com-
75% for CPP and 25% for infertility, among whom endo- plained of cyclic pain radiating to the leg (right leg in
metriosis was found in 192 women (30%). The frequency 15 women, left leg in 9 women, and both legs in 1
of peritoneal defects in women with CPP was 7%. In 7 woman), pain over the buttocks and paresthesia of the
(28%) of the 25 women, the defect was the only fmding, thighs, knees, or both, exacerbated during menses.
but 17 (68%) had associated pelvic endometriosis. Laparoscopic findings were endometriosis nodules in 5
patients, peritoneal pockets, endometriosis, or both in
In a follow-up study of an additional 309 patients undergo- 19 patients, and inflammatory peritoneum in 1 patient.
ing laparoscopy for CPP, infertility, or both, Chatman and Associated pelvic endometriosis was identified and
Zbella59 found that 53 patients had pelvic peritoneal confirmed in 17 women (68%); no additional lesions
were found in the other 8 (32%). After excision of the the adhesiolysis group (n = 52) and 27% of the controls
15 pockets, histologic examination showed endometri- (n = 48) reported resolution or substantial reduction of
osis in 9 (60%), endosalpingiosis in 2 (13%), chronic pain.68 There were no complications in the diagnostic lapa-
inflammation in 1 (7%), and normal tissue in 3 (20%). roscopy group, but 5 of the 52 patients in the adhesiolysis
After laparoscopic excision, sciatic symptoms were group had complications (some had more than one com-
eliminated in 19, were lessened in 4, and remained the plication): small bowel perforation in 2 patients and hemor-
same in 2; symptoms recurred in 3 patients after rhage during surgery (necessitating blood transfusion),
2 years. The authors concluded that cyclic leg pain is abdominal abscess, rectovaginal fistula, and protracted par-
associated with pelvic peritoneal pockets, endometri- alytic ileus after surgery in 1 patient each. The authors con-
osis nodules, or surface endometriosis of the postero- cluded that laparoscopic adhesiolysis cannot be
lateral pelvic peritoneum. They hypothesized that the recommended as a treatment for adhesions in patients
pain was likely referred from the pelvic peritoneum with chronic abdominal pain.
rather than due to direct irritation of the lumbar
plexus of the sciatic nerve. A recent publication69 reviewed the relation between adhe-
sions and pelvic pain and the effectiveness of adhesiolysis
in pain control. The most common laparoscopic findings
ADHESIONS in patients with or without pelvic pain were endometriosis
and adhesions. Multiple adhesiolysis techniques were used,
Intraperitoneal adhesions are caused mainly by surgery and and outcomes of surgery ranged from no pain relief to
to a lesser extent by endometriosis and abdominal and pel- relief in 90% of patients. The authors concluded that a cor-
vic inflammation or infection.64 The fmancial impact of relation between pelvic pain and adhesions remains uncer-
adhesions is enormous.65 In the United States, adhesiolysis tain. Adhesiolysis has not been shown to be effective in
was responsible for 303 836 hospitalizations during 1994, achieving pain control in randomized clinical studies.
primarily for procedures on the digestive and female repro-
ductive systems, which accounted for 846 415 days of inpa-
tient care and $1.3 billion in hospitalization and surgeon PELVIC INFLAMMATORY DISEASE (PID)
expenditures.66
PID is a common condition that carries several long-term
Adhesions are found in 25% to 50% of women with CPP, sequelae, one of which is CPP. CPP has been reported to
but their role as a cause of CPP remains controversial.26,67 occur in 18% to 33% of women after an episode of PID,
regardless of mode of antibiotic therapy.70,71 The corre-
Diamond and Freeman65 reviewed four uncontrolled, sponding figure was 5% in a control series of women who
cohort studies involving 269 women and 4 men and found had never had PID.68 Although pelvic adhesions after PID
rates of 69% to 82% for relief or reduction of chronic pain are thought to be the cause of CPP, the exact etiology
after adhesiolysis. remains unknown. One study showed a reduction in physi-
cal and mental health among women with CPP after PID.72
One study randomly assigned 48 women with CPP and
laparoscopically diagnosed pelvic adhesions to adhesiolysis Women with CPP were less likely to be black (P < 0.001)
by laparotomy (n = 24) or "wait-and-see" management and more likely to report a history of PID (P < 0.004), a
(n = 24).64 Adhesiolysis proved to be of no more benefit greater number of previous PID episodes (P < 0.001),
than the wait-and-see approach. Only the 15 women with and continued pelvic pain at 30 days (P < 0.001). CPP
severe multiple vascularized adhesions involving the serosa was associated with greater age (P = 0.079), being married
of the small bowel or, to a lesser extent, the colon benefit- (P =0.084), lesser education (P = 0.074), and 3 or more
ted from adhesiolysis (P < 0.01). The authors concluded days between the onset of PID symptoms and treatment
that adhesiolysis is not indicated for the treatment of pelvic (P =0.182). CPP was associated with lower physical (P <
pain in women with mild or moderate pelvic adhesions but 0.001) and mental health composite scores (P < 0.001)
that it may benefit women with severe adhesions involving 5 days after enrolment.70
the intestinal tract.
Among 684 sexually active women with PID followed up
A recent multicentre, blinded, randomized trial of laparo- for a mean of 35 months,73 self-reported persistent and
copic adhesiolysis versus diagnostic laparoscopy alone in consistent condom use was associated with lower rates of
87 women and 13 men with chronic abdominal pain found PID sequelae. After adjustment for covariates, the relative
that at 12 months after randomization, 27% of patients in risk for condom users versus nonusers was 0.5 (95% CI
0.3-0.9) for recurrent PID, 0.7 (95% CI 0.5-1.2) for CPP, resolution of the CPP. Women with ovarian remnants may
and 0.4 (95% CI 0.2-0.2) for infertility. present with CPP, sometimes cyclical, or a pelvic mass.
The absence of vasomotor symptoms should make one
OVARIAN CYSTS suspicious of ORS in a woman with CPP who has previ-
ously undergone bilateral oophorectomy. On vaginal exam-
Unilateral CPP is often attributed to ovarian cysts, if pres- ination, a tender lateral pelvic cyst may be palpated.
ent. Chronic ovarian cysts, however, do not usually pro- Premenopausal levels of follicle-stimulating hormone and
duce pain. Although small studies have shown successful estradiol, along with the ultrasonographic detection of a
treatment of CPP in patients with ovarian cysts,74 no ran- pelvic cystic structure, are helpful in diagnosis.
domized clinical trials have addressed this issue.
Treatment of ORS may be attempted with agents such as
RESIDUAL OVARY SYNDROME (ROS) GnRH analogues with add-back therapy. There are no
reports of large series addressing this issue. The main man-
ROS is characterized by either recurrent pelvic pain or a agement option at present is surgical excision of the ovar-
persistent pelvic mass after hysterectomy.75 ian remnant with a retroperitoneal approach, wide local
excision, and lysis of adhesions.65,79 The risks of ureteric
One study reported an incidence of ROS of 2.8%
and bowel injury should be discussed with the patient pre-
(73 cases) after 2561 hysterectomies with preservation of
operatively.
one or both ovaries over a 20-year period.76 There was no
correlation between unilateral or bilateral ovarian preserva-
tion and development of ROS. Indications for removal of PELVIC CONGESTION SYNDROME
one or both of the residual ovaries included CPP in 52
patients (2.0%), persistent asymptomatic pelvic mass in 18 For more than half a century, dilated pelvic veins have been
patients (0.7%), and acute pelvic pain in 3 patients (0.1%). observed in some women with CPP. Symptoms may
Re-exploration occurred within 5 years in 1.3% and within include a dull aching pain as well as menstrual disorders.
