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Women's Health > L21: Chronic Pelvic Pain (CPP) > Flashcards

L21: Chronic Pelvic Pain (CPP) Flashcards

1
Q

What is pain?

EXAM QUESTION

A

A subjective phenomenon described as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage Just because one person has pain –> not every one will have that pain

Protective

  • I don’t want to do this because it might cause me pain
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2
Q

What is acute pelvic pain?

A

local damage to tissue resulting in pain and dysfunction ( normal tissue healing guidelines) 4-6 weeks?

  • Eg. 2nd degree perineal tear post SVD
  • Eg. Post surgical hysterectomy
  • Eg. Ectopic Pregnancy
  • Eg. Ovarian cyst
  • Eg. I sprained by ankle and its going to get better
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3
Q

What are 4 chronic pelvic pain?

A
  1. Persistent pain lasting > 6months
  2. Recurrent episodes of abdomino-perineo-pelvic pain.
  3. Hypersensitivity of tissue / muscle / nerve (Eg. to light touch)
  4. Sexual dysfunction (pain) often in the absence of organic etiology. (Dyspareunia • Very undereducated) I have pain and this is not getting better –> Vicious cycle
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4
Q

CPP accounts for ________% of referrals to women’s health services ( ie. O&G, WH Physio)

A

20

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5
Q

What are 5 etiological characteristics of CPPS?

A
  1. Urological ( eg.bladder / urethral)
  2. Gynaecological (eg. endometriosis)
  3. Neurogenic ( eg. pudendal nerve)
  4. Musculoskeletal (eg. pelvic floor)
  5. Rheumatic (eg.auto-immune diseases) -RARE
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6
Q

What are 3 things pain is modulated by?

A
  1. Cognition (If not cognitively aware = less pain)
  2. Emotions
    • If you are really emotional = more pain (catastrophizing
    • Stress = more painful
  3. memory / attention
    • Poor experience with pain in the past = more pain (catastrophizing)
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7
Q

What are 5 impacts that chronic pelvic pain has?

A
  1. daily life,
  2. mood
  3. sleep
  4. relationships
  5. activities.
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8
Q

CPP is ______

A

bio-psycho-social

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9
Q

What are the characteristics of CPP as a bio-psycho-social?

A
  1. Biological causes ( eg. Gynaecological) are important to diagnose if relevant –O&G
  2. Local tissue pain ( eg. Pelvic floor myalgia) are important to diagnose if relevant –WH Physio However……..
  3. Attention to the psychological / social aspects of pain is an important part of effective assessment and treatment !
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10
Q

Why do patients get hesitant about treatment with pain?

A
  1. Poor treatment
  2. Painful treatment
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11
Q

What are 5 activities do pain during pelvic involve?

A
  1. Empty bladder/bowel
  2. Sitting
  3. Intercourse
  4. Childbirth
  5. Wearing tight pants/jeans (causes too much pain)
    • Due to the rubbing
    • Usually wear flowly skirts, recurrent rubbing dermatitis (but don’t actually)
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12
Q

Who does the Multidisciplinary approach to CPP involve?

A
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13
Q

Very difficult to Ax / Rx CPP if no further training in ______ examinations (VE) –post graduate.

A

vaginal

  • Must build trust and rapport
  • Getting them to give a good subjective –> sometimes scared of pelvic exam
  • Understand the signs and symptoms in the subjective Ax refer to an experienced WH physio.
  • Or, reassess your MSK patient if no progress
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14
Q

What are 4 common complaints of pain in CPP?

A
  1. abdomino-pelvic pain
  2. pain with sitting or with movement or with change of posture
  3. with sexual activit
  4. unilateral or bilateral pain.
  • Possible pain with voiding or bowel evacuation
  • Sitting pain
  • Burning groin pain
  • Pain with intercourse
  • No pain at night (this is not back neuropathic pain)
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15
Q

What are 5 structures that MSK pain can originate from?

A

Musculoskeletal pain may originate from

  1. muscle
  2. fascia
  3. ligaments
  4. joint
  5. bones
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16
Q

What are the 6 types of MSK sources of CPP?

