Chronic pelvic pain

Introduction to chronic pelvic pain Chronic pelvic pain (CPP) refers to pelvic pain that is non-periodic and lasts for more than 6 months (also considered to be more than 3 months) and is ineffective for non-opioid therapy. Chronic pelvic pain is one of the most common symptoms in women. Pelvic pain has acute and chronic points. Chronic pelvic pain is characterized by a complex etiology. Sometimes, even if a laparoscopic or open laparotomy is performed, no obvious cause can be found. The degree of pain is not necessarily proportional to the degree of the disease. basic knowledge Probability ratio: Susceptible people: women Mode of infection: non-infectious Complications: headache, swelling, varicose veins, endometriosis, inguinal hernia

Causes of chronic pelvic pain

Pelvic tissue lesions (35%)

The pelvic organ distortion caused by adhesions and endometriosis causes pain. The location and extent of the pelvic organs are not necessarily related to the location and severity of the lesion. Some pelvic lesions can also cause pain, such as chronic pelvic inflammatory disease. Endometriosis, adenomyosis, pelvic adhesions and other organic lesions.

Psychological factors (20%)

There are many patients with only mild pathological changes or no organic changes. Some patients can get some explanation from the social-psychological aspect. Doctors often diagnose functional chronic pelvic pain, but according to the modern bio-social psychology model. The theory should be called psychological (mental) chronic pelvic pain. Some scholars in China have conducted investigations. The cause of CPP is caused by social psychological factors, accounting for 5% to 25% of the total.

Other factors (10%)

The study found that the disease is also associated with depression, traumatic sexual experience, and marital misfortune.

Chronic pelvic pain prevention

1. Actively treat chronic pelvic diseases and actively carry out psychological treatment.

2. Closely observe the mental state of the suspected individual and be alert to psychological chronic pelvic pain. Educate women to develop an optimistic and uplifting mental state, rest properly, and face the pressure of work, life, and study.

3, pay attention to menstruation and puerperium hygiene, to prevent pelvic infection, which leads to pelvic pain.

Chronic pelvic pain complications Complications, headache, swelling, varicose veins, endometriosis, inguinal hernia

First, the general complications:

Often accompanied by autonomic dysfunction such as rapid breathing, hyperhidrosis, rapid heart rate, and unstable blood pressure.

Second, pelvic congestion syndrome:

It occurs 7 to 10 days before menstruation. When a woman is sitting or standing, the pain is exacerbated and she is relieved when lying down. Due to vascular congestion or pelvic varices.

It is often accompanied by low back pain, leg pain, dyspareunia and uncommon fatigue, emotional instability, headache and swelling of the abdomen.

Due to the increased venous return in the Trendelenburg position, varicose veins may disappear. Transvaginal ultrasound and transcervical venography are minimally invasive and more accurate methods, preferably before laparoscopic surgery.

Third, endometriosis (EM):

Typical EM lesions may not be difficult to identify, but CPP patients often have atypical EM. A variety of subtle non-pigmented lesions require close proximity (1 to 2 cm from the lens) and multi-angle observations. Sometimes a peritoneal biopsy is needed to find out.

EM stoves are often hidden under the scar tissue, and should be alert to signs such as adhesions, scars and anatomical deformation. With the aid of the instrument and the intraoperative vaginal rectal triad, patience palpation can minimize the missed diagnosis.

Fourth, adhesion:

Not all adhesions found during surgery are the culprit of CPP. In general, membranous adhesions are not related to CPP, and dense adhesions, which cause anatomical distortion and destruction of organ function, are most likely causes of pain.

According to the pain mapping map drawn by preoperative examination and the mutual confirmation in the operation, it is helpful to differentiate the diagnosis.

V. Inguinal hernia:

Under the laparoscope, the peritoneal fistula on the side of the round ligament is present. Straight sputum can sometimes find weak areas or defects of the peritoneum in the Hai's triangle. If the display is unclear, the peritoneum of the Hai's triangle can be pulled to the cephalic side to find wrinkles or sacs. The exposure of the femoral hernia under laparoscopy is relatively complicated.

