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Chronic Pelvic Pain (CPP) can be defined as pain in the area of the pelvis that has been present on most days for more than six months.1 CPP is estimated to affect 15–25% of Australian Women and 8% of Australian Men.3 With so many people affected, general practitioners (GPs) will provide the majority of care for this condition and are essential in coordinating patient care with other specialists and health professionals. Despite this, few guidelines for management are available, and few medical practitioners feel adequately skilled to manage the complex range of symptoms that present. This article provides a practical framework for the clinical assessment and management of CPP in general practice.
Chronic Pelvic Pain, like other chronic pains, can be broken down to four parts:
- Pain from pelvic organs
- The musculoskeletal response to pain
- Central sensitisation of nerve pain pathways
- Psychological sequelae of chronic pain including the stigma and effects of self-identity surrounding gender, fertility and sexuality.
Assessment of Chronic Pelvic Pain - History
One of the reasons that women find it difficult to get comprehensive care is that several organs may be contributing, and multiple comorbidities may be present. Care easily becomes fragmented across a range of specialists and allied health…
Examination of a patient with Chronic Pelvic Pain
The aims of examination are to assess the relative importance of each component of the patient’s pain and exclude infection. A sequence of examination may include…
Management of Chronic Pelvic Pain
Once pain is persistent, a reduction in pain together with improved function and wellbeing may be more achievable goals than cure. Even so, substantial improvement is achievable with the right team of health professionals…
The Role of Laparoscopy
A laparoscopy is an excellent tool for removing endometriosis or for hysterectomy in older women with dysmenorrhoea. However, repeated laparoscopies increase the risk of exacerbating central sensitisation and surgical complications. Without specific indications for repeat laparoscopy, non-surgical options are preferred, at least in the first instance. Where abnormalities are found at laparoscopy, these may or may not be the major cause of the current pain. Many causes of pain cannot be ‘seen’ at laparoscopy, and endometriosis is only one (albeit important) aspect of PPP.
Although photographs from the patient’s laparoscopy can be used positively to illustrate the parts of her pelvis that are normal or where ovaries are normal, fertility is unlikely to be severely affected.
The Role of Opioid Analgesics
Regular opioid use became popular with the rise of palliative care, where the patient’s condition was terminal. In patients with benign long-term pain, the development of dependence with regular use is common and the use of opioids should be discouraged.
There is increasing evidence that opioids sensitise nerve pathways when used regularly.21 Darnell outlines the gender-specific risks and consequences of long-term opioid therapy in women.22 By contrast, nerve pathway (neuropathic) medications are more effective, can be used long term and may help avoid the use of opioids.