A
  1. Pelvic Floor Muscle Pain (Pelvic Floor Myalgia) pain in the muscles of the pelvic floor, perineal or levator ani),
  2. Intra-pelvic Muscle
    • Pain in the pelvic side wall muscles (obturator internus, piriformis, coccygeus)
    • Was a trigger –> no trigger is gone –> becomes over protective(contracting due to fear of pain or body is trying to protect as it thinks there is something wrong)
  3. Pelvic/Lower Abdominal Muscle Pain
    • pain in the rectus abdominus, oblique or transverse abdominus muscles, described below the umbilicus
  4. Posterior Pelvic/Buttock Muscle Pain pain in the gluteal muscles
  5. Coccyx Pain
  6. Pelvic Joint, Ligament, or Bony Pain
    • Joint pain
      • Sacroiliac or pubic symphysis joint
    • Ligament pain
      • Sacro-spinous or Sacro-tuberous ligament
    • Bony pain
      • pubic ramus, ilium, ischial spine or ischial tuberosity
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17
Q

What is provoked pain?

A

Only sore when you do an exam and push on the muscles

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18
Q

What is unprovoked pain?

A

Pain constantly –> referred pain

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19
Q

What are 8 characteristics of pelvic floor pain (myalgia)?

A
  1. History of Childbirth injuries, POP, pelvic organ malignancy, pelvic surgery
  2. Urinary/defecatory dysfunction
  3. Dyspareunia
    • Pain with intercourse
  4. Pain with sitting
    • Leading type of pain and is highest diagnostic activity (can feel like they are sitting on something –> due to the nerves (pedundal nerve) –> referred
  5. Bulge
  6. Vaginal discharge, bleeding
  7. Organ and/or nerve injury related to surgery
    • Sometimes they think that there is something there but it isn’t there –> just because they are contracting
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20
Q

Where can pain come from in CPP in joint pain?

A

Sacroiliac or pubic symphysis joint

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21
Q

Where can pain come from in CPP in ligament pain?

A

Sacro-spinous or Sacro-tuberous ligament

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22
Q

Where can pain come from in CPP in bony pain?

A

pubic ramus, ilium, ischial spine or ischial tuberosity

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23
Q

When pain causes the brain to think there is a threat, what happens?

A
  • Stores and cnetralises pain
  • Starts to protect their pain –> contract the muscle (overocnrtact) –> unable to stop (but contributes to pain) –> nerve pain and centralises
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24
Q

What are the 2 Urological Sources of CPP?

A
  1. Bladder Pain
    • Common complaints: urgency, frequency, nocturia, pain, pressure, discomfort, hesitancy, intermittency, incomplete emptying, incontinence, dysuria
  2. Urethra Pain
    • Pain usually with voiding, with/ night frequency.
    • Feeling of dull pressure,
    • Radiating to groin, sacral and perineal area ?
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25
Q

What are the common complaints of bladder pain in CPP?

A

urgency, frequency, nocturia, pain, pressure, discomfort, hesitancy, intermittency, incomplete emptying, incontinence, dysuria

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26
Q

What are the common complaints of urethra pain in CPP?

A
  • Pain usually with voiding, with/ night frequency.
  • feeling of dull pressure,
  • Radiating to groin, sacral and perineal area ?
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27
Q

What are vulval sources of CPP?

A
  1. Vulva, Vestibular and Clitoral Pain Pain externally
    • Eg. can’t wear tight pants, sitting for prologned time
  2. Pain in the vagina or the external genital organs. (chronic vaginal/vulvar pain syndrome)
  3. Pain is described as sharp, burning, aching and/or stabbing in nature
    • Due to chronic nerve pain
    • Vulva tissue –> outside
    • Sitting
    • Wearing tight pant
    • Idiopathic –> Cause unknown Vagina –> inside
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28
Q

What are 8 GIT sources of CPP?

A
  1. Gastro-Intestinal Pain
  2. Constipation / diarrhea and
  3. Dyssynergic defecation
  4. Pain with defecation
  5. Bleeding / discharge
  6. Cramping abdominal pain,
  7. Recurrent rectal pain / rectal pressure
  8. Burning sensation or aching episodes
29
Q

How is the diagnosis of CPP done?

A

Neurologial Pain

  • Common complaints: Burning, throbbing, stabbing, electrical, tingling, stinging and paresthesia pain in the pelvis and/or perineal region.
  • There may be a change in skin color and temperature.
  • Hand in Hand with PFM Myalgia
  • Eg. Pudendal nerve, sacral nerve
  • See ICS review of CPP for exact nerve referral patterns.
30
Q

What are the 6 common complaints in neurological pain in CPP?

A
  1. Burning
  2. throbbing
  3. stabbing
  4. electrical
  5. tingling
  6. stinging and paresthesia pain in the pelvis and/or perineal region.
31
Q

What does the anatomy of pudendal nerve look like?

A
32
Q

How do you diagnose pudendal nerve pain?

A

Positive test of pudendal nerve block test

  • Inject –> have pain relief
33
Q

Pain is modulated by _____, _____, ____, ___ and _____.