Chronic pelvic pain symptoms Common symptoms Endometriosis Abdominal pain Severe pain Dull pain Anxiety Excited Insomnia

Chronic pelvic pain (CPP) is a non-specific term that includes laparoscopic gynecological diseases such as endometriosis, pelvic inflammatory disease, pelvic adhesions, and pelvic venous congestion syndrome. Some occult physical diseases (usually diseases other than gynecology) such as intestinal irritation syndrome, also include non-somatic (mental) diseases.

First, symptoms and signs

Lower abdominal pain, so the clinical pelvic pain is called lower abdominal pain.

1. Psychological pelvic pain:

The main symptoms:

Lower abdominal pain or back pain: lower abdominal pain can be the entire lower abdomen, or bilateral or unilateral axillary, or no obvious positioning, often accompanied by vaginal discomfort, persistent or intermittent dull pain or Hidden pain; patients can not tell which factors are related to the increase and relief of pain;

Depression: Pain is caused or aggravated by sexual intercourse, but does not affect sexual life. Patients have significant depressive symptoms such as loss of appetite, fatigue, insomnia, loss of libido or lack of interest in anything, or impulsivity, poor self-control, and sometimes anger directly to the physician. Some patients have symptomized all emotions, or negated repression, showing indifferent satisfaction;

Abnormal disease behavior: They have a physical prejudice, convinced that they have a disease, do not respond to the doctor's guarantee, adhere to their pain symptoms, although they seek treatment, doctors do their best to treat, but they have been painful.

Second, physical examination

1. Mental and mental examination:

Often accompanied by neurotic symptoms, the doctor is impressed that the patient is exhausted, depressed or anxious, nervous, and irritated. Although the pain is unbearable, no positive signs can be detected.

Psychological investigations have a comprehensive and accurate assessment of the condition and serve as a basis for future evaluation of the progress of the disease or the efficacy of the treatment. The meaning of this layer should be explained to the patient to be fully coordinated.

2. Physical examination

While guiding the patient to relax the abdomen, thighs and vaginal opening muscles to alleviate the discomfort during the examination, the extent to which the patient controls muscle tension can be understood. Anal examination touches the levator ani muscle and piriformis causing pain, suggesting that there is tension in the pelvic floor muscles. The feeling of discomfort usually manifests as pelvic pressure and radiation pain to the ankle, close to the attachment point of the levator ani muscle. This condition is often the result of certain pelvic pains, but it can also be a disease.

Double and triple diagnosis:

Attention should be paid to the presence or absence of thickening in the attachment area, the degree of activity, the presence or absence of pelvic floor relaxation, tenderness of the tailbone, and lesions that may cause sexual pain. A gentle palpation may detect sensitive areas that correspond to vaginal vestibulitis or trigger points at higher vaginal points. Gently palpating the abdominal wall with your fingertips reveals tender points in muscle tissue.

Pelvic examinations sometimes need to be combined with local nerve block to remove interference and facilitate differential diagnosis. For example, in the abdominal wall or the pain point of the pelvic wall, local anesthetic is injected to repeat the pelvic examination after the local muscle pain is relieved. The doctor can distinguish whether it is true organ pain or surrounding muscle pain. If the uterine sacral nerve is blocked by the vagina, if the pain in the basin is relieved or disappeared, it is estimated that the pain originates from the uterus; and if the pain is not relieved, it is difficult to distinguish the possibility of block failure except the pain is not the source of the uterus.

3, pelvic examination:

No positive findings, but the pelvic cavity was overly sensitive, and even severe palpation was severe pain.

Medical history and physical examination should be carried out carefully and comprehensively to perform necessary auxiliary examinations to identify organic diseases. The development of modern medical technology has provided clinicians with a variety of diagnostic tools, but sometimes it is still difficult to diagnose complex lesions such as CPP. In the absence of obvious organic causes of pelvic pain, doctors should not easily diagnose psychological pelvic pain, but should discuss it with psychiatrists, conduct rational analysis and judgment, and make a final diagnosis. Care should also be taken to avoid repeated or unnecessary inspections or diagnostic tests.

