Practice guidelines were created and developed by the American College of Obstetricians and Gynecologists with the help of Dr. Fred Howard in the United States to help clinicians make appropriate decisions during obstetrical and gynecologic consultations. However, it should be stated that the application of the guidelines should not exclude other treatment options, and at the same time, the treatment process should be flexible and change according to the individual patient’s needs, the consultation setting and the modus operandi.
I. Guidelines for the treatment of chronic pelvic pain
DD Clinical Guidelines of the American college of obsyeyrics and gynecology (ACOG)
Translated from American Journal of Obstetrics and Gynecology 2004, Vol. 51, No. 3, March p589-605
Chronic pelvic pain is a common condition in women, but because it is difficult to treat adequately and cure completely, it often leads to embarrassing situations in diagnosis. Clinical treatment is often directed at the specific causes of chronic pelvic pain, but sometimes these causes are not well understood, so treatment of chronic pelvic pain remains grounded in the relief of clinical symptoms. The purpose of this guideline is to provide information on the differential diagnosis of chronic pelvic pain, as well as to review some of the current therapeutic perspectives and clinical evidence.
Background.
Pain is an unpleasant sensory and emotional experience associated with actual underlying tissue damage, or that can be described in terms of tissue damage. As such, pain is often subjective. Many patients also complain of pain in the absence of tissue damage or similar cases of physical cause, and pain in such cases may have a psychological basis. If the patient perceives her experience as pain and describes the sensation as if she had suffered a tissue injury, the sensation should then be considered pain. The above definition of pain makes every effort to avoid associating pain with irritation.
There is no single accepted definition of chronic pain. In the obstetrical and gynecological literature, the vast majority, although not all, define chronic pain over a 6-month trial. Defining pain solely in terms of its duration can lead to the creation of ambiguous concepts that ultimately lead to differences in the enrolled population in some studies. Therefore, an acceptable definition of chronic pain should define the characteristics of the temporary characteristics, localization, and severity of pain. Temporal characteristics of pain include: periodic, intermittent, and non-periodic. Many scholars tend to define chronic pain in terms of nonperiodic pain because they believe that the underlying etiology of pain leading to nonperiodic pain is different from that of periodic pain such as dysmenorrhea and painful intercourse; pain localization. It is often assumed that pelvic sufficiently localized pain is sufficient, however, visceral pain is often in the umbilicus with vague sensation, whereas somatic chronic pelvic pain can often be precisely localized in the sacrococcygeal joint, posterior gluteal region, and some other such more detailed areas. In addition, chronic vulvar pain may or may not be chronic pelvic pain, depending on the localization of the pain. Therefore, in reviewing the literature that examines chronic pelvic pain, it is necessary to clarify which definition of chronic pelvic pain is used.
One definition considers chronic pelvic pain to be non-cyclical, lasting more than 6 months, localized in the anterior abdominal wall, umbilicus, posterior lumbosacral region, and buttocks of the anatomical pelvis, and of sufficient magnitude to cause the body to function and require treatment. It is also emphasized that the absence of abnormalities on physical examination does not negate the patient’s subjective pain, and the absence of abnormalities on routine examination does not exclude pelvic pathology.
Although there is no exact figure for the incidence of chronic pelvic pain in the general population, current data show that nearly 15-20% of people aged 18-50 years have a history of chronic pelvic pain for more than 1 year.
II. Epidemiology of chronic pelvic pain
Potential chronic pelvic pain includes two types: visceral-derived and somatic-derived. Chronic pelvic pain can also be divided into central and peripheral psychological or neurological disorders; chronic pelvic pain can also be divided into obstetrical and gynecological and non-obstetrical causes according to the department of consultation; obviously, obstetricians and gynecologists should have the ability to diagnose and treat chronic pelvic pain caused by non-obstetrical causes. The ability to diagnose and treat non-obstetric causes of chronic pelvic pain.
Traditional epidemiological methods have demonstrated that there are a number of diseases that are causally associated with causing chronic pelvic pain, so although not all, there are a number of diseases that are thought to cause chronic pelvic pain. There is ample evidence that several common conditions in women are causally associated with chronic pelvic pain, such as endometriosis, interstitial cystitis, and irritable bowel syndrome. The gynecologic and non-gynecologic causes of common chronic pelvic pain are categorized by level of evidence. The ranking is shown in the table below.