10 years in 2.1% of patients. Ovarian malignancy was Vulvar varicosities may be associated. Pelvic venography,
found in 9 women (serous in 6 patients, mucinous in 1 Doppler ultrasonography, and MRI have been used to
patient, and borderline in 2 patients), for a rate of 3.5 per diagnose pelvic congestion syndrome.80-82 A recent study
1000 cases in which ovaries were preserved. Indications of asymptomatic kidney donors showed a 38% incidence
for hysterectomy included combinations of fibroid uterus of pelvic congestion syndrome, diagnosed by MRI detec-
(in 62 patients), abnormal uterine bleeding (in 34), uterine tion of dilated pelvic veins. Hysterectomy as a management
prolapse (in 8), and grade 1 cervical intraepithelial neopla- option for pelvic congestion syndrome has fallen out of
sia (in 1). favour. Although there have been case reports of ovarian
vein ligations and percutaneous embolizations, no con-
OVARIAN REMNANT SYNDROME (ORS)
trolled clinical trials have evaluated the safety and long-
term effectiveness of these approaches.
ORS is the persistence of functional ovarian tissue after
the intended removal of the ovary. The true incidence POST-HYSTERECTOMY CPP
of ORS is not known. The condition is often not sus-
pected in women with CPP who have had oophorecto- CPP has been listed as the principal preoperative indi-
mies.77 The syndrome arises from unintentional, cation for 10% to 12% of hysterectomies in the United
incomplete dissection and removal of the ovary during States83,84 and Canada.40 Stoval et al.85 evaluated 99
a difficult or emergency oophorectomy or implantation women with CPP of unknown etiology after excluding
and growth of displaced ovarian tissue in the abdomen endometriosis and adhesions. Histopathologic analysis
or pelvic cavity during oophorectomy. The condition is of surgical specimens revealed adenomyosis in 20% of
often encountered in patients with severe endometriosis patients, fibroids in 12%, and both in 2%. At an aver-
and pelvic adhesions or similar conditions associated age follow-up of 22 months, 22% of the women
with severe pelvic adhesions. reported persistent pelvic pain.
In a cohort study of 119 women presenting with CPP who Hillis and colleagues84 reported on a prospective cohort
had previously undergone oophorectomy, ovarian rem- study of 279 women from the Collaborative Review of
nants were found in 18%.78 Five years after removal of the Sterilization Study (CREST) who underwent non-emer-
ovarian remnants, 80% of women reported complete gency hysterectomy for the relief of CPP. After 1 year,
74% of the women reported complete resolution of syndrome, and interstitial cystitis, should be suspected
pain, 21% reported decreased but continued pain, and when patients present with pain as the main symptom.
5% reported unchanged or increased pain. The proba-
bility of persistent pain was higher among women less Pain associated with uterine fibroids may present as dysme-
than 30 years old, those with no identified pelvic dis- norrhea, pressure symptoms, or both. Resection of submu-
ease, those who were economically disadvantaged, those cosal uterine fibroids associated with menorrhagia and
with more than two pregnancies, and those with a his- dysmenorrhea, as well as myomectomy or hysterectomy for
tory of PID. For each of these subgroups, 30% to 40% large, symptomatic uterine fibroids, may reduce the chronic
continued to have pelvic pain. Unilateral or bilateral sal- pain. However, no clinical trials have specifically assessed sur-
pingo-oophorectomy was not found to play a role. A gical intervention for uterine fibroids as therapy for CPP.
separate set of 97 women with dysmenorrhea as their
primary complaint reported resolution (95%), reduction The Maine Women's Health Study,89 a prospective cohort
(4%), or no change (1%) in their dysmenorrhea 1 year study of 418 women undergoing hysterectomy, found that
after hysterectomy.84 35% of the procedures were performed for uterine fib-
roids. Hysterectomy was highly effective for the relief of
symptoms and was associated with a marked improvement
POST-HYSTERECTOMY ENDOMETRIOSIS
in quality of life.
Among women with a previous hysterectomy and BSO
(for different conditions), when laparoscopy was per-
formed because of CPP, endometriosis was found in ADNEXAL TORSION
34%.86
Adnexal torsion may produce pain by mechanical, hypoxic,
or chemical tissue changes. Unilateral CPP is often attrib-
PELVIC PAIN IN THE ABSENCE OF GENITAL uted to ovarian cysts, if present. Chronic ovarian cysts,
PELVIC ORGANS
however, do not usually produce pain. Although small
Behera and associates87 evaluated laparoscopically 115 studies have shown successful treatment of CPP in patients
women, 22 to 68 years old, with chronic pain after hyster- with ovarian cysts,74 no randomized clinical trials have
ectomy and BSO. Findings at laparoscopy were adhesions addressed this issue.
in 107 patients, adnexal remnants in 32 (ovarian in 26 and
tubal in 6), abnormal appendix in 19, and abnormal perito- Recommendations
neum in 14. Four peritoneal biopsies revealed endometri-
1. Hysterectomy for endometriosis or adenomyosis with
osis. Six appendices showed disease: endometriosis in two,
ovarian conservation can be an acceptable alternative.
chronic inflammation in one, and obliterated lumen in
The patient should be informed of the possible conse-
three. Of the 104 patients who were followed up for 1 to
quences (residual ovary syndrome, persistent pain, and
12 years, 61 (59%) reported a reduction in pain and the
reactivation of endometriosis) (II-2A).
other 43 no change in pain. Reduced pain as reported by
2. Ovarian cystectomy, rather than oophorectomy,
70% of those with ovarian remnants, 62% of those with
should be an individual decision, based on the
endometriosis, 52% of those with adhesiolysis, and 50% of
patient's age and wishes, fertility issues, and surgical
those with appendectomy.
feasibility (II-3B).
3. The management of symptomatic uterine fibroids
UTERINE FIBROIDS should follow the clinical practice guidelines of the
Society of Obstetricians and Gynaecologists of Can-
Uterine fibroids (leiomyomas) are benign monoclonal
ada (II-3B).
tumours derived from the smooth muscle of the uterus.
4. The management of adnexal torsion should be deter-
These tumours may be due to genetic pleiomorphisms,
mined according to the patient's age and wishes, fer-
with a genetic-environmental interaction. They may be sub-
tility issues, and surgical judgment (II-3B).
mucosal, intramural, subserosa!, or pedunculated. A
5. Since the rate of recurrence of endometriosis with
detailed clinical practice guideline on uterine myomas was
hormone replacement therapy (HR1) in women
published in the Journal if Obstetrics and GynaecoloJ!)I Canada
undergoing hysterectomy plus bilateral salpingo-
in 2003.88 Although dysmenorrhea and pelvic pressure
oophorectomy (BSO) is very low, HRT should not
symptoms may be due to the fibroids, other conditions,
be contraindicated (I-B).
such as endometriosis, adenomyosis, irritable bowel
6. In women with an intact uterus, when total hysterec- The prevalence ofiC in the United States is 10 to 67/100
tomy has not been performed because of technical 000; women predominate 10 to 1.90-92 Possible causes
difficulties, the recurrence of endometriosis contrain- include infection, lymphatic or vascular obstruction,
dicates the use of HRT (I-B). immunologic deficiencies, glycosaminoglycan layer defi-
7. Hysterectomy can be indicated in the presence of ciency, presence of a toxic urogenous substance, neural fac-
severe symptoms with failure of other treatment tors, and primary mast cell disorder.93
when fertility is no longer desired (I-B).
8. Pelvic peritoneal defects (pockets) are frequently Characteristics and Clinical Significance
associated with endometriosis and should be treated Most patients present with pelvic pain and irritative voiding
surgically (II-B). symptoms, such as frequency, urgency, and nocturia.
9. Endosalpingiosis is an incidental histologic finding Patients void 8 to 15 times per day, with an average volume
and does not appear to require specific treatment of 70 to 90 mL. Voiding can occur once or twice per night.
