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66INTRODUCTIONTheInternationalAssociationfortheStudyofPain(IASP)definespainasfollows:'Painisanunpleasantsensoryandemotionalexperienceassociatedwithactualorpotentialtissuedamage,ordescribedintermsofsuchdamage'1.
Thisdefinitionwasintroducedin1979andisim-portantbecauseitacceptsthatpaincanoccurwith-outtissuedamageandthatpsychologicalfactors(learning,memory,thesoul,mood,feelings,etc.
),aswellassocioculturalfactorsplayavitalroleintheperceptionofpain2.
Beingabletoexperiencepainisessentialforsur-vival3.
Acutepainhasaprotectivefunction:itisabruptinonsetandleadstoimmediatewithdrawalfromthecauseofthepainaswellastoseekinghelpifthepainisinternalorsevere.
Acutepaindis-appearsastheaffectedtissuesheal.
Chronicpainisdifferent.
Itpersists.
Itmayhavestartedwithanepisodeofacutepain,itmaybeassociatedwithanon-goingdiseaseprocess,butitmayalsoarisewith-outanydiscerniblephysicalcause4.
Thephysiologyofpainiscomplex.
Thebrainandspinalcordhavemechanismsthatareabletomodifytheperceptionofastimulusandeitherin-creaseordecreasesensationsfeltaspain.
Whenastimulusbecomesrepetitive(i.
e.
chronic),forexamplefrompersistentinflammation,itcanlowerthethresholdforpainperceptionsothatevennor-malactivitywithinanorganisperceivedaspainful3.
Thisiswhypeoplewithoutobjectiveevidenceofdiseasecanstillexperiencepain.
Anotherimportantaspectofpainisthatthemindcanthinkitisorigi-natingfromonearea,butinfactitiscomingfromanother.
Thishappensbecausenervefibersfromdifferentareasconvergeastheyenterthespinalcordandsignalscan'jump'fromonenervetoanother3.
Chronicpainisasymptomwhich,whenarisingfromaninternalorgan,isoftenaccompaniedbyothernon-painfulsymptomsfromthesameorganorarea.
Chronicpainarisingfromthepelvicorganscanbeasymptomofdysfunctioninthereproduc-tivetract,gastrointestinaltract(irritablebowelsyn-drome,IBS),urinarytract(bladderpainsyndrome,BPS)orthemusculoskeletalsystem.
Chronicpelvicpainthereforecomesundertheremitofseveraldifferentspecialties.
Thetime-framefordecidingwhenapainfulexperiencehasbecomechronicisimportantforre-searchpurposesbutnotsoimportantintheclinicalsetting.
AhelpfulworkingdefinitionsuggestedbyBonica(citedbyJanicki5)thatdoesnotencompassanactualtimeframeisasfollows:'Ifpainpersistsbeyondtheusualcourseofanacuteinjuryordisease,orrecurseveryfewmonthsoryears,itisregardedaschronic'.
Definitionsofchronicpelvicpain,ofwhichtherearemany,tendtouseaminimumtimeperiodof6monthsforthepresenceofpain.
Thefollowingisanexample:'intermittentorconstantpaininthelowerabdomenorpelvisofatleast6monthsdura-tion,notoccurringexclusivelywithmenstruationorintercourseandnotassociatedwithpregnancy'6.
Thischapterwilluseamixtureoftheabovetwodefinitionsandwilldiscussthemanagementofwomenpresentingwithchronicpelvicpain.
THECONSULTATIONThefirstconsultationhasbeenshowntobesoim-portantthatitislikelytobethedeterminingfactor6ChronicPelvicPainVanessaSangalaChronicPelvicPain67Figure1Flowchartshowingmanagementofchronicpelvicpain(CPP).
IBS,irritablebowelsyndrome;COC,combinedoralcontraceptive;BPS,bladderpainsyndromePatientwithCPPHistory,examination,HIVtest,urinalysis,ultrasound(ifavailable)PregnancytestifindicatedDiagnosisendometriosisDiagnosisIBSPregnancynotdesired:suppressovulationforatleast6monthswitheither:COC(e.
g.
Microgynon);medroxyprogesteroneacetatetabletsornorethisteronetablets;Depomedroxyprogesteroneacetate(DepoProvera);Implanon;Norplant;IUS(Mirena).
Pregnancydesired:Investigateforinfertilityifappropriate.
Provideanalgesia.
ReferforlaparoscopyifavailableSymptomdiarytoidentifytriggerevents.
Pharmacologicalsymptomcontrol:AntispasmodicsAntidiarrhealsAmitriptylineNonpharmacologicalsymptomcontrol:Dietary/behavioral/lifestylemodifications.
DiagnosisBPSVoidingdiary.
Identifypossibledietarytriggers.
Avoidtea,coffee,alcohol,spicyfoodsBladder'retraining'.
AmitriptylinePelvicfloormuscleAnalgesiaPhysiotherapyAmitriptylinePsychologicalsupport;behaviortherapy;traditionalandherbalremedies;alternativemedicine.
Explainfindings,discussdiagnosisandtreatmentoptions.
Reassurenomalignancy,andnoincreasedriskofmalignancy.
Besympathetic,listentoclient'sconcerns.
Developtreatmentstrategywithclient.
UnknownetiologyAnalgesiaHormonetherapyNeedforfurtherinvestigationsidentified,makearrangementsorreferraltohigherlevelhealthcareNoneedforfurtherinvestigations,diagnosismadeGYNECOLOGYFORLESS-RESOURCEDLOCATIONS68inwhethertheoutcomeisbeneficial7.
Bytheendoftheconsultationtheclinicianshouldhavedeci-dedfromwhichorgansystem(s)thepainisarisingandhaveformulatedamanagementplan.
ForanoverviewofthemanagementseeFigure1.
Womenwithchronicpelvicpainhavesymp-tomsrelatedtotheirreproductive,genitourinaryandintestinaltractsandtheywillonlydisclosethesesymptomstosomeonetheytrust.
A'safe'reasonfortheirvisitwillbeinventedandtheywillmakeasrapidanexitaspossibleiftheirfirstimpressionsareunfavorable.
Thiswillleadtoconsultationsinotherclinicsorwithtraditionalhealers,withcompound-ingoftheirpain.
Cultural,ethnic,socioeconomic,religiousandgenderperspectives,aswellasattitudes,beliefsandbiasesallcometoplayduringtheconsultationpro-cess,affectingboththehealthproviderandtheirclient8.
Inunder-resourcedcountriesthesocio-economicdifferencesbetweenhealthproviderandclient,especiallyintheruralareasmaybeenor-mous.
Eveninurbanareastheremaybewidecul-turaldifferencesandbeliefsandlanguagemayalsobeanissue.
Involvementofaninterpreterwillbringyetanotherdimensionintotheconsultation.
Healthprovidersneedtobecognizantofthesefactorsanddoeverythingtheycantoputtheirclientatherease.
Greetingclientswarmly,introducingone'sselfandanyotherpeopleintheroom,maintainingeyecontactandlookinginterestedhelpinstillconfi-dence,dispelfearandbringhopetowhatmaybefelttobeadesperatesituation.
Healthprovidersshouldbenoticingandassessingtheirnewclientassheenterstheroom:thewayshewalksandsitsdown,whethersheshowssignsofbeingunwellorinpain,howsherespondstobeinggreetedandhergeneraldemeanor.
ThehistoryTakingagoodhistoryisthemostimportantpartoftheconsultation.
Itlaysthefoundationforastruc-turedphysicalexamination,afterwhichtheneedforfurtherinvestigationsisdetermined.
Ifpossibleanymedicalrecordsheldattheclinicshouldbereadbeforethecliententerstheroom.
Hand-heldrecordsthattheclientmayhavebroughtwithhershouldbecarefullyreviewed.
Theclient'sstoryThiswillsetthebasisfortherestoftheconsultationandneedstobeattentivelylistenedto.
Hearingthestoryisthebeginningofthehealingprocess.
Thisistrueforanycomplaint,butisofvitalimportanceforpeoplewithchronicdisorders,whooftenfeeltheyarenottakenseriously7.
Iftheclienthasprevi-ouslysoughthelpfromelsewhere,itisimportanttoaskwhyshehascometothepresentclinicatthisparticulartimeandwhatherhopesforthecon-sultationare.
Askingwhattheclientthinksisthecauseofherpainisahelpfulandoftenrevealingquestion9.
Ifthepainhasbeenpresentforover6monthsitisunlikelytobecausedbyalife-threateningillness,butthisassumptionshouldnotbemade.
Some-timesthesensitivenatureoftheirsymptomsdeterswomenfromseeingahealthproviderinatimelymanner,especiallyiftheyhavehadbadexperiencesinthepast,heardnegativestoriesaboutthehealthservice,arefrightenedofwhatmayhappentothem,orifthereareculturalmythsabouttheirsymptomsthatmakethemdifficulttodivulge.
Thefollowingareimportantpointstoclarifyaboutthepain:WhenandhowdidthepainbeginHowbadisthepain,doesitinterferewitheverydayactivities,issleepdisturbedIstheremorethanonetypeofpainWhereisthepain,doesitmoveWhenpresenthowlongdoesthepainlastDoesanythingmakeitbetterorworseDoesithaveanyrelationshiptothemenstrualcycle,i.
e.
worsebefore,duringorafterthemensesIssexpainfulIsdefecationpainfulArethereanyotherbowelsymptomsIsurinationpainfulArethereanyotherurinarysymptomsIswalking,sittingorstandingforlongperiodspainfulMenstrualhistoryAgeatmenarcheandanysignificantmenstrualproblemsneedtobeenquiredabout.
Aremen-strualproblemsacurrentconcernIfso,anytreat-mentalreadyreceivedanditseffectivenessshouldChronicPelvicPain69bedocumented.
Thedateofthelastnormalmen-strualperiodandiftherehasbeenanyabnormalbleedingsincethatdateshouldbenoted.
Pastmedical,surgicalandobstetrichistoriesEnquiryneedstobemadeaboutanypastseriousmedicalillnesses,includingpsychiatricillness,anyoperations,HIVandsexuallytransmittedinfec-tions,andanypregnanciestogetherwiththeirout-comes.
Fornulliparouswomenenquiryshouldbemadeabouttheirpregnancyintentions.
Aretheycurrentlytryingtoconceive,ifso,forhowlongandisfailuretoconceiveananxietyWantingachildisacommonreasonforwomentomakere-peatedvisitstoahealthfacility,especiallyinunder-resourcedcountrieswherebearingchildrenisespeciallyimportantforawoman'sself-esteem.
Pastandpresentcontraceptiveuseshouldbere-corded,togetherwithanyunpleasantside-effects.
Itishelpfultoknowwhetherthereisahistoryofsexualorphysicalabuse,eitherasachild,adult,orboth.
Thetimingofthisenquirydependsontherapportbuiltupwiththeclient,anditcanbedoneatanyappropriatetimeduringtheconsultation.
Althoughnotclearlyunderstood,thereappearstobearelationshipbetweenchronicpelvicpainandchildhoodsexualabuse,especiallyifthereiscon-tinuingabuseintoadulthood6.
ThephysicalexaminationThephysicalexaminationisimportantforelicitingsignsthatwillhelpformulatethediagnosis.
Itisalsoa'psychodynamicevent'9andthewaytheclientrespondsmaygiveaninsightintothewaytheyfeel.
ReadmoreonthegynecologicalexaminationinChapter1ifyoufeelunsureaboutthedifferentprocedures.
Anexplanationshouldbegivenabouthowtheexaminationwillbeconducted,startingwiththeneedtoperformanabdominalexamina-tionandexploringthepossibilitiesofdoingvaginalandspeculumexaminations.
Intimateexaminationsareusuallyconsentedto,buttheycaninthemselvescausemuchdistressespeciallyifawomanhasbeeninanabusiverelationship.
Thehealthprovidermustbeawareofthesepossibilitiesandstopanexaminationthatiscausingdistress.
Womenwhodeclinevaginalexaminationsshouldnotbemadetofeeltheyhavecompromisedtheirchancesofbeinghelped.