Evidence grading for a causal relationship between disease and chronic pelvic pain based on
Grade A: There is good, correlational evidence confirming a causal relationship between these diseases and chronic pelvic pain
Grade B: limited, less relevant evidence of a causal relationship between these diseases and chronic pelvic pain
Grade C: Based on expert opinion that these disorders are causally related to chronic pelvic pain
The ranking is as follows.
Common gynecologic causes of chronic pelvic pain
Evidence grading Disease name
A Endometriosis
Gynecologic malignancy (especially advanced)
Residual ovary syndrome and ovarian remnant syndrome (RESIDUAL OVARY SYNDROME, OVARIAN REMNANT SYNDROME)
pelvic venous stasis syndrome
pelvic inflammatory disease
tubulitis nodosa
B adhesions
benign cystic mesothelioma
postoperative peritoneal cyst
C Adenomyosis
Atypical dysmenorrhea and ovulation pain
Adnexal cysts (except chocolate cysts)
Cervical canal stenosis
Obsolete ectopic pregnancy
Old endometriosis
Fallopian tube endometriosis
Intrauterine device
Ovulation pain
residual accessory ovary
Symptomatic pelvic organ prolapse
Common non-gynecological causes of chronic pelvic pain
Disease name
Evidence grading Urinary system Gastrointestinal system Musculoskeletal system Other
A Bladder malignancy
Interstitial cystitis
Radiation cystitis
Urinary tract syndrome Colorectal cancer
Constipation
Inflammatory bowel disease (ulcerative colitis and Crohn’s disease)
Irritable bowel syndrome Abdominal myoepithelial pain (trigger point pain)
Chronic caudalgia (back pain)
Poor posture
Fibromyalgia
Inferior iliac abdominal neuralgia, genitofemoral neuralgia
Pelvic floor muscle pain (pear-shaped muscle, anal raphe pain) Abdominal cutaneous nerve stretched or compressed by post-surgical scar
Depression
Somatization disorder
B Unstoppable bladder contraction (dyscoordination of the detrusor muscle) Low back pain
Spinal or sacral neuropathy Celiac disease
Neurological disorders
Porphyria
Herpes zoster
Sleep disorders
C Chronic urinary tract infections
Recurrent, acute cystitis
Recurrent, acute urethritis
Urolithiasis
Urethral caruncle Colitis
Chronic incomplete bowel obstruction
Diverticular disease Lumbar spine compression
degenerative joint disease
Hernia: inguinal hernia, femoral hernia
Muscle strain or sprain
Spinal joint ankylosis Abdominal epilepsy
Abdominal migraine
Bi-directional personality disorder
Familial Mediterranean fever
Many of the above disorders are thought to be associated with chronic pelvic pain, and although the relationship between some disorders and chronic pelvic pain has not been conclusively established, the current clinical situation is that once a patient is diagnosed with chronic pelvic pain, the physician treats it accordingly, and this ambiguity of treatment makes interpretation of the causes and effects of chronic pelvic pain very difficult.
The incidence of chronic pelvic pain in women is unknown, and the methods of examination for its specificity have not yet been unified. A large survey in the UK found that chronic pelvic pain in women is more related to urology and gastrointestinal tract than gynecology, with urology accounting for 30.8%, gastrointestinal tract for 37.7%, and gynecological diseases accounting for only 20.2%. Further studies have shown that 25 to 50% of those attending the clinic with chronic pelvic pain have more than 1 disease related to The most common diseases causing chronic pelvic pain are: endometriosis adhesions, irritable bowel syndrome, and interstitial cystitis.
If more than one system or organ is involved, the pain is often more severe than if a single system or organ is involved. For example, 43% of patients with chronic pelvic pain with a single symptom of the gastrointestinal or urinary system have moderate to severe pain, while in those with combined gastrointestinal and urinary symptoms, the figure is 71%; the proportion of patients with chronic pelvic pain who have dysmenorrhea and painful intercourse is high, with 81% having dysmenorrhea and 41% having painful intercourse, while the proportions of dysmenorrhea and painful intercourse in the general population are only 58% and 14%, respectively; combined gastrointestinal, urinary In patients with gastrointestinal and urinary symptoms, the nature and degree of pain is more intense.
