Highlights of the International Pelvic Pain Society Annual Meeting
Highlights of the International Pelvic Pain Society Annual Meeting
The International Pelvic Pain Society program was held in Simsbury, Connecticut April 30 - May 1, 1999. The program was jointly sponsored by the University of Rochester School of Medicine and Dentistry and the International Pelvic Pain Society. The course directors were Dr. Fred Howard, President of the IPPS and Debra Metzger, Ph.D., M.D.
This course was intended for anyone with an interest in chronic pelvic pain: primary care providers, gynecologists, nurses, urologists, surgeons, anesthesiologists, neurologists, physical therapists, pharmacists, psychologists and psychiatrists. The symposium provided the practitioner with state of the art, holistic approaches to the evaluation and management of chronic pelvic pain. New strategies provided included advances in diagnostic methods, pain management, the role of nutrition, surgical approaches and psycho-neuropharamcology
Video of this program is available through the International Pelvic Pain Society. Visit the International Pelvic Pain Society web site at www.pelvicpain.org.
Fred Howard, M.D., President of IPPS opened the symposium with welcome news about the exciting growth of the Society which is now over 175 members in over 14 countries. He announced the planning for the October 20, 1999 Fort Lauderdale, FL program which can be accessed through the Internet site of the IPPS at www.pelvicpain.org. Also, a chronic pelvic pain symposium is planned May 13, 2000 in association with the Royal Society of Medicine in London, England and in conjunction with the World Congress of Endometriosis to be held in London at that time.
Jill Peters-Gee, M.D. presented new approaches to Interstitial Cystitis. There are 100,000 diagnosed interstitial cystitis patients and 1 million or more patients with urgency, frequency, bladder pain and negative urine cultures. The signs of interstitial cystitis include urgency, frequency, a negative urine culture and pain and discomfort in the pelvic, bladder and perineal areas and pain with intercourse. Common misdiagnoses include recurrent UTIs, non-bacterial prostatitis, urethral syndrome and urethral stenosis. Interstitial cystitis has multiple etiologies including inflammatory, allergic, neurogenic, and epithelial dysfunction. The interstitial cystitis bladder has a damaged uroepithelium, a mucus deficit, potassium diffusion, and inflammation leading to fibrosis. The pathogenesis of interstitial cystitis begins with a bladder insult which results in activation of C-fibers and substance P-release. This leads to mast cell activation and histamine release which results in epithelial layer damage. This results in a potassium leakage resulting in more injury and the cycle is continued. Up to 35% of premenopausal women, complain of premenstrual exacerbation of the symptoms of interstitial cystitis. Up to 70% of patients with interstitial cystitis will also have pain with intercourse. Vulvodynia is closely associated with interstitial cystitis and as both anatomic areas are derived from the urogenital sinus, there may be a common etiology. To diagnose interstitial cystitis use the O'Leary - Sant interstitial cystitis symptom and problem indices. Reference: O'Leary MP, Sant GR, et al. The Interstitial Cystitis Symptom Index and Problem Index, Urology, Vol 49 Supplement 5A pg 55-63. These indices are well-validated techniques for using patient history relating to symptom severity and problems as a technique for diagnosing interstitial cystitis. In the physical examination rule out vaginitis, vulvodynia, urethral diverticula, ureteral vaginal prolapse, and pelvic floor dysfunction. At physical examination, the findings consistent with interstitial cystitis include anterior vaginal wall tenderness, suprapubic tenderness, and pelvic floor spasm. Diagnostic tests include a urinalysis, voiding log, urine culture, and potassium sensitivity index. Normal subjects void on average 6.5 times per day where as interstitial cystitis subjects void 16.5 times per day. When 40 ml of 400 mEq/liter KCl solution is instilled into a normal bladder there are no symptoms. In patients with I.C., there is epithelial dysfunction and the potassium diffuses across the transitional cells and stimulates sensory nerves and creates urgency and pain. For selected patients, urine cytology, cystoscopy, laparoscopy, hydrodistention and cystometrogram may be indicated. At cystoscopy glomerulations will be seen with over-distention of the bladder and there may be a Hunner's ulcer. Under anesthesia, interstitial cystitis patients have on average 775 cc capacity where the normal patient has 1115 cc capacity.