Theclientshouldemptyherbladderbeforethephysicalexamination,whichwillmaketheproceduremorecomfortableaswellasprovideaspecimenforimmediateurinalysis.
AbdominalexaminationInspectionwillrevealsignsofprevioussurgeryandanyobviousmassesordistention.
Iftheclientisexperiencingpainpriortoabdominalpalpation,askinghertoliftherheadandshouldersoffthebedandenquiringwhetherthiseasesthepainormakesitworsewilldeterminewhetherthepainisorigi-natingfromwithintheabdominalcavityortheabdominalwall.
Tensingtheabdominalwallmusclestendstolessenintra-abdominalpain,whereasthepainwillbemadeworseifthepatho-logyisintheabdominalwall10.
Abdominalpalpationshouldcommenceinapain-freesiteandproceedsystematicallyaroundthewholeabdomen.
Anytenderareas,obviousmassesorloadedbowelshouldbenoted.
SpeculumexaminationThisisadvisableforwomenwhoaresexuallyactive,andshouldalwaysbeperformediftherehasbeenpost-coitalbleeding,anabnormalvaginaldischargeoriftheclienthasneverhadtheircer-vixinspected.
Sometimesbluishdepositsofendometriosiscanbeseenintheposteriorfornix.
Cervicalscreeningisnotreadilyavailableinunder-resourcedcountriesandmanywomenwithcervicalcancerpresentwithuntreatablelate-stagedisease.
Opportunisticdetectionofearlycervicalcancergivestheonlychanceforsurgicalcurewhenradio-therapyservicesareunavailable.
Ifthecervixlooksnormalandvaginalinspectionwithaceticacid(VIA)isaservicethatislocallyavailable,informa-tioncanbegiventotheclientsothatifappropriateshecanattendatherconvenience(seeChapter26onhowtodoVIA).
VaginalexaminationInspectionofthevulvawillrevealsignsofirrita-tion,inflammation,ulcers,wartsordischarge.
Digitalexaminationshouldbeomittedinanyonewhohasnotbeensexuallyactiveoranyonewhoprefersnottohavethisdone.
Ifdigitalexaminationisdeclinedornottolerated,gentleexaminationGYNECOLOGYFORLESS-RESOURCEDLOCATIONS70withalongcotton-woolbudmaybeagreeduponandcangiveusefulinformation.
Initialdigitalexaminationshouldbewithonefingertominimizediscomfortsothatpotentialpainfulareascanbebetterlocalized.
Ifwelltoler-ated,twofingerscanbeinsertedlatertoaidfurtherexamination.
Gentlepalpationoftheanteriorvaginalwallwilldetermineanyurethralorbladderbasetenderness.
Examinationoftheposteriorvaginalwallandposteriorfornixwillrevealanytendernodulesthatcouldindicateendometriosis.
Askingtheclienttocontractandrelaxherpelvicfloormuscles,togetherwithgentledigitalexami-nationofthemuscles,canassesspainoriginatinginthepelvicmusculature.
Bimanualexaminationwilldeterminethesize,position,mobilityorfixationoftheuterus,whethertheuterusistenderandwhetherthereareanyobviousadnexalmasses.
AdditionalexaminationsWomenwiththefollowingsignsandsymptomsneedadditionalinvestigationsandpossiblyreferral:Rectalbleeding/bloodinstool:proctoscopy,possiblecolonoscopyorbariumenemaMacroscopichematuria:cystoscopyandintra-venouspyelogram(IVP)Microscopichematuria,afterexcludingcystitis,schistosomiasisandtuberculosis(TB),andre-peatingthetest:cystoscopyandX-IVPNewbowelsymptomsoverage50:colonos-copyorbariumenemaNewpainafterthemenopause:ultrasoundPelvicorabdominalmass,includingfibroids(seeChapter19):ultrasoundandpossiblesurgeryAscites:ultrasoundandifpossiblecytologyofascitesandstainingforTBIrregularvaginalbleedingoverage40:ultra-soundandVIA/cervicalbiopsy/endometrialbiopsyPost-coitalbleeding:VIAandifpossiblechlamy-diascreeningorpresumptivetreatmentforchlamydiaandgonorrheafollowedbyreassess-mentafter4weeksCervixsuspiciousofcarcinoma:biopsyofcervicallesion/urgentsurgeryasdeemedappropriateExcessiveweightloss:HIVtest,considerposs-iblemalignancyInvestigationsUrine,stoolandpregnancytestingSimpledipsticktestingofurine,preferablyonamidstreamspecimen,shouldbeperformed.
Ifmacroscopichematuriaispresenttheclientneedsfurtherinvestigation,butalwayschecksheisnotmenstruating!
Thepresenceofleukocytesornitritesmayindicatecystitisandiftheclientissympto-maticacourseofantibioticsshouldbeprescribedaccordingtolocalguidelines.
Ifmicroscopichematuriaisdetectedthesampleshouldbesentformicroscopytoexcludeschistosomiasis,andconsid-erationgiventotestingfortuberculosis.
Tubercu-losiscanmimicalmostanydiseaseandinendemicareasshouldnotbeforgotten.
Microscopichema-turiaisquitecommonandcanoccurafterexerciseandsexualintercourse,andfortransientunknownreasons.
Beforereferralformoreextensiveinvesti-gationsthetestshouldberepeatedtwice.
Urinarytractcancerisextremelyrareinwomenunder4011.
Othermedicalcauses(includingsicklecelldisease)wouldbeinferredfromthehistory.
Microscopyofastoolsampleshouldalsobearranged,asparasiticinfectionscancauseabdominal/pelvicpain.
Pregnancytestingmaybeimportantdependingonthemenstrualhistory.
BloodtestsAllwomenshouldbeofferedHIVtestingiftheirstatusisunknownoriftheyhaveconcernsregard-ingsexualexposuresinceapreviousnegativetest.
Missingthisopportunityinaclientcomplainingofabdomino-pelvicpainwouldbenegligent.
Afullbloodcountwithdifferentialisagoodbasictestifavailable.
Otherbloodtestsshouldbeorderedde-pendingontheclinicalfindingsandtheirlocalavailability.
UltrasoundscanningUltrasoundscanningisbecomingincreasinglyavailableinlow-resourcedcountries.
Abdominalultrasoundshouldbeusedtoassesstheuterusandovariesinadolescentswithpelvicpain,inwomenwhodeclineavaginalexaminationandallwomenwhohaveanabdominalmass.
Transvaginalscan-ningissuperiortoabdominalscanningforvisual-izingpelvicmassesandisusefulfordetectingadenomyosisandsmallendometriomasthatwouldindicateendometriosis,orhydrosalpinxthatwouldChronicPelvicPain71indicatechronicpelvicinflammatorydisease.
Peri-tonealdepositsofendometriosiswillnotbevisual-ized.
Thevaginalprobecanbeusedtoidentifyparticularlytenderareas,andanexperiencedultra-sonographerisabletodetectthepositionandmobilityoftheovaries.
Immobilityofanovarymaybepredictiveofendometriosisoradhesions12.
InfertilityinvestigationsInfertilityisprobablyoneofthecommonestcausesofchronicpelvicpaininunder-resourcedcoun-tries,thepainoftennotbeingreproducibleduringphysicalexamination,butratherbeinganemotionalpain.
Ifthisistheworkingdiagnosis,investigationsforinfertilityaccordingtolocalprotocolsshouldbearranged.
Iftheclienthasnotcomewithherpart-nersheshouldbeencouragedtoreturnwithhimsothattheycanbeseentogether.
Thecommonestcauseofinfertilityinlow-resourcesettingsisinfec-tion-relatedtubaldamage.
Unfortunatelywomenandmeninunder-resourcedcountriesdonothaveaccesstothetreatmentoptionsavailableinrichercountries,butcompassionatemanagementshouldinstillhope,asitisrarelypossibletostatethatawomanwillneverbeabletoconceive.
Afterconductingtheclinicalexaminationandre-viewingtheresultsofalltestsundertakentheclini-cianshouldhavecomeupwithaworkingdiagnosisonwhichtobasetreatment.
Thefollowingcondi-tionsarethemostlikelytocausechronicpelvicpainandwillnowbereviewed.
Itispossibleformorethanoneconditiontobepresentinthesameindividual:EndometriosisIBSBPSPelvicmuscledysfunctionAdhesionsENDOMETRIOSISEndometriosisis'thepresenceofendometrial-liketissueoutsidetheuteruswhichinducesachronicinflammatoryreaction'13.
Itisanestrogen-dependentcondition,withsymptomsusuallyappearingafterthemenarcheandresolvingafterthemenopause.
Riskfactorsforendometriosisinclude:earlyageatmenarche,shortmenstrualcycles,heavymenstrualflow,painfulmenstruation,infertility,endometriosisinafirst-degreerelative,andimmunedisorders14.
Threedifferentformsofendometriosishavebeendescribed,andanymixtureoflesionsispossible15:Peritonealendometriosis,whereendometriosisisfoundonthepelvicperitoneumand/orthesurfaceoftheovaries.
Endometriomas,whichareovariancystslinedwithendometrial-liketissueandcontainingathick,tarry,'chocolate-like'fluid.
Asolidmassofendometrial-liketissuemixedwithfattyandfibroustissuethatformsnodulesbetweenthevaginaandrectum.
Endometrioticlesionscanvaryfrombeingverysmallandbarelyvisible,tolesionscausinglargeovariancysts,extensiveadhesionsandsometimesinfiltratingintotheboweland/orbladder.
About30–50%ofwomenwithendometriosisareinfertile16.
However,normallyfertilewomenhavealsobeenfoundwithendometriosis.
Inferti-lityistobeexpectedwhenendometriosiscausesadhesionswithblockageordistortionofthefallo-piantubes,butforreasonsnotfullyunderstoodwomenwithmilddiseasecanalsohavedifficultyconceiving.
DiagnosingendometriosisAworkingdiagnosisofendometriosisismadefromacombinationofsymptomsandphysicalfindings.
Transvaginalultrasoundifavailable(orabdominalultrasoundinthosenotsexuallyactive)maybehelpful,especiallyfordiagnosingendometriomas.
Thefollowingsymptomshavebeenshowntoberelevanttoadiagnosisofendometriosis:DysmenorrheaMenorrhagiaIrregularmenstrualcycleDeepdyspareunia(whichmayindicateinvolve-mentoftheuterosacralligaments)Paininthelowerabdomen/pelvisthatispoorlylocalizedandmaybeconstantorcyclicalUrinarytractsymptoms:frequency,painonmicturitionPastdiagnosisofirritablebowelsyndromePasthistoryofovariancystsDifficultyconceivingPastepisodesofpelvicinflammatorydiseaseSleepdisturbances.
GYNECOLOGYFORLESS-RESOURCEDLOCATIONS72Womenwithmorethanoneoftheabovearesig-nificantlylikelytohaveendometriosiscomparedtowomenwithoutendometriosis17.
Theyshouldbeofferedtreatmentdependingonwhetherornottheyaretryingtoconceive.
TreatmentofendometriosisHormonaltherapy,analgesicsandsurgeryallhavearoletoplayinpatientmanagement,whichneedstobeindividuallytailoredaccordingtosymptomsanddesireforfertility.
Opendiscussionwithwomenabouttheeffectivenessandside-effectsofthedifferentoptionsandencouragingtheiractivein-volvementindecidingwhichoptiontochoose,givesthebestchanceforsuccess.
HormonaltherapyInhibitionofovulationisofteneffectiveinsuppress-ingendometriosisandcontrollingcyclicpainandmenstrualdisorders.
However,itisonlyanoptionforwomenwhoacceptthattheywillnotconceivewhileonmedication.
Thereisnoevidencethatsup-pressingovulationforaperiodoftimewillimprovethelaterchanceofconception16andwomenshouldnotbefalselyleadtobelievethatitwill.
Therapyshouldbecontinuedforaslongasnecessary,symp-tomsbeinglikelytorecurwhenitisstopped.
Aminimumof6monthsisrecommended18.
Thecombinedoralcontraceptive(COC)pillisusuallyreadilyavailableinunder-resourcedcoun-triesaspartoftheirfamilyplanningprograms.
