Diagnosis and Management of Chronic Pelvic Pain

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Dr. Paul Indman:  “Hi, I’m Dr. Paul Indman, we’re at the AAGL meeting in Orlando, Florida and I’m fortunate to have with me Dr. Anthony Luciano.”

Dr. Anthony A. Luciano:  “Thank you, Paul.”

Dr. Paul Indman:  “He will be joining the OBGYN.net Laparoscopy/Hysteroscopy Board - welcome.”

Dr. Anthony A. Luciano:  “My pleasure and a honor to join your Board.  Thank you for inviting me.”

Dr. Paul Indman:  “I’d like to talk to you about your management of pelvic pain.  How would you handle a woman who comes in and says - I’ve been having lower abdominal pain over the last two years, it’s getting worse, I’ve seen seventeen different doctors, they’ve all done various different things, and I’m still hurting?”

Dr. Anthony A. Luciano:  “Including a laparoscopy?”

Dr. Paul Indman:  “I had a laparoscopy three years ago, I don’t know what they found.”

Dr. Anthony A. Luciano:  “This is not an uncommon scenario, pelvic pain or chronic pelvic pain is a very common problem, unfortunately, not always easily amenable to successful therapy.  A patient like this one needs foremost a very thorough and comprehensive medical history to find out whether or not the chronic pelvic pain is associated exclusively or mostly with the pelvic organs or reproductive organs or it also involves the GI tract which is frequently involved and a problem of the musculoskeletal region.  Usually, not all the time but usually, a thorough medical history will point you in one direction or another and then the next step is to perform a very thorough and careful examination.  I’m not saying that the previous eighteen doctors have not done that but if you’re going to assume charge and the care of this patient, you must do it yourself.  You cannot take their word for it or their medical records words for it, you have to do it yourself but once you’ve done that, usually you will get an idea as to where to look and what the problem is.  The next step in the diagnostic evaluation may involve some laboratory tests and some imaging tests.  Try to do things that are least invasive first because this patient has probably already undergone lots of fairly invasive procedures.  You already mentioned that she’s had a laparoscopy and she doesn’t know exactly what was done or what was found so one thing that you must do is obtain the medical records and the operative report, and then proceed on.  If you think there is a high index of suspicion that the patient may have GI problems then it is very important to get a gastrointestinal consult, and most gastroenterologists may not be well attuned in the diagnosis and management of pelvic chronic pain.  Therefore, it is important that you get someone who’s interested, who’s interested in working with you, who’s a very patient guy, and between the two of you, you usually will arrive on some sort of diagnosis and develop some sort of a management plan.”

Dr. Paul Indman:  “What are some of the things that you would look for on physical examination?”

Dr. Anthony A. Luciano:  “Physical examination is very important in looking for musculoskeletal problems such as hernias, such as point tenderness, and trigger points in the abdomen.”

Dr. Paul Indman:  “I’m going to interrupt you because I think that’s a very important point, and it’s not unusual to find someone who’s had prior surgery.  You find a little tender trigger point and you inject it with some local anesthetic and the pain goes away.  It may not be permanent but then you know it’s not an intraabdominal process.”

Dr. Anthony A. Luciano:  “Exactly, I’m glad that you emphasized that point.  That’s very, very important that’s why I’m saying that a thorough physical examination is extremely important to find out.  Don’t right away get to the pelvic exam, just look at the whole patient, look at the abdominal wall, feel the abdominal wall very, very thoroughly, feel the groin area which is an area that’s frequently associated with hernias, with lymphadenopathy, etc. and you may find your diagnosis in that area.  Ask the patient to cough and strain, these may also point towards either inflammatory process in the abdomen or a hernia for a musculoskeletal problem.  Then proceed on with your pelvic examination.  These women are usually very tender, they have a lot of guarding, and you must reassure them that you’re not going to hurt them.  You must reassure them that you’re going to be very gentle and explain to the patient every movement that you make and explain to her what to expect.  After you’ve performed a pelvic examination, look in particularly for areas of tenderness that may involve endometriosis such as the uterosacral ligament, the rectovaginal wall, the anterior cul-de-sac, etc.  On the pelvic sidewall look for nodularities, fibrosis, trigger points of tenderness, etc. and once you’re satisfied with that and include a rectal examination, you may find the ultrasound is usually very, very useful.  Some patients may have fibroids, adenomyosis, and so on and ultrasound will be very helpful at least for the diagnosis of fibroids.”