(II-2B). Pain can radiate to any location in the pelvis, in the supra-
10. Current evidence does not support routine adhesiol- pubic area, to the perineum, vulva, vagina or low back, and
ysis for chronic pelvic pain. However, diagnostic even to the medial thighs. Pain can increase during or after
laparoscopy remains of value (I-B). sexual intercourse. Symptoms fluctuate during the men-
strual cycle, with a premenstrual flare, in 18% of women
with IC.94 Patients often have overlapping symptoms
related to the pelvic organs-urologic, gastrointestinal,
CHAPTER 6: UROLOGIC AND GASTROINTESTINAL gynaecologic, and pelvic floor. Up to 75% of patients with
CAUSES OF CHRONIC PELVIC PAIN
CPP who visit gynaecologists have urologic symptoms.95
Louise Lapensee, MD, FRCSC In one retrospective study of 60 women with CPP,96 the
patients were noted to have presented with dyspareunia
Montreal QC and dysmenorrhea, along with CPP, with or without uri-
nary symptoms. Pelvic, uterine, and bladder tenderness
Chronic pelvic pain (CPP) is a complex syndrome that were noted on physical examination. Laparoscopy, cystos-
involves biologic and psychosocial phenomena. This chap- copy, and hydrodistention of the bladder were performed
ter will focus on urologic and gastrointestinal causes in each patient. Of the 60 women, 58 (97%) had IC,
(Table 6.1), particularly the two most frequently found in according to the guidelines of the US National Institutes of
women with CPP. Health (NIH). Of the 48 (80%) who had biopsy-confirmed
active endometriosis,47 98% had IC. Endometriosis is
INTERSTITIAL CYSTITIS (IC) commonly associated with CPP but is not always responsi-
ble for the pain. In this study, 78% of the patients had
IC is a poorly understood chronic inflammatory condition both endometriosis and IC. The decision to perform cys-
of the bladder whose study is complex and frustrating. Its toscopy should not be based on symptoms alone, because
causes are unknown, its pathophysiology remains uncer- 25% of women with IC would have been missed.
tain, and the efficacy of treatment regimens is questionable.
In another study, 45 women scheduled to undergo laparos-
copy for CPP were recruited and screened for IC with the
Table 6.1. Causes of chronic urologic and gastrointesti- Interstitial Cystitis Symptom Index and Problem
nal pelvic pain
Index.97,98 Cystoscopy with hydrodistention of the bladder
Urologic Gastrointestinal was performed at the time of laparoscopy. The prevalence
Interstitial cystitis (IC) Irritable bowel syndrome of IC was 38%. Of the 21 women with endometriosis 7
Bladder dysfunction Chronic constipation (33%) hadiC; of the 10with adhesions, 4 (40%) had IC;
Urethral diseases Diverticular diseases and of the 14 with normal results oflaparoscopy, 6 (43%)
Bladder neoplasm Inflammatory bowel disease
had IC. The presence ofiC did not necessarily correlate
Chronic urinary tract infection Appendiceal diseases
with the laparoscopic findings. It is therefore not possible
to suggest that cystoscopy is necessary only if the results
Radiation cystitis Meckel's diverticulum
oflaparoscopy are negative or to suggest that cystoscopy is
Renal stone or urolithiasis Neoplastic lesions
unnecessary if endometriosis or other pelvic disorders are
Chronic intermittent bowel obstruction
found (III-C).
represents inaccurate diagnosis by gynaecologists, the pres- found in 14% and genitourinary disorders in 11% of all
ence of multiple disorders in women with IBS, or an etio- 122 patients.
logic link between gynaecologic disorders and IBS is not
clear.67
PATHOPHYSIOLOGICAL ASPECTS
involve a high resting tone in the muscles and fascia that OFFICE APPROACH TO MYOFASCIAL SOURCES
attach to the bony pelvis. OF GYNAECOLOGIC PAIN
Interstitial cystitis (IC), vulvodynia, and urethral syndrome Gynaecologic pain, or pain of pelvic origin, can arise from
associated with pelvic floor tension myalgia may contribute visceral organs in the pelvis, the muscular body wall
to the pain associated with these conditions.123 Dyspareu- (including the abdomen and low back muscles), the
nia is common in patients with IC. muscles of the hip region and upper thigh, and the lumbo-
sacral nerves (nerve roots and peripheral nerves). Visceral
Weiss124 recently reported successful outcomes in 52 pain has a wide variety of causes, both pathological (e.g.,
patients using manual physical therapy to treat IC and ure- those associated with tissue damage or inflammation) and
thral syndrome. The rationale was that pelvic floor myofas- nonpathological (e.g., distention or increased capsular pres-
cial trigger points are not only a source of pain and voiding sure). Pain in muscles, whether those of the body wall (e.g.,
symptoms but also a trigger for neurogenic bladder symp- abdominal or low back muscles) or of the hips and extrem-
toms. Moderate to marked improvement occurred in 35 ities (e.g., gluteal and adductor muscles) is associated with
(83%) of the 42 patients with urethral syndrome and 7 of discrete bands of muscle hardness and tenderness (myofas-
the 10 patients with IC. Electromyography demonstrated a cial trigger points).
decrease in pelvic floor resting tone. Symptoms had been
Visceral and myofascial sources of pain can refer pain else-
present for 6 to 14 years.
where. In particular, visceral pain can cause pain to be felt in
Scars in the abdominal wall may cause abdominal or pelvic the body wall and hip region, and myofascial trigger points
pain and in such cases usually demonstrate limited mobility. can cause pain to be felt as deep pain, as if coming from the
Similarly, perineal scars can affect sexual function if not viscera. Myofascial trigger points are also associated with vis-
sufficiently mobile. Reactive muscle contraction can pro- ceral organ dysfunction, such as irritable bladder syndrome
duce vagtrusmus. and irritable bowel syndrome. Conditions such as IC associ-
ated with urinary frequency and pain can be worsened by
Myofascial pelvic pain may develop over time in response myofascial trigger points in the abdomen, hip region, and pel-
to pain caused by gynaecologic disease or as a direct result vic floor. These trigger points can also cause pain that is felt
of faulty body mechanics or other problems. Differentiat- to be coming from pelvic organs and can be indistinguishable
ing the cause of the pelvic pain is often difficult for the from the pain of endometriosis.
gynaecologist and is best approached in conjunction with a
physical therapist. Myofascial trigger points are caused by muscle stress or
overuse and are most likely associated with local ischemia,
which promotes both the contracted, hard band of the trig-
ger point and the release ofvasoactive substances that cause
TREATMENT OVERVIEW
vasodilation and neurogenic edema and activate peripheral
Patient education on pelvic floor function is vital to suc- nerve nociceptive receptors, causing pain. Trigger points are
cessful physical therapy. Physiological quieting and general identified by physical examination. Treatment of the muscu-
relaxation with the use of biofeedback are taught to lar or myofascial component of pelvic pain syndromes is
patients. accomplished by inactivating the trigger point through man-
ual means, as in physical therapy, or by needling or injection
Manual soft tissue release is essential to reduce pelvic floor of local anesthetic into the trigger point. Identification and
resting tone and tension. Acupuncture may also be correction of predisposing, initiating, and perpetuating fac-
helpful.121 tors associated with the pain syndrome, whether muscular
or visceral, is necessary to complete treatment and reduce or
It is important to inactivate trigger points to restore muscle eliminate the likelihood of recurrence.
to its normal resting length before strengthening. Trigger
points can be injected with local anesthetic, dry-needled, The gynaecologist can evaluate the abdomen for tender-
massaged, or sprayed with a coolant such as ethylchloride ness and myofascial trigger points, particularly looking for
and then actively stretched, a technique that has been those that reproduce the patient's pain. The same can be
reported to be effective.122 Physical therapists may use done with the pelvic floor muscles, including the obturator,
other modalities, such as high-voltage galvanic stimulation, piriformis, and levator ani muscles. The muscle examina-
ultrasound, heat, and ice. Therapeutic exercises are used to tion can be done at the time of the pelvic examination or
correct muscle weakness, tightness, and spasms. in conjunction with it. A careful examination to exclude
abdominal wall hernias must be performed, and the clini- 6. Perform a sitting forward-flexion test. If there is scoli-
cian must bear in mind that myofascial pain may coexist osis when the patient is sitting, then there is pelvic
with other pelvic disorders. The interested and knowledge- height asymmetry, or shortening of one of the
able gynaecologist can extend the examination, as needed, muscles that bends the spine (quadratus lumborum
using the following multiple-level examination protocol, a or iliopsoas). Palpate the PSISs as the patient bends
screening examination for mechanical causes of pelvicre- forward. The PSISs should move symmetrically. If
gion pain. The protocol guides the examiner through the they do but there was an abnormal result in the stand-
examination process and instructs him or her in the treat- ing forward-flexion test, then the abnormality is
ment or correction of the low back and pelvic structural caused by iliac bone rotation (pelvic torsion). Sitting
dysfunctions that often accompany visceral pelvic pain stabilizes the iliac bone so that it will not rotate when
problems. The protocol assumes that a neurologic exami- the body flexes while sitting. If the PSISs move asym-
nation for disorders of the ilioinguinal, iliohypogastric, gen- metrically, then there is sacroiliac joint hypomobility.
itofemoral, and pudendal nerves has been conducted. 7. If there is evidence of iliac bone rotation, correct it.