Anylow-doseCOC(notmorethan35gethinylestra-diol)canbeused.
Itisbesttakencontinually,ratherthaninthetraditionalcyclicway,sothatmenstrua-tionisabolished18.
Thismeansexplainingtowomenthattheyshoulddiscardthesevenplacebotabletsineachpacketifpillswiththesearetheonlyoptionsavailable.
Breakthroughbleedingisthemainside-effectoftakingtheCOCcontinuously,butifthishappensa7-daybreakcanbetakenandthepillsthenre-started.
Somewomenfindtakinga5-or7-daybreakevery3monthspreventsbreak-throughbleeding.
Analgesicscanbetakentoaugmentpainreliefifnecessary.
Womenwithcontraindicationstoanestrogen-containingpill,orwomenwhohavehadpreviousunacceptableside-effectswiththeCOC,cantryaprogestogen-onlymethod.
Theinjectabledepotmedroxyprogesteroneacetate(DMPA),150mgevery3monthsisveryeffective.
Progestogenscanalsobegivenorally,e.
g.
medroxyprogesteroneacetateornorethisterone,startingat10mgdailyandincreasingthedoseifbreakthroughbleedingoccurs.
Womenmayprefertheoptionoftryingoneoftheprogestogenicimplants,whicheverisavailable.
Thereissomeevidencethattheetono-gestrelimplantisaseffectiveasDMPAinrelievingendometriosis-relatedpain19.
Irregularbleedingisacommonside-effectofprogestogentherapythatmaytakeseveralmonthstosettle.
Thelevonorgestrelintrauterinesystem(IUS)isanotheroption.
Thisdevicereducesmenstrualflow,ofteninducesamenorrhea,andhasbeenshowntohaveabeneficialeffectonendometriosisinsomewomen20.
Levelsofcirculatinghormoneareextremelylowwhichmaymakethemethodmoreacceptableforwomenwithhormonalside-effectsfromtheothermethods.
Unfortunately,itisratherexpensiveinsomecountriesandnotavail-ableinallunder-resourcedcountries.
WomenwantingtoconceiveThetreatmentoptionsforwomenwhowanttoconceivearelimitedtoanalgesiaor,ifappropriate,surgery.
Referralforlaparoscopy,ifavailable,canbeconsidered.
Ahistorysuggestiveofendometrio-sisdoesnotmeanthatendometriosisisdefinitelythecauseoffailuretoconceive,andacoupleshouldbeinvestigatedinthesamewayasanyothercouplewithsubfertility.
AnalgesicsforchronicpelvicpainEffectiveanalgesiaisveryimportantforwomenwithchronicpain,whateverthecause.
Oncethishasbeenachieved,thereisabetterchanceofbreak-ingtheviciouspaincyclewithreturntonormalfunctionanddailyactivity.
Itisimportanttoworkwiththeclientgivingherarangeofoptionsandstrategiesthatwillenablethebestanalgesicchoicestobemade.
Avoidingaddictivenarcoticanalgesiashouldbeamajoraim.
Therearethreemaintypesofanalgesicdrug:non-steroidalanti-inflammatorydrugs(NSAIDs),paracetamolandopioids.
Non-steroidalanti-inflammatorydrugsNSAIDsaredrugsthatworkbypreventingprosta-glandinrelease.
Prostaglandinsareformedinalmostalltissuesinthebodyandhavediverseeffects.
TheyareintimatelyinvolvedintheinflammatoryChronicPelvicPain73responseandcanreducepainthresholdsbyeffectsonboththeperipheralandcentralnervoussys-tem21.
NSAIDsareparticularlyusefulwhenpainistheresultofinflammation,asinendometriosis,butcanalsobehelpfulinothertypesofpain.
Theside-effectsofNSAIDsrelatetotheirinter-ferencewithotherphysiologicalpropertiesofpros-taglandinproduction,includingreductionofgastricacid,bronchodilatoreffectsandrenalvasodilatoreffects22.
Theyarespecificallycontraindicatedforwomenwithahistoryofgastriculceration,asthmaorrenaldisease.
ThereissomeevidencethatNSAIDsmayinterferewiththeprocessofovula-tion,sotheyareprobablybestavoidedinwomenhavingdifficultyconceiving23.
Ibuprofenisprobablythemostuniversallyavail-ableNSAID,butitdoesnotmatterwhichoneisprescribed(otherexamplesareindometacin,diclo-fenacandmefenamicacid).
Commencingmedica-tionadayortwopriortotheexpectedonsetofcyclicalpaingivesbetterpainrelief,andthemedi-cationshouldbecontinuedfor7–10days.
ParacetamolParacetamolinhibitsprostaglandinproductioninthebrainbuthashardlyanyeffectonprostaglandinsynthesiselsewhere22.
Itdoesnothavethesameside-effectsasNSAIDsandisthereforeausefuldrugwhenthesearecontraindicated.
ItcanbeusedinconjunctionwithNSAIDswhenalonetheyarenotprovidingenoughpainrelief.
OpioidsOpioiddrugsareextremelyeffectiveanalgesics.
Theybindtospecificopioidreceptorsfoundinthenervoussystemwhichareinvolvedwithpaininhi-bition.
Opioidsareeitherextractsoftheopiumpoppyorsynthetic/semisyntheticdrugswithasimilaraction.
Morphineandcodeinearebothnaturalopiumderivatives.
Morphineisastronganalgesicthatshouldonlybeusedtomanageseverepain.
Itishighlyaddictiveandisnotneededintheroutinemanagementofchronicpelvicpain.
Codeineisamuchweakeropioidanalgesicthanmorphine,andiseffectiveinthemanagementofmildtomoderatepain.
ItcanbeusedtogetherwithaNSAIDorwithparacetamol,andmaybeavail-ableintabletformasafixedcombination.
How-evertakingthemedicationsasseparatetabletsispreferableifthecombinationpreparationscontaininadequatedosages.
Constipationisaside-effectofcodeine,whichcanbealimitingfactorbutmaybeanassetforwomenwithepisodicdiarrhea.
Itismuchlessaddictivethanmorphine.
AdjuvantdrugsThesearedrugsthatarenotanalgesics,butwhenusedalongsideanalgesicscanreducetheperceptionofpain.
Thetricyclicantidepressantamitriptylineiseffectiveandusuallyreadilyavailable.
Itnotonlyhasanantidepressanteffect,whichmaybeofmajorbenefit,butitalsoincreasestheeffectivenessofthenaturalpain-inhibitionprocesseswithinthenervoussystem21.
Itsmildsedativeeffectcanbebeneficial.
Theusualdoseistocommencewith10mgintheevening,increasingslowlybyincre-mentsifneeded,upto75mg.
Otherantidepres-santsmaybemoreappropriateifclinicaldepressionissignificant.
SurgerySurgeryisindicatedforwomenwithpelvicmasses,orovariancysts/tumoursthatmaybeendometrio-ticbutcouldbeofmoresinisterorigin.
Itmayalsobeindicatediffibroidsarepresentastheycansometimesbethecauseofchronicpain(seeChapter19).
Surgerymaybedifficultandshouldonlybeundertakenbyexperiencedcliniciansinhospitalsthatcandealwithunforeseencomplications,in-cludingdamagetobowel,bladderandureters.
Womenmustfullyunderstandtheproposedprocedure.
Iffertilityisdesiredtheaimshouldbetodotheminimumtoenablethispossibility.
How-ever,womenneedtobecounseledthathyster-ectomymaybecomenecessarydependingonthefindings.
Endometriomasshouldbecompletelyex-cisedasithasbeenshownthatifthecystwallisnotremoved,recurrenceismorelikely.
Hysterectomyandremovalofbothovariesmaybethebestoptionforwomennotwantingtheirfertilitywhohavefailedtorespondtoconservativetreatment24.
IRRITABLEBOWELSYNDROMEIBSisoneofthefunctionalgastrointestinaldis-orders(FGIDs).
Functionaldisordersareonesforwhich:'thereisnoevidenceofaninflammatory,anatomic,metabolic,orneoplasticprocessthatexplainsthepatient'ssymptoms'25.
GYNECOLOGYFORLESS-RESOURCEDLOCATIONS74TheyarerelativelycommondisordersintheWesternworldbutmaybelesssoinunder-resourcedcountries,althoughdifferencesinhealthserviceprovision,aswellassignificantlyfewerre-searchpossibilities,makescomparisondifficult.
Asystematicliteraturereviewconductedin2005toassesstheinfluenceofgeographyandethnicityonIBSconcludedtherewas'noconvincingevidenceofadifferencebetweenwesternanddevelopedcountries'26.
DefinitionCriteriahavebeendevelopedandregularlyre-viewed,knownastheRomecriteria,onwhichadiagnosisofanFGIDcanbebased27.
Thisclassifica-tiondividestheFGIDsaccordingtothemostlikelysiteofgastrointestinaldysfunction,fromesophagustorectum.
Itacknowledgesthatthereisoftenanoverlapbetweenthedifferentdisordersandthat,astheyarecommon,thereisahighpossibilityofco-existencewithotherdiseases.
Thedisordersaffect-ingboweldysfunctionincludeIBS,functionalbloating,functionalconstipationandfunctionaldiarrhea.
Ofthese,onlyIBShasanelementofpainordiscomfort.
IBScanco-existwithanyoftheotherfunctionalboweldisorders.
SymptomsareknowntofluctuateinallindividualswithanyFGDI.
ThefollowingaretheRomeIIIdiagnosticcri-teriaforIBS.
Symptomsmusthavebegunatleast6monthspriortothepatientpresenting,andbeenpresentduringtheprevious3months,toindicatecurrentdiseaseactivity27:recurrentabdominalpainordiscomfortforatleast3dayspermonthassoci-atedwith2ormoreofthefollowing:ImprovementwithdefecationOnsetassociatedwithachangeinfrequencyofstoolOnsetassociatedwithachangeinform(appear-ance)ofstool.
DiagnosisIBSisadiagnosisbasedonsymptomsandtheexclusionoforganicdisease.
Afullhistoryandphysicalexaminationwillrevealtheneedforfur-therinvestigations.
Iftherearenoneofthefollow-ing'alarm'symptomsorsigns,thenadiagnosisofIBScanbemadeandtreatmentcommenced28.
Alarmsymptoms/signsRectalbleedingWeightlossFeverAnemiaFamilyhistoryofcoloncancerAbdominal/pelvicmassHigherythrocytesedimentationrateAstoolsampleshouldalwaysbesentformicros-copytoexcludeparasiticinfectionsandanHIVtestresultshouldideallybeknown.
TreatmentThiswillbeginwithanexplanationofthecondi-tion.
Individualsneedtobetoldthatforvariousreasons,whichmayormaynotbecomeevident,theirintestineshavebecomeover-responsivetocertainstimulithatwouldotherwisenotcausesymptoms.
Recordingsymptomsinadiaryoveraperiodofafewweeksmayidentifythosefactorsthatcauseanexacerbationofsymptoms.
Thesemayberelatedtodiet,stressoralmostanyactivityorevent.
ReassuranceshouldbegiventhatIBSisnotacanceranddoesnotincreasetheriskofcancerdeveloping.
Whencertaintriggereventshavebeenidenti-fied,helpmaybeneededtoenabletheindividualdevelopbettercopingstrategies,ratherthanrely-ingonmedication.
Howeasyitistodothiswilldependonthelocalservicesavailable.
Inthefirstinstanceitmaybesomethingthewomancanexplorewithherownfamilyoraclosefriend/confidant.
Ifvariousfooditemsareknowntotriggersymp-toms,dietarymodificationwillbehelpful.
Undulyrestrictivedietshavenotbeenshowntobeeffec-tive.
Whenconstipationistroublesome,increasingdietaryfiberwillhelp;ifdiarrheaisaproblem,re-ducingtheamountofdietaryfructosemayhelp;ifbloatingistroublesomereducingtheintakeoffoodsthatferment,suchascabbageandbeans,maybeallthatisneeded29.
Ifsymptomsaremoresevereornotcontrolledbylife-styleadjustments,specifictreatmentshouldbeoffereddependingonthemosttroublesomesymptomsatthetime.