Treatment for interstitial cystitis (IC) requires treatment of pelvic floor dysfunction with biofeedback, physiological quieting, and physical therapy. The direct treatment of interstitial cystitis relies on self-help such as dietary modification and bladder training, pharmacologic therapy with intravesical and oral therapy and surgical therapy with hydrodistention, augmentation/diversion and sacral nerve stimulation. The intravesical treatments that have been used include DMOS, chlorpactin, silver nitrate and Cystistat (hyaluronic acid). Medical therapy is available with Pentosan polysulfate sodium (Elmiron) 100 mg three times a day and with patients who have allergies, treatment with hydroxycine hydrochloride (Atarax). In addition, the use of amitriptyline hydrochloride (Elavil), paroxetine (Paxil), fluoxetine (Prozac) and doxepin (Adapin). Relief from Elmiron may require up to 3 to 6 months of continued therapy, but it does provide long-term improvement when the therapy is continued. The role of anti-depressants is to assist sleep, increase pain threshold and elevate mood. The role of antihistamines is to inhibit the role of mast cells in the IC picture. Sacral nerve stimulation (InterStim from Medtronics) relies on stimulation of the sacral nerve roots with permanent implant if the test is successful. This device is approved by the FDA for use in intractable urge incontinence.
The treatment of IC requires diet modification, self-help and has proved to be very responsive to the Elmiron therapy. Treatment of the allergy component with antihistamines, the depression and sleep deprivation component with anti-depressants and the severe pain with either hydrodistention or intravesical medication for the short-term are also important adjunctive therapies.
The next presentation was made by Dr. John Gibbons on Vulvar Vestibulitis.
The elements of vulvar vestibulitis are: severe pain on vestibular touch or attempted vaginal entry; tenderness to light vestibular pressure; varying vestibular erythema. The important anatomy of the vestibule are Hart's line, the hymenal ring, the Bartholin and Skene ducts and the urinary meatus. Embryologically, the urogenital sinus divides into urethra, bladder and distal vagina. These are endodermic structures. Therefore the vestibule is entirely from the same embryologic structures. These structures also develop into bladder and urethra. Therefore, that which affects the vestibule may well in fact affect the urethra and the bladder itself. The etiology of vulvar vestibulitis is not known but it may be related to human papilloma virus, hypersensitivity to Candida or to oxalate crystals or some other factor which we as yet have not determined. The history that is given is abrupt onset of dyspareunia. The condition is usually long-standing and is not cyclic and there are no periods of remission. On physical examination, there is no dermatitis and no evidence of a vaginitis but there is extreme tenderness to light touch and patchy erythema. The differential diagnosis is vaginitis, vulvitis, vulvar dermatoses, cyclic vulvitis and dysesthetic vulvodynia. The treatment options are vulvar hygiene, diet, biofeedback, interferon, and surgery. For vulvar hygiene, the patient eliminates irritants, eliminates allergens, uses cotton underwear and uses non detergent soap, avoids tight clothing and pantyhose. The diet option is basically the low oxalate and calcium citrate. The biofeedback option utilizes electromyographic controlled biofeedback with an intra vaginal probe to assist the patient in reducing the hypertonicity which is frequently present in the levator muscles when they have this condition of vulvodynia. Interferon injection therapy has been successful in 50% of case with intralesional therapy of 1 million units of Alpha 2 Beta recombinant therapy for 12 doses. Surgical intervention involves the U-shaped vestibulectomy with perineorrhaphy. A wide excision is used with vaginal advancement. Post-operatively the patient uses ocean salt Sitz baths and even with this therapy the patient may still require biofeedback for control of her pain.