The side that is ipsilateral to the rising or rostrally
Examination for Hip and Pelvic-Region Function
moving PSIS is anteriorly rotated and needs to be
and Symmetry
posteriorly rotated. This can be done with muscle
energy techniques, using the gluteus maximus to pos-
1. Evaluate the patient while she is walking for scoliosis teriorly rotate the iliac bone and the rectus femoris to
and for foot and knee abnormalities, such as excessive anteriorly rotate the iliac bone.
foot pronation, leg and foot rotation, and knee defor- 8. To check the abnormality in a second examination
mities. position, have the patient lie supine and stand at the
2. Evaluate the patient while she is standing for shoulder foot of the examination table. With the patient
height and iliac crest asymmetry. If the ipsilateral straight, check the anterior and posterior heights of
shoulder and iliac crest are both high, there is S- the ASISs to determine if one side is high, which
shaped scoliosis. If the contralateral iliac crest and would indicate anterior or posterior rotation of the
shoulder are high, there is C-shaped scoliosis. In pelvis (which accompanies anterior or posterior rota-
either case, the clinician must determine whether the tion of the sacrum). Assess the positions of the medial
scoliosis is caused by a fixed structural abnormality or malleoli relative to each other. They should be level. If
a correctable functional abnormality. not, note which one is higher (and thus which leg is
3. Assess posterior superior iliac spine (PSIS) symmetry. functionally shorter). The patient then sits, the legs
If one PSIS is higher than the other, there is either a sliding downward with the anterior rotation of the
tilt of the pelvis due to real or pseudo-inequality in leg pelvis. Note if one side moves further down than the
length or pelvic torsion, similar to asymmetry in iliac- other. They should move equally. If not, there is pelvic
crest height. rotation. The side that moves further is anteriorly
4. Assess anterior superior iliac spine (ASIS) symmetry. rotating. In general, there is agreement between the
If one ASIS is higher than the other, there is either results of the forward-flexion tests and the supine-to-
pelvic tilt or torsion. If the PSIS and the ASIS are sitting test. Correct rotation as described for the iliac
both high on one side, there is real or pseudo-inequal- bone.
ity in leg length. If the contralateral PSIS and ASIS are 9. Assess levels of the inferior lateral angle of the sacrum
high, there is pelvic torsion. for tilt. Assess the angle for anterior or posterior dis-
5. Perform a standing forward-flexion test, palpating the placement. A sacral tilt will increase pressure on the
PSISs, to determine if they move symmetrically or if ipsilateral sacroiliac joint.
one moves more rostrally than the other. The one 10. Assess function of the gluteus medius muscle with the
that moves is "hypermobile" and the one that does Trendelenburg test. A drop of the hip on the side
not move as well is "fixed" or "hypomobile". If the opposite to the standing leg means that the gluteus
PSISs do not move symmetrically, there is torsion of medius is weak, either actually or functionally. Exam-
the pelvis during flexion. Torsion can be seen with ine the gluteus medius for trigger points. If present,
any restriction or imbalance of the pelvis, including they should be treated and the Trendelenburg test
leg-length inequality, iliac bone rotation, and sacroiliac repeated to see if the result becomes normal.
joint hypomobility. The examination sequence is 11. Evaluate the pubic symphysis for tenderness and
intended to distinguish between these possibilities. symmetry. If abnormal, the symphysis should be
mobilized by activating the adductor muscles. The from the sacrum, to increase the joint space and achieve
patient is supine, feet together, and hips and knees mobility.
flexed. The knees are abducted 45° to 60°. Standing
at the patient's side, place a forearm between the Muscle Examination for Myofascial Trigger Points
patient's knees, your hand on the far knee and your Record the areas of tenderness and the referred-pain pat-
elbow against the near knee. Ask the patient to adduct tern of myofascial trigger points on a body diagram.
the knees against your forearm, which causes the
adductor muscles to pull on the pubic ramus, widen-
ing the pubic symphysis. Do this at the same time as Levell
the sacroiliac flare described in step 13. The patient lies supine, with the knees bent and supported
12. The patient is now prone. Standing at the patient's on a pillow to relax the abdomen. Palpate the abdominal
side, examine the sacrum for movement of the sacro- wall, including the insertions of the abdominal muscles at
iliac joint. The sacrum rotates about a diagonal line the costal margins, at the iliac crest, and at the pubic bones,
that runs from one superior aspect of the joint to the to assess tenderness and tightness of the abdominal wall.
opposite inferior lateral angle. Depress one inferior Palpate in both diagonal directions to detect tight linear
lateral angle while palpating the contralateral superior bands of contracted muscle in the external and internal
aspect of the joint. The sacrum should rock across oblique abdominal muscles, as well as vertically to detect
the diagonal axis. If not, it must be mobilized. tight bands of contracted muscle in the horizontal fibres of
13. Before mobilizing the sacrum, flare the sacroiliac the transverse abdominal muscle. Palpate the rectus
joints by having the patient lie supine, knees and hips abdominus muscle across the fibres (i.e., with a transverse
flexed and feet together. The thighs are abducted 45° motion of the fingers) to detect tight, contracted bands of
to 60°. Place your hands on the outside (lateral aspect) muscle. Assess tenderness of the abdominal wall through-
of each knee. Ask the patient to abduct the thighs out the examination. The patient then distends the abdom-
against your hands. This places a laterally directed inal wall, lifting it away from the contents of the abdominal
force on the iliac bones. cavity. The patient should be able to maintain the disten-
14. To mobilize the sacrum, place the hypermobile side tion while breathing and talking. Palpate the abdominal
superiorly while the patient lies in the lateral decubitus wall again for tenderness (which will be from the abdomi-
position. The legs are flexed at the hip and at the knee. nal wall and not from the internal organs) and discrete
If the hypermobile side is posteriorly rotated (the sacral areas of hardness.
sulcus on the hypermobile side being more shallow
Palpate the adductor muscles of the medial thigh for bands
than on the freely moving side), it must be rotated ante-
of tight muscle and tenderness. Compress any tender spot
riorly. To accomplish this, bring the upper shoulder for-
firmly for 5 to 10 seconds to elicit referred pain, which
ward during mobilization of the sacroiliac joint. If the
might be felt in the groin, inner aspect of the thigh, or (in
hypermobile side is anteriorly rotated (the sacral sulcus
the case of the adductor magnus muscle) deeply, but poorly
on the hypermobile side being deeper than the freely
localized, in the pelvis.
moving joint), place the upper shoulder posteriorly dur-
ing mobilization. Correction of anterior or posterior The patient now turns to the lateral decubitus position, the
rotation is accomplished by creating the opposite condi- head and arm supported by pillows. Position the superior
tion (posterior rotation when the side is anterior, ante- leg behind the lower leg to drop the pelvis and increase the
rior rotation when the side is posterior). Now, have the space between the rib cage and the iliac crest to facilitate
patient bring her knees to the edge of the table, ankles palpation of the quadratus lumborum muscle. The lateral
and feet together, and bring the ankles and feet off the border of this muscle is between the 12th rib and the iliac
side of the table. Stand in front of the patient at the side crest, directly above the transverse processes of the lumbar
of the table so that the patient's knees are stabilized by spine, into which the muscle inserts medially. Note any
your left hand under the thigh, just above the knee. tight bands and tenderness in this muscle.
