Also see: Endometriosis and Laser Surgery for Menstrual Pain
Introduction: Although the ACOG implies that Chronic Pelvic Pain
is often a mystery, our combined medical, anesthetic and surgical approach has
brought freedom from pain to hundreds of women.
Excerpts from ACOG Technical Bulletin 1996 (May) number 223
Chronic pain is often accompanied by poorly defined symptoms and a sense of failure by both doctor and patient. When confronted with such pain, the practitioner may feel daunted by the process of establishing the cause. In spite of the challenge inherent to the management of chronic pain, it is reasonable to anticipate a positive outcome. Obstetricians and gynecologists are often confronted with patients who have chronic pelvic pain, which may or may not have a gynecologic cause. Pain that is not gynecologic in origin may require a different approach and possible referral.
Pain of any duration is assessed by history and physical examination. The technique of assessment is similar regardless of the duration of the pain. Laboratory and diagnostic studies also may be helpful depending on the clinical findings.
- Describe the location and characteristics of the pain. Does the pain radiate, what makes the pain better or worse. Does the pain change with bowel movements, menstrual periods, sexual relations, or bending over.
- Are there associated symptoms. Is there nausea, vomiting, constipation, decreased appetite, fatigue or fever?
- Has there been previous surgery, infections, obstetrical deliveries? Is the pain related?
- Has there been sports or orthopedic injuries or surgery? Are there headaches, sleep disturbances, evidence of major dental or jaw repair?
- Has there been a history of marital or sexual abuse?
- Abdominal exam: Are there scars from previous surgery? Is tenderness in these areas? Is the pain in the lower or upper abdomen? Does the pain radiate? Is the tenderness pin-point or diffuse? Are the bowel sounds normal?
- Flank and back exam: Are the flanks tender over the kidneys? Is the point tenderness near the mid back? Is there pain in the buttocks (sciatica) with radiation down the legs? Is the pain reproduced by rotating the legs outward, inward, toward one's head?
- Head and upper back exam: Does the patient's head lean forward? Are her jaw muscles clenched? Is her neck and shoulders locked and stiff?
- Gynecologic and rectal exam: Is the pain brought on by just one finger touch? Is the pain reproducible by palpating the ovaries, the uterus, the bladder, the rectum? Is the pain of intercourse reproducible? Is the pain of a bowel movement reproducible?
Laboratory and Diagnostic Tests
- Laboratory tests are usually not helpful. I use a sedimentation rate to rule out chronic inflammation from pelvic infection or colitis. Diagnostic X-rays and ultrasounds rarely are able to determine an origin of the pain. To treat irritable bowel, we add a regimen of B12 injections weekly and pancreatic enzymes to every meal. If the bowel pattern normalizes but the pain is not affected, we return to our diagnostic evaluation.
- Diagnostic laparoscopy may be quite helpful in the evaluation and treatment of patients with chronic pelvic pain. Hysteroscopy is of little or no help in these patients.
- Medications. To avoid surgery, we use two medications in trial. The first is Flagyl (and/or Vibramycin) to rule out any chronic pelvic inflammation, urinary or urethra chronic infection. If a 10 day course is not helpful, we might suggest a 30 day treatment course with Danocrine(Danazol). Danocrine will suppress ovulation, endometriosis and even Crohn's disease. Danocrine in half dose of 200mg twice daily for 25 of 30 days will also suppress PMS, menstrual flow and menstrual pain and increase muscle mass.
As noted on page 3 of the ACOG bulletin, "In selected cases, diagnostic laparoscopy may be helpful in the evaluation and treatment of patients experiencing chronic pelvic pain." Page 6 reports on the use of surgical therapies for chronic pelvic pain.
"Surgical therapy for chronic pain is limited to the treatment of surgically correctable etiologies. Even in those patients with surgically correctable conditions, both the physician and the patient must understand the possibility (if not the probability) that the pain may be unchanged, or even worsened, by the procedure, and that other non-surgical therapies may still be applicable."
Dr. Lichten was one of the first to propose an outpatient surgical procedure for the treatment of pelvic pain. This laparoscopic uterine nerve ablation (L.U.N.A.) procedure is described in great detail elsewhere. L.U.N.A. Based on the anatomical work of Ruggi, Jabolay, Counselor, Black and others, the major pathways of gynecological pain run through the utero-sacral nerves to the hypogastric plexus (pre-sacral nerves). A physician can evaluate the contribution of these pathways by injecting 5cc of lidocaine in the cervix at 3:00 and 9:00 positions. If pain relief is noted, L.U.N.A. or presacral neurectomy will be effective at continued pain relief.
We feel that diagnostic laparoscopy is warranted when treatments with antibiotics, enzymes and trigger point injections to the back and abdomen have failed. At the time of laparoscopy, L.U.N.A. is performed. For the most chronic pain, we perform pre-sacral neurectomy as an open procedure with laparotomy.
Under these strict conditions, we have been mostly successful when using hysterectomy as a last resort for the treatment of chronic pelvic pain. This does not negate the important role that psychiatrists, marriage counselors and pain specialist have in the treatment of this disease. But for the majority of pain management, the one thorough doctor approach will give the best results.
Chronic Pain Video Interview
1. . Treat as endometriosis
with Danocrine or Lupron. If the pain is due to the cyclicity of estrogen,
then results may be dramatic.
2. Anesthesiology referral.
Perform a pre-sacral block to determine if the pain is pelvic or
psycho-somatic. The muscle blockade is at a different level to the
anesthetic blockade and will not fool the pain specialist. Appropriate
pain relief demands surgical intervention.
3. Consider surgical
out-patient laparoscopy with vaporization of endometriosis, lysis of
adhesions, LUNA surgery and pre-sacral neurectomy.