Tricia Mulready, M.D. discussed Syndrome X: Insulin Resistance as well as nutritional factors that are important to patients with pelvic pain. Insulin resistance occurs when cell receptors have decreased sensitivity to insulin and therefore are down regulated which results in increased insulin production by the pancreas. As a result of this high level of insulin there are increased lipids, hypertension, inflammation and pain and the condition may result in diabetes. Uncoupling of the mitochondrial energy factory results in fatigue. In addition substance P is released and inflammation results. To diagnose Syndrome X, a history of hypoglycemia, chronic fatigue, inflammation together with a diet of process foods, simple carbohydrates and saturated fats in a person with a family history of diabetes, hypertension or coronary artery disease is very indicative of this condition. At physical examination, the patient may be found to have hypertension, hirsutism, apple shaped obesity and dry, flaky skin. To confirm the diagnosis of Syndrome X a two hour glucose tolerance test may be performed. In addition cholesterol levels will very likely be increased with HDL being decreased. Treatment of Syndrome X requires a diet which reduces simple carbohydrates and increases legumes and non-starchy vegetables. Omega-3 fish oil and flaxseed oil are useful anti-inflammatories as well as olive oil. Protein should be obtained in the form of chicken, turkey, lamb or soy and soluble fiber should be encouraged as well as some insoluble fiber. Patients with Syndrome X require 200 to 400 mg a day of magnesium, 300 mcg of biotin, 200 mcg of chromium, 500 to 1000 mg of carnitine, 50 mg of selenium and trace amounts of zinc, copper, and manganese. In addition vitamin E at 400 IU, alpha lipoic acid, venadium, inositol, and COQ 10 are excellent micro-nutrients for these patients. Unless the underlying condition of hyperinsulinemia is treated patients with pelvic floor pain especially from muscle spasms and trigger points will likely recur with their condition in spite of the best interventions.
Mary Casey Jacob, Ph.D. then presented Survival Techniques for the Physician. It is clear that the patient with chronic pelvic pain simply don't get better without a great deal of involvement of their providers and this is a challenge for them and their providers. In order for the provider to cope with the chronicity, it is necessary to broaden the definition of success, educate your patients about chronicity and help them to focus on taking their lives back from the pain. People with chronic pain are often told and often think that they are being told "It's all in your head". In fact, very pure psychogenic pain is rare. There are however psychological and social influences on the pain severity and so the pain management needs to be multidisciplinary. It is important to acknowledge the suffering of people with chronic pain and it is important to recognize that the pain has changed the individual's life and to acknowledge this. People with chronic pain may have difficulty distinguishing between acute and chronic pain because of the severity of their discomfort. Frequently people with chronic pain require narcotics and it is important to establish guidelines for prescribing narcotics. These should be used in conjunction with rehabilitation. After the limits of the rehabilitation are clear; they should be prescribed on a fixed schedule. There should be clear rules and guidelines and written contracts. Emergency prescriptions are not suggested. Patients should take the narcotics as directed, they should receive the drug from only one M.D., they should report side effects promptly and they should not stop the drug abruptly. Contraindications to narcotic use include present or past substance abuse, presence of some psychiatric disorders and when the narcotics are used in anticipation of possible pain, to relax or for sleep.
Ibrahim Daoud, M.D. discussed Occult Hernias and Pelvic Pain. Dr. Daoud evaluated 100 consecutive patients who were diagnosed with occult hernias (i.e.: non-palpable hernias). All patients were females age 20 to 48 with pelvic pain due to occult hernias suspected on the basis of: 1) longstanding history (6 months to 20 years) of inguinal pain radiating to the labia and/or thigh, 2) reproduction of pain by internal palpation of the inguinal/femoral ring (or bi-manual exam), 3) tenderness of internal and external rings on external exam, 4) evidence of tender inguinal bulge on impulse. Diagnostic laparoscopy revealed obvious (visible) hernias in 12% of the patients and pre-peritoneal dissection revealed one or more findings: 1) enlarged internal ring and incarcerated fat, 2) incarcerated fat and a large femoral ring, 3) indirect sac, femoral hernia or defect in the transforsalis fascia.
All hernias were repaired laparoscopically using Gore-Tex Micromesh Patch.
The average follow up was 3 to 16 months. 62% of patients reported complete relief of pain, 23% partial relief and 15% no change in their pain after surgery. Dr. Daoud concluded that occult hernias are a common cause of chronic pelvic pain and effective pain relief can be obtained by a diagnostic laparoscopy and laparoscopic repair in carefully selected patients.