Itneedstobestressedthatsymptomsarelikelytowaxandwaneandthatpharmacologicaltreatmentshouldbediscontinuedwhentheconditionsubsides.
ChronicPelvicPain75AntispasmodicsAntispasmodicsareoftenhelpfulasIBSisassociatedwithincreasedcolonicmotility.
Theprecisemedi-cationusedwilldependonlocalavailability.
Hyo-scinebutylbromidehasbeenshowntobeeffectiveandwelltoleratedforthetreatmentofrecurrentcrampyabdominalpaininadoseof10mg3timesdaily.
Itispoorlyabsorbedfromthegastrointestinaltractandexertsitseffectsmainlybylocalaction30.
BulkingagentsandantidiarrhealsTheseareindicatedonlyifthereareassociatedsymp-tomsofconstipationordiarrheathathavenotre-spondedtodietarymanipulation.
BulkingagentsdonotimprovesymptomsofIBSunlessthereisasso-ciatedconstipation.
Likewiseloperamideinadoseof2–4mgupto4timesdailyimprovesdiarrhea,butdoesnotimproveothersymptomsofIBS29.
TricyclicantidepressantsAmitriptylineinadoseof10–25mgatnight,maybeofbenefitforpatientswhosepaindoesnotim-provewiththeabovesuggestions.
BLADDERPAINSYNDROMEThebladderisasignificantpelvicorganthatcanbeinvolvedinanumberofdiseaseprocessescausingchronicpain.
Inordertoclarifythecriteriafordiagnosingchronicpainarisinginthebladder,theEuropeanSocietyfortheStudyofInterstitialCystitisin2008proposedthatthetermbladderpainsyndrome(BPS)isusedwhen:'Chronicpelvicpain(>6months),pressureordiscomfort,perceivedtoberelatedtotheurinarybladderisaccompaniedbyatleastoneotherurin-arysymptomsuchaspersistenturgetovoidorurinaryfrequency.
Confusablediseasesthatcouldcausethesymptomsshouldbeexcluded'31.
Themaintreatablediseases('confusablediseases')thatneedtobeexcludedare:Urinarytractinfection:microscopy/cultureofurine(iffacilitiesavailable)orresponsetoantibioticsChlamydiainfectionoftheurethra:history,sexualriskfactors,swabsorurinetestsifavail-able(seeChapter17)Schistosomiasis:microscopyurineandstool,biopsyofcervixBladderstone,uretericstone:history,IVPBladdermalignancy:presenceofmacroscopichematurianeedingcystoscopy,ultrasound,cystographTuberculosis:generalexamination+chestX-rayforpulmonarytuberculosis.
Staining/cultureofurinefortuberculosisespeciallyifsterilepyuriaOveractivebladder:womencomplainthatwhentheyfeeltheneedtovoidtheyhavetorushtothetoiletortheymaywetthemselves.
TheydonotcomplainofpainEndometriosis:canoccasionallyaffectthebladderandwouldcausehematuria.
ThecauseofBPSisunknown,buthypothesesin-cludeinflammation,autoimmunemechanisms(thereisanassociationwithsystemiclupuserythematosus,Sjgren'ssyndromeandinflammatoryboweldis-ease),andabnormalitiesofthebladderwall32.
DiagnosisThepainofBPSistypicallysuprapubic,itmaybeasharppainbutcanalsobemoreofaburningorpressurepain.
Itcharacteristicallyoccursasthebladderfills,andisrelievedbyvoiding33.
Thepainmustbeaccompaniedbyatleastoneotherurinarysymptom,whichinpracticeusuallymeansmultiplesymptomsincludingurinarysymptomsrelatedtointercourse.
Sometimesthereisreferredpaintotheback,groinorvagina,andpainmaybeworsedur-ingmenstruation.
Physicalexaminationmayrevealbladdertendernessbutisotherwiseunremarkable.
Urinalysisisnormal.
Avoidingdiaryisoftenhelpful.
Thewomanrecordsherfluidinputaswellasherperceptionofpainandtheamountofurineshepasseseachtimeshevoidsovera3-dayperiod.
Womenshouldalsonoteanyfoodsordrinksthatmakethepainworse.
TreatmentThismustbeginwithafullexplanationofthecon-dition,thatsymptomsarelikelytofluctuateovertime,butworseningisuncommon,andthereisnoassociationwithlaterdevelopmentofbladdercan-cer.
ManysufferersofBPSfindthatcertainfoodsanddrinksmaketheirsymptomsworse.
Acidicandspicyfoods,coffee,tea,carbonatedandalcoholicdrinksseemtobethemosttroublesome.
Avoidingthesesubstancesmaybehelpful34.
Fluidrestrictionshouldnotbeadvisedasthiscanincreasepain.
GYNECOLOGYFORLESS-RESOURCEDLOCATIONS76Bladder'retraining'maybehelpful.
Withthisthewomanisencouragedtoveryslowlyincreasethetimebetweeneachactofvoiding,sogentlyincreasingbladdercapacity35.
AnalgesicssuchasparacetamolandNSAIDscanbetakenifnecessary.
Amitriptylineisthemainstayoftreatment.
Itworksinanumberofwaystoreducepain,increasebladdercapacity,reducefrequencyandaidsleep36,actionsthatshouldbeexplainedtothewomenforwhomitisprescribed.
Itisnotbeingprescribedasanantidepressant.
Womenshouldbereferredforaurologicalopinioniftheirsymptomsaresevereordonotimprove.
PELVICFLOORMUSCLEDYSFUNCTIONThepelvicfloormusclesplayavitalrolein:main-tainingpelvicstability,childbirth,maintainingurinaryandfecalcontinenceandfemalesexualfunction.
Weakeningofthepelvicfloormusclesasaresultofdifficultchildbirthand/orrepeatedchildbearingcanincreasetheriskofgenitalpro-lapseandurinarystressincontinence.
Overactive,chronicallytense,pelvicmusclesareassociatedwithconstipation,BPS,dyspareuniaandendometriosisanditisoftendifficulttodeterminewhethertheincreasedmuscletoneisthecauseoreffectofthesecomplaints.
Ahistoryofsexualabuseisanotherriskfactor37.
Whenamusclebecomeschronicallytensethereisoftenaspecificsensitiveareawithinthemusclethatcanbelocalizedbypalpationduringvaginalexamination.
Thisareaiscalledatriggerpoint.
Triggerpointscanbeaggravatedbyspecificmove-mentsandalleviatedincertainpositionssothatpatientsmayforexample,sitononebuttockandmovecautiously.
Treatmentisdifficultinunder-resourcedcoun-triesasitisbestundertakenbyphysiotherapistswithaspecialinterestinthisproblem.
TheconditionislikelytoimprovewhenassociatedconditionssuchasIBS,BPSorendometriosisarecontrolled.
Analgesicsandamitriptylineshouldbetried.
ADHESIONSAdhesionsmaydevelopinthepelvisfrompelvicinflammatorydisease,endometriosis,appendicitisandafteranysurgicalprocedure,suchascesareansection,salpingectomy,ovariancystectomyandhysterectomy.
Althoughoftenpresumedtobethecauseofpain,evidenceforthisislacking38.
Itisunlikelythatrepeatsurgeryforadhesionswillim-provechronicpelvicpainandmaymakeitworse.
Itisbettertocounselthepatient,providepainreliefwithNSAIDsand/orparacetamolandgivedietaryadvicesothatbloatingandconstipationareavoided.
Therearetwosituationswhenadhesionsdoappeartobethecauseofpain.
Oneis'retainedovarysyndrome',whenanovaryleftinsituatthetimeofhysterectomybecomesburiedindenseadhesions,andtheotheris'ovarianremnantsyn-drome',whenasmallpartofanovaryisleftafteroophorectomyandbecomesinvolvedindenseadhesions.
Inboththesecircumstancesovulationsuppressionisusuallyhelpful6.
Repeatsurgeryislikelytobedifficultandshouldnotbeundertakenbytheinexperienced.
MANAGEMENTOF'UNEXPLAINED'CHRONICPELVICPAINIfthehistoryandexaminationdonotpointtoanyspecificcauseofthepain,reassuranceisvitalandanalgesiaasdescribedearliershouldbemadeavail-able.
Hormonaltreatmentasexplainedaboveforendometriosisisoftenalsohelpful.
PSYCHOLOGICALASPECTSOFPAINMANAGEMENTThepsychehasanimportantroletoplayintheper-ceptionofpain.
Aperson'sfeelingsareextremelyimportantintheirappreciationofandabilitytocopewithpain.
Fearwillmakepainworse.
Want-ingtoknowthecauseofphysicalpainisnormal.
Whenacauseisnotfound,andadequateexplana-tionhasnotbeengiven,apatientislikelytoseekadvicefromeitheranotherhealthclinic(repeatingthewholecycleofinvestigations)orfromoutsidetheformalhealthsector.
Healthworkersmustexplain'negativefindings'carefullytotheirclientsothatreliefthataseriousunderlyingdisorderhasnotbeenfound,ratherthanconcernthatonehasbeenmissed,becomesparamount.
Involvingacloserelativeorfriendinthediscussionmaybebeneficial.
BehavioralandothertherapiesUnfortunately,accesstopsychologicalhelpisnotreadilyavailableinunder-resourcedcountries,butChronicPelvicPain77ifthepossibilityexistsitshouldbeutilized.
En-couraginggentleresumptionofactivitiescanbebeneficialtogetherwithsettingobtainablegoalsoverasensibletimeperiod39.
Takinganinterestintheclient'sprogressandkeepingthedooropenforthemtoreturniftheyfeeltheyarenotimprovingareimportantstrategies.
Clientswhoareclinicallydepressedneedtobeappropriatelyreferredforeffectivemanagement.
Traditionalhealers,complementarytherapyandherbalremediesTraditionalhealersplayanimportantroleinthehealthcareofmanypeopleinunder-resourcedcountries.
Ifclientswanttouseherbalremedies,orseekspiritualhelpfromtraditionalhealersthisshouldnotbediscouraged,aslongastheseclientshavebeenfullyinvestigated,understandthefind-ings/orlackoffindings,andareawareofthecon-ventionalmedicaloptionsavailable.
Theyshouldtrytoidentifyhealerswhoareregisteredwithlocalrelevantassociationsandneedtobeawarethattheefficacy,basedonresearch,ofmanyherbalreme-diesisunknown40.
Sometimestherecanbestrongbeliefsinwitchcraftasthecauseofpain41.
Itmaynotbepossibleforahealthprovidertodissuadeapersonfromthesebeliefs.
Possibilitiesmayexistforahealthfacilitytoidentifyrelevanttraditionalhealersintheirsur-roundingsandinitiateco-operation/trainingwiththemsothattheycantakecareofclientswithchronicpain(whennoidentifiablecausehasbeenfound)intheframeworkofhome-basedcarepro-grams.
Thiscouldreducethepatientburdenforthehealthfacility.
Recognizedcomplementarymedicalpractice,suchasacupuncture,maynotbeavailableinunder-resourcedcountriesoutsideAsia,butiftheyareandwomenwanttousethem,thisshouldbeen-couraged41.
CONCLUSIONSThischapterhasgivenanoverviewofthecausesandmanagementofchronicpelvicpaininwomen.
Psychologicalfactorshaveanimportantroletoplayintheetiologyofchronicpain,andthequalityofinteractionswithhealthproviderswhomwomenconsultwillhaveamajorimpactonwhetherasuc-cessfuloutcomeforindividualwomenisachieved.
Mostwomenwithchronicpelvicpainhavenoidentifiablediseaseprocess,butthiswillonlybedeterminedafterfullhistorytaking,physicalexami-nationandbasicinvestigations.
Chronicpainsyn-dromestendtofluctuateinintensityovertimeandarerarelycured;howevertheydonotprogresstobecomemalignantdiseases.
Womenwiththesecon-ditionstendtobepoorlymanagedinunder-resourcedcountriesbecauseofthehighworkloadofclinicians.
