Surgical Procedures for Chronic Pelvic Pain:
Surgical Procedures for Chronic Pelvic Pain: How to Perform Them, When Not to Perform Them and What to Do If They Don’t Work (Didactic) PROGRAM CHAIR Michael Hibner, MD Fred M. Howard, MD Georgine M. Lamvu, MD Sponsored by AAGL Advancing Minimally Invasive Gynecology Worldwide Professional Education Information Target Audience Educational activities are developed to meet the needs of surgical gynecologists in practice and in training, as well as, other allied healthcare professionals in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME. Table of Contents Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 3 Diagnosing Pelvic Pain G.M. Lamvu .................................................................................................................................................. 5 The Role of Laparoscopy in Treatment of Pelvic Pain F.M. Howard ............................................................................................................................................... 12 What if Surgery Fails to Cure Pain? M. Hibner ................................................................................................................................................... 26 Evidence for Surgical Intervention in Patients with Pelvic Pain G.M. Lamvu ................................................................................................................................................ 36 What if Surgery Causes Pain? M. Hibner ................................................................................................................................................... 43 Surgical Treatment of Endometriosis G.M. Lamvu ................................................................................................................................................ 53 Treatment of Less Known Conditions Causing Pelvic Pain M. Hibner ................................................................................................................................................... 58 CPP as We Understand It Today F.M. Howard ............................................................................................................................................... 71 Cultural and Linguistics Competency ......................................................................................................... 82 PG 112 Surgical Procedures for Chronic Pelvic Pain: How to Perform Them, When Not to Perform Them and What to Do If They Don’t Work (Didactic) Michael Hibner, Chair Faculty: Fred M. Howard, Georgine M. Lamvu Course Description This course will help gynecologists advance their knowledge and skills in treatment of common and less common conditions causing pelvic pain. This will be accomplished by review of current evidence for effectiveness of surgical intervention in patients with chronic pelvic pain. The role of laparoscopy in diagnosing pathology as well as its usefulness in treatment of disorders causing pelvic pain will be discussed. Current concepts in surgical treatment of endometriosis will be presented. Less known or less common conditions such as painful bladder syndrome, pelvic floor tension myalgia, pelvic congestion syndrome, adhesions and pelvic nerve entrapment syndrome will also be discussed. Finally it will offer treatment choices in cases when surgery fails to relieve pain and when surgery produces pain. This is especially important amidst growing concerns about the risks of procedures utilizing surgical mesh. Course Objectives At the conclusion of this course, the participant will be able to: 1) Summarize key components of the diagnostic process in patients with CPP; 2) discuss evidence for performing surgery to treat pelvic pain; 3) describe the role of laparoscopy in diagnosis and treatment of CPP; 4) apply proper surgical treatment of endometriosis in patients with CPP; 5) describe treatment in patients in whom surgery fails to relieve pain; and 6) identify conditions which may cause pain after pelvic surgery. Course Outline 1:30 Welcome, Introductions and Course Overview M. Hibner 1:35 Diagnosing Pelvic Pain G.M. Lamvu 2:00 The Role of Laparoscopy in Treatment of Pelvic Pain F.M. Howard 2:25 What if Surgery Fails to Cure Pain? 2:50 Evidence for Surgical Intervention in Patients with Pelvic Pain 3:15 Questions & Answers 3:25 Break 3:40 What if Surgery Causes Pain? 4:05 Surgical Treatment of Endometriosis M. Hibner G.M. Lamvu All Faculty M. Hibner G.M. Lamvu 1 4:30 Treatment of Less Known Conditions Causing Pelvic Pain 4:55 CPP as We Understand It Today 5:20 Questions & Answers 5:30 Course Evaluation M. Hibner F.M. Howard All Faculty 2 PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Viviane F. Connor Consultant: Conceptus Incorporated Frank D. Loffer, Executive Vice President/Medical Director, AAGL* Linda Michels, Executive Director, AAGL* Jonathan Solnik Other: Lecturer - Olympus, Lecturer - Karl Storz Endoscopy-America SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: CooperSurgical, Ethicon Women's Health & Urology, Intuitve Surgical Other: Royalties - CooperSurgical Linda Bradley Grants/Research Support: Elsevier Consultant: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharmaceuticals Speaker's Bureau: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharm Keith Isaacson Consultant: Karl Storz Endoscopy Rosanne M. Kho Other: Honorarium - Ethicon Endo-Surgery C.Y. Liu* Javier Magrina* Ceana H. Nezhat Consultant: Intuitve Surgical, Lumenis, Karl Storz Endoscopy-America Speaker's Bureau: Conceptus Incorporated, Ethicon Women's Health & Urology William H. Parker Grants/Research Support: Ethicon Women's Health & Urology Consultant: Ethicon Women's Health & Urology Craig J. Sobolewski Consultant: Covidien, CareFusion, TransEnterix Stock Shareholder: TransEnterix Speaker's Bureau: Covidien, Abbott Laboratories Other: Proctor - Intuitve Surgical FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Michael Hibner* Fred M. Howard Consultant: Ethicon Women's Health & Urology Speaker's Bureau: Abbott Laboratories Georgine M. Lamvu* Frank F. Tu Consultant: Ethicon Endo-Surgery 3 Asterisk (*) denotes no financial relationships to disclose. 4 Disclaimer DIAGNOSING PELVIC PAIN DISORDERS • I have no financial relationships to disclose. Georgine Lamvu, MD, MPH Director of MIS and Advanced Gynecology Fellowship Medical Director of Gynecology Florida Hospital Orlando Lamvu, AAGL 2012 1 Lamvu, AAGL 2012 2012 IOM Report Prevalence and Costs of Chronic Pain Disorders Objectives • Review epidemiology and basic physiology of chronic pelvic pain • Review the basic requirements of the initial clinical evaluation in women with chronic clinical evaluation in women with chronic pelvic pain • Review recommendations for evaluation • Important selected references listed on the last slide Lamvu, AAGL 2012 2 • 116 million adults affected by chronic pain disorders annually in the U.S. • Estimated costs $560‐635 billion annually (poor health and low productivity) • Medicare bears ¼ of medical expenditures for pain, in 2008 it was $65.3 billion • Pain is a universal experience 3 Lamvu, AAGL 2012 4 Dysmenorrhea: Cyclical Pelvic Pain Summary of US Prevalence • 25 million women with chronic pelvic pain, prevalence ranges from 4‐49% in various populations • 14 million women with vaginal or vulvar 14 million women with vaginal or vulvar pain • 25‐43% of the world’s female population has been affected by chronic pelvic pain 106 studies, 125,249 women Prevalence: 16‐81%; 8.7% (Bulgaria) to 97% (Finland) P Latthe, M Latthe, Say, et al. BMC Public Health 2006 Lamvu, AAGL 2012 5 Lamvu, AAGL 2012 5 6 Dyspareunia Noncyclical Pelvic Pain 18 studies, 299,740 women Prevalence: 2.1%‐24%; 5.2% (India) to 43.2% (Thailand) 54 Studies, 35,973 women Prevalence: 8%‐21%; 1.1% (Sweeden) to 45% (US) P Latthe, M Latthe, Say, et al. BMC Public Health 2006 Lamvu, AAGL 2012 P Latthe, M Latthe, Say, et al. BMC Public Health 2006 7 Lamvu, AAGL 2012 8 Main Objective Today To clarify and simplify your understanding of chronic pelvic pain which is often viewed by general medical providers as a difficult, puzzling and frustrating disorder with few treatment options. Epidemiology of Chronic Pelvic Pain LESS THAN 5% OF PATIENTS WITH CHRONIC PAIN ARE SEEN BY A PAIN SPECIALIST Lamvu, AAGL 2012 9 Lamvu, AAGL 2012 The Literature Supports Our Clinical Observations How Do We Improve? PRICE J, et. al. BJOG 2006;113:446‐52. SELFE SA,et al. Pain 1998;77:215‐25. GRACE VM. Health Care Women Int 1995;16:509‐19 • • • • Most women with CPP have negative perceptions of their interactions with providers… especially gynecologists Women often feel like they y Are not receiving personalized care Are not understood or taken seriously Often dismissed without reassurance or explanation for their pain CPP patients have difficulty understanding and accepting normal test results CPP patient often express disappointment with the overall quality of the consultation Lamvu, AAGL 2012 10 11 Negative perceptions Patient care Pain relief Quality of life Lamvu, AAGL 2012 6 12 Chronic Pain is Not The Same as Acute Pain A FEW CHRONIC (PELVIC) PAIN PRINCIPLES TO REMEMBER That are supported by research Lamvu, AAGL 2012 13 Acute Pain Chronic Pain Symptom of injury or disease Well defined onset, recent Expected to end in days or weeks Essential biologic warning function Remote onset and may change in character and severity over time p Unpredictable duration No apparent biologic function Progressive or persistent May be associated diseases that exacerbate or precipitate manifestations of chronic pain Lamvu, AAGL 2012 14 Pelvic Neuro-anatomy • Pelvic organs share neural pathways Depression Anxiety Catastrophizing Frustration Expectations Anger Lamvu, AAGL 2012 Facilitation Substance P Glutamate Serotonin Neurotensin Nerve growth factor CCK BRAIN Bowel Bl dd Bladder Uterus – The spinal cord The spinal cord innervates several organs – Several organs simultaneously send input into the spinal cord 15 Lamvu, AAGL 2012 Inhibition Norepinephrine Opioids GABA Cannabinoids Adenosine 16 Measuring Levels of Pain • Uni‐dimensional scales such as the Visual Analogue Scale (VAS) are not enough to capture many important aspects of pain such as: SPINAL CORD – Multi‐organ co‐morbidity – Impairment of quality of life and important functions such as sexual function – Impairment of poor coping and stress associated with chronic pain – Changes in function in response to treatment PERIPHERAL NEURON Neural cross‐talk in the pelvis Lamvu, AAGL 2012 17 Lamvu, AAGL 2012 7 18 Current Definition of Pain The 1,2,3 of the Initial Evaluation 1. Establish pattern of chronicity 2. Determine how many organs are involved 3. Physical exam to include the three M’s • Mood: psychological and quality of life Mood: psychological and quality of life • Musculoskeletal exam (internal/external) • Mucosal exam IASP definition: an unpleasant sensory and emotional experience associated with actual or potential damage or described in terms of such damage described in terms of such damage. Pain is both a physiologic process composed of impulse transmission along neural pathways, involving the release of neurotransmitters , and subjective and emotional experience. Lamvu, AAGL 2012 19 Lamvu, AAGL 2012 Slide courtesy of Anne Marie Fras, MD Slide courtesy of Anne Marie Fras, MD Establish How Many Organs Are Involved Establish a Pattern Of Chronicity • Use open‐ended questions • • • • Timing Onset Duration Previous treatments tried • Associated gastrointestinal, urinary and musculoskeletal symptoms • Alleviating or exacerbating factors • Allow patient to express how pain effects • Daily function • Quality of life Gastrointestinal Urologic • Allow patient to identify what is most distressing The quality of the initial gynecological consultation is associated with success of follow up and recovery Reproductive Musculoskeletal Selfe et al. Factors influencing outcome in consultations for chronic pelvic pain. J Womens Health, 7: 1041‐8. 1998. Lamvu, AAGL 2012 20 Zondervan KT. Br J Obstet Gynaecol. 1999;106:1156‐1161. Howard FM. Obstet Gynecol. 2003:101:594‐611. 21 Lamvu, AAGL 2012 22 Pelvic Pain Examination Physical Examination Appearance • Sequential examination, you may not be able to do everything in one visit! • Don’t get stuck on one diagnosis – It may change It h – Multiple organ systems may be involved Mood Affect • Remember your neurobiology and think central mechanisms Muscle Skeletal Abdominal Walking Standing Strength Reflexes Sensory Motor Sensory Contraction Relaxation Insertion points Scars Trigger points Pelvic External Internal single digit speculum bimanual rectovaginal •Identify location that REPLICATES pain •Pain intensity and affective response •Referral pattern Lamvu, AAGL 2012 23 Lamvu, AAGL 2012 8 24 Musculoskeletal Examination Low Back Pain Musculoskeletal Evaluation • Identify asymmetry and pain associated with movement of the – – – – PSIS, ASIS Iliac Crest, Pubic Symphysis Greater Trochanter Greater Trochanter • Palpate paraspinal structures • With sciatica symptoms: Lasegue’s test – (+) test suggests L4–5 or L5–S1 disc herniation Vroomen JC, et al, J Neurol. 