Place your right hand on top of both of the patient's
ankles and rotate the legs downward together slowly Palpate the lumbar paraspinal muscles for linear bands of
(over 5 to 10 seconds) until a barrier is reached. Have hardness or tautness, and note the patterns of any referred
the patient use the Lewit technique125 of post-isometric pain.
contraction and relaxation to facilitate stretch and mobi-
lization. Repeat this sequence until full motion is Palpate the three gluteal muscles (maximus, medius, and
achieved. This action lifts the superior iliac bone away minimus), the piriformis, and the tensor fascia lata muscles
for discrete bands of hardness or tautness and tenderness, amount of anesthetic, usually 0.1 or 0.2 mL, is injected into
and note the patterns of any referred pain. the trigger zone. The needle is withdrawn to just below the
skin and its angle changed; the needle is then passed
through the muscle to another trigger zone. A conical vol-
Level 2
ume of muscle can thus be examined for active trigger
The patient lies supine, with the knee ipsilateral to the side
points without withdrawal of the needle through the skin.
being examined bent to relax the abdomen. Stand at the
The trigger zone is explored in this manner until no further
patient's side, the fmgertips of the palpating hand lateral to
local twitch responses are obtained. At this point, the taut
the border of the rectus abdominus muscle, from the level of
band is usually gone, and the spontaneous pain of the trig-
the umbilicus caudally. Place the other hand over the examin-
ger point has subsided.
ing hand and guide the examining fmgers so that the fmger-
tips are pointing to the psoas muscle. Move the hand slowly Historically, procaine has been used for this purpose,
into the abdomen, over six breaths from the patient, to although lidocaine is also commonly used today. Procaine, in
move aside the bowel. The fmgers will come to rest on the a dilute solution of 0.5%, has a short half-life, which is an
psoas muscle. Confirm location by moving the ipsilateral advantage if the anesthetic solution spreads between tissue
knee a few inches toward the chest to contract the psoas. planes and produces a nerve block. When diluted to 0.25%
Assess the muscle for tenderness. The examining technique in water, lidocaine has been shown to produce the least pain
can also be used for manual treatment of the muscle. after injection, although when diluted in normal saline it
works well enough, with minimal pain after injection.
Examine the obturator internus with the patient supine and
the legs flexed at the hips and knees, feet together, the legs
Glucocorticosteroids and ketorolac have also been used,
falling away to the side. Palpate the muscle posterior (dor-
but they have not been the subject of controlled studies
sal) to the adductor brevis, where it inserts onto the femur.
comparing their effectiveness against that of either local
Palpate the pectineus muscle for groin pain, as it lies under- anesthesia or dry needling. Steroids have the disadvantage
neath the femoral neurovascular bundle. Palpate the mus- of being locally myotoxic, and repeated administration can
cle medially and superiorly to the femoral artery. produce all of the associated unwanted side effects. Saline
or dry needling can be performed on persons allergic to
local anesthetics. A systematic review of the literature
Level 3 found no advantage to the addition of any substance,
Examine the levator ani muscle per rectum, sweeping the whether steroids, ketorolac, or vitamin B12, which is some-
examining fmger from anterior to posterior on each side, times added to the mix.128
noting any tenderness and horizontal bands of tightness or
hardness. Botulinum toxin has been successful in trigger-point inactiva-
tion.129-131 It is of particular interest in the treatment of myo-
Examine the piriformis and obturator internus muscles for fascial pain syndromes, including myogenic headaches or
tenderness and discrete bands of tightness rectally or vaginally. headaches of muscular origin, because it has a direct effect
on pain mechanisms as well as on muscle contraction.132
Reproduction of all or part of the patient's pain is sought
when examining the pelvic and abdominal regions for ten-
derness and muscle hardness. There is no limit to the number of trigger-point injec-
tions that can be given. Common sense and patient
comfort dictate restraint. Nevertheless, a sufficient
TREATMENT OF MYOFASCIAL TRIGGER POINTS
number of muscles in the region must be treated to
Injections resolve a regional myofascial pain syndrome and allow
Inactivation of a trigger point by injection appears to result effective stretching. Five to ten trigger-point sites can
from the mechanical action of the needle at the trigger readily be treated per session, and some skilled physi-
point, since it can be accomplished by dry needling without cians will treat considerably more in one session.
local anesthesia or the use of other materials. Local anes- Repeat injections into the same area are best done after
thesia is more comfortable for many patients and results in an interval of a week to allow the muscle to recover.
a longer-lasting reduction in trigger-point pain.126,127 Complications are infrequent and include bleeding,
pain, and, rarely, anaphylaxis if local anesthetics are
A local twitch response or a report of referred pain indi- used. Inadequate attention to postinjection aspects of
cates that the trigger zone has been entered. A small treatment leads to failure to relieve pain.
Gunn and colleagues133,134 reported on a method of trigger- techniques have been influenced by the work of Gunn133
point inactivation called intramuscular stimulation (IMS). of Canada and Lewit125 of Czechoslovakia.
IMS involves insertion of the needle directly into the trigger
point and is a form of dry needling. It may be combined The protocol involves the decrease or elimination of pain
with electrical stimulation through the needle (percutaneous by direct finger pressure on the trigger zone; that is, the ten-
electroneural stimulation). None of these techniques has der part of the hard or taut band of muscle. Decrease in
been subjected to clinical trials for effectiveness. pain usually occurs within 15 to 20 seconds, and relaxation
of the taut band usually occurs within 1 minute of compres-
The abdominal contents can be avoided by depressing the sion. Compression is followed by a firm stretch of the local
abdominal wall with a tongue blade or the finger, so that the segment of muscle: a fmger is run along the taut band for
needle can be inserted laterally into the wall trigger point about 1 to 2 inches for about 3 to 5 repeats. Mobilization
without risking injection through the wall into the bowel. of the fascia is done next, with strong, firm pressure on the
Trigger points in the lateral abdominal wall can be needled or muscle directed through the referred-pain pattern. These
injected by grasping the wall musculature between the index therapeutic stretches of each muscle treated are performed
and long fingers and the thumb to move the bowel out of to lengthen the shortened bands of contracted or hard mus-
the way and then injecting the grasped muscle with the nee- cle. The stretches are muscle-specific and must be done
dle, perpendicular to the plane of the muscle. with knowledge of the functional anatomy of the muscle.
Stretching must be limited in hypermobile women.
The piriformis muscle can be injected from the outside
(percutaneously), after identifying the muscle by palpation, Concurrently, the patient is taught a home-treatment
between the superior trochanteric insertion of the muscle program.
and the sacral origin of the muscle below the PSIS.
Most muscles can be treated outside of the internal pelvis.
The obturator internus can be injected from outside the However, stretching the levator ani can be very helpful to
pelvis or through the vagina. Rhonda Kotarinos, a Chicago some patients and requires a stretch per rectum. The piri-
physical therapist, uses a metal flute to guide the needle to formis muscle can be stretched via the pelvic approach but
the muscle trigger point when her gynaecologic colleagues also can be treated outside the pelvis.
inject trigger points through the vagina.
This program is continued until pain is reduced and range
The levator ani muscle can be injected by inserting the needle of motion is improved, at which time strengthening and
lateral and a little ventral to the coccyx, one finger of the other core or lumbar stabilization can be introduced.
hand in the rectum at the trigger point guiding the needle.
Other physical therapy modalities can supplement this pro-
Physical Therapy tocol. Few studies have been published on the effectiveness
The goal of physical therapy for myofascial pain syndrome of specific treatment techniques in myofascial pain syn-
is to restore function to the affected person. Dysfunction dromes, and fewer have been controlled or randomized.
is the result of pain that interferes with use of a body part The reported outcome, however, is that ultrasound, mas-
or with sleep. Dysfunction therefore results from the mani- sage, stretching, and heat can all be helpful in reducing
festations of the trigger point; namely, tenderness, shorten- pain and restoring function. Relaxation techniques and
ing of the muscle, with resultant limited or painful range of then manual stretching of the rectal sphincter and levator
motion, and weakness. Referred pain falls into the category ani can be very helpful in persons with pelvic pain. Disten-
of pain-associated limitations, except that trigger points sion of the bladder can be very effective in reducing urinary
can be found in the zone of referred pain. frequency in persons with irritable bladder syndrome.