Howevercaringclinicianscaneasilyhelpmostwomen,evenwhenonlybasicresourcesareavailable,resultinginprofessionalsatisfactionandclientswhowillnotbeastrainonthehealthsector.
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Thisdefinitionwasintroducedin1979andisim-portantbecauseitacceptsthatpaincanoccurwith-outtissuedamageandthatpsychologicalfactors(learning,memory,thesoul,mood,feelings,etc.
),aswellassocioculturalfactorsplayavitalroleintheperceptionofpain2.
Beingabletoexperiencepainisessentialforsur-vival3.
Acutepainhasaprotectivefunction:itisabruptinonsetandleadstoimmediatewithdrawalfromthecauseofthepainaswellastoseekinghelpifthepainisinternalorsevere.
Acutepaindis-appearsastheaffectedtissuesheal.
Chronicpainisdifferent.
Itpersists.
Itmayhavestartedwithanepisodeofacutepain,itmaybeassociatedwithanon-goingdiseaseprocess,butitmayalsoarisewith-outanydiscerniblephysicalcause4.
Thephysiologyofpainiscomplex.
Thebrainandspinalcordhavemechanismsthatareabletomodifytheperceptionofastimulusandeitherin-creaseordecreasesensationsfeltaspain.
Whenastimulusbecomesrepetitive(i.
e.
chronic),forexamplefrompersistentinflammation,itcanlowerthethresholdforpainperceptionsothatevennor-malactivitywithinanorganisperceivedaspainful3.
Thisiswhypeoplewithoutobjectiveevidenceofdiseasecanstillexperiencepain.
Anotherimportantaspectofpainisthatthemindcanthinkitisorigi-natingfromonearea,butinfactitiscomingfromanother.
Thishappensbecausenervefibersfromdifferentareasconvergeastheyenterthespinalcordandsignalscan'jump'fromonenervetoanother3.
Chronicpainisasymptomwhich,whenarisingfromaninternalorgan,isoftenaccompaniedbyothernon-painfulsymptomsfromthesameorganorarea.
Chronicpainarisingfromthepelvicorganscanbeasymptomofdysfunctioninthereproduc-tivetract,gastrointestinaltract(irritablebowelsyn-drome,IBS),urinarytract(bladderpainsyndrome,BPS)orthemusculoskeletalsystem.
Chronicpelvicpainthereforecomesundertheremitofseveraldifferentspecialties.
Thetime-framefordecidingwhenapainfulexperiencehasbecomechronicisimportantforre-searchpurposesbutnotsoimportantintheclinicalsetting.
AhelpfulworkingdefinitionsuggestedbyBonica(citedbyJanicki5)thatdoesnotencompassanactualtimeframeisasfollows:'Ifpainpersistsbeyondtheusualcourseofanacuteinjuryordisease,orrecurseveryfewmonthsoryears,itisregardedaschronic'.
Definitionsofchronicpelvicpain,ofwhichtherearemany,tendtouseaminimumtimeperiodof6monthsforthepresenceofpain.
Thefollowingisanexample:'intermittentorconstantpaininthelowerabdomenorpelvisofatleast6monthsdura-tion,notoccurringexclusivelywithmenstruationorintercourseandnotassociatedwithpregnancy'6.
Thischapterwilluseamixtureoftheabovetwodefinitionsandwilldiscussthemanagementofwomenpresentingwithchronicpelvicpain.
THECONSULTATIONThefirstconsultationhasbeenshowntobesoim-portantthatitislikelytobethedeterminingfactor6ChronicPelvicPainVanessaSangalaChronicPelvicPain67Figure1Flowchartshowingmanagementofchronicpelvicpain(CPP).
IBS,irritablebowelsyndrome;COC,combinedoralcontraceptive;BPS,bladderpainsyndromePatientwithCPPHistory,examination,HIVtest,urinalysis,ultrasound(ifavailable)PregnancytestifindicatedDiagnosisendometriosisDiagnosisIBSPregnancynotdesired:suppressovulationforatleast6monthswitheither:COC(e.
g.
Microgynon);medroxyprogesteroneacetatetabletsornorethisteronetablets;Depomedroxyprogesteroneacetate(DepoProvera);Implanon;Norplant;IUS(Mirena).
Pregnancydesired:Investigateforinfertilityifappropriate.
Provideanalgesia.
ReferforlaparoscopyifavailableSymptomdiarytoidentifytriggerevents.
Pharmacologicalsymptomcontrol:AntispasmodicsAntidiarrhealsAmitriptylineNonpharmacologicalsymptomcontrol:Dietary/behavioral/lifestylemodifications.
DiagnosisBPSVoidingdiary.
Identifypossibledietarytriggers.
Avoidtea,coffee,alcohol,spicyfoodsBladder'retraining'.
AmitriptylinePelvicfloormuscleAnalgesiaPhysiotherapyAmitriptylinePsychologicalsupport;behaviortherapy;traditionalandherbalremedies;alternativemedicine.
Explainfindings,discussdiagnosisandtreatmentoptions.
Reassurenomalignancy,andnoincreasedriskofmalignancy.
Besympathetic,listentoclient'sconcerns.
Developtreatmentstrategywithclient.
UnknownetiologyAnalgesiaHormonetherapyNeedforfurtherinvestigationsidentified,makearrangementsorreferraltohigherlevelhealthcareNoneedforfurtherinvestigations,diagnosismadeGYNECOLOGYFORLESS-RESOURCEDLOCATIONS68inwhethertheoutcomeisbeneficial7.
Bytheendoftheconsultationtheclinicianshouldhavedeci-dedfromwhichorgansystem(s)thepainisarisingandhaveformulatedamanagementplan.
ForanoverviewofthemanagementseeFigure1.
Womenwithchronicpelvicpainhavesymp-tomsrelatedtotheirreproductive,genitourinaryandintestinaltractsandtheywillonlydisclosethesesymptomstosomeonetheytrust.
A'safe'reasonfortheirvisitwillbeinventedandtheywillmakeasrapidanexitaspossibleiftheirfirstimpressionsareunfavorable.
Thiswillleadtoconsultationsinotherclinicsorwithtraditionalhealers,withcompound-ingoftheirpain.
Cultural,ethnic,socioeconomic,religiousandgenderperspectives,aswellasattitudes,beliefsandbiasesallcometoplayduringtheconsultationpro-cess,affectingboththehealthproviderandtheirclient8.
Inunder-resourcedcountriesthesocio-economicdifferencesbetweenhealthproviderandclient,especiallyintheruralareasmaybeenor-mous.
Eveninurbanareastheremaybewidecul-turaldifferencesandbeliefsandlanguagemayalsobeanissue.
Involvementofaninterpreterwillbringyetanotherdimensionintotheconsultation.
Healthprovidersneedtobecognizantofthesefactorsanddoeverythingtheycantoputtheirclientatherease.
Greetingclientswarmly,introducingone'sselfandanyotherpeopleintheroom,maintainingeyecontactandlookinginterestedhelpinstillconfi-dence,dispelfearandbringhopetowhatmaybefelttobeadesperatesituation.
Healthprovidersshouldbenoticingandassessingtheirnewclientassheenterstheroom:thewayshewalksandsitsdown,whethersheshowssignsofbeingunwellorinpain,howsherespondstobeinggreetedandhergeneraldemeanor.
ThehistoryTakingagoodhistoryisthemostimportantpartoftheconsultation.
Itlaysthefoundationforastruc-turedphysicalexamination,afterwhichtheneedforfurtherinvestigationsisdetermined.
Ifpossibleanymedicalrecordsheldattheclinicshouldbereadbeforethecliententerstheroom.
Hand-heldrecordsthattheclientmayhavebroughtwithhershouldbecarefullyreviewed.
Theclient'sstoryThiswillsetthebasisfortherestoftheconsultationandneedstobeattentivelylistenedto.
Hearingthestoryisthebeginningofthehealingprocess.
Thisistrueforanycomplaint,butisofvitalimportanceforpeoplewithchronicdisorders,whooftenfeeltheyarenottakenseriously7.
Iftheclienthasprevi-ouslysoughthelpfromelsewhere,itisimportanttoaskwhyshehascometothepresentclinicatthisparticulartimeandwhatherhopesforthecon-sultationare.
Askingwhattheclientthinksisthecauseofherpainisahelpfulandoftenrevealingquestion9.
Ifthepainhasbeenpresentforover6monthsitisunlikelytobecausedbyalife-threateningillness,butthisassumptionshouldnotbemade.
Some-timesthesensitivenatureoftheirsymptomsdeterswomenfromseeingahealthproviderinatimelymanner,especiallyiftheyhavehadbadexperiencesinthepast,heardnegativestoriesaboutthehealthservice,arefrightenedofwhatmayhappentothem,orifthereareculturalmythsabouttheirsymptomsthatmakethemdifficulttodivulge.
Thefollowingareimportantpointstoclarifyaboutthepain:WhenandhowdidthepainbeginHowbadisthepain,doesitinterferewitheverydayactivities,issleepdisturbedIstheremorethanonetypeofpainWhereisthepain,doesitmoveWhenpresenthowlongdoesthepainlastDoesanythingmakeitbetterorworseDoesithaveanyrelationshiptothemenstrualcycle,i.
e.
worsebefore,duringorafterthemensesIssexpainfulIsdefecationpainfulArethereanyotherbowelsymptomsIsurinationpainfulArethereanyotherurinarysymptomsIswalking,sittingorstandingforlongperiodspainfulMenstrualhistoryAgeatmenarcheandanysignificantmenstrualproblemsneedtobeenquiredabout.
Aremen-strualproblemsacurrentconcernIfso,anytreat-mentalreadyreceivedanditseffectivenessshouldChronicPelvicPain69bedocumented.
Thedateofthelastnormalmen-strualperiodandiftherehasbeenanyabnormalbleedingsincethatdateshouldbenoted.
Pastmedical,surgicalandobstetrichistoriesEnquiryneedstobemadeaboutanypastseriousmedicalillnesses,includingpsychiatricillness,anyoperations,HIVandsexuallytransmittedinfec-tions,andanypregnanciestogetherwiththeirout-comes.
Fornulliparouswomenenquiryshouldbemadeabouttheirpregnancyintentions.
Aretheycurrentlytryingtoconceive,ifso,forhowlongandisfailuretoconceiveananxietyWantingachildisacommonreasonforwomentomakere-peatedvisitstoahealthfacility,especiallyinunder-resourcedcountrieswherebearingchildrenisespeciallyimportantforawoman'sself-esteem.
Pastandpresentcontraceptiveuseshouldbere-corded,togetherwithanyunpleasantside-effects.
Itishelpfultoknowwhetherthereisahistoryofsexualorphysicalabuse,eitherasachild,adult,orboth.
Thetimingofthisenquirydependsontherapportbuiltupwiththeclient,anditcanbedoneatanyappropriatetimeduringtheconsultation.
Althoughnotclearlyunderstood,thereappearstobearelationshipbetweenchronicpelvicpainandchildhoodsexualabuse,especiallyifthereiscon-tinuingabuseintoadulthood6.
ThephysicalexaminationThephysicalexaminationisimportantforelicitingsignsthatwillhelpformulatethediagnosis.
Itisalsoa'psychodynamicevent'9andthewaytheclientrespondsmaygiveaninsightintothewaytheyfeel.
ReadmoreonthegynecologicalexaminationinChapter1ifyoufeelunsureaboutthedifferentprocedures.
Anexplanationshouldbegivenabouthowtheexaminationwillbeconducted,startingwiththeneedtoperformanabdominalexamina-tionandexploringthepossibilitiesofdoingvaginalandspeculumexaminations.
Intimateexaminationsareusuallyconsentedto,buttheycaninthemselvescausemuchdistressespeciallyifawomanhasbeeninanabusiverelationship.
Thehealthprovidermustbeawareofthesepossibilitiesandstopanexaminationthatiscausingdistress.
Womenwhodeclinevaginalexaminationsshouldnotbemadetofeeltheyhavecompromisedtheirchancesofbeinghelped.
Theclientshouldemptyherbladderbeforethephysicalexamination,whichwillmaketheproceduremorecomfortableaswellasprovideaspecimenforimmediateurinalysis.