R. William Stones, M.D. traveled from the University of Southampton from Princess Anne Hospital to discuss The Mechanism of Pain in Pelvic Congestion. Dr. Stones discussed the pain from vessels as resulting from mechanical distention, released algesic endothelial agents such as from hypoxia, shear or agonists; and from neurogenic causes. Dr. Stones discussed the concept of a pelvic migraine in that the ovarian circulation is anastamotic and turbulent. A sympathetically mediated arterial spasm can result in a release of endothelial agents with action of sensory nerves near venioles and coincidental vasodilatation of large veins down-stream. This can result in a pain syndrome similar to cerebral migraines. The putative peripheral algesic agents include substance P, norepinephrine, ATP, serotonin, nitric oxide, and endothelian-1. The mechanisms demonstrated in ovarian circulation include sympathetic enervation, algesic endothelial factors and flow mediated ATP and peptide release. This model explains acute episodes better than continuous pain and the sensory enervation is not well characterized. The therapeutic indications include the role of vasoactive agents for prevention and maintenance similar to treatment for cerebral migraines. There are also therapeutic implications for the role of vasoactive agents in the treatment of acute episodes. Ongoing studies in potential medical therapy for pelvic congestion are being carried out by Dr. Stones. Currently however the only treatment available for this condition is surgical.
Kendra Shappee, P.T. presented A Holistic Approach to Physical Therapy in the treatment of chronic pelvic pain. The physical therapy evaluation involves a history, structural evaluation, active range of motion, palpation, muscle length and strength, neurologic screening, gait, and functional activity assessment. Posture is evaluated for an exaggerated lordotic posture of the lumbar spine, hypermobility and instability, asymmetrical pelvic posture and a slumped sitting posture. The pudendal nerve supplies all of the muscles of the pelvic floor. It maintains continence, provides sexual response and also supports some internal organs. It is important to note that the fascia which is a tough connective tissue found throughout the body can reorganize itself in response to physical stress and thickens along the lines of tension. Trigger points which are hyperirritable trigger points within taut skeletal muscle or fascia are painful and compression will refer pain and will reduce flexibility and cause a decrease in strength. A pain cycle is frequently set up where a physical trauma will occur, muscle guarding occurs, metabolites are retained causing inflammation and ischemia which causes pain, which decreases activity which results in additional pain and muscle weakness and this then causes increased stress and the cycle continues. A musculoskeletal screening examination should include a history which looks for pain which altered by positional changes, a history of low back pain or injury, pain related to time of day, results of laparoscopy which are normal, a lack of response to gynecologic and psychological intervention and increased symptoms with stress. Mobility problems which are indicators of musculoskeletal problems include increased lumbar lordotic curve, pelvic obliquity, a unilateral standing pattern, a slouched sitting posture, obesity and scoliosis. Palpation should be used with a single digit examination to evaluate for trigger points in the pelvic floor, abdominals and hips. Tenderness should be sought in the lumbar and lower thoracic musculature. Patients who have an inability to stand on one leg, an inability to lower the legs in a supine position, increased resting tone of the pelvic floor or weakness of the pelvic floor all are candidates for physical therapy treatment. Physical therapy treatment involves specific postural exercise programs, patient education and the physiology of pain, instruction in muscle relaxation techniques, scar mobilization, myofascial release, trigger point treatment and electrotherapy and biofeedback. With the use of these modalities, it is possible to intervene and reduce the level of pain that is a result of myofascial injuries and dysfunction.
Debra A. Metzger, M.D. presented A Systomatic Approach to the Diagnosis and Management of Chronic Pelvic Pain. Dr. Metzger defined chronic pelvic pain as pain lasting a minimum of 3 to 6 months and the syndrome as the pain lasting 3 to 6 months in which function gradually declines, depression worsens and pain spreads. She identified the sources of pelvic pain as those which are common (endometriosis, adenomyosis, adhesions and irritable bowel syndrome); common but often missed (interstitial cystitis, pelvic congestion, hernias, ilioinguinal, iliohypogastric neuropathy, unexcised, fibrotic endometriosis, uterine retroversion (dyspareunia), ovarian remnants/residual ovary); and those not generally associated with chronic pelvic pain (ovarian cysts, filmy adhesions which do not distort anatomy, fibroids). Dr. Metzger stressed the importance of a complete history and a complete physical exam with mapping with an attempt to reproduce the site of the pain during which an ongoing dialogue is established with the patient and which exam needs to be performed very systematically.