1999 Slide courtesy of Frank Tu, MD Slide courtesy of Frank Tu, MD. Lamvu, AAGL 2012 25 Lamvu, AAGL 2012 Abdominal Examination •Evaluate abdominal wall for tender muscular points (trigger points, myofascial pain) •Assess both deep and superficial (brush) pain sensitivity especially around scars • While the patient performs a “crunch” p p palpate the rectus and obliques q • To distinguish visceral/ intr‐aperitoneal pain from regional somatic pain • deep pelvic pain improves when the muscles are contracted • Muscular pain worsens when the muscles are contracted Slide courtesy of Frank Tu, MD Lamvu, AAGL 2012 26 Vaginal Examination Look First! External Survey Carnett’s test • Vulvar or vestibular skin lesions – ulcerations, fissures • Swelling or redness • Vestibular hypersensitivity with Q‐ti touch • Atrophic changes • Urethral meatus • Pelvic organ prolapse 27 Lamvu, AAGL 2012 28 Vaginal Examination: Palpate Second: Internal Single Digit Vulvar Pain: Sensory Innervation of the Perineum • Voluntary contraction, strength, relaxation and pain of muscles: • Introitus p • Levator plate • Obturator • Pain of • • • • Lamvu, AAGL 2012 29 Lamvu, AAGL 2012 9 Bladder Cervix Urethral Ischeal tuberosity and alcock’s canal 30 Internal Examination Speculum Examination Internal Bimanual and Rectovaginal Examination Uterus Ovaries Uterosacrals Posterior cul‐de‐ sac • Rectovaginal vault • • • • • Vaginal walls • Vaginal fornices – or vaginal cuff • Cervix • Vaginal discharge – pH – Wet mount – STI cultures Lamvu, AAGL 2012 31 Lamvu, AAGL 2012 Integrate Your Examination Findings Into a Diagnosis and Treatment Plan Musculoskeletal Somatic Organ Specific Myofascial syndrome Physical therapy Trigger points Muscle relaxants Loss of muscle function Trigger point injections Urinary i Dietary changes i h Gastrointestinal Anti‐spasmotics Reproductive Cycle suppression Visceral 32 Therapies for CPP Disorders Surgeries Depression Mood Antidepressants Anxiety Anxiolytics Poor coping Cognitive behavioral therapy Sexual dysfunction Lamvu, AAGL 2012 33 Lamvu 2011 34 Summary Surgical Alternative Complimentary Therapy Physical Therapy – Size – Location – Mobility – Tenderness – Nodularity – Masses Hormonal Individualized Multidisciplinary Multidisciplinary Therapy • Take more time with the history and physical than with anything else • Try to distinguish whether multiple organs are involved • Use single digit exam over global bimanual to l d l b lb l optimize specificity • Always consider primary or secondary musculoskeletal causes • Always consider the psychosocial and sexual environment Neuropathic Blocks Cognitive Behavioral Therapy Analgesics Antidepressants Anticonvulsants Lamvu 2011 Lamvu, AAGL 2012 35 10 36 References • • • • • • [email protected] THANK YOU • • • Lamvu, AAGL 2012 37 P Latthe, M Latthe, Say, et al. BMC Public Health 2006 PRICE J, et. al. BJOG 2006;113:446‐52. SELFE SA,et al. Pain 1998;77:215‐25. GRACE VM. Health Care Women Int 1995;16:509‐19 Selfe et al. Factors influencing outcome in consultations for chronic pelvic pain J Womens Health, consultations for chronic pelvic pain. J Womens Health 7: 1041‐8. 1998. Zondervan KT. Br J Obstet Gynaecol. 1999;106:1156‐ 1161. Howard FM. Obstet Gynecol. 2003:101:594‐611. Vroomen JC, et al, J Neurol. 1999 Institute of Medicine: Relieving Pain in America. 2012 Lamvu, AAGL 2012 11 38 DISCLOSURE The Role of Laparoscopy in the Treatment of Pelvic Pain Consultant: Ethicon Women's Health & Urology Speaker's Bureau: Abbott Laboratories Fred M. Howard, MS, MD Professor Emeritus of Obstetrics‐Gynecology U i University of Rochester i fR h School of Medicine & Dentistry Rochester, New York [email protected] OBJECTIVES Traditional Role of Laparoscopy in CPP • Identify the disorders that may require laparoscopy for diagnosis • List the important disorders in CPP that do not require laparoscopy & have negative laparoscopic findings • Formulate the appropriate role for laparoscopy in women with CPP • Routine part of the evaluation of chronic pelvic pain • Abnormal exam correlates with abnormal laparoscopic findings in 70‐90% of cases • Normal exam in Normal exam in >1/2 1/2 with abnormal laparoscopic with abnormal laparoscopic findings Laparoscopy in Women with Prior Treatment Laparoscopy in Women with Prior Treatment 80 70 60 50 % with 40 Improvement 30 20 10 0 – Laparoscopy may allow the detection of potentially treatable pathology not detected by exam • Multidisciplinary evaluation & treatment “is more likely to result in a reduction of pelvic pain than is the standard form of care.” • “If a carefully taken history and an expert pelvic examination are negative, it is doubtful whether invasive measures such as laparoscopy have any additional information to offer.” Gyn Laparoscopy G L Multidisciplinary General Daily Assoc Sxs Activities McGill Peters AAW, et al. Obstet Gynecol 1991;77:740 Peters AAW, et al. Obstet Gynecol 1991;77:740 12 Evidence Based Evaluation of Diagnoses Associated with CPP Level A Evidence Diagnoses Reproductive Tract Diagnoses • Endometriosis • Gynecologic malignancies • Ovarian retention syndrome • Ovarian remnant syndrome • (Pelvic congestion syndrome) • Pelvic inflammatory disease • Tuberculous salpingitis Level A Evidence Diagnoses Level A Evidence Diagnoses Reproductive Tract Diagnoses • Endometriosis • Gynecologic malignancies • Ovarian retention syndrome • Ovarian remnant syndrome • (Pelvic congestion syndrome) • Pelvic inflammatory disease • Tuberculous salpingitis Urinary Tract Diagnoses • Bladder malignancy • Interstitial cystitis • Radiation cystitis Radiation cystitis • Urethral syndrome Level A Evidence Diagnoses Level A Evidence Diagnoses Urinary Tract Diagnoses • Bladder malignancy • Interstitial cystitis • Radiation cystitis Radiation cystitis • Urethral syndrome Gastrointestinal Tract Diagnoses • Carcinoma of the colon • Constipation • Inflammatory bowel disease • Irritable bowel syndrome 13 Level A Evidence Diagnoses Level A Evidence Diagnoses Musculoskeletal System Diagnoses • Abdominal wall myofascial pain (trigger points) • Abdominal cutaneous nerve entrapment in surgical scar • Chronic coccygeal or back pain • Faulty or poor posture • Fibromyalgia • Neuralgia of iliohypogastric, ilioinguinal, and/or genitofemoral nerves • Pelvic floor myalgia (levator ani or piriformis syndrome) • Peripartum pelvic pain syndrome Gastrointestinal Tract Diagnoses • Carcinoma of the colon • Constipation • Inflammatory bowel disease • Irritable bowel syndrome Level A Evidence Diagnoses Level A Evidence Diagnoses Musculoskeletal System Diagnoses • Abdominal wall myofascial pain (trigger points) • Abdominal cutaneous nerve entrapment in surgical scar • Chronic coccygeal or back pain • Faulty or poor posture • Fibromyalgia • Neuralgia of iliohypogastric, ilioinguinal, and/or genitofemoral nerves • Pelvic floor myalgia (levator ani or piriformis syndrome) • Peripartum pelvic pain syndrome Psychological Diagnoses • Depression • Catatrophizing • Somatization disorder Level A Evidence Diagnoses Level B Evidence Diagnoses Psychological Diagnoses • Depression • Catatrophizing • Somatization disorder Reproductive Tract Diagnoses • Adhesions • Benign cystic mesothelioma • Leiomyomata • Postoperative peritoneal cysts 14 Level B Evidence Diagnoses Level B Evidence Diagnoses Reproductive Tract Diagnoses • Adhesions • Benign cystic mesothelioma • Leiomyomata • Postoperative peritoneal cysts Urinary Tract Diagnoses • Adhesions • Uninhibited bladder contractions (detrusor d dyssynergia) i ) • Urethral diverticulum Level B Evidence Diagnoses Level B Evidence Diagnoses Urinary Tract Diagnoses • Adhesions • Uninhibited bladder contractions (detrusor d dyssynergia) i ) • Urethral diverticulum Gastrointestinal Tract Diagnoses • Adhesions • Celiac disease • Porphyria Level B Evidence Diagnoses Level B Evidence Diagnoses Gastrointestinal Tract Diagnoses • Adhesions • Celiac disease • Porphyria Musculoskeletal System Diagnoses • Herniated nucleus pulposus • Low back pain • Neurologic dysfunction • Neoplasia of spinal cord or sacral nerve • Shingles 15 Level B Evidence Diagnoses Level B Evidence Diagnoses Musculoskeletal System Diagnoses • Herniated nucleus pulposus • Low back pain • Neurologic dysfunction • Neoplasia of spinal cord or sacral nerve • Shingles Psychological Diagnoses • Sleep disturbances Level B Evidence Diagnoses Level C Evidence Diagnoses Psychological Diagnoses • Sleep disturbances Reproductive Tract Diagnoses • Adenomyosis • Atypical dysmenorrhea or ovulatory pain • Adnexal cysts (nonendometriotic) • Cervical stenosis • Chronic ectopic pregnancy p p g y • Chronic endometritis • Endometrial or cervical polyps • Endosalpingiosis • Intrauterine contraceptive device • Ovarian ovulatory pain • Residual accessory ovary • Symptomatic pelvic relaxation (genital prolapse) Level C Evidence Diagnoses Level C Evidence Diagnoses Reproductive Tract Diagnoses • Adenomyosis • Atypical dysmenorrhea or ovulatory pain • Adnexal cysts (nonendometriotic) • Cervical stenosis • Chronic ectopic pregnancy p p g y • Chronic endometritis • Endometrial or cervical polyps • Endosalpingiosis • Intrauterine contraceptive device • Ovarian ovulatory pain • Residual accessory ovary • Symptomatic pelvic relaxation (genital prolapse) Urinary Tract Diagnoses • Chronic urinary tract infection • Recurrent, acute urethritis Recurrent, acute urethritis • Recurrent, acute cystitis • Stone/urolithiasis • Urethral caruncle 16 Level C Evidence Diagnoses Level C Evidence Diagnoses Gastrointestinal Tract Diagnoses • Abdominal epilepsy • Abdominal migraine • Colitis • Chronic intermittent bowel obstruction • Diverticular disease • Familial Mediterranean fever Urinary Tract Diagnoses • Chronic urinary tract infection • Recurrent, acute urethritis • Recurrent, acute cystitis • Stone/urolithiasis • Urethral caruncle Level C Evidence Diagnoses Level C Evidence Diagnoses Musculoskeletal System Diagnoses • Compression of lumbar vertebrae • Degenerative joint disease • Hernias: ventral, inguinal, femoral, spigelian Hernias: ventral inguinal femoral spigelian • Muscular strains and sprains • Rectus tendon strain/Rectus abdominis pain syndrome • Spondylosis Gastrointestinal Tract Diagnoses • Abdominal epilepsy • Abdominal migraine • Colitis • Chronic intermittent bowel obstruction • Diverticular disease • Familial Mediterranean fever Level C Evidence Diagnoses Level C Evidence Diagnoses Musculoskeletal System Diagnoses • Compression of lumbar vertebrae • Degenerative joint disease • Hernias: ventral, inguinal, femoral, spigelian Hernias: ventral inguinal femoral spigelian • Muscular strains and sprains • Rectus tendon strain/Rectus abdominis pain syndrome • Spondylosis Psychological Diagnoses • Bipolar personality disorders 17 Level C Evidence Diagnoses Diagnoses “Requiring” Diagnostic Laparoscopy 1. 2. Psychological Diagnoses • Bipolar personality disorders 3. 4. 4 5. 6. Endometriosis Ovarian remnant syndrome Pelvic inflammatory disease Tuberculous salpingitis Tuberculous salpingitis Adhesions Benign cystic mesothelioma 7. Postoperative peritoneal cysts 8. Adnexal cysts (nonendometriotic) 9. Chronic ectopic pregnancy 10 Endosalpingiosis 10. 11. Residual accessory ovary 12. Hernias: ventral, inguinal, femoral, spigelian Interim Points Interim Points • Abandon the idea that laparoscopy is essential in the evaluation of CPP • Abandon the idea that laparoscopy is the penultimate diagnostic test in CPP penultimate diagnostic test in CPP • Laparoscopy often has a therapeutic role in chronic pelvic pain • Preferred approach to surgical treatment of many of the disorders amenable to operative many of the disorders amenable to operative treatment – Negative findings do not mean there is no organic diagnosis Diagnoses “Requiring” Diagnostic Laparoscopy 1. 2. 3. 4. 4 5. 6. Endometriosis Ovarian remnant syndrome Pelvic inflammatory disease Tuberculous salpingitis Tuberculous salpingitis Adhesions Benign cystic mesothelioma Diagnosis of Endometriosis 7. Postoperative peritoneal cysts 8. Adnexal cysts (nonendometriotic) 9. Chronic ectopic pregnancy 10 Endosalpingiosis 10. 11. Residual accessory ovary 12. Hernias: ventral, inguinal, femoral, spigelian • Histologic diagnosis, not laparoscopic diagnosis • Ectopic endometrial glands and stroma must be present – Requires a tissue specimen 18 VISUAL DIAGNOSIS Visual Diagnosis Description of Lesion Black Brown White Red Clear papules Glandular Peritoneal defects Superficial yellow-brown Adhesions (ovarian) Carbon Adhesions (non-ovarian) Cribriform peritoneal defects Confirmation of Diagnosis 90% 78% 76% 67% 67% 67% 41% 40% 40% 17% 12% 9% • • • • Positive predictive value Negative perdictive value Sensitivity = 97% Specificity = 77% = 45% = 99% Walter et al. Am J Obstet Gynecol 2001;184:1407 Not a Visual Diagnosis Not a Visual Diagnosis Not a Clinical Diagnosis Clinical Diagnosis Clinical vs Histological Diagnosis • Of 95 women clinically diagnosed with endometriosis, 81% had confirmations at the time of laparoscopy – Suggests that laparoscopy is not necessary before starting medical treatment Negative Histology Positive Histology Total Endometriosis not clinically y diagnosed 134 (76%) 43 (24%) 177 Endometriosis clinically diagnosed 72 126 (64%) 198 206 169 375 Total Ling FW. Obstet & Gynecol 1999;93:51-8 Howard FM. Unpublished data 19 Not a Clinical Diagnosis NOT A VISUAL DIAGNOSIS NOT A CLINICAL DIAGNOSIS Clinical vs Histological Diagnosis Negative Histology Positive Histology Total Endometriosis not clinically y diagnosed 134 (76%) 43 177 Endometriosis clinically diagnosed 72 126 (64%) 198 206 169 375 Total • Clinical diagnosis – Positive predictive value – Negative predictive value = 64% = 76% • Visual laparoscopic diagnosis Vi l l i di i – Positive predictive value – Negative predictive value Howard FM. Unpublished data = 45% = 99% Howard FM. Unpublished data Walter et al. Am J Obstet Gynecol 2001;184:1407 Laparoscopy for Endometriosis Diagnoses “Requiring” Diagnostic Laparoscopy 1. 2. • Thorough knowledge of the various appearances of endometriosis • Liberal use of excisional biopsies • Thorough evaluation of the pelvis h h l i f h l i 3. 4. 4 5. 6. – At least a double‐puncture technique – "Near‐contact" laparoscopy Endometriosis Ovarian remnant syndrome Pelvic inflammatory disease Tuberculous salpingitis salpingitis Adhesions Benign cystic mesothelioma 7. Postoperative peritoneal cysts 8. Adnexal cysts (nonendometriotic) 9. Chronic ectopic pregnancy 10 Endosalpingiosis 10. 11. Residual accessory ovary 12. Hernias: ventral, inguinal, femoral, spigelian Ovarian Remnant Syndrome Ovarian Remnant Syndrome Diagnostic Studies • Pelvic pain or mass due to persistence of ovarian fragments unintentionally left in situ during (difficult) oophorectomy • Most commonly described after a previous bilateral salpingoophorectomy and hysterectomy • Occurs more commonly than generally thought • Vaginal ultrasound shows pelvic mass in 50‐85% of cases – Diagnostic accuracy improved by pretreatment with clomiphene citrate if functional follicles are present • FSH levels – No hormonal replacement for three weeks or more N h l l t f th k – Pre‐menopausal FSH levels in 50‐75% • GnRH‐a stimulation test – Baseline & 3‐7 day post‐injection levels of estradiol 20 Ovarian Remnant Syndrome Ovarian Remnant Syndrome Medical Treatment • Hormonal suppression Ovarian Remnant – Depot‐medroxyprogesterone acetate (150 mg IM each month) – Danazol (600 mg per day PO) ( gp y ) – Depot‐leuprolide acetate (3.75 mg IM each month) – Combined estrogen‐progestagen Ovarian Remnant Endometriosi s • Radiation treatment (2000‐3000 cGy) Ureter Diagnoses “Requiring” Diagnostic Laparoscopy 1. 2. 3. 4. 4 5. 6. Endometriosis Ovarian remnant syndrome Pelvic inflammatory disease Tuberculous salpingitis salpingitis Adhesions Benign cystic mesothelioma Pelvic Inflammatory Disease 7. Postoperative peritoneal cysts 8. Adnexal cysts (nonendometriotic) 9. Chronic ectopic pregnancy 10 Endosalpingiosis 10. 11. Residual accessory ovary 12. Hernias: ventral, inguinal, femoral, spigelian • 30% of women develop CPP after PID Ness RB et al. Am J of Obstet Gynecol 186:929-37, 2002 Diagnoses “Requiring” Diagnostic Laparoscopy 1. 2. 3. 4. 4 5. 