AbdominalexaminationInspectionwillrevealsignsofprevioussurgeryandanyobviousmassesordistention.
Iftheclientisexperiencingpainpriortoabdominalpalpation,askinghertoliftherheadandshouldersoffthebedandenquiringwhetherthiseasesthepainormakesitworsewilldeterminewhetherthepainisorigi-natingfromwithintheabdominalcavityortheabdominalwall.
Tensingtheabdominalwallmusclestendstolessenintra-abdominalpain,whereasthepainwillbemadeworseifthepatho-logyisintheabdominalwall10.
Abdominalpalpationshouldcommenceinapain-freesiteandproceedsystematicallyaroundthewholeabdomen.
Anytenderareas,obviousmassesorloadedbowelshouldbenoted.
SpeculumexaminationThisisadvisableforwomenwhoaresexuallyactive,andshouldalwaysbeperformediftherehasbeenpost-coitalbleeding,anabnormalvaginaldischargeoriftheclienthasneverhadtheircer-vixinspected.
Sometimesbluishdepositsofendometriosiscanbeseenintheposteriorfornix.
Cervicalscreeningisnotreadilyavailableinunder-resourcedcountriesandmanywomenwithcervicalcancerpresentwithuntreatablelate-stagedisease.
Opportunisticdetectionofearlycervicalcancergivestheonlychanceforsurgicalcurewhenradio-therapyservicesareunavailable.
Ifthecervixlooksnormalandvaginalinspectionwithaceticacid(VIA)isaservicethatislocallyavailable,informa-tioncanbegiventotheclientsothatifappropriateshecanattendatherconvenience(seeChapter26onhowtodoVIA).
VaginalexaminationInspectionofthevulvawillrevealsignsofirrita-tion,inflammation,ulcers,wartsordischarge.
Digitalexaminationshouldbeomittedinanyonewhohasnotbeensexuallyactiveoranyonewhoprefersnottohavethisdone.
Ifdigitalexaminationisdeclinedornottolerated,gentleexaminationGYNECOLOGYFORLESS-RESOURCEDLOCATIONS70withalongcotton-woolbudmaybeagreeduponandcangiveusefulinformation.
Initialdigitalexaminationshouldbewithonefingertominimizediscomfortsothatpotentialpainfulareascanbebetterlocalized.
Ifwelltoler-ated,twofingerscanbeinsertedlatertoaidfurtherexamination.
Gentlepalpationoftheanteriorvaginalwallwilldetermineanyurethralorbladderbasetenderness.
Examinationoftheposteriorvaginalwallandposteriorfornixwillrevealanytendernodulesthatcouldindicateendometriosis.
Askingtheclienttocontractandrelaxherpelvicfloormuscles,togetherwithgentledigitalexami-nationofthemuscles,canassesspainoriginatinginthepelvicmusculature.
Bimanualexaminationwilldeterminethesize,position,mobilityorfixationoftheuterus,whethertheuterusistenderandwhetherthereareanyobviousadnexalmasses.
AdditionalexaminationsWomenwiththefollowingsignsandsymptomsneedadditionalinvestigationsandpossiblyreferral:Rectalbleeding/bloodinstool:proctoscopy,possiblecolonoscopyorbariumenemaMacroscopichematuria:cystoscopyandintra-venouspyelogram(IVP)Microscopichematuria,afterexcludingcystitis,schistosomiasisandtuberculosis(TB),andre-peatingthetest:cystoscopyandX-IVPNewbowelsymptomsoverage50:colonos-copyorbariumenemaNewpainafterthemenopause:ultrasoundPelvicorabdominalmass,includingfibroids(seeChapter19):ultrasoundandpossiblesurgeryAscites:ultrasoundandifpossiblecytologyofascitesandstainingforTBIrregularvaginalbleedingoverage40:ultra-soundandVIA/cervicalbiopsy/endometrialbiopsyPost-coitalbleeding:VIAandifpossiblechlamy-diascreeningorpresumptivetreatmentforchlamydiaandgonorrheafollowedbyreassess-mentafter4weeksCervixsuspiciousofcarcinoma:biopsyofcervicallesion/urgentsurgeryasdeemedappropriateExcessiveweightloss:HIVtest,considerposs-iblemalignancyInvestigationsUrine,stoolandpregnancytestingSimpledipsticktestingofurine,preferablyonamidstreamspecimen,shouldbeperformed.
Ifmacroscopichematuriaispresenttheclientneedsfurtherinvestigation,butalwayschecksheisnotmenstruating!
Thepresenceofleukocytesornitritesmayindicatecystitisandiftheclientissympto-maticacourseofantibioticsshouldbeprescribedaccordingtolocalguidelines.
Ifmicroscopichematuriaisdetectedthesampleshouldbesentformicroscopytoexcludeschistosomiasis,andconsid-erationgiventotestingfortuberculosis.
Tubercu-losiscanmimicalmostanydiseaseandinendemicareasshouldnotbeforgotten.
Microscopichema-turiaisquitecommonandcanoccurafterexerciseandsexualintercourse,andfortransientunknownreasons.
Beforereferralformoreextensiveinvesti-gationsthetestshouldberepeatedtwice.
Urinarytractcancerisextremelyrareinwomenunder4011.
Othermedicalcauses(includingsicklecelldisease)wouldbeinferredfromthehistory.
Microscopyofastoolsampleshouldalsobearranged,asparasiticinfectionscancauseabdominal/pelvicpain.
Pregnancytestingmaybeimportantdependingonthemenstrualhistory.
BloodtestsAllwomenshouldbeofferedHIVtestingiftheirstatusisunknownoriftheyhaveconcernsregard-ingsexualexposuresinceapreviousnegativetest.
Missingthisopportunityinaclientcomplainingofabdomino-pelvicpainwouldbenegligent.
Afullbloodcountwithdifferentialisagoodbasictestifavailable.
Otherbloodtestsshouldbeorderedde-pendingontheclinicalfindingsandtheirlocalavailability.
UltrasoundscanningUltrasoundscanningisbecomingincreasinglyavailableinlow-resourcedcountries.
Abdominalultrasoundshouldbeusedtoassesstheuterusandovariesinadolescentswithpelvicpain,inwomenwhodeclineavaginalexaminationandallwomenwhohaveanabdominalmass.
Transvaginalscan-ningissuperiortoabdominalscanningforvisual-izingpelvicmassesandisusefulfordetectingadenomyosisandsmallendometriomasthatwouldindicateendometriosis,orhydrosalpinxthatwouldChronicPelvicPain71indicatechronicpelvicinflammatorydisease.
Peri-tonealdepositsofendometriosiswillnotbevisual-ized.
Thevaginalprobecanbeusedtoidentifyparticularlytenderareas,andanexperiencedultra-sonographerisabletodetectthepositionandmobilityoftheovaries.
Immobilityofanovarymaybepredictiveofendometriosisoradhesions12.
InfertilityinvestigationsInfertilityisprobablyoneofthecommonestcausesofchronicpelvicpaininunder-resourcedcoun-tries,thepainoftennotbeingreproducibleduringphysicalexamination,butratherbeinganemotionalpain.
Ifthisistheworkingdiagnosis,investigationsforinfertilityaccordingtolocalprotocolsshouldbearranged.
Iftheclienthasnotcomewithherpart-nersheshouldbeencouragedtoreturnwithhimsothattheycanbeseentogether.
Thecommonestcauseofinfertilityinlow-resourcesettingsisinfec-tion-relatedtubaldamage.
Unfortunatelywomenandmeninunder-resourcedcountriesdonothaveaccesstothetreatmentoptionsavailableinrichercountries,butcompassionatemanagementshouldinstillhope,asitisrarelypossibletostatethatawomanwillneverbeabletoconceive.
Afterconductingtheclinicalexaminationandre-viewingtheresultsofalltestsundertakentheclini-cianshouldhavecomeupwithaworkingdiagnosisonwhichtobasetreatment.
Thefollowingcondi-tionsarethemostlikelytocausechronicpelvicpainandwillnowbereviewed.
Itispossibleformorethanoneconditiontobepresentinthesameindividual:EndometriosisIBSBPSPelvicmuscledysfunctionAdhesionsENDOMETRIOSISEndometriosisis'thepresenceofendometrial-liketissueoutsidetheuteruswhichinducesachronicinflammatoryreaction'13.
Itisanestrogen-dependentcondition,withsymptomsusuallyappearingafterthemenarcheandresolvingafterthemenopause.
Riskfactorsforendometriosisinclude:earlyageatmenarche,shortmenstrualcycles,heavymenstrualflow,painfulmenstruation,infertility,endometriosisinafirst-degreerelative,andimmunedisorders14.
Threedifferentformsofendometriosishavebeendescribed,andanymixtureoflesionsispossible15:Peritonealendometriosis,whereendometriosisisfoundonthepelvicperitoneumand/orthesurfaceoftheovaries.
Endometriomas,whichareovariancystslinedwithendometrial-liketissueandcontainingathick,tarry,'chocolate-like'fluid.
Asolidmassofendometrial-liketissuemixedwithfattyandfibroustissuethatformsnodulesbetweenthevaginaandrectum.
Endometrioticlesionscanvaryfrombeingverysmallandbarelyvisible,tolesionscausinglargeovariancysts,extensiveadhesionsandsometimesinfiltratingintotheboweland/orbladder.
About30–50%ofwomenwithendometriosisareinfertile16.
However,normallyfertilewomenhavealsobeenfoundwithendometriosis.
Inferti-lityistobeexpectedwhenendometriosiscausesadhesionswithblockageordistortionofthefallo-piantubes,butforreasonsnotfullyunderstoodwomenwithmilddiseasecanalsohavedifficultyconceiving.
DiagnosingendometriosisAworkingdiagnosisofendometriosisismadefromacombinationofsymptomsandphysicalfindings.
Transvaginalultrasoundifavailable(orabdominalultrasoundinthosenotsexuallyactive)maybehelpful,especiallyfordiagnosingendometriomas.
Thefollowingsymptomshavebeenshowntoberelevanttoadiagnosisofendometriosis:DysmenorrheaMenorrhagiaIrregularmenstrualcycleDeepdyspareunia(whichmayindicateinvolve-mentoftheuterosacralligaments)Paininthelowerabdomen/pelvisthatispoorlylocalizedandmaybeconstantorcyclicalUrinarytractsymptoms:frequency,painonmicturitionPastdiagnosisofirritablebowelsyndromePasthistoryofovariancystsDifficultyconceivingPastepisodesofpelvicinflammatorydiseaseSleepdisturbances.
GYNECOLOGYFORLESS-RESOURCEDLOCATIONS72Womenwithmorethanoneoftheabovearesig-nificantlylikelytohaveendometriosiscomparedtowomenwithoutendometriosis17.
Theyshouldbeofferedtreatmentdependingonwhetherornottheyaretryingtoconceive.
TreatmentofendometriosisHormonaltherapy,analgesicsandsurgeryallhavearoletoplayinpatientmanagement,whichneedstobeindividuallytailoredaccordingtosymptomsanddesireforfertility.
Opendiscussionwithwomenabouttheeffectivenessandside-effectsofthedifferentoptionsandencouragingtheiractivein-volvementindecidingwhichoptiontochoose,givesthebestchanceforsuccess.
HormonaltherapyInhibitionofovulationisofteneffectiveinsuppress-ingendometriosisandcontrollingcyclicpainandmenstrualdisorders.
However,itisonlyanoptionforwomenwhoacceptthattheywillnotconceivewhileonmedication.
Thereisnoevidencethatsup-pressingovulationforaperiodoftimewillimprovethelaterchanceofconception16andwomenshouldnotbefalselyleadtobelievethatitwill.
Therapyshouldbecontinuedforaslongasnecessary,symp-tomsbeinglikelytorecurwhenitisstopped.
Aminimumof6monthsisrecommended18.
Thecombinedoralcontraceptive(COC)pillisusuallyreadilyavailableinunder-resourcedcoun-triesaspartoftheirfamilyplanningprograms.
Anylow-doseCOC(notmorethan35gethinylestra-diol)canbeused.