Chronic pelvic pain examination

Vaginal secretion examination, hormone level detection, tumor marker examination, histopathological examination.

1. Imaging examination

(1) Ultrasound: As the most commonly used non-invasive imaging method in gynecology, ultrasound can detect abnormal anatomy of the pelvis, distinguish the nature of the mass (cyst or solid), and distinguish the vascular characteristics by color Doppler, but It is not always possible to provide information on the cause of CPP. Whether it is transabdominal or vaginal ultrasound, the pelvic organic lesions can be initially excluded, which is helpful to relieve the patient's ideological doubts. Combined with detailed medical history data and comprehensive physical examination, ultrasound is not necessarily necessary. The items examined, but for patients with abdominal wall tension, who can not cooperate with or do not receive pelvic examination, have important diagnostic significance. In recent years, the progress of multi-dimensional ultrasound technology will certainly open up wider application prospects for it.

(2) X-ray: including intravenous pyelography, barium enema, upper gastrointestinal angiography, abdominal plain film and pelvic image, etc., mainly for non-gynecological conditions that cause common CPP, such as urinary stones, intestinal lesions and bone lesions, etc. Purposefully selective application.

(3) CT and MPI: It is a more sensitive but also more expensive examination item. Before the selection, the doctor should be clear whether there is obvious tendency of suspected diagnosis. It needs to be confirmed by such examination, such as: 1 suspected malignant tumor; 2 suspected retroperitoneal lesion 3, rectal vaginal septum or suspicious endometrial ectopic foci of the vaginal fornix, etc., it is not appropriate to use the above two examinations to confirm the positive signs that have been found in physical examination.

2. Endoscopy

(1) cystoscopy: When considering the symptoms from the lower urinary tract, cystoscopy is necessary in the case of exclusion of infection, general cystoscopy can be performed in the clinic, but if the pain is accompanied by frequent urination, dysuria, And when the symptoms are aggravated when the bladder is full, suspected interstitial cystitis, need to be fully evaluated under hospital anesthesia, interstitial cystitis in the case of bladder filling, can see the typical congestion point on the bladder wall, and this If the procedure is not given anesthesia, the patient is intolerable.

(2) Colonoscopy: Symptoms originating from the intestine are not uncommon in CPP. Alternation of diarrhea and constipation is most likely an irritable bowel syndrome, but if the patient is mainly diarrhea and has blood and mucus in the stool, it must be checked. With or without colonic mucosa, colonoscopy is the most accurate examination of the lower digestive tract, which clearly shows intestinal mucosal and submucosal lesions, but it is still necessary to emphasize specific indications.

Laparoscopy

Laparoscopy as a minimally invasive diagnostic tool for direct vision is considered by women scientists to be an indispensable tool for the evaluation of CPP. According to statistics, more than 40% of laparoscopic examinations are used to evaluate CPP. Laparoscopy can obtain pelvic and abdominal cavity. Clear images of the surface of each organ can also collect pathological specimens for pathological examination, so that pathological conditions that cannot be found by physical examination and imaging examination can be found. It is worth noting that laparoscopic can only confirm 60% CPP. The cause, even if a laparoscopic lesion is found to be part of the cause of CPP, so before deciding to perform a laparoscopy, it should be based on preliminary assessments from medical history, physical examination, and other complementary diagnostic findings. All possible pain-causing factors are performed only when the results of the laparoscopic examination are confirmed to actually change the treatment of the patient.

In recent years, the development of new small-caliber fiber endoscopes has enabled diagnostic laparoscopy to be widely carried out in outpatient clinics. The slim "needle" mirror has better optical properties and less trauma to enter the abdominal cavity. Laparoscopy has a unique advantage. Because the patient is conscious during surgery, it can cooperate with the surgeon to find painful lesions, such as pulling the adhesion to cause the patient's usual pain, then further adhesion decomposition is reasonable.

