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MACS PAIN CLINIC

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ABDOMINO-PELVIC PAIN

ABDOMINO-PELVIC PAIN

ABDOMINO-PELVIC PAIN

Abdominal pain or “Stomach pain” or “Tummy ache” is a common condition and is used to describe any pain felt anywhere below the rib cage and above the pelvis. Pelvic pain can affect up to 15% of people and is felt in the lower part of the tummy and are associated with uro-gynaecological and rectal symptoms. Sudden onset pains should be treated promptly as they could be surgical emergencies like acute appendicitis, rupture of ectopic pregnancies and bowel obstruction. Pain associated with bleeding or passing blood in urine or stools or vomiting blood or associated with weight loss also need urgent medical attention. However, most of the stomach pains are mild and self-limiting without any surgical management. Some of these pains can persist even in the absence of investigations and would require the expertise of a pain consultant for its long-term management as it is a major cause of sickness absenteeism and disability.

Differential Diagnosis-

Chronic Pancreatitis

Abdominal pain

Chronic Pelvic Pain

Genital pain

Pudendal Neuralgia

Vulvodynia

Coccydynia

Testicular pain

SYMPTOMS & SIGNS

Many words can be used to describe abdominal pain – dull-ache, cramp, sharp, knotted & twisting, spasmodic and burning. The pain can be constant or intermittent coming as waves. It could be associated with nausea and vomiting or as in pelvic pains with bladder and bowel dysfunction. Upper abdominal pain are felt in the centre of the stomach and can spread to the back, up into the chest and feel diffuse around the belly-button. It can be sudden onset (following blunt trauma or bowel perforation) or gradually getting worse. Some pains are worse on movement as in peritonitis and is associated with guarding. Pelvic pain symptoms may be related to the menstrual cycle, being a dull or spasmodic pain; it can be diffuse or localised. The presence of infection could be identified with foul smelling discharge or signs of inflammation including redness and swelling. The severity of these pains could be described as mild, moderate or severe.

  • CAUSES
  • DIAGNOSIS

The abdomen and pelvis contain many organs and any condition affecting them could cause pain.  The commonest causes are infection/ inflammation, obstruction, perforation, ischaemia (lack of adequate blood flow) and malignancy.  The surrounding tissues, muscles, bone and nerves can also be causing pain.

Causes of abdominal pain:

  • Visceral pain:
    • Mild – Common causes include vomiting, constipation, diarrhoea, gastroenteritis, food intolerance and acid reflux disease.  Stress and starvation can also aggravate heart-burn.
    • More serious causes from the bowel include infections like appendicitis and peritonitis, bowel obstruction due to hernias, tumours and adhesions and traumatic injury.  Perforation of gastric or duodenal ulcers, diverticulitis and inflammatory bowel diseases like Ulcerative colitis and Crohns disease can lead on to persistent abdominal pain.  Hiatus hernia and diseases of the oesophagus can also lead on to upper abdominal pain.  Chronic conditions like tuberculosis and sarcoidosis can also present as abdominal pain.  Volvulus or twisting of the bowel and intussusception can also cause pain and obstruction.  Mesenteric ischaemia is a serious condition that needs urgent management.  Ascites is the filling of the abdomen with fluid causing distension and pain.
    •  Other visceral causes include hepatitis, pancreatitis, cholecystitis and cholangitis (infection/inflammation of gall bladder and biliary tree), obstructive jaundice, kidney infection and urinary obstruction due to stones can lead on to upper abdominal pain.
    • Cardiovascular causes including myocardial infarction, angina, heart failure can manifest as abdominal pain.  Abdominal Aortic Aneurysm is a life-threatening swelling of the main blood vessel and leakage from it can present as abdominal pain radiating to the back.
    • Tumours and cancers particularly of pancreas, gall bladder, stomach, carcinoma and sarcomas of the bowel and soft tissue could present with pain but would be associated with other symptoms.
    • Most of the chronic abdominal pains do not have an identifiable cause despite extensive investigations.  Sometimes these can be attributed to medication use or opioid withdrawal, but most are classed as functional disorders and may be identified as part of irritable bowel syndrome (IBS).
    • Myofascial pain: are often missed when presented as abdominal pain.
      • Trigger points in the rectus abdominis and oblique muscles
      • ACNES – abdominal cutaneous nerve entrapment syndrome
      • Psoas muscle spasm
    • Neuropathic pain
      • Shingles and post-herpetic neuralgia
      • Scar pain – this could be post-trauma or post-surgical pain.  Post gall bladder surgery and repair of hernias with mesh is a common cause of persistent pain.  The risk of developing nerve pain is increased if there was post-operative wound infection.
    • Referred pain: This could be from anywhere in the body cavity or surrounding structures.  Spinal pain due to arthritis, disc prolapses and foraminal stenosis can be manifested as abdominal pain.  Tumours and infection of the spine can cause referred pain to the abdomen.  Pleural irritation due to pneumonia or effusion can refer to the abdomen.  Pain from the pelvic viscera including urinary bladder, uterus and ovaries are other causes of referred pain.
    • The pelvis contains the bowel, bladder and reproductive organs and is enclosed in a bony structure with several nerves and plexuses that supply the pelvis and lower limbs as well as blood vessels.  The pelvic musculature is also complex.