6. Endometriosis Ovarian remnant syndrome Pelvic inflammatory disease Tuberculous salpingitis Tuberculous salpingitis Adhesions Benign cystic mesothelioma Adhesions 7. Postoperative peritoneal cysts 8. Adnexal cysts (nonendometriotic) 9. Chronic ectopic pregnancy 10 Endosalpingiosis 10. 11. Residual accessory ovary 12. Hernias: ventral, inguinal, femoral, spigelian • Etiology – – – – – 21 PID Endometriosis Perforated appendix Prior surgery Inflammatory bowel disease Adhesions Adhesions • Presently the only definitive way to diagnose adhesions is by surgical visualization • Excision & histology may be important in women with endometriosis • Physical appearance of adhesions are not specific to the underlying cause Laparoscopic Treatment of Adhesion‐Associated Pelvic Pain Reformed Adhesions • Observational studies suggest efficacy of 60‐90% • RCT laparoscopic adhesiolysis showed no efficacy at 12 months Reformed Adhesions 100 90 80 70 60 % with 50 Adhesions 40 30 20 10 0 Swank et al. Lancet 2003;361:1247 • RCT adhesiolysis y by laparotomy showed no difference at 11 y p y months Peters AAW, et al. Br J Obstet Gynaecol 1992;99:59 • RCT paracolic adhesiolysis showed improvement in pain at 4‐ 8 weeks. Keltz et al. JSLS 2006: 10; 443‐46 Ovarian Laparoscopy Laparotomy Diamond M, et al. Fertil Steril 1991;55:700-704 Franklin RR, et al. Obstet Gynecol 1995;86:335-340 Diagnoses “Requiring” Diagnostic Laparoscopy Laparoscopic Treatment of Adhesion‐Associated Pelvic Pain 1. 2. • Prevention of recurrent adhesions 3. – Unnecessary suture material – Residual blood or clots – Unnecessary tissue trauma & handling 4. 4 5. 6. • Currently Interceed is only product with evidence of efficacy that can be used laparoscopically 22 Endometriosis Ovarian remnant syndrome Pelvic inflammatory disease Tuberculous salpingitis Tuberculous salpingitis Adhesions Benign cystic mesothelioma 7. Postoperative peritoneal cysts 8. Adnexal cysts (nonendometriotic) 9. Chronic ectopic pregnancy 10 Endosalpingiosis 10. 11. Residual accessory ovary 12. Hernias: ventral, inguinal, femoral, spigelian Benign Cystic Mesothelioma Diagnoses “Requiring” Diagnostic Laparoscopy 1. 2. 3. 4. 4 5. 6. Endometriosis Ovarian remnant syndrome Pelvic inflammatory disease Tuberculous salpingitis Tuberculous salpingitis Adhesions Benign cystic mesothelioma Postoperative Peritoneal Cyst 7. Postoperative peritoneal cysts 8. Adnexal cysts (nonendometriotic) 9. Chronic ectopic pregnancy 10 Endosalpingiosis 10. 11. Residual accessory ovary 12. Hernias: ventral, inguinal, femoral, spigelian Diagnoses “Requiring” Diagnostic Laparoscopy 1. 2. 3. 4. 4 5. 6. Endometriosis Ovarian remnant syndrome Pelvic inflammatory disease Tuberculous salpingitis Tuberculous salpingitis Adhesions Benign cystic mesothelioma Diagnosis of Ovarian Cysts 7. Postoperative peritoneal cysts 8. Adnexal cysts (nonendometriotic) 9. Chronic ectopic pregnancy 10 Endosalpingiosis 10. 11. Residual accessory ovary 12. Hernias: ventral, inguinal, femoral, spigelian Laparoscopy & Ovarian Cysts • Presence of ovarian cysts can be diagnosed without laparoscopy • Residual ovary syndrome – – – – – Ovarian retention El‐Minawi A, Howard FM. J Am Assoc Gynecol Laparosc 1999 6 297 1999 6:297. • Recurrent functional cysts Ultrasound CT scan MRI scan Physical examination • Identification of ovarian cysts may require histology Stone SC, Swartz WJ. Am J Obstet Gynecol 134:310,1979. 23 Diagnoses “Requiring” Diagnostic Laparoscopy Treatment of Ovarian Cysts 1. 2. • Precautions re: malignancy • Complete removal or destruction of cyst wall destruction of cyst wall • Histology 3. 4. 4 5. 6. Endometriosis Ovarian remnant syndrome Pelvic inflammatory disease Tuberculous salpingitis Tuberculous salpingitis Adhesions Benign cystic mesothelioma 7. Postoperative peritoneal cysts 8. Adnexal cysts (nonendometriotic) 9. Chronic ectopic pregnancy 10 Endosalpingiosis 10. 11. Residual accessory ovary 12. Hernias: ventral, inguinal, femoral, spigelian Endosalpingiosis Endosalpingiosis • Ectopic fallopian tubal glandular epithelium • Diagnosis – Usually not recognized or misdiagnosed as endometriosis – Important to biopsy – White‐yellow, opaque or translucent, or translucent, punctate, cystic lesions • Evidence re: CPP – Observational & limited Diagnoses “Requiring” Diagnostic Laparoscopy 1. 2. 3. 4. 4 5. 6. Endometriosis Ovarian remnant syndrome Pelvic inflammatory disease Tuberculous salpingitis Tuberculous salpingitis Adhesions Benign cystic mesothelioma Ventral Umbilical Hernia 7. Postoperative peritoneal cysts 8. Adnexal cysts (nonendometriotic) 9. Chronic ectopic pregnancy 10 Endosalpingiosis 10. 11. Residual accessory ovary 12. Hernias: ventral, inguinal, femoral, spigelian 24 Laparoscopic Pain Mapping Sciatic Hernia Non‐CLPM series (65) • Endometriosis 38% • Adhesions 34% • Decreased pain 78% • Pain‐free 45% CLPM series (50) • Endometriosis 40% • Adhesions 54% • Decreased pain 44% • Pain‐free 16% Howard FM, et al. Obstet Gynecol 2000; 96: 934 THANK YOU REFERENCES • • • • • • • • • • • • • • Whosoever is spared personal pain must feel himself called to help in diminishing the pain of others…… Pain is a more terrible lord of mankind than even death….. Dr. Albert Schweitzer Albert Schweitzer, 1875 – 1965 • 25 Peters AAW, et al. Obstet Gynecol 1991;77:740 Walter et al. Am J Obstet Gynecol 2001;184:1407 Ling FW. Obstet & Gynecol 1999;93:51‐8 Ness RB et al. Am J of Obstet Gynecol 186:929‐37, 2002 Diamond M, et al. Fertil Steril 1991;55:700‐704 Franklin RR, et al. Obstet Gynecol 1995;86:335‐340 Howard & Sanchez. Obstet Gynecol y 2000; 96: 934 ; Howard FM. Obstet Gynecol 2003;101:594‐611 Howard FM. J Am Assoc Gynecol Laparosc 1996; 4:1,85‐94 Swank et al. Lancet 2003;361:1247 Peters AAW, et al. Br J Obstet Gynaecol 1992;99:59 Keltz et al. JSLS 2006: 10; 443‐46 El‐Minawi A, Howard FM. J Am Assoc Gynecol Laparosc 1999 6:297. Stone SC, Swartz WJ. Am J Obstet Gynecol 134:310,1979. Disclosure What if surgery fails to relieve pain? relieve pain? • I have no financial relationships to disclose. Michael Hibner, MD, PhD, FACOG, FACS Director, Division of Surgery and Pelvic Pain St. Joseph’s Hospital and Medical Center, Phoenix, Arizona Professor of Obstetrics and Gynecology Creighton University School of Medicine Objectives Clinical scenario 1 24 years old nulligravida has a history of chronic pelvic pain, dysmenorrhea, dyspareunia for the past 4 years. Two years ago she had a laparoscopy which showed a moderate endometriosis. Resection helped with pain until six months ago. • Identify causes of ongoing pain after gy gynecologic surgery for pelvic pain g g y p p • Describe diagnostic process in those cases • State available treatments for ongoing pain after gynecologic surgery for pelvic pain Clinical scenario 1 Clinical scenario 1 Patient states that her pain is getting progressively worse; she is unable to have intercourse and has to get up to go to the bathroom several times a night to urinate. On physical examination she has significant tenderness in the pelvis in all areas. You decide to proceed with another laparoscopy. On laparoscopy you again find moderate endometriosis involving both uterosacral ligaments and posterior cul‐de‐sac. You successfully remove all the lesions but six weeks after surgery patients pain is unchanged. 26 Why did the surgery fail? Coexisting conditions Howard, 2011 Issa et al., 2012 Longstreth et al., 1990 Chung et al., 2005 72 % • Wrong diagnosis? g g • Incomplete diagnosis? • Wrong treatment? 86 % Endo 65% 21% 50 % 25 % 31% PFTM IBS IC 23 % 50 % Koziol, 1994 Coexisting conditions Howard, 2011 Interstitial cystitis/Painful bladder syndrome Suprapubic pain related to bladder filling accompanied by other symptoms such as increased daytime and nighttime frequency in the absence of proven urinary tract infection or other obvious pathology INTERSTITIAL CYSTITIS International Continence Society 2002 27 Interstitial cystitis Interstitial cystitis Ulcer Scarring Pain Frequency Urgency Driscoll & Teichman, 2001 Driscoll & Teichman, 2001 Numbers Natural history • Prevalence 1‐3% general population (2.7‐6.5% of women) • 5:1 ratio of women to men 3‐8 8 million of patients in US million of patients in US • 3 • 12% of women may have early symptoms • Median age 43 years (30‐70) • 10 times higher incidence of childhood bladder problems in IC/PBS patients than controls • 90% stable disease (no progression) • 10% progress • Some studies show 50% spontaneous remission rate 15 16 Koziol et al., 1993 Berry et al., 2011 Etiology Bladder overdistention Autoimmune disorder Neurogenic inflammation Pelvic floor dysfunction Antoproliferative Factor secreted by epithelial cells Bladder trauma Bacterial cystitis Damage to bladder epithelium Bladder fails to repair damage Leak of urine into interstinum C‐fiber activation/s ubstance P release Chronic neuropathic pain central sensitization Mast cell activation and histamine release Immune and allergic response Butrick, 2003 Evans, 2002 28 Associated diseases • • • • • Symptoms • • • • • Irritable bowel syndrome (IBS) Inflammatory bowel disease (IBD) y ( ) Fibromyalgia Systemic Lupus Erythematous (SLE) Endometriosis • Dyspareunia (especially worse in certain positions) • Pain with sexual arousal Butrick et al., 2010 Butrick et al., 2010 Symptoms Diagnosis • Some patients feel pressure not pain • Pain outside the bladder: vulva, lower back, abdomen • Worsening of symptoms with • History: symptoms as above • Questionnaires • Filling of the bladder (voiding improves symptoms) • Certain foods • • • • • • • Bladder pain Urgency (84%) Frequency (92%) Nocturia Multiple sexual symptoms • PUF (pain/urinary frequency) • Used for screening purposes • Score > 12 highly suggestive of IC/PBS Citrus fruits and juices Tomatoes Cranberry Pineapple Caffeine Alcohol Carbonated drinks • O’Leary‐Saint • Used for research • Symptoms 12, problem 7 – inclusion in research Butrick et al., 2010 Butrick et al., 2010 Diagnosis Rule out other causes Parsons et al., 2002 29 Diagnosis Diagnosis • Voiding diary • Cystoscopy with hydrodistention (diagnostic) • > 8 voids/day – abnormal • Preformed under anesthesia • Bladder filled to 80 cm of water • Glomerulations • Exam • Tenderness with single digit palpation of trigone • Pinpoint Pinpoint petechial hemorrhages petechial hemorrhages • Associated with IC/PBS but also seen in other conditions • 45% of women with any lower urinary tract symptoms without IC/PBS have glomerulations • 10‐34% with IC/PBS do not have glomerulations • Laboratory studies b d • Urine analysis • Rule out UTI • Check for hematuria • Hunner’s ulcer • Negative cystoscopy does not rule out IC/PBS • Urine cytology • Vaginal cultures Butrick et al., 2010 Butrick et al., 2010 Diagnosis Treatment • Potassium Sensitivity Test (PST) • Avoidance of triggers • Stress reduction • Diet modification • First solution 50 ml of NS • Second solution 40 ml of 0.4M (400 mEq/l) KCl solution • Difference of ≥ 2 above 0 (scale 0‐5) in pain or urgency and solution 2 worse than solution 1 solution 2 worse than solution 1 • If pain with solution 2, drain bladder and rate, if not, wait 5 minutes to rate • Controversial: Parsons – pro, Hanno – con • 50‐60% of patients can identify foods causing symptoms • Eliminate all foods on the IC diet list • Reintroduce 1 food item every other day and look for worsening of symptoms • Most patients can figure out the proper diet based on this elimination • Parsons: sensitivity 80% specificity 93% • Intravesical Anesthetic Challenge 28 Parsons et al., 2002 Butrick et al., 2010 Treatment Treatment • Pentosan polysulfate sodium (Elmiron) • • • • • Only FDA approved medication for IC/PBS Replenishes defective GAG layer Inhibits mast cell degranulation Start 100 mg TID and reassess in 3 months d h Mixed results: • Effective in ≈ 30% of patients and it may take 6 months to see the effect • 45‐50% improvement in 32 weeks of treatment (RCT) • Improves frequency more than pain 29 30 Parsons et al., 2002 30 Treatment Treatment • Pentosan polysulfate sodium (Elmiron) • Amitryptiline • • • • • • • 31 Blocks Ach and H1 receptor Anticholinergic and sedative Decreases symptoms of urgency Decreases symptoms of urgency Start 10 mg/day and titrate up Effective doses 50‐75 mg/day Side effects: Nausea, constipation, drowsiness 63% of patients satisfied with treatment (RCT) 32 Treatment Treatment • Hydroxizine • • • • • • Gabapentin (Neurontin) Blocks H1 receptor Decreases mast cell activation Doses 10‐75 mg/day Side effects: Drowsiness, constipation, dry mouth Sid ff t D i ti ti d th Mixed results • Mimics GABA receptor activation by an independent mechanism to modify pain response • Start at 300 mg/day and titrate up to 3600 Start at 300 mg/day and titrate up to 3600 mg/day • Side effects: Nausea, drowsiness and constipation • 50% of patients report improvement of symptoms (CS) • 40% improvement in symptom scores • 55% improvement in patients with seasonal allergies • No better than placebo in quality of life and number of voids (RCT) 33 34 Treatment Treatment 35 36 31 Treatment Treatment • Intravesical therapy • Physical therapy • DMSO • Heparin and alkalinized lidocaine • Pentosan polysulfate (Elmiron) • Decrease pelvic floor muscle spasm • Release of painful scars 37 38 Treatment Treatment • Cystoscopy with hydrodistention (therapeutic) • • • • • • Cystoscopy with hydrodistention (therapeutic) Fill bladder with saline to pressure of 80 cm of water 0 minutes 6 minutes 6 minutes Prolonged Mechanism of action: • Outcomes • ≈ 60%of patients have improvement of symptoms • Improvement lasts for approximately 3 months I l f i l 3 h • Complications • Bladder perforation 2‐3% • Bladder necrosis (extremely rare) • Increases HB‐EGF and decreases AFP • Damage to submucosal nerve plexus and stretch receptors 39 40 Botulinum toxin Treatment • Botulinum toxin A + HD • GRA improvement 3 months 72% vs. 48% HD only • Success at On August 25th 2011 FDA approved Botulinum toxin A for treatment of incontinence due to overactive bladder in people with spinal cord injuries and multiple sclerosis (not IC) • 3 months • 6 months • 12 months – 69% – 45% – 26% • No statistical difference between 100u and 200u of BtxA 41 42 32 Treatment • Treatments that should not be offered: • Long term oral antibiotics • Intravesical instillation of BCG (Bacillus Calmette‐ Guérin) • Intravesical instillation of RTX (Resiniferatoxin) • High pressure long term hydrodistention (> 100 cm H2O and > 10 min) • Systemic long term glucocorticoids IRRITABLE BOWEL SYNDROME 43 Irritable bowel syndrome Subtypes • Recurrent abdominal pain or discomfort at least 3 days a month for the past 3 months, associated with two of the following: improvement with defecation onset improvement with defecation, onset associated with a change in frequency of stool or onset associated with a change in form of stool • 10‐15% population meet these criteria • • • • IBS‐D IBS‐C IBS‐A IBS‐PI predominant diarrhea predominant constipation alternating post‐infectious Rome III criteria 2006 Etiology Comorbidities • Headache • Fibromyalgia • Chronic fatigue syndrome • Depression • Unknown • Psychological factors Psychological factors – “derailing derailing of brain‐gut of brain‐gut axis” • Post‐infectious – small intestinal bacterial overgrowth Mayer, 2008 • Endometriosis • Interstitial cystitis • Inflammatory bowel disease • Unnecessary surgery (cholecystectomy) Whitehead et al., 2002 33 Irritable bowel syndrome Diagnosis • History • Physical examination Physical examination • Routine laboratory studies not including colonoscopy • Patients with IBS are more likely to undergo: Patients with IBS are more likely to undergo: – Cholecystectomy x 3 – Hysterectomy x 2 Longstreth & Yao, 2004 Mayer, 2008 Diagnosis Treatment • • • • • Diet Medications Cognitive behavioral therapy Stress relief Alternative medicine – Probiotics, herbal remedies, yoga, acupunctirure Mayer, 2008 Mayer, 2008 Treatment Conclusions • Chronic pelvic pain is often caused by multiple conditions • Interstitial cystitis, irritable bowel syndrome, pelvic floor tension myalgia are often present pelvic floor tension myalgia are often present in addition to other conditions (endometriosis) • All those have to be recognized and treated Mayer, 2008 34 References • • • • • • • References Berry, S. H., Elliott, M. N., Suttorp, M., Bogart, L. M., Stoto, M. a, Eggers, P., Nyberg, L., et al. (2011). Prevalence of symptoms of bladder pain syndrome/interstitial cystitis among adult females in the United States. The Journal of Urology, 186(2), 540–4. Butrick, C. W. (2003). Intersitial Cystitis and Chronic Pelvic Pain: New Insights in Neuropathology, Diagnosis and Treatment. Clinical Obstetrics and Gynecology, 46(4), 811– 823. Butrick, C. W., Howard, F. M., & Sand, P. K. (2010). Diagnosis and treatment of interstitial cystitis/painful bladder syndrome: a review Journal of Women’ss Health, 19(6), 1185–93. cystitis/painful bladder syndrome: a review. Journal of Women Health 19(6) 1185–93 Chung, M. K., Chung, R. P., & Gordon, D. (2005). Interstitial cystitis and endometriosis in patients with chronic pelvic pain: The “Evil Twins” syndrome. JSLS 9(1), 25–9. Driscoll, a, & Teichman, J. M. (2001). How do patients with interstitial cystitis present? The Journal of urology, 166(6), 2118–20. Evans, R. J. (2002). Treatment Approaches for Interstitial Cystitis: Multimodal Therapy. Reviews in Urology, 4(1), 16–20. Howard, F. M. (2011). Surgical treatment of endometriosis. Obstetrics and Gynecology Clinics of North America, 38(4), 677–86. • • • • • • • 35 Issa, B., Onon, T. S., Agrawal, a, Shekhar, C., Morris, J., Hamdy, S., & Whorwell, P. J. (2012). Visceral hypersensitivity in endometriosis: a new target for treatment? Gut, 61(3), 367 Koziol, J. A., Clark, D. C., Gittes, R. F., & Tan, E. M. (1993). The natural history of interstitial cystitis: a survey of 374 patients. The Journal of Urology, 149(3), 465–9 Koziol, J. A. (1994). Epidemiology of interstitial cystitis. The Urology Clinic of North America, 21(1), 7–20. Longstreth, G F, Preskill, D. B., & Youkeles, L. (1990). Irritable bowel syndrome in women having diagnostic laparoscopy or hysterectomy. Relation to gynecologic features and outcome Digestive diseases and sciences 35(10) 1285–90 outcome. Digestive diseases and sciences, 35(10), 1285 90. Mayer, E. (2008). Irritable bowel syndrome. New England Journal of Medicine, 358(16), 1692– 1699. Parsons, C. L., Dell, J., Stanford, E. J., Bullen, M., Kahn, B. S., Waxell, T., & Koziol, J. A. (2002). Increased prevalence of intersitial cystitis: previously unrecognized urologic and gynecologic cases identified usling a new symptom questionnaire and intravesical potassium sensitivity. Urology, 60(4), 573–578. Whitehead, W. E., Palsson, O., & Jones, K. R. (2002). Systematic review of the comorbidity of irritable bowel syndrome with other disorders: What are the causes and implications? Gastroenterology, 122(4), 1140–1156. Disclaimer • I have no financial relationships to disclose. Surgical Intervention in Patients with Chronic Pelvic Pain Georgine Lamvu, MD, MPH Director of MIS and Advanced Gynecology Fellowship Medical Director of Gynecology Florida Hospital Orlando Lamvu, AAGL 2012 1 Lamvu, AAGL 2012 2 Epidemiology Surgical Intervention for CPP Objectives • Review the evidence on surgical treatment of pelvic pain • Discuss the role of hysterectomy in the management of pelvic pain g p p • Review summary recommendations for surgical pain intervention • In the U.S. CPP is the primary indication for – 40% of laparoscopies – 12% of hysterectomies – Less than 5% of patients with chronic pain Less than 5% of patients with chronic pain disorders are actually seen by pain specialists Agency or Healthcare Research and Quality Effective Health Care Program. Noncyclic Chronic Pelvic Pain Therapies for Women: Comparative Effectiveness, 2012. Lamvu, AAGL 2012 3 Lamvu, AAGL 2012 Chronic Pelvic Pain Etiology and Treatments Gastrointestinal 37% Urologic 31% Reproductive 20% Diet Stimulants Bulking Antispasmodics Motility Drugs Diet Elmiron Mast cell Inhibitors Anesthetics Hormonal Regulation Surgical Analgesics Mood Stabilizers Sleep Therapy Sexual Therapy Cognitive Behavioral Therapy Lamvu, AAGL 2012 4 Surgical Treatment for CPP Indications for Surgery Types of Surgery • To avoid side effects of Coagulation / resection of endometriosis lesionsmedical therapies • To provide relief in In cases Adhesiolysis Ovarian cystectomy of failed medical management management S l i Salpingectomy t • To improve fertility Uterosacral ligament transection (LUNA) • The opportunity for prompt Uterine suspension or definitive management? Presacral neurectomy (PSN) Musculo‐ Skeletal 12% Muscle Relaxants Physical Therapy Oophrectomy Hysterectomy,+/- oophrectomy 5 Lamvu, AAGL 2012 36 6 Adhesiolysis What is the Evidence for Using Surgical Interventions to Treat Chronic Pelvic Pain? Chronic Pelvic Pain? Lamvu, AAGL 2012 7 Peters, 1992 (Source: Cochrane database). Adhesiolysis Lamvu, AAGL 2012 8 Adhesiolysis • May help patients patients with severe adhesions: • Swank DJ, et al. Laparoscopic adhesiolysis in patients with chronic abdominal pain: a blinded randomised controlled multi‐centre trial Lancet 2003 361(9365): 1247‐51 trial. Lancet, 2003, 361(9365): 1247 51 – Infertility especially if tubal anatomy is “very” distorted – Pelvic pain if uterine anatomy is distorted (e.g. p y ( g adhesions post cesarean delivery) – Severe bowel dysfunction if adhesions restrict motility of bowel – Adhesiolysis at diagnostic laparoscopy vs. diagnostic laparoscopy – Adhesiolysis N=51 vs. Diagnostic N=47 – No significant differences in VAS pain score at 12 months between two groups (both improved) • Remember to biopsy adhesions • Remember to use intra‐pelvic fluid (LR, saline) or other adhesion barrier device or fluid Lamvu, AAGL 2012 9 Lamvu, AAGL 2012 10 Uterosacral Nerve Ablation (UNA) Uterosacral Nerve Ablation (UNA) Pooley AS, et al. Fertil Steril. 1997;68:1070‐1074. Vercellini P, et al. Fertil Steril. 1997;68:393‐401. Daniels J, et al. Laparoscopic uterosacral nerve ablation for alleviating chronic pelvic pain: a randomized controlled trial, JAMA, 2009, 302 (9):955‐61. LUNA at diagnostic laparoscopy vs. diagnostic laparoscopy alone No significant differences in pain improvement between the two Laparoscopic UNA in addition to endometriosis surgery p p g y does not have additional effect on pain relief Johnson NP, et al. A double‐blind randomised h l d bl bl d d d controlled ll d trial of laparoscopic uterine nerve ablation for women with chronic pelvic pain. BJOG, 2004, 111(9): 950‐9. Differences in pain from baseline and no differences between the two groups Looked for more than 50% improvement Lamvu, AAGL 2012 11 Lamvu, AAGL 2012 37 12 Uterine Suspension for the Retroverted Uterus Presacral Neurectomy (PSN) • Uterine Suspension • Two randomized trials – 1st described in 1882 – ~200 methods (including 12 laparoscopic methods) described in the literature – Many past indications • Dysmenorrhea, pelvic pain, infertility, back pain Dysmenorrhea pelvic pain infertility back pain • Most did not provide long term cure – Dypareunia secondary to penile collision with a retroverted uterus & suspension following excision of deep cul‐de‐sac endometriosis remain currently accepted indications – Tjaden B, et al. Obstet Gynecol. 1990;76:89. – Candiani GB, et al. Am J Obstet Gynecol. 1992;167:100‐103. • No difference in overall pain relief compared to surgical treatment of endometriosis alone treatment of endometriosis alone • Both suggest PSN is beneficial when midline pain is present, but of no value for other pain • 90% of patients with PSN experienced constipation postoperatively Lamvu, AAGL 2012 Lamvu, AAGL 2012 13 Current Evidence for Uterine Suspension MUST Study Perry CP, Presthus J, Nieves A. Laparoscopic uterine suspension for pain relief. J Reprod Med 2005 • Dyspareunia • Uncontrolled prospective cohort (N=62) • All VAS scores significantly decreased (p<0.0001) post op • At least 50% Improvement of: At least 50% Improvement of: – Chronic Pelvic Pain 57% – Dysmenorrhea 46% – Dyspareunia 81% – Carter: 85% (n = 64) reported pain reduction from 8.1 to 1.5 on a 10‐ point scale – up to 24 months follow‐up • J Repro Med 44:417, 1999 • Dysmenorrhea – Ostrzenski Ostrzenski –– 87.5% (n=28) experienced relief – 87 5% (n=28) experienced relief – at least 24 months at least 24 months follow‐up • J Repro Med 43:361, 1998 – Carter – 100% (n=75) reported pain reduction from 8.4 to 1.7 on a 10‐ point scale ‐ up to 24 months follow‐up • J Repro Med 44:417, 1999 Lamvu, AAGL 2012 14 15 Lamvu, AAGL 2012 16 Conservative Surgical Treatment • Adhesiolysis‐ may improve pain relief or fertility when anatomy is severely affected • Presacral Neurectomy – may be effective but only may be effective but only for treatment of “midline” pain. May cause constipation and urinary urgency WHAT EVIDENCE SUPPORTS THE USE OF HYSTERECTOMY TO TREAT CHRONIC PELVIC PAIN? • Uterosacral Neurectomy (LUNA) –studies show minimmal to no benefit Lamvu, AAGL 2012 17 Lamvu, AAGL 2012 38 18 Hysterectomy Outcomes in Non‐ Painful Gynecologic Conditions Hysterectomy Outcomes in Women with Chronic Pelvic Pain Kjerulf KH, 2000. Carlson KJ, 1997. Rhodes JC, 1999. • Stovall TG, Ling FW, Crawford DA, 1990 – 99 women with idiopathic chronic pelvic pain – 22% reported continued pelvic pain after hysterectomy – Women were thought to have clinical and histologic evidence of uterine disease • Major complication rate is less than 5% • Vaginal, laparoscopic and robotic techniques with short hospital stays (<48hrs) and rapid ith h t h it l t ( 48h ) d id recovery • Up to 95% of women who undergo hysterectomy report improvement of symptoms and up to 80% report improvement in sexual function 12 months after surgery Lamvu, AAGL 2012 • Hillis SD, Marchbanks PA, Peterson HB, 1995 – 308 women with chronic pelvic pain, 1 year after hysterectomy – 21% had continued but decreased pain – 5% had unchanged or increased pain – In specific subsets up to 40% had continued pain • Age <30 years, uninsured, history of PID, without an identifiable pathology at the time of surgery 19 Lamvu, AAGL 2012 Hysterectomy Outcomes in Women with Chronic Pelvic Pain Risk Factors for Chronic Pelvic Pain After Hysterectomy • Hartmann KE, Ma C, Lamvu GM, Langenberg PW, Steege JF, Kjerulff KH, 2004 • Brandsborg B, Nikolajsen L, Hansen CT, Kehlet H, Jensen TS, 2007. – 1200 women monitored for 24 months after hysterectomy – Women with pre‐operative pain vs. women with pre‐ operative pain and depression vs. women with pre‐ operative depression all compared to a control group operative depression, all compared to a control group – 78‐86% of women had improvement after surgery – 50% had improved physical or social function – 14% had results worse than they expected – 26% had recovery slower than expected – Women with pre‐existing pain or depression were 3‐5 times more likely to have impaired quality of life, pelvic pain and dyspareunia than controls. Lamvu, AAGL 2012 20 – Danish nationwide survey of 1299 women, 1 year after hysterectomy – Women with pre‐operative pelvic pain had 3x higher odds of continued pain – Women with pre‐operative pain elsewhere had 3x higher odds of pelvic pain after surgery – 14% of women reported new onset pain after surgery 21 Lamvu, AAGL 2012 22 Potential Causes of Chronic Pelvic Pain • More than 70% of chronic pelvic pain has potentially non‐gynecologic etiology, a matter of missed diagnosis – 90% of women do not undergo a full multidisciplinary evaluation before surgery • Certain pathophysiology of certain subtypes of chronic pelvic pain may not be amendable to surgical l i i tb d bl t i l treatment – IC – IBS – Pelvic floor myalgia WHY DIFFERENT OUTCOMES IN WOMEN WITH CHRONIC PELVIC PAIN? Lamvu, AAGL 2012 • Certain pathophysiology may affect multiple organs and removal of one organ may not be enough 23 Lamvu, AAGL 2012 39 24 Neurophysiology of Pain • Pathways of chronic pain may be centrally established and not amendable to peripheral organ surgery • The subjective experience of pain and j p p recovery from may be affected by the environment, psychological state of the patient What can we do for our patients with chronic pelvic pain now? RECOMMENDATIONS – Psychiatric, environmental and relationship dysfunction may potentiate persistence of pain Lamvu, AAGL 2012 25 Lamvu, AAGL 2012 26 Recommendations Pre‐operative Discussion 1. Improve the consent and pre‐operative counseling process 2. Perform a full multi‐system evaluation before surgery 3. Discuss additional therapies that target pain and function 4. Improve pre‐operative, intra‐operative and post‐operative pain management • Up to 40% of women may have continued pain • Up to 5% may have worse pain after surgery • Up to 30% have a recovery much slower than Up to 30% have a recovery much slower than expected • Patients should consider alternative options such as analgesics, hormonal therapy, physical therapy, neural blocks, complimentary alternative therapy and cognitive behavioral therapy that improve coping Lamvu, AAGL 2012 27 Lamvu, AAGL 2012 Perform and Document a Multi‐ System Pre‐Operative Evaluation • • • • • • • 28 Discuss Additional Therapies Some May Need to Be Continued After Surgery • Urinary symptoms Urinary symptoms and function Gastrointestinal symptoms and function Musculoskeletal evaluation Other chronic pain syndromes Psychiatric dysfunction Sexual function and pain function Physical function and disability – Bladder retraining, diet, physical therapy, bladder antispasmotics • Gastrointestinal – Bowel regimen to address constipation or diarrhea • Musculoskeletal – Physical therapy, muscle relaxants Physical therapy, muscle relaxants • Other chronic pain syndromes – Analgesics, antiepieleptics, antidepressants • Psychiatric dysfunction – Antidepressants, cognitive behavioral therapy • Sexual function and pain function – Sexual counseling • Physical function and disability – Physical therapy Lamvu, AAGL 2012 29 Lamvu, AAGL 2012 40 30 Pain Management Before, During and After Surgery • Pre‐operative Agency or Healthcare Research and Quality Effective Health Care Program – Neuroleptics, antidepressants, physical therapy • Intra‐operative January 2012 – Acetominophen, NSAIDS Acetominophen NSAIDS • Post‐operative – – – – Noncyclic Chronic Pelvic Pain Therapies for Women: Comparative Effectiveness Consider scheduled vs. “as needed” dosing Consider a pre‐op epidural or post‐op PCA Adjust dosing for patients who previously used opioids Investigate post‐operative acute pain Lamvu, AAGL 2012 31 Lamvu, AAGL 2012 32 Research Findings Key Question 2 • Evaluated literature on diagnostic laparoscopy, laparotomy, hysterectomy, adhesionlysis, LUNA and PSN studies did not meet criteria. Uterine suspension was not evaluated. • Comparison to medical therapy, sham surgery and no therapy th • 7 studies: 5 were RCTs, 2 were prospective cohort • 3 compared to non‐surgical, 4 compared to diagnostic laparoscopy or other surgery • All studies had varying definitions for CPP • 1 was considered good quality, 1 fair and 5 as poor Among women with CPP what is the effect of surgical intervention on pain effect of surgical intervention on pain status, functional status, satisfaction with care and quality of life? Lamvu, AAGL 2012 33 Lamvu, AAGL 2012 AHRQ Conclusions Summary • Prior to surgery document the presence and location of pain, chronicity, associated symptoms and counseling • Counsel patients with CPP that surgery may have diagnostic benefits but not necessarily therapeutic benefits. Document counseling on risk of complications but also risk of: • Surgical and non‐surgical interventions both improved pain status, but neither was more effective than the other • LOA and LUNA did not improve pain over LOA and LUNA did not improve pain over diagnostic laparoscopy Lamvu, AAGL 2012 34 – Failure to treat pain – Risk of slower or prolonged recover – Risk of worsening of pain • Emphasize a multidisciplinary evaluation for pain prior to surgery and counsel that this option was given… and the patient had a chance to think about it. Do rush patients with chronic pain to surgery unless you suspect an acute process. • Discuss and optimize pre‐operative and post‐operative pain management • LUNA is a dead horse, stop beating it. 35 Lamvu, AAGL 2012 41 36 Summary References • When it comes to surgical outcomes for the treatment of CPP we have a lot of work to do! CPP we have a lot of work to do! • If you are not a researcher continue to follow your patients long term… Lamvu, AAGL 2012 37 Lamvu, AAGL 2012 39 Lamvu G. Role of Hysterectomy in the Treatment of Chronic Pelvic Pain. Obstetrics and Gynecology, May 2011, vol 117 (5); pp 1175. Agency or Healthcare Research and Quality Effective Health Care Program. Noncyclic Chronic Pelvic Pain Therapies for Women: Comparative Effectiveness, 2012. Swank DJ, et al. Laparoscopic adhesiolysis in patients with chronic abdominal pain: a blinded randomised controlled multi‐centre trial. Lancet, 2003, 361(9365): 1247‐51 Pooley AS, et al. Fertil Steril. 1997;68:1070‐1074. Vercellini P, et al. Fertil Steril. 1997;68:393‐401. Brandsborg B, Nikolajsen B Nikolajsen L, Hansen CT, Kehlet L Hansen CT Kehlet H, Jensen TS, 2007. H Jensen TS 2007 Hartmann KE, Ma C, Lamvu GM, Langenberg PW, Steege JF, Kjerulff KH, 2004 Stovall TG, Ling FW, Crawford DA, 1990 Hillis SD, Marchbanks PA, Peterson HB, 1995 Daniels J, et al. Laparoscopic uterosacral nerve ablation for alleviating chronic pelvic pain: a randomized controlled trial, JAMA, 2009, 302 (9):955‐61. Johnson NP, et al. A double‐blind randomised controlled trial of laparoscopic uterine nerve ablation for women with chronic pelvic pain. BJOG, 2004, 111(9): 950‐9. Kjerulf KH, 2000. Carlson KJ, 1997. Rhodes JC, 1999. Perry CP, Presthus J, Nieves A. Laparoscopic uterine suspension for pain relief. J Reprod Med 2005 Lamvu, AAGL 2012 THANK YOU 42 38 Disclosure • I have no financial relationships to disclose What if surgery causes pain? pain? Michael Hibner, MD, PhD, FACOG, FACS Director, Division of Surgery and Pelvic Pain St. Joseph’s Hospital and Medical Center, Phoenix, Arizona Professor of Obstetrics and Gynecology Creighton University School of Medicine Objectives • To identify causes of de novo pain after gynecologic surgery • To describe diagnostic process in those cases • To present available treatments for de novo il bl f d pain after gynecologic surgery Clinical scenario 1 Clinical scenario 1 45 year old CSx2 undergoes robotic hysterectomy for symptomatic uterine leiomyomata. Surgery is uncomplicated and patient is discharged home on POD #1. #1 Because she is unable to pass the voiding trial she is discharged with the leg bag and asked to return to the office in 2‐3 days. She is also instructed to refrain from intercourse for 6 weeks. On day 4 she is still not able to void completely and Foley catheter is kept for another week. week She returns for a 6 week visit and notices significant pain with speculum exam. Vaginal cuff is healed and patient is allowed to have intercourse. 43 Clinical scenario 1 Clinical scenario 1 She calls back complaining of significant pain with intercourse as well as worsening hesitancy. On repeat physical exam vaginal cuff is intact but speculum causes significant pain. Digital exam reveals significant tenderness of the vagina and the bladder Incidence of postsurgical pain Postsurgical pain • Study of 1299 women undergoing hysterectomy – 31.9% had pain 1 year after hysterectomy – 14.9% de novo pain p – Risk factors: • previous cesarean delivery (OR 1.54), • pain as indication for surgery (OR 2.98) • pain problems elsewhere (OR 3.19) – No difference between the routes of hysterectomy – Spinal anesthesia decreases the risk (OR 0.42) Bransborg et at., 2007 Possible etiology Visceral and referred pain Giamberardino et al., 2010 44 Pelvic floor muscles PELVIC FLOOR TENSION MYALGIA Symptoms Examination of pelvic floor muscles • Pain with stretching of pelvic floor muscles Obturator Internus – Intercourse and postcoital dyspareunia – Gynecological exam – Most of activities involving lower extremities Most of activities involving lower extremities Pubococcygeous X X • Hesitancy • Sensation of incomplete voiding Iliococcygeous Coccygeous X X Pyriformis X Butrick, 2009 Diagnosis Diagnosis Prendergast, 2003 Butrick, 2009 45 Treatment Treatment Identify Underlying Cause • Valium 5mg/Baclofen 4 mg vaginal suppository • Belladonna 16.2 mg/Opium 30 mg rectal suppository dysbehavoirs, trauma, surgery, inflammation, pain Treat perpetuating factors p p g IC Endometriosis Treat Pelvic Floor Muscle relaxation Central Sensitization Howard et al., 2000 Hibner et al., 2010 Treatment Treatment • Botulinum toxin A (Botox) • Done under anesthesia/sedation • Examine patient prior to sedation to identify most tender areas • After sedation do pudendal nerve block with 0.5% B i Bupivacaine with epinephrine i ith i hi • Dilute 200 units of Botulinum toxin in 20 ml of NS • Inject using pudendal nerve block needle at volumes 1 ml per injection deep into levator and obturator muscles • Usually patients start feeling relief from Botox about a week after the injection. If no relief and muscles feel relaxed pain is most likely due to nerve injury, not muscle spasm Prendergast, 2003 Abbott, 2008 Treatment Treatment 46 Outcomes • • • • Clinical scenario 2 55 year old SVD x 3 is diagnosed with grade 3 uterine prolapse, grade 3 cystocele and grade 2 rectocele. Patient undergoes uneventful vaginal hysterectomy and Prolift® mesh repair. 70% experience improvement of pain 99% effective in producing muscle relaxation 99% effective in producing muscle relaxation Effect last for 3‐4 months 80% effective for patients with bladder pain syndrome Hibner et al. 2010 Clinical scenario 2 Clinical scenario 2 Patient wakes up from surgery in PACU and immediately starts complaining of severe rectal pain. Pain seems to be located on the right side only. She is given several doses of narcotics which only partially help her. Pain is exacerbated by any movement and especially by sitting. Pain management is called to see patient. She is started on Hydromorphone, Baclofen, Gabapentin and pain becomes tolerable. She is transitioned to long acting narcotics and discharged home. At 6 week visit vaginal epithelium and all the incisions are healed. Pain is unchanged and almost unbearable. Patient is unable to sit at all and cannot preform her daily activities. Symptoms • Pain in the area of innervation of the pudendal nerve • Pain is neuropathic in nature • Paresthesia – burning, tingling, prickling, numbness sensation • Allodynia – y pain in response to non painful stimulus p p p • Hyperalgesia – pain out of proportion to the stimulus • • • • PUDENDAL NEURALGIA Pain is more severe with sitting Pain absent or significantly less when lying down Pain less when sitting on the toilet vs. chair Sensation of foreign body in the rectum or vagina (allotriesthesia)* Hibner et al., 2010 47 Symptoms Causes • Urinary symptoms – frequency, urgency, hesitancy • Dyschesia • Dyspareunia i • Pain with orgasm • Pain with sexual arousal • Persistent sexual arousal • Caused by injury to the pelvic floor by: • Surgery • Direct – mesh injury • Indirect – hysterectomy, cystocele repair, prolapse repair g • Vaginal childbirth • Trauma • Falls • Cycling • Intense lower extremity exercise (abductor machine) • Excessive masturbation • Excessive use of anal vibrators Hibner et al., 2010 Hibner et al., 2010 Pelvic floor pain floor pain syndrome Pelvic floor muscle spasm Pelvic floor muscle spasm compressing the nerve the nerve Mechanical nerve compression Disease of the nerve (HSV, DM) • Physical therapy + botulinum toxin • Physical therapy + botulinum toxin • Surgical decompression • Treatment of underlying disease Hibner et al., 2010 Hibner et al., 2010 Diagnosis Diagnosis • History • Pudendal nerve motor terminal latency (PNMTL) • Pain in the area of pudendal nerve (but often there is also pain outside elsewhere – lower back, anterior and posterior thighs, sciatica) • Onset of pain coincides with traumatic event(s) • Unreliable in multiparous patients • High interobserver and intraobserver variability • Sensory threshold testing • Warm detection threshold testing • Two point discrimination testing • If no traumatic event PFTM more likelyy • If bilateral pain PFTM more likely • MRI • Anatomical MRI • Functional MRI (MR neurography) • Exam • Significant tenderness to palpation along the course of Alcock’s canal (vaginal) • Palpation of the course of the nerve reproduces symptoms (Tinel’s sign) • Diagnostic CT guided pudendal nerve block • Patients must have at least temporary relief of pudendal neuralgia (part of Nantes criteria) Hibner et al., 2010 Hough et al., 2003 48 Treatment Treatment • Self care – avoidance of pain, use of sitting support • Pelvic floor physical therapy • Oral medications • • • • • Gabapentin (Neurontin) up to 2400 mg/day Pregabalin (Lyrica) start at 75 mg BID up to 600 mg daily Amitryptiline 25‐50 mg/day Duloxetine (Cymbalta) Appropriate pain management (narcotics) • Suppositories • Belladonna and Opium 16.2/30 mg rectal suppository BID • Diazepam 5 mg/Baclofen 4 mg vaginal suppository BID Hibner et al., 2010 Prendergast, 2003 Treatment Treatment • Therapeutic CT guided pudendal nerve block • Bupivacaine 0.5% with epinephrine • Triamcinolone (Kenalog) 80 mg (40 mg per side if bilateral) • Injections repeated every 6 weeks (3 total) McDonald & Spigos, 2000 Treatment Treatment 49 Treatment Outcomes Conservative management Surgery 3 months 6 2% 6.2% 50% 12 months 13.3% 71.4% 48 months 50% Improvement defined as decrease in VAS by 3 and decrease of behavioral quality of life to ≤ 3 Robert et al., 2005 In the Oct. 20, 2008 FDA Public Health Notification, the number of adverse events reported to the FDA for surgical mesh devices used to repair POP and SUI for the previous 3-year period (2005 – 2007) was “over 1,000.” Since then, from Jan. 01, Audience: Health care providers who implant surgical mesh to repair pelvic organ prolapse 2008 through Dec. 31, 2010, the FDA received 2,874 additional reports of and/or stress urinary incontinence complications associated with surgical mesh devices used to repair POP and SUI, Health care providers involved in the care of patients with surgical mesh implanted with 1,503 reports associated with POP repairs and 1,371 associated with SUI to repair pelvic organ prolapse and/or stress urinary incontinence repairs. Although it is common for adverse event reporting to increase following an Patients who are considering or have received a surgical mesh implant to repair FDA safety communication, we are concerned that the number of adverse event pelvic organ prolapse and/or stress urinary incontinence reports remains high. Symptoms from Mesh Complications Pelvic Floor Both mesh erosion and mesh contraction may lead to severe pelvic pain, painful sexual intercourse or an inability to engage in sexual intercourse. Also, men may experience irritation and pain to the penis during sexual intercourse when the mesh is exposed in mesh erosion. The complications associated with the use of surgical mesh for POP repair Neurological Hesitancy Clitoral pain Dyspareunia Vaginal pain Bladder pain Rectal pain have not been linked to a single brand of mesh. Castellanos, AAGL 2012 50 Mesh injury Treatment • Requires immediate attention and possible removal of mesh • All mesh should be removed, no partial resection • Vaginal resection of mesh may not remove the mesh from the pudendal nerve Castellanos et al., AAGL 2012 Castellanos et al., AAGL 2012 Route of removal of mesh Mesh removal ‐ evidence Castellanos et al., AAGL 2012 Prolift® Ridgeway et al., 2008 Castellanos, AAGL 2012 51 Prolift® References • • • • • Right (mm) Pudendal n. 15.6 (± 2.5) Inferior rectal n. 11.0 (± 1.5) Left (mm) 18.0 (± 2.9) 8.3 (± 2.6) • • • • • • • • Castellanos, AAGL 2012 52 Abbott, J. (2008). The use of botulinum toxin in the pelvic floor for women with chronic pelvic pain‐a new answer to old problems? Journal of minimally invasive gynecology, 16(2), 130–5. Butrick, C. W. (2009). Pelvic floor hypertonic disorders: identification and management. Obstetrics and gynecology clinics of North America, 36(3), 707–22. Bransborg, B., Nikolajsen, L., Hansen, C. T., Kehlet, H., & Jensen, T. (2007). Risk Factors for Chronic Pain after Hysterectomy. Anesthesiology, 106(5), 1003–1012. Castellanos ME, Yi J, Atashroo D, Hibner M. Pudendal neuralgia after placemen of mesh kits for posterior vaginal wall repair: An anatomical study and case series. Global Congress of Minimally Invasive Gynecology. Las Vegas, Nevada, November 2012 Giamberardino, M. A., Costantini, R., Affaitati, G., Fabrizio, A., Lapenna, D., Tafuri, E., & Mezzetti, A. (2010). Viscero‐visceral hyperalgesia: characterization in different clinical models. Pain, 151(2), 307–22. Hibner, M., Desai, N., Robertson, L. J., & Nour, M. (2010). Pudendal neuralgia. Journal of Minimally Invasive Gynecology, 17(2), 148–53. Hibner M, Castellanos ME, Bochenska K, Desai N, Wadsworth L, Balducci J. Onabotulinum toxin A in treatment of chronic pelvic pain associated with pelvic floor tension myalgia. Poster presentation at International Pelvic Pain Society Meeting. Chicago, Illinois, October 2010 Hough, D. M., Wittenberg, K. H., Pawlina, W., Maus, T. P., King, B. F., Vrtiska, T. J., Farrell, M. A., et al. (2003). Chronic Perineal Pain Caused by Pudendal Nerve Entrapment: Anatomy and CT‐Guided Perineural Injection Technique. American Journal of Roentgenology, 181(August), 561–567. Howard, F. M., Perry, P., Carter, J., & El‐Minawi Ahmed M. (2000). Pelvic Pain: Diagnosis and Management (1st ed., p. 529). Lippincott Williams & Wilkins. McDonald, J. S., & Spigos, D. G. (2000). Computed tomography‐guided pudendal block for treatment of pelvic pain due to pudendal neuropathy. Obstetrics and gynecology, 95(2), 306–9. Prendergast, S. A. (2003). Causes of Pelvic Pain. Clinical obstetrics and gynecology, 46(4), 773–782. Ridgeway, B., Walters, M. D., Paraiso, M. F. R., Barber, M. D., McAchran, S. E., Goldman, H. B., & Jelovsek, J. E. (2008). Early experience with mesh excision for adverse outcomes after transvaginal mesh placement using prolapse kits. American journal of obstetrics and gynecology, 199(6), 703.e1– 7. Robert, R., Labat, J.