The common CPP mirrors are as follows:

(1) Endometriosis (EM): Typical EM lesions may not be difficult to identify, but CPP patients often have atypical EM, and various subtle non-pigmented lesions need close distance (1 to 2 cm from the lens). And multi-angle observation can be detected, sometimes need to do a peritoneal biopsy to find that EM stoves are often hidden under the scar tissue, should be alert to adhesions, scars and anatomical deformation and other signs, with the aid of the instrument and intraoperative vaginal rectal triad, Patience palpation is the most likely to miss the diagnosis.

(2) Adhesion: not all adhesions found during surgery are the culprit of CPP. In general, membranous adhesion is not related to CPP, and dense adhesion, anatomical distortion and damage of organ function are most likely The cause of the pain is based on the pain mapping map drawn by the preoperative examination and the mutual confirmation in the operation to help differentiate the diagnosis.

(3) inguinal hernia: under the laparoscope, the peritoneal fistula on the side of the round ligament, the sputum can sometimes find the weak area or defect of the peritoneum in the Hai's triangle. If the display is unclear, the Hai's triangle can be used. Pulling to the head side, you can find wrinkles or sacs, and the exposure of the femoral hernia under laparoscopic is relatively complicated.

(4) pelvic congestion syndrome: Laparoscopy is not the most reliable method for diagnosing pelvic varices. Due to the increased venous return in the Trendelenburg position, varicose veins may disappear. Transvaginal ultrasound and transcervical venography are minimally invasive and more accurate. The method is best done before laparoscopic surgery.

(5) Others: Some cases are often seen in the laparoscopic examination of CPP, but very few are the causes of CPP, such as functional ovarian cysts, Morgagni cysts, peritoneal window (Allen-Masters syndrome), etc. Attention and neglect to continue to look for the real cause of pain.

Diagnosis and diagnosis of chronic pelvic pain

Diagnostic criteria:

Medical history inquiry and physical examination should be carried out carefully and comprehensively to make necessary auxiliary examinations to find organic diseases. The development of modern medical technology provides clinicians with a variety of diagnostic tools, but sometimes it is still difficult to dial CPP. In complex lesions, doctors should not easily diagnose psychological pelvic pain when they cannot find obvious organic causes of pelvic pain. Instead, they should discuss it with psychiatrists, conduct rational analysis and judgment, and make a final diagnosis. Also, care should be taken to avoid repeated or unnecessary inspections or diagnostic tests.

In patients undergoing laparoscopic surgery for chronic pelvic pain, if a lesion that causes pelvic pain is found, diagnosis and treatment are not difficult. CPP without obvious somatic lesions is called idiopathic pelvic pain (pelvagia), diagnosis and treatment. It is quite tricky.

Diagnostic tests for CPP should focus on the following objectives: 1 to find and identify corrective causes of pain; 2 to rule out fatal diseases, such as cancer; 3 to prompt treatment and to guide prognosis, and diagnostic methods should start with economic, minimally invasive methods According to the analysis of logic to judge.

Medical history collection:

To receive CPP patients, we should first eliminate the initial fear in a relaxed language and easy-going attitude, accept the fact that she is painful, and don't rush to guess how much pain she complains about comes from the body, how much comes from the mind, and strives to make the patient honest. The mentality tells about his illness and discusses his emotional concerns.

Descriptions of pain, including location, duration, time characteristics, accompanying symptoms, relationship between pain type and position change during activity, and relationship between pain and changes in body function are important issues such as focal, location-related Pain may be related to adhesion; pelvic pain in the morning may be related to pelvic congestion, and with the prolongation of CPP, even if the organic lesion remains stable, the range of pain may gradually increase.

The complete CPP medical history data should also include all aspects of disease history and its treatment history, sexual life history and emotions, marital conflicts, etc.; when collecting information, valuable clues are often obtained from the materials provided by the patient's family, especially the spouse.