Dr. Paul Indman:  “Do you think that fibroids often cause pain?”

Dr. Anthony A. Luciano:  “Not often but frequently, especially the intramural fibroids.  I had one patient who had terrible chronic pain for many, many years and what she had was an intramural fibroid that was giving her pains.  She described that it felt like she was in labor all the time and that’s exactly what she was doing.  Her uterus was contracting constantly trying to expel this fibroid from the uterine cavity, which could not come out through a closed cervix, and once we removed that it went away.  Now that fibroid we could never have felt on pelvic examination but the vaginal probe ultrasound gave us the diagnosis right away.”

Dr. Paul Indman:  “I think another thing that the ultrasound is useful for is knowing exactly what you’re touching that is causing tenderness.  Often you can touch the perimetria or around the adnexal area and all of it’s tender.  That’s a lot different then if you touch the ovary and - ooh that’s the pain and it’s consistent, you go back and forth.  Occasionally we’ll find one ovary that’s painful whenever you touch it on repeated visits, and you know you’re touching that ovary nowhere around it and they look normal.  You take it out through a laparoscope and the pain may go.  I don’t know why it hurts but the ultrasound can really help us localize the pain.”

Dr. Anthony A. Luciano:  “Excellent.”

Dr. Paul Indman:  “Let me ask you one more question, there’s been a lot of talk about using GnRH agonists empirically without laparoscopy.  Would that be something that you would consider is the next step for this lady?”

Dr. Anthony A. Luciano:  “I am not a fan of the use of GnRH without a firm diagnosis but I can see cases where that may be a very useful tool both for diagnostic and for therapeutic reasons if you’re not sure.  As you know, a lot of patients have endometriosis but they don’t necessarily have pain.  A lot of patients have adhesions but they don’t necessarily have pain so making the diagnosis of endometriosis or pelvic adhesions by laparoscopy does not guarantee you that that’s really the reason for the patient’s pain so in such a patient it may not be a bad idea to try a six-month therapy for GnRH analogue.  I say six months because that’s the usual traditional duration of therapy but if the patient doesn’t respond by the third month of therapy, I think, you can abandon the therapy at that point.  At the other end, if she is responding but the pain is not resolved completely, you may continue for six months.  After six months if the pain has improved significantly then you’ve done this patient a tremendous service plus you have some ideas to what the diagnosis is.  You know that that diagnosis will have to involve the reproductive organs, which are almost exclusively affected by GnRH analogue in the suppression of ovarian function and inducing a high progesterone in this state.  You don’t know whether it’s endometriosis, adenomyosis, fibroids, or pelvic adhesions but you know it’s one of those.”

Dr. Paul Indman:  “Recently there was an article in the Journal of Reproductive Medicine about the GI effects of estrogens and progesterone and I’m wondering could, for example, irritable bowel be affected by GnRH agonists so that it may resolve?  Here we’re thinking it’s endometriosis when in fact it may be irritable bowel.  Do you think that’s a possibility or…?”

Dr. Anthony A. Luciano:  “I think it’s a very good possibility but the fact that they have responded to GnRH tells you that although they have irritable bowel syndrome, they also have an excessive bastion of their disease and their symptoms by the circulating levels of estrogen.  As you know, with each menstrual period patients produce and release lots of prostaglandins which are very strong simulators of bowel activity, and so they may exacerbate irritable bowel syndrome, and if you find that after they’ve responded to GnRH analogue that there is no endometriosis there, then you can go back to irritable bowel syndrome as your main diagnosis.”

Dr. Paul Indman:  “I think it’s safe to say that just because someone responds to GnRH agonists that does not necessarily mean we can diagnosis them with endometriosis.”

Dr. Anthony A. Luciano:  “That’s correct.”

Dr. Paul Indman:  “I think that’s an important point because a lot of women are diagnosed with that and that causes all kinds of psychological problems so it may be a good test to see if the pain goes away but it’s not diagnostically true.”

Dr. Anthony A. Luciano:  “Absolutely, that’s very true.”

Dr. Paul Indman:  “Good, Tony, I want to welcome you to the Board of OBGYN.net, and thank you very much.”

Dr. Anthony A. Luciano:  “My pleasure to be here.  Thank you.”