Physical therapy, or, more properly, manual therapy, is Rolfing and other techniques have their advocates and can
directed toward decrease of pain and restoration of a nor- also be effective. Rolfing is defined as creating a holistic
mal, pain-free range of motion. Referred pain will decrease system of soft tissue manipulation and movement educa-
with this treatment, but trigger points in the referred-pain tion that organizes the whole body in gravity. It is named
zone must also be treated directly. after Ida Rolf, who first described the technique.135
A treatment protocol that we have found to be effective Part of a physical therapy program is the identification and
has been adapted from the work of Dejong122 of Switzer- treatment of structural abnormalities, such as pelvic asym-
land and Travell and Simons122 of the United States. The metry and scoliosis.
In a word, physical therapy can be effective when carried chapter. Although many of these functional tests have not
out about twice weekly, until the myofascial syndrome has been validated among therapists, it is generally recognized
begun to resolve. A home program is essential. Treatment that individual therapists have particular skills in this area
can be brief for acute syndromes but can continue for of investigation and are capable of evaluating pain from
months for CPP. this site and establishing its relation to sacroiliac joint laxity.
At present, there are no commonly used tests of sacroiliac
stability other than clinical examination, although research-
Sacroiliac Joint
ers are beginning to use ultrasound to detect movement in
The sacroiliac joint and its relation to pelvic pain are of his-
the joint.138,139
torical importance as well as interest. Pain emanating from
the region of this joint was recognized in the late 19th cen- This pattern of pain is very common in women. There still
tury and has remained in the fields of osteopathy and chi- is no clear understanding of the mechanics of the joint in
ropractic ever since. The sacroiliac joint lost its popularity relation to pain and joint mobility, although there have
in favour of disc surgery and is only now being evaluated been investigations into the biomechanics of the joint.140
in relation to CPP. This joint is included in the discussions New approaches to the management of pain that are under
of CPP because of the clinical presentation, which may increasing evaluation include prolotherapy,141 in which a
mimic visceral problems, especially in the lower quadrants sucrose solution is injected into the sacroiliac joint space or
of the abdomen, and the recent availability of treatments into multiple joint spaces in the vertebral column. The
that hold promise. inflammation produced in the joint space results in restric-
teq motion and reduced mobility. Although this therapy is
The sacroiliac joint is a large joint made of articular carti-
becoming popular for pain in the lower back due to joint
lage. In men, there are ridges that interlock and prevent
laxity, additional clinical trials into its use in the manage-
movement of the joint. This interlocking is generally absent
ment of sacroiliac pain would be ideal.142
in women, who have a smooth articular surface that has
been assumed to assist with mechanical changes associated
with childbirth. The sacroiliac joint braces the weight of SUMMARY STATEMENT
the torso and conveys force outward toward the ilium. Physical therapists are an important part of the health
Movement in the joint spaces has been appreciated by team in relation to CPP due to myofascial dysfunction (I).
experienced therapists, and recently, more thorough testing
of this movement has begun. The joint is held in place by
dense ligaments. Current observations indicate that for- Recommendations
ward movement of the pelvis in relation to the spine (nuta- 1. Health care providers should become more aware of
tion) is limited by the long dorsalligament of the spine and myofascial dysfunction as a cause of chronic pelvic
the thoracolumbar fascia. The opposite movement, coun- pain (CPP) and the available treatment options (IB).
ternutation, in which the sacrum flexes on the vertebral
2. Patients should participate in the management of
column, is held in check by the sacrotuberous ligament.
CPP due to myofascial dysfunction by actively using
The role of these ligaments, regulating nutation (forward
a home stretching and exercise program (II-2B).
movement of the sacrum) and counternutation (backward
movement of the sacrum), is considered important in
CHAPTER 8: MEDICAL THERAPY-EVIDENCE ON
sacroiliac stability.136,137 The actual mechanisms of pain in
EFFECTIVENESS
this joint remain poorly understood.
Clinically, pain emanating from the sacroiliac joint is appre- Claude Fortin, MD; 1 Robert H. Lea, MD2
ciated in the posterior pelvis, with some radiation into the
lateral aspect of the thigh. Some women experience 1
Montreal QC
abdominal pain in the right and left lower quadrants that is 2
Halifax NS
perhaps due to irritation of the psoas muscle, which
courses along the anterior aspect of the joint. INTRODUCTION
Diagnosis of the sacroiliac problem is based on the appre- In clinical practice, there are two approaches to the treat-
ciation of pain associated with strain induced in the region ment of chronic pelvic pain (CPP). One is to treat the pain
of the joint. A number of procedures are used in evaluating as a diagnosis and the other is to treat the disorders that
the joint, but their description is beyond the scope of this cause or contribute to the pain.26 In many patients,
effective medical therapy could be achieved by using both pain control have failed and when persistent pain is the
approaches. major impediment to improved function.
Detailed treatment of CPP associated with endometriosis Successful pain management with opioids requires that
was outlined in the SOGC consensus guideline in 1999.27 adequate analgesia be achieved without excessive adverse
A meta-analysis of interventions for CPP not associated effects (constipation, nausea, and vomiting). Although
with endometriosis, primary dysmenorrhea, chronic pelvic there may be individual variability in sensitivity to opioid
inflammatory disease (PID), or irritable bowel syndrome side effects, there is little information in the literature sug-
determined that medroxyprogesterone acetate (MPA) was gesting that one opioid has a better or worse adverse effect
associated with a reduction of pain during treatment. proftle than any other.149 Withdrawal symptoms can occur
Counselling supported by ultrasound scanning was associ- when therapy is stopped or after conversion from another
ated with reduced pain and improvement in mood. A mul- opioid.
tidisciplinary approach was beneficial for some outcome
measures. Adhesiolysis was not associated with an The advocated approach to the relief of moderate to severe
improved outcome except where adhesions were severe.143 chronic pain involves around-the-dock use of sustained-
Treatment of chronic pain, which is different from acute release opioids, the dose individually tailored according to
pain, requires acceptance of the concept of managing response, with assessment of safety, compliance, and mis-
rather than curing pain. use. There should be detailed documentation in the
patient's chart that non-narcotic treatment has failed and
Pharmacologic treatment of pain is based on the knowledge that the patient has been counselled on potential risks.
that different proftles and mechanisms for transmission of There should also be a written contract with the patient
pain information are involved.9 After proper evaluation for stating that the treating doctor is the sole provider of
possible causes of CPP, collection of adequate objective and opioids and that the patient will actively participate in strat-
subjective data, and determining that the pain could be egies to develop alternative pain therapies.26 Close and reg-
related to or associated with endometriosis, most gynaecol- ular follow-up are essential, and most patients should be
ogists will choose a course of medical management, either seen monthly. If inappropriate use, drug diversion, or
empiric or specific, before further testing. This course could hoarding occurs and control cannot be maintained, the
very well be both diagnostic and therapeutic. opioid treatment should be stopped.
evaluated in RCTs, but, with its low side-effect proflle and whereas the results were inferior with the other medica-
risks, as well as high level of comfort, continuous mono- tions or placebo.147,151 Empiric use of a GnRH agonist
phasic treatment should be in the first line in most was evaluated in an RCT involving 100 women with non-
regimens.9,36 cyclic pain and clinically suspected endometriosis.159 After
12 weeks of therapy with depot leuprolide acetate (3.75
Progestins mg/month) the treatment group showed a significant
Progestins induce decidualization and acyclicity _of endo- reduction in pain scores, dysmenorrhea, and tenderness.
metrium and endometriotic tissue. Therefore, in patients Laparoscopy performed after completion of therapy
with CPP suspected to be endometriosis-related, MPA has showed less endometriosis in the group treated with the
shown beneficial effects. In one 12-month trial, MPA GnRH agonist than in the placebo group. Even patients
depot (150 mg every 3 months) had effects equivalent to with no visualized endometriosis responded favourably to
GnRH agonists.143 Oral MPA in a 50-mg daily dosage was treatment with a GnRH agonist.