Itisbesttakencontinually,ratherthaninthetraditionalcyclicway,sothatmenstrua-tionisabolished18.
Thismeansexplainingtowomenthattheyshoulddiscardthesevenplacebotabletsineachpacketifpillswiththesearetheonlyoptionsavailable.
Breakthroughbleedingisthemainside-effectoftakingtheCOCcontinuously,butifthishappensa7-daybreakcanbetakenandthepillsthenre-started.
Somewomenfindtakinga5-or7-daybreakevery3monthspreventsbreak-throughbleeding.
Analgesicscanbetakentoaugmentpainreliefifnecessary.
Womenwithcontraindicationstoanestrogen-containingpill,orwomenwhohavehadpreviousunacceptableside-effectswiththeCOC,cantryaprogestogen-onlymethod.
Theinjectabledepotmedroxyprogesteroneacetate(DMPA),150mgevery3monthsisveryeffective.
Progestogenscanalsobegivenorally,e.
g.
medroxyprogesteroneacetateornorethisterone,startingat10mgdailyandincreasingthedoseifbreakthroughbleedingoccurs.
Womenmayprefertheoptionoftryingoneoftheprogestogenicimplants,whicheverisavailable.
Thereissomeevidencethattheetono-gestrelimplantisaseffectiveasDMPAinrelievingendometriosis-relatedpain19.
Irregularbleedingisacommonside-effectofprogestogentherapythatmaytakeseveralmonthstosettle.
Thelevonorgestrelintrauterinesystem(IUS)isanotheroption.
Thisdevicereducesmenstrualflow,ofteninducesamenorrhea,andhasbeenshowntohaveabeneficialeffectonendometriosisinsomewomen20.
Levelsofcirculatinghormoneareextremelylowwhichmaymakethemethodmoreacceptableforwomenwithhormonalside-effectsfromtheothermethods.
Unfortunately,itisratherexpensiveinsomecountriesandnotavail-ableinallunder-resourcedcountries.
WomenwantingtoconceiveThetreatmentoptionsforwomenwhowanttoconceivearelimitedtoanalgesiaor,ifappropriate,surgery.
Referralforlaparoscopy,ifavailable,canbeconsidered.
Ahistorysuggestiveofendometrio-sisdoesnotmeanthatendometriosisisdefinitelythecauseoffailuretoconceive,andacoupleshouldbeinvestigatedinthesamewayasanyothercouplewithsubfertility.
AnalgesicsforchronicpelvicpainEffectiveanalgesiaisveryimportantforwomenwithchronicpain,whateverthecause.
Oncethishasbeenachieved,thereisabetterchanceofbreak-ingtheviciouspaincyclewithreturntonormalfunctionanddailyactivity.
Itisimportanttoworkwiththeclientgivingherarangeofoptionsandstrategiesthatwillenablethebestanalgesicchoicestobemade.
Avoidingaddictivenarcoticanalgesiashouldbeamajoraim.
Therearethreemaintypesofanalgesicdrug:non-steroidalanti-inflammatorydrugs(NSAIDs),paracetamolandopioids.
Non-steroidalanti-inflammatorydrugsNSAIDsaredrugsthatworkbypreventingprosta-glandinrelease.
Prostaglandinsareformedinalmostalltissuesinthebodyandhavediverseeffects.
TheyareintimatelyinvolvedintheinflammatoryChronicPelvicPain73responseandcanreducepainthresholdsbyeffectsonboththeperipheralandcentralnervoussys-tem21.
NSAIDsareparticularlyusefulwhenpainistheresultofinflammation,asinendometriosis,butcanalsobehelpfulinothertypesofpain.
Theside-effectsofNSAIDsrelatetotheirinter-ferencewithotherphysiologicalpropertiesofpros-taglandinproduction,includingreductionofgastricacid,bronchodilatoreffectsandrenalvasodilatoreffects22.
Theyarespecificallycontraindicatedforwomenwithahistoryofgastriculceration,asthmaorrenaldisease.
ThereissomeevidencethatNSAIDsmayinterferewiththeprocessofovula-tion,sotheyareprobablybestavoidedinwomenhavingdifficultyconceiving23.
Ibuprofenisprobablythemostuniversallyavail-ableNSAID,butitdoesnotmatterwhichoneisprescribed(otherexamplesareindometacin,diclo-fenacandmefenamicacid).
Commencingmedica-tionadayortwopriortotheexpectedonsetofcyclicalpaingivesbetterpainrelief,andthemedi-cationshouldbecontinuedfor7–10days.
ParacetamolParacetamolinhibitsprostaglandinproductioninthebrainbuthashardlyanyeffectonprostaglandinsynthesiselsewhere22.
Itdoesnothavethesameside-effectsasNSAIDsandisthereforeausefuldrugwhenthesearecontraindicated.
ItcanbeusedinconjunctionwithNSAIDswhenalonetheyarenotprovidingenoughpainrelief.
OpioidsOpioiddrugsareextremelyeffectiveanalgesics.
Theybindtospecificopioidreceptorsfoundinthenervoussystemwhichareinvolvedwithpaininhi-bition.
Opioidsareeitherextractsoftheopiumpoppyorsynthetic/semisyntheticdrugswithasimilaraction.
Morphineandcodeinearebothnaturalopiumderivatives.
Morphineisastronganalgesicthatshouldonlybeusedtomanageseverepain.
Itishighlyaddictiveandisnotneededintheroutinemanagementofchronicpelvicpain.
Codeineisamuchweakeropioidanalgesicthanmorphine,andiseffectiveinthemanagementofmildtomoderatepain.
ItcanbeusedtogetherwithaNSAIDorwithparacetamol,andmaybeavail-ableintabletformasafixedcombination.
How-evertakingthemedicationsasseparatetabletsispreferableifthecombinationpreparationscontaininadequatedosages.
Constipationisaside-effectofcodeine,whichcanbealimitingfactorbutmaybeanassetforwomenwithepisodicdiarrhea.
Itismuchlessaddictivethanmorphine.
AdjuvantdrugsThesearedrugsthatarenotanalgesics,butwhenusedalongsideanalgesicscanreducetheperceptionofpain.
Thetricyclicantidepressantamitriptylineiseffectiveandusuallyreadilyavailable.
Itnotonlyhasanantidepressanteffect,whichmaybeofmajorbenefit,butitalsoincreasestheeffectivenessofthenaturalpain-inhibitionprocesseswithinthenervoussystem21.
Itsmildsedativeeffectcanbebeneficial.
Theusualdoseistocommencewith10mgintheevening,increasingslowlybyincre-mentsifneeded,upto75mg.
Otherantidepres-santsmaybemoreappropriateifclinicaldepressionissignificant.
SurgerySurgeryisindicatedforwomenwithpelvicmasses,orovariancysts/tumoursthatmaybeendometrio-ticbutcouldbeofmoresinisterorigin.
Itmayalsobeindicatediffibroidsarepresentastheycansometimesbethecauseofchronicpain(seeChapter19).
Surgerymaybedifficultandshouldonlybeundertakenbyexperiencedcliniciansinhospitalsthatcandealwithunforeseencomplications,in-cludingdamagetobowel,bladderandureters.
Womenmustfullyunderstandtheproposedprocedure.
Iffertilityisdesiredtheaimshouldbetodotheminimumtoenablethispossibility.
How-ever,womenneedtobecounseledthathyster-ectomymaybecomenecessarydependingonthefindings.
Endometriomasshouldbecompletelyex-cisedasithasbeenshownthatifthecystwallisnotremoved,recurrenceismorelikely.
Hysterectomyandremovalofbothovariesmaybethebestoptionforwomennotwantingtheirfertilitywhohavefailedtorespondtoconservativetreatment24.
IRRITABLEBOWELSYNDROMEIBSisoneofthefunctionalgastrointestinaldis-orders(FGIDs).
Functionaldisordersareonesforwhich:'thereisnoevidenceofaninflammatory,anatomic,metabolic,orneoplasticprocessthatexplainsthepatient'ssymptoms'25.
GYNECOLOGYFORLESS-RESOURCEDLOCATIONS74TheyarerelativelycommondisordersintheWesternworldbutmaybelesssoinunder-resourcedcountries,althoughdifferencesinhealthserviceprovision,aswellassignificantlyfewerre-searchpossibilities,makescomparisondifficult.
Asystematicliteraturereviewconductedin2005toassesstheinfluenceofgeographyandethnicityonIBSconcludedtherewas'noconvincingevidenceofadifferencebetweenwesternanddevelopedcountries'26.
DefinitionCriteriahavebeendevelopedandregularlyre-viewed,knownastheRomecriteria,onwhichadiagnosisofanFGIDcanbebased27.
Thisclassifica-tiondividestheFGIDsaccordingtothemostlikelysiteofgastrointestinaldysfunction,fromesophagustorectum.
Itacknowledgesthatthereisoftenanoverlapbetweenthedifferentdisordersandthat,astheyarecommon,thereisahighpossibilityofco-existencewithotherdiseases.
Thedisordersaffect-ingboweldysfunctionincludeIBS,functionalbloating,functionalconstipationandfunctionaldiarrhea.
Ofthese,onlyIBShasanelementofpainordiscomfort.
IBScanco-existwithanyoftheotherfunctionalboweldisorders.
SymptomsareknowntofluctuateinallindividualswithanyFGDI.
ThefollowingaretheRomeIIIdiagnosticcri-teriaforIBS.
Symptomsmusthavebegunatleast6monthspriortothepatientpresenting,andbeenpresentduringtheprevious3months,toindicatecurrentdiseaseactivity27:recurrentabdominalpainordiscomfortforatleast3dayspermonthassoci-atedwith2ormoreofthefollowing:ImprovementwithdefecationOnsetassociatedwithachangeinfrequencyofstoolOnsetassociatedwithachangeinform(appear-ance)ofstool.
DiagnosisIBSisadiagnosisbasedonsymptomsandtheexclusionoforganicdisease.
Afullhistoryandphysicalexaminationwillrevealtheneedforfur-therinvestigations.
Iftherearenoneofthefollow-ing'alarm'symptomsorsigns,thenadiagnosisofIBScanbemadeandtreatmentcommenced28.
Alarmsymptoms/signsRectalbleedingWeightlossFeverAnemiaFamilyhistoryofcoloncancerAbdominal/pelvicmassHigherythrocytesedimentationrateAstoolsampleshouldalwaysbesentformicros-copytoexcludeparasiticinfectionsandanHIVtestresultshouldideallybeknown.
TreatmentThiswillbeginwithanexplanationofthecondi-tion.
Individualsneedtobetoldthatforvariousreasons,whichmayormaynotbecomeevident,theirintestineshavebecomeover-responsivetocertainstimulithatwouldotherwisenotcausesymptoms.
Recordingsymptomsinadiaryoveraperiodofafewweeksmayidentifythosefactorsthatcauseanexacerbationofsymptoms.
Thesemayberelatedtodiet,stressoralmostanyactivityorevent.
ReassuranceshouldbegiventhatIBSisnotacanceranddoesnotincreasetheriskofcancerdeveloping.
Whencertaintriggereventshavebeenidenti-fied,helpmaybeneededtoenabletheindividualdevelopbettercopingstrategies,ratherthanrely-ingonmedication.
Howeasyitistodothiswilldependonthelocalservicesavailable.
Inthefirstinstanceitmaybesomethingthewomancanexplorewithherownfamilyoraclosefriend/confidant.
Ifvariousfooditemsareknowntotriggersymp-toms,dietarymodificationwillbehelpful.
Undulyrestrictivedietshavenotbeenshowntobeeffec-tive.
Whenconstipationistroublesome,increasingdietaryfiberwillhelp;ifdiarrheaisaproblem,re-ducingtheamountofdietaryfructosemayhelp;ifbloatingistroublesomereducingtheintakeoffoodsthatferment,suchascabbageandbeans,maybeallthatisneeded29.
Ifsymptomsaremoresevereornotcontrolledbylife-styleadjustments,specifictreatmentshouldbeoffereddependingonthemosttroublesomesymptomsatthetime.