Physical examination:

The physical examination of CPP requires clinicians to be familiar with the relevant pathophysiology and organ anatomy of CPP and the relationship between functions, so as to be comprehensive, meticulous and skillful.

While guiding the patient to relax the abdomen, thigh and vaginal muscles to reduce the discomfort during the examination, the patient can control the degree of muscle tension, the anus examination touches the levator ani muscle and the piriformis cause pain, suggesting that the pelvic floor muscles are tense and uncomfortable. The feeling usually manifests as pelvic pressure and radiation pain to the ankle, close to the attachment point of the levator ani muscle. This condition is often the result of some pelvic pain, but it can also be a disease.

Double and triple consultation should pay attention to whether there is thickening in the attachment area, how the activity is, whether there is pelvic floor relaxation, tenderness of the tail bone and lesions that may cause sexual pain, etc., soft palpation may be detected with vaginal vestibulitis or The sensitive area of the higher part of the vagina triggers the point, and the tender point in the muscle tissue can be found by gently palpating the abdominal wall with the fingertip.

Pelvic examination sometimes needs to be combined with local nerve block to remove the interference, which is helpful for differential diagnosis. For example, local anesthetic is injected at the pain point of the abdominal wall or the pelvic wall, so that the local musculoskeletal pain is relieved and the pelvic examination is repeated. The doctor can distinguish the true dirty. The pain is still around the muscle pain, and if the uterine nerve is blocked by the vagina, if the pain in the basin is relieved or disappeared, it is estimated that the pain is from the uterus; and if the pain is not relieved, it is difficult to remove the pain other than the source of the uterus. Distinguish the possibility of block failure.

Psychological assessment:

The psychological problem of CPP patients is whether they are causes or fruits. It is still difficult to distinguish them. It is worth noting that psychological assessments that are out of date or lack of skills may cause greater psychological stress on patients. The result of the investigation is not to determine whether the patient's pain is psychological or who needs surgery, but to have a comprehensive and accurate assessment of the condition, and as a basis for evaluating the progress of the disease or the efficacy of the treatment measures in the future, the patient should be explained The layers are meant to be fully coordinated.

In short, the causes of CPP are complex and not clear, and there are many related disciplines involved. The correct diagnosis is very challenging. Establishing a harmonious relationship between doctors and patients and close interdisciplinary cooperation is the foundation for establishing a diagnosis. On this basis, looking for a new type of The problem of research methods also needs to be solved.

Differential diagnosis:

Chronic pelvic pain should be differentiated from the following symptoms:

First, pelvic cancer pain:

Cancer pain, or advanced cancer pain, is one of the causes of major pain in patients with advanced cancer. At this stage, the patient is physically and mentally in pain. 80% of patients with advanced cancer have severe pain, and it is estimated that at least 5 million people in the world suffer from pain every day.

Cancer pain has become an important target in the daily work of all relevant departments, especially the important content of pain diagnosis and treatment.

When the tumor cells invade or oppress the pelvic nerves, severe pain can occur. Tumor cells invade blood vessels, which can cause blood vessels to be impeded and cause pain.

Second, psychological chronic pelvic pain:

Psychological pelvic pain is dull pain, persistent seizures, often pain after awakening, seizures in the presence of psychosocial factors, inconsistent pain and nerve distribution, no radiation pain, metastasis changes and diffuse, long-term maintenance of the same pain, It will not trigger or increase pain after the examination, and it will happen when the interpersonal relationship is not handled properly.

Third, organic lower abdominal pain:

Organic lower abdominal pain is sharp, sputum, intermittent, can occur at any time, can be awakened by pain during sleep, radiates along the nerve distribution pathway, has typical tender points, develops or quickly improves or becomes more intense, Generated or exacerbated after a manual inspection, not affected by emotions.

Fourth, other:

Chronic non-localized pain should also consider other diseases not associated with gynecology, such as tuberculous peritonitis, intestinal adhesions, intestinal ascariasis, and neurosis.

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