Dr. Metzger reviewed :symptoms of frequency, urgency, nocturia; physical exam with + or - bladder tenderness; labs of negative urine culture; and cystoscopy.
Dr. Metzger also reviewed pelvic congestion with symptoms including lateral pelvic pain which is made worse with standing and lifting; post-coital ache; and pain which may be cyclic. On physical examination patients with pelvic congestion frequently have ovarian point tenderness, adnexal tenderness which reproduces the patient's pain. For laboratory studies, an ultrasound that measures the ovarian vein diameter and the parametrial and/or a transcervical venogram is important. Treatment can be accomplished with medroxyprogesterone acetate 30 to 50 mg per day (for those that can tolerate it), laparoscopic ovarian vein ligation for isolated ovarian vein varicosities and hysterectomy for more generalized congestion.
Dr. Metzger also reviewed symptomatic uterine retroversion with symptoms of deep pain with intercourse and intercourse pain which is reproduced by palpating the uterine-cervical junction of the retroverted uterus. Treatment by laparoscopic uterine suspension has a very high rate of success in this condition (approximately 90%).
Dr. Metzger also reviewed inguinal hernia with symptoms of pain which increases with activities associated with increased intra-abdominal pressure and the pain may be cyclic and worse during menses. At physical examination inguinal ring tenderness, a small bulge, internal inguinal tenderness and occasionally ilioinguinal neuropathy. Inguinal hernia is a clinical diagnosis and generally is not apparent at laparoscopic examination. Relief may be obtained by suppressing periods with continuous oral contraceptives but a laparoscopic transperitoneal repair may be required using a Gore-Tex Patch.
Dr. Metzger also reviewed abdominal wall trigger points with symptoms of intense pain localized to the abdominal wall which are often related to activity. At physical examination with tensed abdominal wall muscles there are very localized areas that are exquisitely tender. Treatment with injection of 0.25% Marcaine into trigger points can completely relieve the pain and the treatment frequently involves a series of 3 to 5 injections.
Dr. Metzger also evaluated dysmenorrhea - incapacitating menstrual cramps at the time of menses unresponsive to nonsteroidal anti-inflammatories and/or oral contraceptive pills. At physical examination there are no distinguishing characteristics although there may be cul-de-sac tenderness suggestive of endometriosis and a boggy, tender uterus that is suggestive of adenomyosis. A sonohystogram would rule out a submucous fibroid and a hysterosalpingogram would rule out a septum or other mullerian anomaly. An MRI or ultrasound may help to identify adenomyosis or adenomyoma. A trial of a paracervical block may be helpful to verify the source of the pain. Treatment can be accomplished with continuous oral contraceptives, Progestasert, progesterone suppositories, possibly Primrose Oil with Slo-Mag plus calcium; a hysteroscopic myomectomy or septoplasty is required if these conditions are present. At times a presacral neurectomy may help with severe dysmenorrhea.
Dr. Metzger wrapped up this very productive program by advising all of us to believe in our patients because "her pain is real". She advised the caregiver to be proactive and to treat the associated symptoms of fatigue, depression, insomnia, pain, nausea and constipation. She advised all of us that our work is to alleviate suffering and therefore we need to provide information and resources, advise the patient on support groups and make regular appointments with the patients. In order to minimize healthcare costs associated with chronic pelvic pain it is important to minimize ER visits and to perform surgery only with a specific purpose and after and appropriate evaluation guided by the evaluation as described. The treatment of chronic pelvic pain requires team work and patients must be referred to healthcare professionals who can properly evaluate and treat these patients. There should be boundaries and limits including pain contracts, no refills of medications after hours, and all of us should encourage patient responsibility and involvement in care. Complementary alternative medicine should be considered and last but not least look for a cure if possible, but improved quality of care may be the best that can be provided some women with chronic pelvic pain.
The program in Simsbury was enlightening and very informative. Full video tapes of all of the presentations are available through the IPPS web site. Visit the International Pelvic Pain Society at www.pelvicpain.org for further information on upcoming programs and the availability of the complete videotapes of the annual meeting from 1999.