Causes of pelvic pain:

  • Gynaecological:
    • Menstrual cramps (dysmenorrhoea) or period pains; this is cyclical in nature
    • Mittelschemrz (associated with Ovulation)
    • Pelvic inflammatory disease
    • Endometriosis
    • Uterine masses including fibroids, adenomyosis and cancer
    • Ovarian cysts – rupture, torsion, bleeding
    • Pregnancy and ectopic pregnancy
    • Chronic pelvic pain – vulvodynia, dyspareunia
  • Urinary Bladder:
    • Urinary tract infection
    • Sexually Transmitted Diseases
    • Interstitial Cystitis
    • Stones in kidney, ureter or bladder
  • Small bowel, Colon and Rectum
    • Chronic constipation
    • Diverticulitis
    • Hernia
    • Anal – Haemorrhoids, Anal fissure, Fistula
  • Testicular pain can be due to infection or inflammation (epididymo-orchitis), trauma, ischaemia due to testicular torsion, varicoceles (swollen veins around the testicle) and hydrocele.  Chronic infection of the prostate (prostatitis) can also give rise to pelvic pain in males.
  • Myofascial pain: pain arising from the surrounding muscles and ligaments of the pelvis and pelvic floor.  This could be trigger points or conditions like pyriformis syndrome.
  • Bony pain:
    • Lumbar spondylosis (osteoarthritis)
    • Joint pains – sacroiliac joint, hip joint
    • Pubic symphysis dysfunction
    • Coccydynia
  • Neuropathic pain: Pudendal neuralgia, post-surgical pain
  • Referred pain from abdomen and lower limbs

Sudden onset or acute pain especially if you feel unwell could be a serious condition and should seek urgent medical attention to rule out surgical emergency. Chronic pain in the absence of a specific treatment could be complex and needs a full assessment. Common investigations include blood tests, urine and stool studies; imaging tests might include X-rays, Ultrasound scans, CT scan and MRI scans. Internal examination include upper and lower endoscopies, colonoscopy, colposcopy, cysto-ureteroscopy and diagnostic laparoscopy.

TREATMENT

Treatment of the pain depends on whether there is an identifiable problem as in many acute conditions.  This could be conservative with the use of analgesics and antispasmodics or it may require surgical intervention.

Chronic Abdomino-pelvic Pain

This is best approached by a multi-modal treatment approach led by a specialist pain consultant with a biopsychosocial approach involving analgesia, interventions, psychological strategies, physiotherapy and rehabilitation.