effective in reducing pain scores at the end of therapy, but
the benefit was not sustained.33,144 Empiric use in selected patients could be considered, but
even if a diagnostic/therapeutic modality has been found to
Since the introduction of the levonorgestrel-medicated be cost effective in the United States160 the evidence is lack-
intrauterine contraceptive device (IUD) (Mirena) in North ing, and the long-term outcomes are unknown. Although
America, we are awaiting studies on its possible beneficial the efficacy of GnRH agonist regimens has been proven,
effect on CPP in patients with suspected endometriosis. In the short- and long-term side effects remain to be eluci-
one study, the use of this IUD alleviated pain and reduced dated. Vasomotor symptoms and osteopenia can now be
the size of lesions in patients with endometriosis of the rec- controlled with add-back therapy. Many steroidal and non-
tovaginal septum,153 and in a pilot study insertion of the steroidal agents have been used that suppress vasomotor
IUD after laparoscopic surgery for symptomatic endome- symptoms completely and protect against decreases in bone
triosis significantly reduced the medium-term risk of recur- density without affecting pain relief. Therefore, when ther-
rence of moderate or severe dysmenorrhea.154 apy with GnRH agonists is prolonged beyond 6 months,
add-back therapy should be considered.108
Danazol
Danazol, a synthetic androgen that inhibits ovarian ste- ANTIBIOTICS
roidogenesis and the pulsatile release of pituitary gona-
dotropins, has been the gold standard for the The value of antibiotics in the management of CPP is con-
evaluation of most other medical treatments.34 Danazol troversial. Most US management algorithms include antibi-
has been found to be more effective for pain relief otics, but these agents are of value only if criteria for PID
than placebo in patients with a laparoscopic diagnosis are present. The US Centers for Disease Control recom-
of endometriosis34 and in patients who had not under- mends treating suspected PID, even if cervical cultures are
gone surgery.155 At a dose of 400 to 800 mg/ day, negative, to prevent complications such as infertility.161
danazol is effective for CPP; it should be given for a
ANTIDEPRESSANTS
minimum of 3 months before other medical options
are considered.9 The use of a danazol-medicated IUD Antidepressants have been used to treat numerous chronic
to treat endometriosis-related CPP is being evaluated. pain syndromes. However, some studies on tricyclic anti-
depressants in women with CPP and normal results of lap-
GnRH Agonists aroscopy have reported a decreased intensity and duration
GnRH agonists induce a hypoestrogenic state by inhibiting of pain.162 Since depression is more frequent in patients
ovarian steroidogenesis. Five generic compounds have with CPP, antidepressant therapy and psychological sup-
been evaluated: goserelin, leuprolide, buserelin, nafarelin port, in conjunction with other medical therapy, might
and tryptorelin. Each suppresses estradiol levels to the improve clinical outcomes.162
postmenopausal range.156 The suppression is more pro-
found and constant with a monthly depot preparation.157 NEUROLYTIC THERAPY
Most studies of GnRH agonists for endometriosis-related
pain and CPP are comparing these agents with danazol, Neurolytic therapy may be done by injecting neurotoxic
progestins, or OCs.145,146 Double-blind placebo-controlled chemicals (phenol or alcohol) or using energy (heat, cold,
studies have demonstrated that after 2 to 3 months of use or laser) in doses sufficient to destroy neural tissue.
of a GnRH agonist, pain was 80% to 100% relieved, Although these therapies are most often used to treat a
particular nerve dysfunction, they may also be used more 2. Hormonal treatment of chronic pelvic pain of .gynae-
centrally to try to decrease pain even if there is no specific cologic origin,including oral contraceptives, proges-
diagnosis or specific nerve dysfunction.146 tins, danazol, and gonadotropin-releasing hormone
agonists, has been studied extensively and should be
TREATMENT OF SPECIFIC DISORDERS considered as the first line for many women, espe-
cially those with endometriosis (I and II-1A).
CPP often originates from a specific disorder. Intersti- 3. Adjuvant medications, such as antidepressants and
tial cystltls, irritable bowel syndrome, adhesions, muscu- antibiotics, can be ofsupporting help in specific situa-
loskeletal diseases, endometriosis, and psychosocial tions (II-3B).
problems are the most frequent. Most of these com-
mon diagnoses have been studied in reasonably good
trials, and their treatment has been addressed elsewhere
CHAPTER 9: SURGERY-EVIDENCE ON
in this consensus guideline.
EFFECTIVENESS
SUMMARY
Nicholas A. Leyland, BSc, MD, FRCSC, FSOGC;1
Selection of a first-line medical therapeutic agent should be Hassan Shenassa, MD, FRCSC2
based on the nature of the pain, contraindications to medica-
tions, and desire for contraception. NSAIDs, OCs, or both 1
Toronto ON
should be tried early on, especially if the origin of the pain is 2
Ottawa ON
suspected to be endometriotic. If therapy fails, second-line
options, such as danazol, a progestin, or a GnRH agonist SURGICAL MANAGEMENT OF PELVIC ADHESIONS
(with add-back therapy), have to be considered for a prede-
termined period. Empiric medical therapy could be cost- There is evidence from one Cochrane study163 that the sur-
effective. If adequate pain relief is obtained, an appropriate gical management of pelvic adhesions associated with
maintenance regimen should be selected. Treatment failure endometriosis is effective in the management of pain for 6
should prompt review of diagnosis and treatment, in view of months. The combined surgical approach of laparoscopic
the multiple causes of CPP. Re-evaluation and treatment revi- laser ablation, adhesiolysis, and uterine nerve ablation is
sion, including a surgical approach, should be considered. likely to benefit patients with pelvic pain associated with
minimal, mild, or moderate endometriosis. However, since
CPP is a serious problem. Diagnosis and treatment can be only one trial was included in the analysis, this conclusion
complex. Medical therapy alone could be insufficient. should be interpreted with caution.
Even if there is no cure, a combination of medical and sur-
gical approaches might meet expectations in light of the Laparoscopic Adhesio/ysis
multiple causes and contributing factors. Intra-abdominal and pelvic adhesions are causes of intesti-
nal obstruction64,67 and infertility.164 As a cause of pelvic
In summary, health care providers should be aiming towards pain, their role is less clear. At the time of laparoscopy,
the least complicated treatment that improves functional intra-abdominal and pelvic adhesions can be found in
capacity despite the fact that chronic pain may continue. approximately 25% of women with chronic pelvic pain
(CPP).165 If adhesions cause CPP, then adhesiolysis should
SUMMARY STATEMENTS resolve the pain. A randomized trial of adhesiolysis by lapa-
1. Most commonly, treatment of CPP will require rotomy versus no adhesiolysis, however, failed to show any
significant reduction in pain in the group treated with adhe-
manag ing rather than curing pain (III).
siolysis compared with the control group.166 The subgroup
2. Medical therapy alone may not be sufficient to allevi-
of women with severe adhesions showed a significant
ate pain in light of the complexity and the multiple
reduction in pain that was attributed to the adhesiolysis. A
causes of CPP (III).
number of observational studies have also shown a signifi-
cant reduction in pain among women with CPP after lysis
of adhesions. These findings suggest that some adhesive
Recommendations
disease may contribute to CPP.167
1. Opioid therapy can be considered for pain control
under adequate supervision (II-3B). Although some imaging techniques may facilitate the diag-
nosis of adhesive disease, the gold standard is laparoscopy.
Laparoscopy is also the gold standard for the treatment of with other surgical procedures. Adjunctive surgical treat-
adhesive disease; its advantage is well-documented. ments for CPP may include lysis of adhesions, resection of
Patients undergoing laparoscopy for the surgical treatment endometriosis, presacral neurectomy (PSN), laparoscopic
of adhesive disease have often had prior abdominal and uterine ne:rve ablation (LUNA), salpingo-oophorectomy,
pelvic surgery, however, so the risk of bowel and omental and hysterectomy. Since gynaecologic disease often accom-
injuries is significant. panies appendiceal disease, it is difficult to demonstrate
that disease of the appendix is responsible for the pain.
Techniques to minimize the risk of such injuries include
open laparoscopy and placement of a trocar-cannula in the One recent retrospective study found that 12% of women
left upper quadrant to allow insertion of the umbilical trocar undergoing diagnostic laparoscopy with appendectomy
under direct vision or to carry out periumbilical adhesiolysis experienced relief of CPP in the absence of any other dis-
before the trocar insertion. Adhesiolysis may be facilitated order.169 Appendectomy was the main procedure in 102
by laser, electrosurgical, or sharp scissors dissection. Hemo- patients, of whom 92 (90%) reported relief of their pelvic
stasis should be obtained, and any injuries to the bowel pain. These results suggest that disease of the appendix
should be immediately repaired. Adhesion barriers to pre- may be a significant cause of CPP.
vent reformation of adhesions should be considered.