A

cognitive, emotional, experience, memory and attention

34
Q

Pain has an impact on many aspects of daily life, affecting ______, _____, ____ and _____.

A

mood, sleep, relationships; activities

35
Q

Attention to the _______ aspects of pain is an important part of effective assessment and treatment

A

psychological

36
Q

People with ______ are more likely to develop chronic pain

A

depression

Possible sexual abuse –> can be a risk factor for chronic pelvic pain

37
Q

What are 5 things that can be done in assessment for CPP?

A
  1. Posture ( slumped / poor tone / pain?)
    • Sitting to one side –> can’t sit due to pain (try to deload)
  2. Gait ( listing)
    • Favouring one leg while walking
  3. Lumbar spine or pelvic joint tests ( diff diagnosis)
  4. Superficial palpation ( abdominals, inner thigh, pubic bone
    • Lumbar spine, pelvic joints, muscles)
  5. Neural Tests ( if applicable)
38
Q

What is done in a vaginal examination?

A
  • Visual inspection of vulva ( redness / skin conditions/ scar tissue)
  • Palpation vulval tissue ( sensitivity / pain/ lesions ?) (Is light touch becoming sharp burning nerve pain?)
  • Perineal body palpation ( pain / over toned?)
  • Vaginismus ( spasm opening of vagina- Repetitively contracting / small introitus)
39
Q

What are the 5 pelvic floor muscles to look at in the vaginal examination?

A
  1. Pubococcygeus
  2. Puborectalis
  3. Obturator Internus
  4. Coccygeus
  5. Urethra / bladder sensitvity
40
Q

How should tone be graded in the vaginal exam?

A

0: normal

+1: some tone

+2: significant tone

41
Q

How are VEs done?

A

One or two fingers

42
Q

How are rectal exminations (PR) done?

A
  • 1 Finger exam in sidelying
  • VE before PR –infection control
  • Ax:
    • Coccygeus (bimanual) –left and right for pain and tone
    • Coccyx pain / deviation / #
    • Dyssynergia –poor timing of EAS with bearing down
43
Q

What is the 3 assessment purposes in the Rectal Examinations (PR)?

A
  1. Coccygeus (bimanual) –left and right for pain and tone
  2. Coccyx pain / deviation / #
  3. Dyssynergia (Muscle doesn’t know what to do anymore (doing something odd due to the pain))–poor timing of EAS with bearing down
44
Q

What is the best outcome measure for CPP?

A
45
Q

What are the 2 questionnaires for outcome measure in CPP?

A
  1. Pelvic Floor Distress Inventory (PFDI)- Very validated –> give a rating
  2. Prolapse and Incontinence Sexual Questionnaire (PISQ)

Validated outcome measures due to psychosocial impact of CPP

46
Q

What is treatment based on?

A

Based on an accurate diagnosis / questionnaires / recognition of chronic pain / and multi disciplinary opinions!

47
Q

What are 10 treatments of CPP?

A
  1. Breathing awareness / pelvic floor down training (How to relax pelvic floor again)
  2. Abdominal wall relaxations
  3. Relaxation!
  4. Medication
    • Eg. Tri-cyclic anti-depressants (neuropathic pain)) / surgery
  5. Neural stretches
  6. Trigger point therapy (VE, PR, and superficial)
  7. TENS (perineal / vaginal)
  8. Bladder and bowel function
  9. De-sensitising techniques (self trigger point / dilators)
  10. Chronic pain management
48
Q

What is important when treating CPP?

A
  • Educate your patient -very important.-create rapport
  • Communicate / referrals to multidisciplinary team
49
Q

What are 5 characteristics of the technique of breathing awareness as treatment for CPP?

A
  1. Shallow breathing pattern
  2. Sympathetic NS
  3. Abdominal wall relaxation = to help relaxation of pelvic floor
  4. Decrease PFM tone / overactivity
  5. Any position
50
Q

Why is the technique of breathing awareness at treatment for CPP helpful?

A

Big tool to help with pain

51
Q

What are the 3 types of medication for CPP?

A
  1. Endep -Amitriptyline
  2. Lyrica -Pregalbin
  3. Gabapentin -Neurontin
52
Q

What are 8 Indication for use for medication in CPP?

A
  1. Not pain medication
  2. Neuropathic pain
  3. Small doses / long periods
  4. Bladder pain / PBS
  5. Hypersensitivity / vulva
  6. Allodynia / vulva
  7. Poor sleep
  8. Adjunct to Physiotherapy
53
Q

What are 3 types of surgery done as treatment for CPP?