High-risk factors of chronic pelvic pain in the population
Large demographic surveys show that there is no difference in age, race, faith, education, socioeconomic status and occupation between patients with and without chronic pelvic pain, but divorced, childbearing-age women are more likely to have chronic pelvic pain. Note: Age itself is not a specific risk factor, and chronic pelvic pain can occur at different ages, despite differences in the diagnostic criteria for slow pain accepted by the general public.
IV. Physical causes and sexual promiscuity
The vast majority of the current literature suggests that physical factors and sexual promiscuity are significantly associated with various types of chronic pelvic pain. 40-50% of people with chronic pelvic pain have a history of sexual promiscuity, but it is uncertain whether sexual promiscuity causes chronic pelvic pain. Those with a history of sexual promiscuity and high somatic scores are more likely to have non-somatic chronic pelvic pain, suggesting that the association between sexual promiscuity and chronic pelvic pain may be psychological or neurological in nature.
Evidence suggests that sexual promiscuity may lead to physical changes in the organism, for example, one study showed a decrease in pain thresholds in adult survivors after controlling for factors that interfere with psychiatric history, and there are also studies showing that sexual promiscuity or injury stimuli (especially abdominal and pelvic risk factors) can increase pain sensitivity and lead to persistent pain. Therefore, in those with chronic pelvic pain, if the patient is informed of a history of sexual promiscuity, it is important to confirm whether the patient is currently promiscuous or similarly behaving.
V. Pelvic inflammatory disease
18-35% of patients with pelvic inflammatory disease develop chronic pelvic pain, but the specific mechanism is unknown, and not all pelvic inflammatory diseases with genital injuries develop chronic pelvic pain. Whether pelvic inflammatory disease is treated as an outpatient or inpatient does not affect the probability of developing chronic pain later (34% and 30%, respectively).
VI. Endometriosis
Ems may be a direct cause of chronic pelvic pain, but it can also indirectly increase the risk of chronic pelvic pain, for example, evidence shows that Ems increases the incidence and level of vaginal pain when complicated by urinary calculi. This cross-reactivity between internal organs has an important role in chronic pelvic pain. This could explain why some women with Ems have pain that persists after the removal of the Ems lesion.
Laparoscopic examination of patients with chronic pelvic pain revealed that 33% had Ems, 24% had adhesive disease, and 35% had no obvious lesions. Although there was a 70-90% compliance rate between abnormal pelvic examination and abnormal laparoscopic findings, nearly half of the patients with abnormal laparoscopy had a normal preoperative pelvic examination.
VII. Interstitial cystitis
Those with interstitial cystitis have a high tendency to develop chronic pelvic pain, which is a chronic inflammatory disease of the bladder with clinical symptoms of urinary irritation, urinary frequency, and urinary urgency, but the examination does not show objective lesions that can cause the above symptoms. It has been reported that 70% of patients with features above have chronic pelvic pain, and 38-85% of women who visit gynecology for chronic pelvic pain have interstitial cystitis.
Eight, irritable bowel syndrome
Irritable bowel syndrome is a common intestinal disorder with an unknown etiology.
In the meantime, I would like to share with you a recipe from my experience.
Da Xue Vine 30g Sulforaphane 30g San Leng 10g Curcuma 10g Fei Xie San 20g (packet)
Spring Caihu 10g, Fried Citrus Aurantium 10g, Atractylodes 10g, Poria 15g, Plantago 10g (pack)
Liu Yi San 10g (Pack) Gui Zhi 10g Radix Codonopsis 10g Astragalus 10g
Radix cornelian 10g Xu Changqing 10g Yanhuosuo 10g
This formula is more suitable for patients with chronic pelvic pain to relieve symptoms and improve the disease, especially for patients with chronic pelvic inflammatory disease and pelvic vein stasis. Take with water decoction, 1 dose/day (decoction twice and drink twice). Take this formula for 7-15 days, and continue for half a month to a month if it is effective.