PSNAND LUNA
Uncontrolled studies have shown that laparoscopic adhesiol-
ysis reduces pain perception in 60% to 90% of patients.168 Adjunctive laparoscopic surgical procedures, including
However, many patients have laparoscopically confirmed PSN and LUNA, can be technically demanding but con-
adhesive disease without any perception of pain. Better- tinue to have a role in the management of CPP.179
designed trials are needed to clarify the issue of adhesiolysis.
Any surgical management of pelvic pain requires an under-
standing of the autonomic innervation of the pelvis. The
Appendectomy disruption of afferent neural signals from the pelvic organs
In gynaecologic practice, the appendix has been an under- can reduce the perception of pain caused by endometriosis
appreciated source of CPP. Many women with CPP are and other disorders.180
found to have appendicopathy. Conversely, many women
with chronic appendicopathy are found to have gynaeco- A prospective comparison of PSN and LUNA indicated
logic disorders when undergoing laparoscopic appendec- that they were equally efficacious in the treatment of dys-
tomy.169 Appendiceal disease as a source of CPP may menorrhea but that PSN had a more prolonged effect.181
coexist with endometriosis. Approximately 20% of women A recent randomized, double-blind trial of conservative
with endometriosis have appendiceal disease.170 In patients laparoscopic surgery with adjunctive PSN or LUNA in
with endometriosis who present with pelvic or abdominal women with severe dysmenorrhea caused by endometriosis
pain (especially right lower quadrant pain), one should demonstrated more pronounced and prolonged pain relief
therefore consider nongynaecologic sources of CPP, with PSN than with LUNA.182
including chronic or recurrent appendicitis.171,172
SUMMARY STATEMENTS
One study suggested that the amount of histopathologic
1. The qualitative evaluation of surgery in the manage-
abnormality exceeds visible disease of the appendix by
11%.169 Moreover, the investigators demonstrated that ment of CPP is limited in terms of randomized clini-
34% of patients with reduced pain after appendectomy cal trials (III).
alone had no visible or histopathologic abnormalities. Two 2. Laparoscopy is the mainstay of diagnosis and surgical
studies further suggested that prophylactic appendectomy treatment of CPP. Careful judgffient is important
may be beneficial in women with CPP as both a therapeutic when repeat surgery is being considered (I and II).
and a preventive measure.173,174
Recommendations
We reviewed six uncontrolled retrospective and prospec-
1. The lack of robust clinical trials of the surgical man-
tive studies that all described laparoscopic appendectomy
agement of chronic pelvic pain should be addressed.
as advantageous in the treatment of CPP.168,173,175-178 Five
The use of alternative epidemiologic models, includ-
of these studies reported relief of chronic pelvic or lower
ing case-controlled and cohort-controlled trials,
abdominal pain after appendectomy in 85% to 97% of
should be considered (III-A).
women undergoing appendectomy alone or in conjunction
2. Further delineation of the role of appendectomy and CBT is typically provided in a group setting, with 8 to
of presacral neurectomy appears warranted in the 12 patients and 1 or 2 therapists, typically psychologists
management of endometriosis-related pain (III-A). or other care providers with a mental health back-
ground. Health care providers with a background in
caring for people with psychological consequences of
CHAPTER 10: PSYCHOLOGICAL TREATMENT FOR
chronic pelvic disorders may also offer these treatments
CHRONIC PELVIC PAIN
in community settings. CBTs are a typical component
of services offered in multidisciplinary pain manage-
ment programs.
Paul Taenzer, PhD, CPsych
In summary, CBTs have broad empiric support for their
Calgary AS effectiveness in reducing perceived pain intensity and distress
in populations with chronic pain. Preliminary data suggest
INTRODUCTION that this approach is effective for women with CPP.
through inpatient or outpatient facilities; the clinics are not specialists with tertiary- level knowledge of CPP is the ideal
engaged in professional training or research and are typi- treatment approach for women with CPP.
cally not associated with major educational or research
institutions. Multidisciplinary pain centres provide clinical
services similar to those of multidisciplinary pain clinics as SUMMARY STATEMENT
well as clinical training and research. Current evidence indicates that tertiary-level multi- dis-
ciplinary chronic pain management is the most effective
treatment approach for women with CPP (I).
SCOPE OF CARE
A case report on a 23-year-old primigravida with CPP at 27 with explanation has been found to help. Massage, sur-
weeks gestation documented that acupuncture significantly face ultrasound stimulation, and TENS may also help
reduced the patient's use of narcotics and allowed her to relieve pain.
maintain normal activity.197 Several recent studies have
also found benefit from acupuncture in back pain200 and
in lumbar and pelvic pain in pregnancy.201 Further, acu- CHAPTER 13: PATIENT PERSPECTIVES
puncture appears to be a durable therapy for symptom
relief in men with chronic prostatitis and CPP syn- John F. Jarrell, MD, Calgary AB
drome.202 Acupuncture/acupressure has received approval
from the Food and Drug Administration in the United PATIENTS' NEEDS
States for use in the relief of chronic pain in oncology
A 2002 needs assessment survey by the Society of Obste-
patients.197
tricians and Gynaecologists of Canada (SOGC) of subjects
As a therapeutic modality, acupuncture has a long tradition with chronic pelvic pain (CPP), undertaken using the prin-
in Chinese medicine for the treatment of gynaecologic and ciples of qualitative research, determined that the following
obstetric problems. There is, as yet, no comprehensive allo- were the most important needs of these patients:
pathic explanation for its clinical benefits, but proposed
the need for the health care professional to legitimize the
mechanisms include gate control of pain pathways, increased
endogenous opioid release, and altered sympathetic tone.202 pain,
the need for the patient to be heard during the patient
PLANTS AND' HERBAL AND DIETARY THERAPIES contact visit,
the need for the patient to receive support in numerous
Traditional healing provides for a large percentage of pri- forms, and
mary health care needs in many populations. One study the need for the patient to take responsibility for a path
screened plants used by South African Zulu traditional towards health (III-B).
healers in the treatment of dysmenorrhea.203 Several plant
extracts exhibited high inhibitory activity against cyclooxy- A LOOK INTO THE FUTURE
genase and therefore the prostaglandin biosynthetic path-
way responsible for painful uterine contractions. In the future, a woman with CPP will be recognized as hav-
ing a condition that requires rehabilitation and not solely
The Cochrane Review of herbal and dietary therapies for pri- acute care management. She will be managed by a team of
mary and secondary dysmenorrhea204 suggested that magne- individuals who are aware of the principles of multidisci-
sium supplementation might help reduce symptoms. plinary care, including a physiotherapist, a psychologist, a
primary care physician, and a gynaecologist. Such an
SUMMARY approach will be funded by the local hospital or regional
health authority on the basis of its effectiveness and cost
CPP is a frustrating and disabling condition, with as yet efficiency.
unclear neuroendocrine etiology. A multidisciplinary
approach to diagnosis and care is currently recom- Emphasis will be placed on achieving higher function in
mended.191 For visceral-peritoneal pain, acupuncture is life with some pain rather than cure. The management of
beneficial. Musculoskeletal sources of pain respond to directed therapy will be based on treatments that have
physiotherapy and biofeedback training. Somatic-myofas- been subjected to clinical trial. There will be a permanent
cial pain has been reduced with massage, ultrasound stimu- record of the findings at any previous laparoscopy that can
lation, TENS, and, especially, trigger-point injection and be shared and compared over time. Health personnel
dry-needling modalities. Grounding all treatment is the sin- involved in the patient's management will have been
cere acknowledgement of the complexity and authenticity trained in the specific areas of myofascial dysfunction and
of this chronic condition. the appropriate clinical use of opiates in the chronic pain
state.
SUMMARY STATEMENT In addition to participating in clinical trials of various thera-
Alternative therapies for chronic pelvic pain that have pies, the patient will become aware of newer approaches
been found helpful include acupuncture, physiotherapy, that may be of assistance through Internet access to the
and biofeedback training. Use of pelvic ultrasonography results of clinical trials. One of the main areas of
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