A
  1. Pudendal Nerve Block ( local / corticosteroid)
  2. Trans vaginal Endometrial resection
  3. Gynae surgery to address local pain
54
Q

What are the purposes of neural stretches in CPP?

A

To give a pedundal nerve a stretch and to mobilise pelvis

55
Q

What are 4 muscles that trigger point therapy can be used in CPP?

A
  1. Pubococcygeus
  2. Puborectalis
  3. Coccygeus
  4. Obturator Internus

After down training / trigger point therapy can be useful if tolerated. –can be pain after Rx

56
Q

When is trigger point therapy used for treatment?

A

After down training / trigger point therapy can be useful if tolerated. –can be pain after Rx

Timely treatment –> Only done when the patient is ready

57
Q

How does the trigger point therapy?

A

Either the physio or patient can do it at home

58
Q

How can TENS be used for CPP (pedundal nerve pain or bladder pain) pain relief?

A
59
Q

Where do you place the TENS electrodes for pain relief of CPP?

A
  • Sacrum for pedundal
  • Or on posterior tibial nerve (medial to ankle)
    • There is evidence to warrant that as treatment for pedendal nerve pain or bladder pain
60
Q

What are 8 treatments to address bladder and bowel function?

A
  1. Address constipation ( structure vs stool form)
  2. Address post void residuals ( > 30 mls)
  3. Poor bladder habits ( positioning, straining)
  4. Poor bowel habits ( positioning)
  5. Diet (low fibre)
  6. Fluid intake ( over or under hydrated)
  7. Treat any UTI’s ( MSU / Ab’s)
  8. Sometimes sitting on toilet and can’t relax pelvic floor to go
61
Q

What are dilators/thera-wands?

A
  • Helps with desensitisation (can use as trigger point as well)
    • If light touch is difficult for then
62
Q

Why is dilator a bad word? What is used as another work?

A

The word –> not good for patients with pelvic pain –> dilate and stretch it out

Therawand is better

63
Q

What are 7 characteristics when educating patients about CPP?

A
  1. Lorimer Mosley “ explain Pain “ –great education tool for patients
  2. Chronic pain vs acute pain
  3. Centralisation of pain
  4. Why MRI/ CT/ USS all NAD –they are confused!
  5. Why the pain is different and changes patterns
  6. Build trust and rapport
  7. Have a management plan and explain this to the patient
64
Q

What are 3 things a graduate physio should know about women’s health?

A
  1. Do not perform a VE or PR without advanced training ( ie. Post grad cert, Level 1 /2/3 APA pelvic floor course, Titled / Specialist)
  2. Highlight subjective symptoms in your consultation –refer to a skilled WH Physio.
  3. Refer on if back pain / SIJ pain / ostetitis pubis etc Rx not responding –think about CPP or gynae conditions Should do a good subjective exam
65
Q

What are 13 subjective signs of CPP?

A
  1. SIJ pain
  2. Pubic bone pain
  3. Inner thigh pain
  4. Bladder pain ( lower abdominal)
  5. Rectal pain
  6. Dysuria ( CPP vs UTI)
  7. Chronic constipation
  8. Hx sexual abuse / depression / anxiety
  9. Painful intercourse / VE’s –dyspareunia
  10. Post childbirth ( SVD/ perineal trauma) ?
  11. Pain on sitting
  12. Coccyx pain
  13. Pain with a PFM contraction.
66
Q

What are 8 symptoms of coccydynia?

A
  1. Pain with sitting ( intermittent)
  2. Pain post vaginal delivery
  3. Pain with pelvic floor contraction
  4. Coccyx pain ( bilat)
  5. Relieved with coccyx wedge
  6. Localised pain on palp over coccyx
  7. No bladder issues
  8. Constipation ?
67
Q

What are 9 symptoms of pudendal neuralgia?

A
  1. Pain with sitting ( constant)
  2. Pain post vaginal delivery
  3. Pain with pelvic floor contraction
  4. Coccyx / SIJ pain ( unilat)
  5. No relief with positioning
  6. Perineal pain /discomfort
  7. Pain with intercourse
  8. Bladder / urethral pain / sensitivity / OAB
  9. Lower abdominal pain / hypersensitivity
68
Q

What are 5 Gynaecologial conditions ( pain > 6 months)?

A
  1. Ovarian Cysts ( often not cause of pain?)
  2. Endometriosis
  3. Adhesions ( previous surgery)
  4. Chronic PID ( pelvic inflammatory disease)
  5. Prolapse
69
Q

CPP is______ and _______

A

complicated; multidisciplinary

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