‐J., Bensignor, M., Glemain, P., Deschamps, C., Raoul, S., & Hamel, O. (2005). Decompression and transposition of the pudendal nerve in pudendal neuralgia: a randomized controlled trial and long‐term evaluation. European urology, 47(3), 403–8. Disclosure • I have no financial relationships to disclose. Surgical Treatment of Endometriosis Georgine Lamvu, MD, MPH Director of MIS and Advanced Gynecology Fellowship Medical Director of Gynecology Florida Hospital Orlando Lamvu, AAGL 2012 1 Lamvu, AAGL 2012 Objectives 2 Definition of Endometriosis • Review the evidence surrounding surgical treatment of endometriosis • Discuss the role of infertility and pain when considering surgical treatment of g g endometriosis • Review final recommendations for management of endometriosis • " the presence of ectopic tissue which possesses the histological structure … of the uterine mucosa" S (1921) – Sampson (1921) • Affects 10‐15% of reproductive age women • Diagnosis – Requires tissue specimen – Ectopic endometrial glands & stroma must be present Lamvu, AAGL 2012 3 Lamvu, AAGL 2012 Pain and Stage May Not Be Related 4 Why are Pain and Stage Unrelated? • Early lesions are small but may be more immunologially active – Vernon MW, et al. Fertil Steril. 1986;44:801-806 Symptoms Most common symptom is dysmenorrhea 40% have dyspareunia 60% h 60% have non‐menstrual chronic t l h i pelvic pain Pain and staging • • • • Stage I: Stage II: Stage III: Stage IV: • More than 80% of patients have endometriosis in the presence of other pain generators such as: IBS, IC, myofascial pain. – Howard FM. J Am Assoc Gynecol Laparosc, 1994; 1:325. – Howard Howard FM. Obstet FM. Obstet Gynecol Clin N Am, 2011; 38:677. N Am, 0 ; 38:677. • Not all endometriosis is alike – Cornillie, et al found that deeply infiltrating endometriosis was most commonly correlated with pain and superficial endometriosis was more commonly associated with infertility 40% 24% 24% 12% Fertil Steril 53:978, 1990 – Ripps found focal tenderness on exam to highly correlate with the presence of deeply infiltrating endometriosis, esp. in the cul de sac, and uterosacral ligaments J Reprod Med 37:620, 1992 Fedele L, et al. Fertil Steril. 1990;53:155-158. Lamvu, AAGL 2012 5 Lamvu, AAGL 2012 53 6 Surgical Therapy for Pelvic Pain Associated with Endometriosis: A Closer Look at the “Data” What is the best surgical technique for removing endometriosis? Lamvu, AAGL 2012 7 Lamvu, AAGL 2012 Surgical Technique Laparoscopy vs. Laparotomy • Diagnostic, ablation, excision, adhesiolysis, nerve ablation • Laparoscopy or laparotomy • Technical objectives of surgery – Restore normal pelvic anatomy p y – Destroy/remove all implants • Clinical objectives of surgery – Relieve pelvic pain – Restore (maintain) fertility • No level I evidence for use of laparotomy to treat endometriosis • Laparoscopy is preferred – Better recovery, small Better recovery small incisions – Allows treatment at diagnosis Batemen et al. Fertil Steril 1994:62;690‐5 Howard. J Am Assoc Gynecol Laparosc 1994;1:325‐31 Howard FM. Obstet Gynecol Clin N Am, 2011; 38:677. Howard. J Amer Assoc Gynecol Laparosc 1994;1:325 Lamvu, AAGL 2012 Laparoscopic Treatment of Peritoneal Endometriosis 10 Laparoscopic Treatment of Peritoneal Endometriosis • Abbott study is second RCT of surgical treatment • Randomized to Delayed Surgery (DS) or Immediate Surgery (IS) • 2 RCTs for laparoscopic treatment of endometriosis – Both studies showed pain improvement by approximately 50% • Sutton CJ, et al. Prospective, randomized, double‐blind controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild and moderate endometriosis Fert Steril, 1994; 62:696. endometriosis. Fert Steril 1994; 62:696 – DS • Diagnostic laparoscopy • 6 months later, surgical 6 months later surgical excision – Laser excision stage I, II, III. – 6 months, 62% of cases improved vs. 23% controls – Patients in stage II and III improved, stage I did not – IS • Excision at initial surgery • 6 months later, surgical excision of any recurrent or residual endometriosis • Abbott J, et al. Laparoscopic excision of endometriosis: a randomized, placebo‐controlled trial. Fertil Steril 2004, 82: 878. – Excision of stages II, III, IV – At 6 months 80% of cases improved vs. 32% of controls Lamvu, AAGL 2012 8 On average, pain is decreased by 50% Abbott J et al. Fertil Steril 2004;82:878‐84 11 Lamvu, AAGL 2012 54 12 Laparoscopic Excision vs. Ablation Deep Excision Technique • Elevate peritoneum • Dissect peritoneum and separate it from vital structures • Use minimal cutting energy to resect tissue • Use fine Use fine grasping and cutting instruments grasping and cutting instruments • Resected area is always larger than you think but make sure you resect with margins (5‐6mm)… mark tissue to be resected (cautery dots or meth blue) • Use visualization aides: e.g. blood painting, close contact, rectal probe • Pre‐operative bowel prep • Peritoneal disease – 2 RCTs – Wright J, et al. A randomized trial of excision versus ablation for mild endometriosis. Fertil Steril, 2010; 94:2536. – Healey M, et al. Surgical treatment of endometriosis: a prospective randomied double‐blinded trial comparing excision and ablation. Fertil double blinded trial comparing excision and ablation Fertil Steril 2010; 94:2536. • Endometriomas – – – – – At least 4 RCTs and other prospective trials Fayez JA, et al. Obstet Gynecol, 1991; 78:660 Hemmings R, et al. Ferilt Steril, 1998; 70:527 Beretta P, et al. Fertil Steril, 1998; 70:1176. Saleh A, et al. Fertil Steril 1999;72:322. Lamvu, AAGL 2012 13 Lamvu, AAGL 2012 Laparoscopic Excision vs. Ablation Laparoscopic Excision vs. Ablation • Peritoneal disease (2RCTs) • No difference in relief of pelvic pain between the two techniques – Caveat: bipolar coagulation only ablates to 2mm of depth, best for superficial disease only best for superficial disease only – For deeper lesions you may not ablate the entire lesion – Ablation also leaves you blind to important structures underneath the peritoneum – Ablation does not allow for biopsy of that tissue – Types of ablation methods: RF electricity, Ultrasonics, Laser Lamvu, AAGL 2012 • Endometriomas – – – – – At least 4 RCTs and other prospective trials Fayez JA, et al. Obstet Gynecol, 1991; 78:660 Hemmings R, et al. Ferilt Steril, 1998; 70:527 Beretta P et al Fertil Steril, 1998; 70:1176. Beretta P, et al. Fertil Steril 1998; 70:1176 Saleh A, et al. Fertil Steril 1999;72:322. • Recurrence of endometriomas is much less likely with excision vs. ablation or coagulation • Thermal energy to remove an endometrioma or for hemostasis may lead to loss of ovarian reserve 15 Lamvu, AAGL 2012 16 Recurrence of Pain After Conservative Surgery (Stage I, II or III)‐ Laparoscopic Treatment of Endometriomas Lamvu, AAGL 2012 14 17 Laser vs. expectant management Sutton et al., 1994 Three Months Six Months Percentage decrease in VAS pain scores attributable to surgical treatment 14% 47% Laser, diagnostic vs. expectant management Fred Howard, 2000 Three Months (CI) Six Months (CI) Twelve Months (CI) Rate of improvement with laser laparoscopic treatment 56% ( 39-73%) 63% (46-79%) 59% (42-76%) Rate of improvement with diagnositic laparoscopy only 48% (33-66%) 23% (8-37%) --------- Absolute benefit increase 8% (-17-33%) 40% (18-62%) --------- Lamvu, AAGL 2012 55 18 Laparoscopy For the Treatment of CPP Associated with Endometriosis Recurrence of Endometriosis After Conservative Surgery • Jacobson TZ, et al. Laparoscopic surgery for pelvic pain associated with endometriosis. The Chochrane database systematic reviews, 2006, Issue 4. • Approximated at – 15% at 1 year – 36% at 5 years – 50% by 7 years – Laparoscopic treatment of endometriosis is superior to diagnostic laparoscopy alone, OR for improvement =7.72 g p py , p (95%CI 2.97‐20.1) – Not all patients respond to removal of endometriosis, especially in stage I disease – Placebo effect ranges from 22 to 32% of patients reporting improvement – Response rate at 6 months, 66% to 80% of patients report improvement • Potential causes include incomplete resection or true disease • Endometriosis is not often identified in follow‐up re‐operation studies of patients with CPP (i.e. continued pain is often found without recurrent endometriosis lesions) Falcone T, et al. Obstetrics and Gynecology, 2011; 118(3): 691. Lamvu, AAGL 2012 19 Lamvu, AAGL 2012 Recurrence of Endometriomas Reoperation After Conservative Surgery Wheeler et al. Am J Obstet Gynecol 1983;146:247 Busacca et al. Am J Obstet Gynecol 1999;180:519 Surgical Treatment for Endometriomas and Impact on Infertility Surgical Treatment of Endometriosis and Impact on Infertility • Surgical treatment in women with mild to moderate endometriosis and infertility • Two RCTs and one Chochrane review of laparoscopic treatment of endometriomas – Conflicting studies – 2003 Cochrane Database Meta‐analysis compared women with endometriosis who had diagnostic ith d t i i h h d di ti laparoscopy vs. surgical treatment – Excision of cyst wall vs. cyst wall ablation OR 5.29; pregnancy rates 61% vs 23.4% within 2 years of surgery – Studies were done in women with pain and endometriomas d ti >3 > 3cm, data has not been replicated in d t h tb li t d i women with asymptomatic endometriomas – Concerns that excision diminishes ovarian reserve in women who already have infertility/ studies suggest lower antral follicle count after excision – Removal of endometriomas is only recommended in symptomatic women, incidentally found endometriomas in asymptomatic women should be left alone • Odds of pregnancy after surgical treatment =1.66 (95% CI;(1.09‐2.51) • Odds of ongoing pregnancy beyond 20 weeks after surgical treatment = 1.64 (95%CI: 1.05‐2.57) • Excision, electracautery ablation and laser ablation yielded similar results Senapati, S, et al. Clinical Obstetrics and Gynecology, 2011, 54, Number 4, 720–726. Lamvu, AAGL 2012 20 Senapati, S, et al. Clinical Obstetrics and Gynecology, 2011, 54, Number 4, 720–726. 23 Lamvu, AAGL 2012 56 24 Numbers Needed to Treat with Surgical Intervention to Improve Infertility in Women With Endometriosis Ovulation Induction for Endometriosis Associated Infertility • In women with infertility and endometriosis, ovulation induction and IUI is beneficial and improves pregnancy rates • There is little doubt that the most beneficial There is little doubt that the most beneficial treatment for infertility with endometriosis is IVF • However, success of ivf is inversely proportional to stage of disease, i.e. more severe disease has lowest success rates NNT for excision, electrocautery ablation or laser ablation Senapati, S, et al. Clinical Obstetrics and Gynecology, 2011, 54, Number 4, 720–726. Lamvu, AAGL 2012 Senapati, S, et al. .Clinical Obstetrics and Gynecology, 2011, 54, Number 4, 720–726. 25 Lamvu, AAGL 2012 Hysterectomy For Endometriosis Associated Pain 26 Summary • Endometriosis has many clinical and surgical presentations • Early surgical intervention is key (before chronic pain syndromes develop) • Pelvic pain is associated with endometriosis but endometriosis can be present with other pain causing co d t o s, p e ope at e e a uat o o ot e o ga conditions, pre‐operative evaluation of other organ systems is important • Endometriosis has been linked to lower ovulation rates, lower fertilization and lower implantation rates • If spontaneous conception fails, IVF is the treatment of choice for patients with endometriosis associated infertility • With ovarian preservation (7 year follow up) – 2 years 95% of women improve – 5 years 86% – 7 years 77% • Without ovarian preservation (7 year follow up) – 2 years 96% – 5 years 91% 5 91% – 7 years91% • However, there is no difference in rate of long term improvement with or w/o ovarian preservation in women aged 30‐39 • Recommendation from experts is to preserve ovaries in young patients Shakiba K, et al. Surgical treatment of endometriosis: a 7‐year follow up on the requirement for further surgery. Obstet Gynecol, 2008; 111: 1285. Falcone T, et al. Obstetrics and Gynecology, 2011; 118(3): 691 Lamvu, AAGL 2012 27 Lamvu, AAGL 2012 Summary References Fedele L, et al. Fertil Steril. 1990;53:155‐158. Fayez JA, et al. Obstet Gynecol, 1991; 78:660 Vernon MW, et al. Fertil Steril. 1986;44:801‐ Hemmings R, et al. Ferilt Steril, 1998; 70:527 806 Beretta P, et al. Fertil Steril, 1998; 70:1176. Howard FM. J Am Assoc Gynecol Laparosc, Saleh A, et al. Fertil Steril 1999;72:322. 