Itneedstobestressedthatsymptomsarelikelytowaxandwaneandthatpharmacologicaltreatmentshouldbediscontinuedwhentheconditionsubsides.
ChronicPelvicPain75AntispasmodicsAntispasmodicsareoftenhelpfulasIBSisassociatedwithincreasedcolonicmotility.
Theprecisemedi-cationusedwilldependonlocalavailability.
Hyo-scinebutylbromidehasbeenshowntobeeffectiveandwelltoleratedforthetreatmentofrecurrentcrampyabdominalpaininadoseof10mg3timesdaily.
Itispoorlyabsorbedfromthegastrointestinaltractandexertsitseffectsmainlybylocalaction30.
BulkingagentsandantidiarrhealsTheseareindicatedonlyifthereareassociatedsymp-tomsofconstipationordiarrheathathavenotre-spondedtodietarymanipulation.
BulkingagentsdonotimprovesymptomsofIBSunlessthereisasso-ciatedconstipation.
Likewiseloperamideinadoseof2–4mgupto4timesdailyimprovesdiarrhea,butdoesnotimproveothersymptomsofIBS29.
TricyclicantidepressantsAmitriptylineinadoseof10–25mgatnight,maybeofbenefitforpatientswhosepaindoesnotim-provewiththeabovesuggestions.
BLADDERPAINSYNDROMEThebladderisasignificantpelvicorganthatcanbeinvolvedinanumberofdiseaseprocessescausingchronicpain.
Inordertoclarifythecriteriafordiagnosingchronicpainarisinginthebladder,theEuropeanSocietyfortheStudyofInterstitialCystitisin2008proposedthatthetermbladderpainsyndrome(BPS)isusedwhen:'Chronicpelvicpain(>6months),pressureordiscomfort,perceivedtoberelatedtotheurinarybladderisaccompaniedbyatleastoneotherurin-arysymptomsuchaspersistenturgetovoidorurinaryfrequency.
Confusablediseasesthatcouldcausethesymptomsshouldbeexcluded'31.
Themaintreatablediseases('confusablediseases')thatneedtobeexcludedare:Urinarytractinfection:microscopy/cultureofurine(iffacilitiesavailable)orresponsetoantibioticsChlamydiainfectionoftheurethra:history,sexualriskfactors,swabsorurinetestsifavail-able(seeChapter17)Schistosomiasis:microscopyurineandstool,biopsyofcervixBladderstone,uretericstone:history,IVPBladdermalignancy:presenceofmacroscopichematurianeedingcystoscopy,ultrasound,cystographTuberculosis:generalexamination+chestX-rayforpulmonarytuberculosis.
Staining/cultureofurinefortuberculosisespeciallyifsterilepyuriaOveractivebladder:womencomplainthatwhentheyfeeltheneedtovoidtheyhavetorushtothetoiletortheymaywetthemselves.
TheydonotcomplainofpainEndometriosis:canoccasionallyaffectthebladderandwouldcausehematuria.
ThecauseofBPSisunknown,buthypothesesin-cludeinflammation,autoimmunemechanisms(thereisanassociationwithsystemiclupuserythematosus,Sjgren'ssyndromeandinflammatoryboweldis-ease),andabnormalitiesofthebladderwall32.
DiagnosisThepainofBPSistypicallysuprapubic,itmaybeasharppainbutcanalsobemoreofaburningorpressurepain.
Itcharacteristicallyoccursasthebladderfills,andisrelievedbyvoiding33.
Thepainmustbeaccompaniedbyatleastoneotherurinarysymptom,whichinpracticeusuallymeansmultiplesymptomsincludingurinarysymptomsrelatedtointercourse.
Sometimesthereisreferredpaintotheback,groinorvagina,andpainmaybeworsedur-ingmenstruation.
Physicalexaminationmayrevealbladdertendernessbutisotherwiseunremarkable.
Urinalysisisnormal.
Avoidingdiaryisoftenhelpful.
Thewomanrecordsherfluidinputaswellasherperceptionofpainandtheamountofurineshepasseseachtimeshevoidsovera3-dayperiod.
Womenshouldalsonoteanyfoodsordrinksthatmakethepainworse.
TreatmentThismustbeginwithafullexplanationofthecon-dition,thatsymptomsarelikelytofluctuateovertime,butworseningisuncommon,andthereisnoassociationwithlaterdevelopmentofbladdercan-cer.
ManysufferersofBPSfindthatcertainfoodsanddrinksmaketheirsymptomsworse.
Acidicandspicyfoods,coffee,tea,carbonatedandalcoholicdrinksseemtobethemosttroublesome.
Avoidingthesesubstancesmaybehelpful34.
Fluidrestrictionshouldnotbeadvisedasthiscanincreasepain.
GYNECOLOGYFORLESS-RESOURCEDLOCATIONS76Bladder'retraining'maybehelpful.
Withthisthewomanisencouragedtoveryslowlyincreasethetimebetweeneachactofvoiding,sogentlyincreasingbladdercapacity35.
AnalgesicssuchasparacetamolandNSAIDscanbetakenifnecessary.
Amitriptylineisthemainstayoftreatment.
Itworksinanumberofwaystoreducepain,increasebladdercapacity,reducefrequencyandaidsleep36,actionsthatshouldbeexplainedtothewomenforwhomitisprescribed.
Itisnotbeingprescribedasanantidepressant.
Womenshouldbereferredforaurologicalopinioniftheirsymptomsaresevereordonotimprove.
PELVICFLOORMUSCLEDYSFUNCTIONThepelvicfloormusclesplayavitalrolein:main-tainingpelvicstability,childbirth,maintainingurinaryandfecalcontinenceandfemalesexualfunction.
Weakeningofthepelvicfloormusclesasaresultofdifficultchildbirthand/orrepeatedchildbearingcanincreasetheriskofgenitalpro-lapseandurinarystressincontinence.
Overactive,chronicallytense,pelvicmusclesareassociatedwithconstipation,BPS,dyspareuniaandendometriosisanditisoftendifficulttodeterminewhethertheincreasedmuscletoneisthecauseoreffectofthesecomplaints.
Ahistoryofsexualabuseisanotherriskfactor37.
Whenamusclebecomeschronicallytensethereisoftenaspecificsensitiveareawithinthemusclethatcanbelocalizedbypalpationduringvaginalexamination.
Thisareaiscalledatriggerpoint.
Triggerpointscanbeaggravatedbyspecificmove-mentsandalleviatedincertainpositionssothatpatientsmayforexample,sitononebuttockandmovecautiously.
Treatmentisdifficultinunder-resourcedcoun-triesasitisbestundertakenbyphysiotherapistswithaspecialinterestinthisproblem.
TheconditionislikelytoimprovewhenassociatedconditionssuchasIBS,BPSorendometriosisarecontrolled.
Analgesicsandamitriptylineshouldbetried.
ADHESIONSAdhesionsmaydevelopinthepelvisfrompelvicinflammatorydisease,endometriosis,appendicitisandafteranysurgicalprocedure,suchascesareansection,salpingectomy,ovariancystectomyandhysterectomy.
Althoughoftenpresumedtobethecauseofpain,evidenceforthisislacking38.
Itisunlikelythatrepeatsurgeryforadhesionswillim-provechronicpelvicpainandmaymakeitworse.
Itisbettertocounselthepatient,providepainreliefwithNSAIDsand/orparacetamolandgivedietaryadvicesothatbloatingandconstipationareavoided.
Therearetwosituationswhenadhesionsdoappeartobethecauseofpain.
Oneis'retainedovarysyndrome',whenanovaryleftinsituatthetimeofhysterectomybecomesburiedindenseadhesions,andtheotheris'ovarianremnantsyn-drome',whenasmallpartofanovaryisleftafteroophorectomyandbecomesinvolvedindenseadhesions.
Inboththesecircumstancesovulationsuppressionisusuallyhelpful6.
Repeatsurgeryislikelytobedifficultandshouldnotbeundertakenbytheinexperienced.
MANAGEMENTOF'UNEXPLAINED'CHRONICPELVICPAINIfthehistoryandexaminationdonotpointtoanyspecificcauseofthepain,reassuranceisvitalandanalgesiaasdescribedearliershouldbemadeavail-able.
Hormonaltreatmentasexplainedaboveforendometriosisisoftenalsohelpful.
PSYCHOLOGICALASPECTSOFPAINMANAGEMENTThepsychehasanimportantroletoplayintheper-ceptionofpain.
Aperson'sfeelingsareextremelyimportantintheirappreciationofandabilitytocopewithpain.
Fearwillmakepainworse.
Want-ingtoknowthecauseofphysicalpainisnormal.
Whenacauseisnotfound,andadequateexplana-tionhasnotbeengiven,apatientislikelytoseekadvicefromeitheranotherhealthclinic(repeatingthewholecycleofinvestigations)orfromoutsidetheformalhealthsector.
Healthworkersmustexplain'negativefindings'carefullytotheirclientsothatreliefthataseriousunderlyingdisorderhasnotbeenfound,ratherthanconcernthatonehasbeenmissed,becomesparamount.
Involvingacloserelativeorfriendinthediscussionmaybebeneficial.
BehavioralandothertherapiesUnfortunately,accesstopsychologicalhelpisnotreadilyavailableinunder-resourcedcountries,butChronicPelvicPain77ifthepossibilityexistsitshouldbeutilized.
En-couraginggentleresumptionofactivitiescanbebeneficialtogetherwithsettingobtainablegoalsoverasensibletimeperiod39.
Takinganinterestintheclient'sprogressandkeepingthedooropenforthemtoreturniftheyfeeltheyarenotimprovingareimportantstrategies.
Clientswhoareclinicallydepressedneedtobeappropriatelyreferredforeffectivemanagement.
Traditionalhealers,complementarytherapyandherbalremediesTraditionalhealersplayanimportantroleinthehealthcareofmanypeopleinunder-resourcedcountries.
Ifclientswanttouseherbalremedies,orseekspiritualhelpfromtraditionalhealersthisshouldnotbediscouraged,aslongastheseclientshavebeenfullyinvestigated,understandthefind-ings/orlackoffindings,andareawareofthecon-ventionalmedicaloptionsavailable.
Theyshouldtrytoidentifyhealerswhoareregisteredwithlocalrelevantassociationsandneedtobeawarethattheefficacy,basedonresearch,ofmanyherbalreme-diesisunknown40.
Sometimestherecanbestrongbeliefsinwitchcraftasthecauseofpain41.
Itmaynotbepossibleforahealthprovidertodissuadeapersonfromthesebeliefs.
Possibilitiesmayexistforahealthfacilitytoidentifyrelevanttraditionalhealersintheirsur-roundingsandinitiateco-operation/trainingwiththemsothattheycantakecareofclientswithchronicpain(whennoidentifiablecausehasbeenfound)intheframeworkofhome-basedcarepro-grams.
Thiscouldreducethepatientburdenforthehealthfacility.
Recognizedcomplementarymedicalpractice,suchasacupuncture,maynotbeavailableinunder-resourcedcountriesoutsideAsia,butiftheyareandwomenwanttousethem,thisshouldbeen-couraged41.
CONCLUSIONSThischapterhasgivenanoverviewofthecausesandmanagementofchronicpelvicpaininwomen.
Psychologicalfactorshaveanimportantroletoplayintheetiologyofchronicpain,andthequalityofinteractionswithhealthproviderswhomwomenconsultwillhaveamajorimpactonwhetherasuc-cessfuloutcomeforindividualwomenisachieved.
Mostwomenwithchronicpelvicpainhavenoidentifiablediseaseprocess,butthiswillonlybedeterminedafterfullhistorytaking,physicalexami-nationandbasicinvestigations.
Chronicpainsyn-dromestendtofluctuateinintensityovertimeandarerarelycured;howevertheydonotprogresstobecomemalignantdiseases.
Womenwiththesecon-ditionstendtobepoorlymanagedinunder-resourcedcountriesbecauseofthehighworkloadofclinicians.
Howevercaringclinicianscaneasilyhelpmostwomen,evenwhenonlybasicresourcesareavailable,resultinginprofessionalsatisfactionandclientswhowillnotbeastrainonthehealthsector.
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