  • Medications:
    • Simple analgesics
    • Anti-spasmodics
    • Neuropathic pain medications
    • Strong opioids
    • Topical options – Lidocaine plasters, Capsaicin
  • TENS Machine, Heat & Cold packs
  • Acupuncture
  • Pain interventions:
    • Trigger point injections, Pyriformis injections
    • Nerve blocks (transversus abdominus plane (TAP) blocks, ilioinguinal, iliohypogastric or genitofemoral nerve blocks, subcostal nerve blocks, intercostal nerve blocks, pudendal nerve block, cluneal nerve blocks)
    • Sympathetic nerve blocks – coeliac plexus, hypogastric plexus or ganglion impar
    • Radiofrequency denervation (RFA), pulsed radiofrequency lesioning (PRF) especially of splanchnic and superior hypogastric plexus
    • Epidural and nerve root steroid injections
    • Botox injections
  • Neuromodulation – Spinal cord stimulation, Dorsal root Ganglion stimulation, Sacral Nerve Stimulation.
  • Nerve stimulation or neuromodulation techniques: advanced pain reduction strategies may include spinal cord stimulation for severe stomach pain. Some forms of spinal cord stimulation are high frequency stimulation (HF10), tonic stimulation, multi-waveform stimulation, Burst DR stimulation and even dorsal root ganglion (DRG) stimulation.
  • Surgery – Laparoscopy and division of adhesions if indicated; D&C
  • Pain Management Programme and Rehabilitation

Frequently Asked Questions

Q: What are the side-effects of injections?

A:

Each injection can have different side-effects. Please refer to appropriate injections information leaflet in the section of treatments.

Q: How can injections help in pain management?

A:

In situations where the pain is disabling severe and not allowing you to do the day-to-day chores, medications have proven inadequate to reduce the pain; injections are targeted to be given either under x-ray guidance or ultrasound guidance at the presumed sources of pain. Injections mainly consist of local anaesthetic with or without steroid. This works as anti-inflammatory at the source of pain.

Injections are not a permanent cure. Injections help by reducing the intensity of pain. The aim is to reduce pain and break the cycle of pain, allow you to carry out rigourous physiotherapy and help and healing. We may have to repeat injections in order to achieve the goals.

There are other injections available when nerves can be ablated (burnt) or we can apply what is called a radio-frequency lesioning at lower temperatures. These treatments have intermediate to long-term benefits and also work to reduce inflammation. These can be offered if the initial injection does not last long enough to follow on with strengthening Physiotherapy. These injections are not operations or permanent treatments. They are used to improve your condition of pain in order for you to carry out rehabilitative strengthening physiotherapy and come out of the vicious cycle of pain.

Q: What can I do if I do not want medications for my pain control or medications have not helped, or I get too many side-effects from medications?

A:

We can offer you Non-injection interventions such as acupuncture. We can introduce you to other means of self management of pain such as using a TENS machine . We have a modalities to offer at our clinic for example Medical yoga therapy, deep electrical muscle stimulation, TENS treatment. If the pain is unbearable, not responding to medications, or you do not want to try the non-invasive modalities ; we could offer you injection therapies.

Q: What will happen then ?

A:

You will have a detailed consultation, examination and then be given information and advice about your condition. We may also organise investigations. We may be able to prescribe you medication and give you details about how to manage pain and other interventional options can be discussed.

Q: Who will be seeing me?

A:

You will be reviewed only by MACS clinic senior Pain Consultants for your condition.

Q: If I am unable to get a GP appointment or don’t want to wait for any appointments how can I get in touch with you?

A:

You could phone us On (020) 7078 4378 or 07868118976; from 9 am to 6 pm; to book an appointment. You could also email us on info@macsclinic.co.uk or you could also get in touch with us on our website www.macsclinic.co.uk

Q: I am concerned about my pain. What should I do?

A:

If your pain is very severe, not responding to over-the-counter painkillers you should contact your GP and get an appointment for review. If you are in severe disabling pain, unable to carry out any routine tasks, you could book an emergency appointment with your GP or go to the local A&E for a review.

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