1994; 1:325. Wheeler et al. Am J Obstet Gynecol Howard FM. Obstet Gynecol Clin N Am, 1983;146:247 2011; 38:677. Busacca et al. Am J Obstet Gynecol Cornillie, et al. Fertil Steril 53:978, 1990 1999;180:519 Ripps, J Reprod Med 37:620, 1992 Senapati, S, et al. .Clinical Obstetrics and l l l b d Batemen et al. Fertil Steril 1994:62;690‐5 Gynecology, 2011, 54, Number 4, 720–726. Sutton CJ, et al. Fert Steril, 1994; 62:696. Jacobson TZ, et al. The Chochrane database Abbott J, et al. Fertil Steril 2004, 82: 878. systematic reviews, 2006, Issue 4. Falcone T, et al. Obstetrics and Gynecology, Falcone T, et al. Obstetrics and Gynecology, 2011; 118(3): 691 2011; 118(3): 691. Wright J, et al. Fertil Steril, 2010; 94:2536. •Shakiba K, et al. Obstet Gynecol, 2008; 111: 1285. Healey M, et al.. Fertil Steril 2010; 94:2536. • Aggressive surgical treatment may offer relief in higher stages • The type of surgery selected depends on the type of lesions found – Endometriomas should always be fully excised – Early and deep lesions may require careful excision Early and deep lesions may require careful excision – Additional adhesiolysis may benefit patients with very distorted anatomy (? Infertility) but may add little to pain relief – Additional LUNA is not very beneficial – Additional PSN neurectomy may be beneficial only in a few select patients – Recurrence rates are high Lamvu, AAGL 2012 28 29 Lamvu, AAGL 2012 57 30 Disclosure Less known conditions causing chronic pelvic pain causing chronic pelvic pain I have no financial relationships to disclose. Michael Hibner, MD, PhD, FACOG, FACS Director, Division of Surgery and Pelvic Pain St. Joseph’s Hospital and Medical Center, Phoenix, Arizona Professor of Obstetrics and Gynecology Creighton University School of Medicine Objectives Case scenario 25 year old G1P2 is six months form vaginal delivery. She presents complaining of pelvic pain and sensation of pressure since delivery. delivery Occasionally she has sharp shooting pain located in the right lower quadrant. This sensation of pressure and sharp shooting pain usually happens with prolonged standing and sitting. • Identify some of the less know conditions leading to chronic pelvic pain. Case scenario Case scenario You schedule patient for laparoscopy. The right side of the abdomen/pelvis looks normal. The left ovary is scarred into the sidewall and has a 4 centimeter mass. You choose to remove that ovary. Patients pain is unchanged but few weeks after laparoscopy patient develops additional pain in the right lower quadrant. This area is tender to palpation and pain is increased with body movements. Patient believes that this sensation of pressure caused by something “falling out”(prolapse). On pelvic exam there is no evidence of prolapse and pain cannot be elicited with palpation. 58 Case scenario Patient also notices cyclical sharp shooting pain in the left lower quadrant which was not present prior to surgery PELVIC CONGESTION SYNDROME Pelvic congestion syndrome Anatomy • Complex network of venous structures • Plexie (plexuses) surround rectum, bladder, vagina, , uterus, and ovaries • All interconnected by anastomoses • Major drainage into internal iliac system • Pelvic venous dilatation associated with reduced venous blood flow and leading to reduced venous blood flow and leading to pelvic pain • Pain is associated with decreased venous return (standing, sitting, Valsalva) Perry, 2006 Perry, 2006 Anatomy • Ovarian veins – Left into left renal vein – Right into vena cava • Normal caliber of ovarian veins • Absence of valves – 13‐15% left ovarian vein – mean 3.8 mm – 6% right ovarian vein – normal normal < 5mm 5mm • When valves are present – 7.5mm if incompetent valves – 43% left are incompetent – 35‐41% right are incompetent Perry, 2006 Perry, 2006 59 Venous related pain syndromes • • • • Pain caused by varicosities • • • • • • • Varicocele in men Varicose veins of the lower extremities Migraine headache Pelvic congestion syndrome Intraluminal pressure/distention Blood flow Ischemia in vessel Ischemia in organs Venous stasis Venous outflow obstruction Release of pain mediators Perry, 2006 Numbers (renal donor) Numbers • Incidence of congested veins – 10% • Incidence of pain if veins are congested – 59% • Nephrectomy (obliteration of vein) • 80% of women without an obvious cause for their pain at laparoscopy have marked venous congestion • 91% of patients with chronic pelvic pain had evidence of varicocele compared with 11% of patients without pain – Pain resolved – 54% – Pain improved – 23% – Pain persistent – 23% • • • • • Belenky et al.,2002 Beard et al.,1998 Predisposing factors Pathophysiology estrogen progesterone pregnancy Parity IUD placement (copper and hormonal) p ( pp ) Uterine malposition (retroversion) Premenopausal (ovarian function) External venous compression Nerve compression Muscle spasm leading to Valsalva voiding and increased intraabdominal pressure Congenital or acquired vein incompetence Venous reflux leading to further vein dilatation and valve failure Fluid and protein extravasation causing edema decreased pH Reduced capillary flow causing hypoxia, inflammation and release of cytokines and tissue damage Stones et al., 1994 Khan et al, 2000 Tu et al., 2010 60 Symptoms Symptoms • Pain associated with prolonged standing or sitting • Pain brought on by increase in intra‐abdominal pressure (Valsalva) • Postcoital dyspareunia 1‐2 days Postcoital dyspareunia 1 2 days • Sensation of heaviness in the pelvis / “something falling out” with occasional sharp shooting pain • Predominantly unilateral L>R • • • • Menstrual cycle defects – 54% Congestive dysmenorrhea – 66% Deep dyspareunia – 71% Post coital ache – 65% Duncan & Taylor, 1952 Tu et al., 2010 Effect on other organs Exam • Polycystic ovaries on ultrasound ‐ 56% • Significantly increased uterine cross sectional area (39 1cm2 vs. 28.3 cm sectional area (39.1cm vs 28 3 cm2) • Endometrial thickness greater in pelvic congestion (11.7mm vs. 8.3mm) • Tenderness with reproduction of pain with deep palpation over ovarian point • Cervical motion tenderness Ce ca ot o te de ess • Blue cervical discoloration (venostasis) • Retrocervical tenderness and paracervical tenderness Adams et al., 1990 Beard et al.,1998 Exam Imaging • Marked ovarian tenderness with gentle compression reproducing pain • Uterine tenderness • • • • • Beard et al.,1998 Ultrasound CT abdomen MRI abdomen Transfundal venogram Percutaneous venogram Tu et al., 2010 61 Ultrasound with color Doppler Ultrasound with Valsalva Computer Tomography Computer Tomography Magnetic Resonance Retrograde flow Enlarged vein Collateral circulation Ovarian varicosity Sophia Virani 2009 Beth Israel Deaconess Medical Center 62 Transfundal venography Diagnosis 1 2 3 Ovarian vein diameter 1‐4 mm 5‐8 mm >8 mm Clearance of contrast 0 s 20 s 40 s Normal Moderate Extensive Ovarian plexus congestion Beard et al.,1998 Beard et al.,1998 Laparoscopy Diagnosis why not diagnostic • • • • Retroperitoneal position of veins Increased intra‐abdominal pressure Trendelenburg position Negative laparoscopy 91% have pelvic congestion Tu et al., 2010 Diagnosis Treatment • Medical – Provera – GnRH agonist • Percutaneous – Embolization • Surgical – Ovarian vein ligation – Oophorectomy – Hysterectomy with BSO Tu et al., 2010 Tu et al., 2010 63 Medical treatment Percutaneous treatment Embolized vein Sophia Virani 2009 Beth Israel Deaconess Medical Center Tu et al., 2010 Percutaneous ovarian vein embolization Percutaneous treatment • • • • Technical success 98 % of patients 4% had migration of embolic agent Total relief of symptoms – 58.5% Moderate relief – 9.7 % Tu et al., 2010 Percutaneous treatment Surgical treatment Ligation Edlundh 1964 No of patients Follow up 6 short Cured No change 6 Mattson 1936 25 1‐3 yrs 25 Metzger 20 0.5‐1.5 yrs 14 Miller 4 ? 4 Runquist 1984 15 0.5‐8 yrs Sharp 1 7 yrs Total Improved 8 3 3 3 4 17% 10% 1 73% Embolization Edwards 1993 1 0.5 yrs 1 Giaccheti 1989 3 1 yr 3 Machan 23 2 yrs Sichlau 1994 3 1 yr Total 16 2 1 6 76% 3% 21% (24) 67% (12) 33% 0% TAH/BSO Beard 1991 Tu et al., 2010 36 1 yr by Dr. DA Metzger 64 Selective pelvic vein ligation TFV – pre and post ligation Colateral circulation Results • 12/18 patients (67%) had improvement of pain at the postoperative visit • No worsening of pain • 8/12 patients had long term follow up (mean 24 months) h) • 7 continued to have improvement of pain (3 pain free) • 1 patient pain returned ‐ cured with hysterectomy Umeoka et al., 2004 Hibner AAGL 2011 Results 9 patients Missing VAS 18 patients 12 Pain improved 4 Lost to F/U 4 Pain improved 3 Pain cured 6 No improvement 1 Pain returned 3 Continued pain 3 Lost to F/U ABDOMINAL WALL NEURALGIAS Hysterectomy Pain cured Hibner AAGL 2011 65 Pelvic nerves3 Risk of nerve injury in gyn surgery • • • • • • • Lateral cutaneous branch of iliohypogastric nerve Iliohypogastric nerve Femoral branch of genitofemoral nerve Genital branch of genitofemoral nerve Inferior rectal nerve Lateral femoral cutaneous nerve Femoral nerve Posterior femoral cutaneous nerve Clitoral/perineal nerves Overall any neuropathy – 1.9% Obturator – 39%, Ilioinguinal/iliohypogastric – 21% Genitofemoral – 17% Femoral ‐ 7.5% Lumbosacral plexus – 0.2% Overall recovery rate – 73% Cutaneous branch of obturator nerve Hibner 2012 Honig, 2002 Ilioinguinal neuralgia Ilioinguinal neuralgia • Burning numbing pain in the lower abdomen radiating to the labia (scrotum) • Worsened by lumbar extension • Compression of the ilioinguinal nerve as it passes through transverse abdominis muscle at the level of ASIS • Result of trauma or surgery Eichenberger et al., 2006 Trocar placement Ilioinguinal/IH injury • Ilioinguinal nerve – to ASIS • 3.1 cm medial • 3.7 cm inferior – to symphisis pubis • • • • • 2.7 cm lateral • 1.7 cm superior p • Iliohypogastric nerve – to ASIS • 2.1 cm medial • 0.9 cm inferior – to symphisis pubis • 3.7 cm lateral • 5.2 cm superior Whiteside et al., 2003 Pfannenstiel incision – 3.7% TVT – 1.7% Laparoscopic ports – ? Hernia repair ‐2% Whiteside et al., 2003 66 Trigger Point Injection Ilioinguinal neuralgia Eichenberger et al., 2006 Eichenberger et al., 2006 Ilioinguinal neuralgia Treatment and Outcomes • Sensory sparring – Nerve Blocks – 25% • Non‐Sensory Sparring – Alcohol Ablation – Al h l Abl i 70% 0% – Neurectomy – 87% Loos et al. 2008 Genitofemoral neuralgia Genitofemoral neuralgia • Symptoms similar to ilioinguinal neuralgia Symptoms similar to ilioinguinal neuralgia • Causes similar to ilioinguinal neuralgia – Placement of vena cava filter Perry, 1997 Parris et al., 2010 67 Genitofemoral neuralgia OVARIAN REMNANT SYNDROME Ovarian remnant syndrome Risk factors • • • • • • Condition occurring in women who have had oophrectomy with or without hysterectomy in oophrectomy with or without hysterectomy in whom some ovarian tissue was left behind • This residual tissue may eventually lead to pelvic mass and pain Magtibay & Magrina, 2006 Magtibay & Magrina, 2006 Presentation • • • • • • Endometriosis Adhesive disease h/o PID h/o appendicites h/o multiple previous surgeries Hormonal status 84% ‐ continuous pelvic pain 26% ‐ dyspareunia 9% ‐ cyclic pelvic pain 7% ‐ dysuria 6% ‐ dyschezia 57% ‐ pelvic mass as presenting diagnosis but 93% of patient have pelvic mass on US or CT • 37% of patients have no symptoms of estrogen deprivation despite not receiving ETR Symmonds & Pettit, 1979 Magtibay et al., 2005 68 Hormonal assays Provocative testing Check hormones 10 days after stopping ERT Estradiol <35mg/mL FSH <30 70% of patients have premenopausal levels of 70% of patients have premenopausal levels of hormones • The likelihood of discovering ovarian remnant during surgical exploration increases when hormone values are premenopausal and patient is not on ERT • • • • • • • • • If remnant not seen on the ultrasound If remnant not seen on the ultrasound – Clomiphene citrate 50 mg PO BID x 10 days – Repeat pelvic ultrasound Magtibay et al., 2005 Kaminski et al., 1990 Medical therapy Radiotherapy • Castrating dose – 1000 rads • Possibly helpful in 70% of patients • Risk Oral contraceptives Danazol GnRH agonists Progestagens – Inconsistent results Inconsistent results – Injury to surrounding organs – Cancer • Should only be offered to patients with substantial surgical risk Magtibay et al., 2005 Shemwell & Weed, 1970 Surgery Outcomes • Open peritoneum lateral and parallel to ovarian vessels • Develop paravesical and pararectal spaces • Divide anterior division of the internal iliac artery • Identify ureter and ovarian vessels • Divide ovarian vessels above the pelvic brim • Remove entire pelvic sidewall peritoneum Webb, 1989 69 Prevention of ovarian remnant Prevention of ovarian remnant • Prevention of ovarian remnant is much easier than removing ovarian remnant later • When removing ovary • Do not remove the ovary: Open peritoneum lateral and parallel to the IP ligament Wid l Widely open the retroperitoneum h i Identify ovarian vessels and ureter Make incision in peritoneum between the ureter and ovarian vessels – Ligate ovarian vessels far away from ovary – Remove ovary with surrounding peritoneum – – – – – without opening retroperitoneum – by retracting ovary medially and ligating the mesovarium with surgical staplers or endoloops Magtibay & Magrina, 2006 Magtibay & Magrina, 2006 References • • • • • • • • • • • References Adams, J., Reginald, P., Franks, S., Wadsworth, J., & Beard, R. (1990). Uterine size and endometrial thickness and the significance of cystic ovaries in women with pelvic pain due to congestion. BJOG, 97, 583–587. Belenky, A., Bartal, G., & Atar, E. (2002). Ovarian Varices in Healthy Female Kidney Donors: Incidence, Morbidity and Clinical Outcome. AJR 179(September), 625–627. Beard, R., Reginald, P., & Wadsworth, J. (1998). Clinical features of women with chronic lower abdominal pain and pelvic congestion. BJOG, 95, 153–161. Duncan, C. H., & Taylor, H. C. (1952). A psychosomatic study of pelvic congestion. AJOG, 64 Eichenberger, U., Greher, M., Kirchmair, L., Curatolo, M., & Moriggl, B. (2006). Ultrasound‐guided blocks of the ilioinguinal and iliohypogastric nerve: accuracy of a selective new technique confirmed by anatomical dissection. British Journal of Anaesthesia, 97(2), 238–43 Honig, J. (2002). Postoperative neuropathies after major pelvic surgery. Obstetrics and Gynecology, 100(5 Pt 1), 1041–2 Kaminski, P., Sorosky, J., Mandell, M. J., Broadstreet, R. P., & Zaino, R. J. (1990). Clomiphene citrate stimulation as an adjunct in locating ovarian tissue in ovarian remnant syndrome. Obstetrics & Gynecology, 76(5), 924–926. Khan, a a, Eid, R. a, & Hamdi, a. (2000). Structural changes in the tunica intima of varicose veins: a histopathological and ultrastructural study. Pathology, 32(4), 253–7. Magtibay, P. M. & Magrina, J. F. (2006). Ovarian remnant syndrome. Clinical Obstetrics and Gynecology, 49(3), 526–34. Magtibay, P. M., Nyholm, J. L., Hernandez, J. L., & Podratz, K. C. (2005). Ovarian remnant syndrome. AJOG 193(6), 2062–6 Loos, M. J. a, Scheltinga, M. R. M., & Roumen, R. M. H. (2008). Surgical management of inguinal neuralgia after a low transverse Pfannenstiel incision. Annals of Surgery, 248(5), 880–5 • • • • • • • • • • 70 Perry, C. P. (2006). Current concepts of pelvic congestion and chronic pelvic pain. JSLS 5(2), 105–10. Perry, C. P. (1997). Laparoscopic treatment of genitofemoral neuralgia. JMIG 4(2), 231–4 Parris, D., Fischbein, N., Mackey, S., & Carroll, I. (2010). A novel CT‐guided transpsoas approach to diagnostic genitofemoral nerve block and ablation. Pain Medicine, 11(5), 785–9. Shemwell, R., & Weed, J. C. (1970). Ovarian Remnant Syndrome. Obstetrics & Gynecology, 36(2), 299–303. Stones, R., Beard, R., & Burnstock, G. (1994). Pharmacology of the human ovarian vein: responses to putative neurotransmitters and endothelin‐1. BJOG, 101(8), 701–706. Symmonds, R. E. & Pettit, P. D. (1979). Ovarian Remanant Syndrome. Obstetrics and Gynecology, 54(2), 174–177 Tu, F. F., Hahn, D., & Steege, J. F. (2010). Pelvic congestion syndrome‐associated pelvic pain: a systematic review of diagnosis and management. Obstetrical & Gynecological Survey, 65(5), 332–40. Umeoka, S., Koyama, T., Togashi, K., Kobayashi, H., & Akuta, K. (2004). Vascular dilatation in the pelvis: identification with CT and MR imaging. Radiographics 24(1), 193–208. Webb, M. J. (1989). Ovarian remnant syndrome. The Australian & New Zealand Journal of Obstetrics & Gynaecology, 29(4), 433–5. Whiteside, J. L., Barber, M. D., Walters, M. D., & Falcone, T. (2003). Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions. AJOG, 189(6), 1574–1578. CHRONIC PELVIC PAIN As we understand it today • Consultant: Ethicon Women's Health & Urology • Speaker's Bureau: Abbott Laboratories Fred M. Howard, MS, MD Professor Emeritus of Obstetrics Professor Emeritus of Obstetrics‐Gynecology Gynecology University of Rochester School of Medicine & Dentistry Rochester, New York [email protected] OBJECTIVES CASE • Identify several of the major differences between visceral & somatic pain • List the mechanisms important in the pathophysiology of CPP • Assess the clinical significance of A h li i l i ifi f – – – – – • 38 y.o. WG2P2002 with CPP x 8‐10 yrs • Hx Laparoscopy, 1998, endometriosis – Decreased pain x 10 mos • Hx LSO, 2002, endometrioma Hx LSO 2002 endometrioma – No change in pain Windup Central sensitization Peripheral sensitization Antidromic transmission Neuroplasticity CASE 1 • Referred for LSH, 2004 – CPP, dysmenorrhea, dyspareunia VAS 7‐10 2 CASE • Cyclical, painful bleeding postop • Rx OCPs • Recurrent pain without bleeding • US showed probable endometrioma • Trachelectomy & RSO, 2006 – BTB and persistent pain • Rx Norethindrone acetate, 5 mg/d Rx Norethindrone acetate 5 mg/d – Endometrioma – Amenorrhea – Decreased pain, VAS 2‐5 • Persistent pain, VAS 0‐8 – Dyspareunia VAS 8 – Vaginal apex allodynia – New onset urinary frequency & nocturia • D/C NE 2006 – Wt gain 71 3 CASE 4 Why review this case? • Potassium test positive • Dx of endometriosis associated pelvic pain – Pentosan polysulfate sodium – Ranitidine • Not cured by several appropriate surgical procedures • Not relieved by hormonal therapy • HRT: estradiol & testosterone • Pain management initiated – – – – • Developed bladder symptoms later Developed bladder symptoms later Amitriptyline Hydrocodone‐actaminophen Ondansetron VAS 1‐7, Avg VAS 5 • Dx as IC/PBS • Inadequate pain relief by medical treatment of IC/PBS • Multimodal pain management • Is a very common type of history with CPP • 2011 – same multimodal treatment – Fully functional Visceral vs Somatic PATHOPHYSIOLOGY OF PAIN Sources of Abdominopelvic Pain • Visceral • Somatic vs Visceral • Nociceptive vs Inflammatory vs Neuropathic – – – – Reproductive organs Gastrointestinal tract Urinary tract Peritoneum • Somatic – – – – – Innervation of Pelvic Viscera: General VISCERAL NOCICEPTION • • Overlap of pathways of different viscera Nociceptors – Multiple viscera converge onto same spinal cord neurons (viscerovisceral convergence) – Silent nociceptors – Low concentration of nociceptors • • • 2 ‐ 10% of all afferents to the spinal cord Makes localization of visceral pain difficult N i Noxious stimuli ti li – – – – – – Muscles Fascia Peritoneum Subcutaneous tissue Skeletal system Distention Ischemia Hemorrhage Referral from other viscera Inflammation Traction of mesentery 72 Innervation of Pelvic Viscera: General • Overlap of pathways of different viscera – Multiple viscera converge onto same spinal cord neurons (viscerovisceral convergence) – There are dichotomous or dichotomizing visceral afferent nerves Innervation of Pelvic Viscera: General • Overlap of pathways of different viscera – Multiple viscera converge onto same spinal cord neurons (viscerovisceral convergence) – There are dichotomous or dichotomizing visceral afferent nerves – Makes identification & localization of visceral pain difficult Classification of Visceral Pain Innervation of Pelvic Viscera: General • Overlap of pathways of different viscera • True visceral pain • Referred pain without hyperalgesia • Referred pain with hyperalgesia – Multiple viscera converge onto same spinal cord neurons (viscerovisceral convergence) – There are dichotomous or dichotomizing visceral afferent nerves – Makes identification & localization of visceral pain difficult • Overlap of pathways with somatic structures O l f th ith ti t t – Viscerosomatic convergence – Results in referred pain – Development of cutaneous or deep tissue hyperalgesia • Does not differ significantly from hyperalgesia secondary to skin or muscle injury – Viscerosomatic convergence 73 Referred Visceral Pain w/ Hyperalgesia Referred Visceral Pain w/ Hyperalgesia • Pain in somatic areas that are metamerically connected to the affected viscus • Secondary hyperalgesia – Pain threshold is decreased P i th h ld i d d • Muscles in area in state of sustained contraction T10 – L2 – Possible cause of trigger points with chronic visceral pain? PATHOPHYSIOLOGY OF PAIN Definition of Nociceptive Pain PAIN MECHANISMS • Visceral • Somatic – – – – – – Nociceptive Inflammatory Neuropathic Psychogenic Mixed Idiopathic – – – – – – • Pain in response to a noxious stimulus that alerts the organism to impending tissue injury Nociceptive Inflammatory Neuropathic Psychogenic y g Mixed Idiopathic – Acts as an early warning system by announcing the presence of stimuli that could damage normal the presence of stimuli that could damage normal tissue • “Normal pain” • “Physiologic pain” Steps in Nociception Treatment of Nociceptive Pain • Disease‐specific – Nociceptive Abbott J et al. Fertil Steril 2004;82:878-84 74 Approaches to Treatment Approaches to Treatment • Disease‐specific • Disease‐specific – Nociceptive – Nociceptive • Pain‐specific P i ifi • Pain‐specific P i ifi – Nociceptive – Nociceptive Intravesical lidocaine IC/PBS Presacral neurectomy Endometriosis Parsons. UROLOGY 2005; 65: 45–48. Zullo et al. Am J Obstet Gynecol 2003;189:5-10 Approaches to Treatment Approaches to Treatment • Disease‐specific • Disease‐specific – Nociceptive – Nociceptive • Pain‐specific P i ifi • Pain‐specific P i ifi – Nociceptive – Nociceptive Opioid analgesics Visceral pain syndrome Cognitive-behavioral therapy Pelvic congestion syndrome Rabkin & Howard, unpublished data Farquhar CM, et al. Br J Obstet Gynaecol 1989;96:1153-62 Definition of Inflammatory Pain Inflammatory Pain • Inflammatory response is physiologic Pain in response to tissue injury and the resulting inflammatory process – Promotes healing • Inflammation may affect neuronal function • With chronic inflammation inflammatory mediators With chronic inflammation inflammatory mediators bind to receptors on pain‐transmitting neurons & alter their function – Increase excitability (allodynia) – Increase pain sensation (hyperalgesia) – May enhance peripheral sensitization 75 Inflammation & Visceral Pain VISCERAL NOXIOUS STIMULI • • • • • • One of the important effects of inflammatory pain is the activation of ‘‘silent nociceptors’’ • Many nociceptors in viscera are silent nociceptors Hemorrhage Infection Inflammation Neoplasm Distention of – Silent nociceptors do not normally respond to mechanical or thermal stimuli – With inflammation of the surrounding tissue, they become sensitized and respond to pressure, distension, or heat – Hollow viscus – Capsule of solid viscus • May be important with endometriosis & IC/PBS which are inflammatory disorders • Traction of mesentery of viscus Gebhart GF. J.J. Bonica Lecture 2000: Physiology, pathophysiology,and pharmacology of visceral pain. Reg Anesth Pain Med. 2000;25:632–638. VISCEROSOMATIC HYPERALGESIA Approaches to Treatment Cutaneous receptive field with colonic distention to 80 mm Hg • Disease‐specific – Nociceptive With repetitive distention • Pain‐specific P i ifi – Nociceptive – Inflammatory After irritation of the colon with turpentine Rofecoxib Endometriosis Ness & Gebhart Cobellis et al. Euro J Obstet Gynecol Reprod Biol 2004;116:100–102 NEUROPATHIC PAIN NEUROPATHIC PAIN • • • • • Pain produced by damage to or dysfunction of neurons in the peripheral or central nervous system Post herpetic neuralgia Complex regional pain syndrome Phantom limb pain Entrapment neuropathy Peripheral neuropathy – – – – • Becomes independent of inciting event • Sustains chronic pain state Diabetes Chronic alcohol use Toxins Vitamin deficiencies • Endometriosis • IC/PBS • IBS 76 Important Terms • • • • • Wind‐up Windup Central sensitization Peripheral sensitization Antidromic transmission Antidromic transmission Neuroplasticity Progressive increase in the amplitude of electrical response of the dorsal horn neurons with repetitive stimulation of a peripheral nociceptor VISCERAL HYPERALGESIA Central Sensitization • Increased excitability of central pain‐ transmitting neurons • Manifests as VAS rating with repeated colonic distention – Reduction in pain threshold (allodynia) Reduction in pain threshold (allodynia) – Increased response to painful stimuli (hyperalgesia) – Increased duration of pain after nociceptor stimulation (persistent pain) Ness et al. Pain 1990;43:377-386. CENTRAL SENSITIZATION Central Sensitization ENDOMETRIOSIS As-Sanie S, Kim JH, Clauw DJ. SGI 2009 (Scotland) (unpublished data) 77 Peripheral Sensitization Peripheral Sensitization • Increase in excitability of peripheral nociceptors • Often mediated by an inflammatory process • Causes increased pain signaling to the spinal cord • In effect, it turns up the volume of pain signals ff i h l f i i l relayed to spinal cord neurons • Amplifies pain signals to the central nervous lifi i i l h l system – The patient feels more pain – Results in increased pain sensation Peripheral Sensitization Antidromic Transmission • Probably due to prolonged generation of pain signals • Can establish a pathologic dorsal root reflex • Afferent dorsal horn cells release mediators that cause action potentials to fire antidromically Clinical Correlation Neuroplasticity Antidromic Transmission • The nervous system’s ability to reorganize itself by forming new neural connections • Enhanced peripheral sensitization – Peripheral tissues more painful than normal – Compensate for injury or disease – Adjust in response to new situations or changes • Allodynia • Hyperalgesia • Mechanism ‐ “Axonal sprouting" p g • Possible referred “trigger points” – Undamaged axons grow new nerve endings to reconnect neurons whose links were injured or severed – Undamaged axons sprout nerve endings & connect with other undamaged nerve cells to form new neural pathways to accomplish a needed function 78 INNERVATION OF ENDOMETRIOSIS DIFFERENCES IN MYOMETRIAL INNERVATION 100 80 60 Endo CPP No CPP % 40 20 0 Perivasc n prolif Atwal et al. Amer J Obstet Gynecol 2005;193:1650–5 Berkley et al. PNAS 2004; 101: 11094-8 Psychogenic Pain DIFFERENCES IN MYOMETRIAL INNERVATION N fibers/0.5 mm3 Microneuromas Endo CPP No CPP 32 22 12 • Pain disorder associated with psychological factors • Pain that is mostly related to psychological factors factors Definition of Mixed Pain Pain that results from any combination of nociceptive, inflammatory, neuropathic and psychogenic mechanisms Probably most cases of CPP Probably most cases of CPP So…..Can we answer some of the clinical conundrums that we see every day in our clinical practices? our clinical practices? 79 Co‐occurrence of Diagnoses in CPP Diagnosis Endo IC/PBS IBS VVS Endo 18% 32% 31% 18% IC/PBS 38% 6% 28% 28% IBS 41% 31% 6% 24% VVS 26% 36% 27% 7% Droz & Howard. JMIG 2011; 18:211-7. Central Sensitization – Antidromic Transmission Central Sensitization 80 REFERENCES Approaches to Treatment • • • • • • Disease‐specific – Nociceptive • • • • • • • • Pain‐specific P i ifi – Nociceptive – Inflammatory – Neuropathic 81 Abbott J et al. Fertil Steril 2004;82:878‐84 Parsons. UROLOGY 2005; 65: 45–48. Zullo et al. Am J Obstet Gynecol 2003;189:5‐10 Farquhar CM, et al. Br J Obstet Gynaecol 1989;96:1153‐62 Gebhart GF. J.J. Bonica Lecture 2000: Physiology, pathophysiology,and pharmacology of visceral pain. Reg Anesth Pain Med. 2000;25:632–638. Cobellis et al. Euro J Obstet Gynecol Reprod Biol 2004;116:100–102 Ness et al. Pain 1990;43:377‐386. As‐Sanie S, Kim JH, Clauw DJ. SGI 2009 (Scotland) (unpublished data) Berkley et al. PNAS 2004; 101: 11094‐8 Atwal et al. Amer J Obstet Gynecol 2005;193:1650–5 Droz & Howard. JMIG 2011; 18:211‐7 Howard FM. Endometriosis and mechanisms of pelvic pain. J Minimally Invasive Gynecol 2009; 16: 540‐50 CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians (researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP). US Population Language Spoken at Home California Language Spoken at Home Spanish English Spanish Indo-Euro Asian Other Indo-Euro English Asian Other 19.7% of the US Population speaks a language other than English at home In California, this number is 42.5% California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the program, the importance of the services, and the resources available to the recipient, including the mix of oral and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm. Executive Order 13166,”Improving Access to Services for Persons with Limited English Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies, including those which provide federal financial assistance, to examine the services they provide, identify any need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access. Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every California state agency which either provides information to, or has contact with, the public to provide bilingual interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population. ~ If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills. A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538. 82
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