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‹footer›<= span lang=3DEN-US style=3D'font-family:Osaka;mso-ascii-font-family:Helvetica;mso= -fareast-font-family: Osaka;mso-hansi-font-family:Helvetica;font-size:58%;layout-flow:vertical; color:white;mso-color-index:3;mso-fareast-language:JA;mso-special-format:la= stCR'>
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------=_NextPart_01C7747D.731FB3E0 Content-Location: file:///C:/8953CAC1/PelvicPain-DrCardosa_files/master05.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C7747D.731FB3E0 Content-Location: file:///C:/8953CAC1/PelvicPain-DrCardosa_files/pres.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C7747D.731FB3E0 Content-Location: file:///C:/8953CAC1/PelvicPain-DrCardosa_files/slide0001.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Pelvic pain
Management of =
chronic pelvic pain
D= r Mary Suma Cardosa
H= ospital Selayang
M= alaysia
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Management (Pain Clinic)
=
üAssessment
<= span style=3D'font-size:129%;layout-flow:horizontal'>= üHistory
= üPhysical examination
<= span style=3D'layout-flow:horizontal'>üI= nvestigations
üManagement Plan
ü
------=_NextPart_01C7747D.731FB3E0 Content-Location: file:///C:/8953CAC1/PelvicPain-DrCardosa_files/slide0002.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Pelvic pain
Pain Clinic management: History
<= span style=3D'font-family:"Times New Roman";font-size:88%;layout-flow:horizonta= l'>üPelvic pa= in X 18 months
<= span style=3D'font-family:"Times New Roman";font-size:88%;layout-flow:horizonta= l'>üLaparosco= py X 2 - no abnormality found
<= span style=3D'font-family:"Times New Roman";font-size:88%;layout-flow:horizonta= l'>üNo improvement with hormonal therapy
ü= ;No relief with analgesic drugs: dologesic / paracetam= ol / diclofenac / mefenamic acid / celecoxib= / etoricoxib / tramadol
<= span style=3D'font-family:"Times New Roman";font-size:88%;layout-flow:horizonta= l'>üCurrently= on antidepressants
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Pain Clinic management: Psychosocial history
üGave up her job as office manager 1 year after pain started
ü= ;married w= ith no children, lives with her husband, who is an investment advisor
<= span style=3D'font-family:"Times New Roman";font-size:88%;layout-flow:horizonta= l'>üpoor communic= ation with her husband&#= 13;
ü= ;Previously depressed, low libido, insomnia<= /span> and s<= span lang=3DEN-US style=3D'font-family:"Times New Roman";mso-ascii-font-family:= "Times New Roman"; mso-fareast-font-family:\65B0\7D30\660E\9AD4;mso-hansi-font-family:"Times = New Roman"; font-size:88%;layout-flow:horizontal;mso-fareast-language:ZH-TW'>uicidal thoughts (better with antidepressants)
------=_NextPart_01C7747D.731FB3E0 Content-Location: file:///C:/8953CAC1/PelvicPain-DrCardosa_files/slide0005.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Pelvic pain
Pain Clinic Management
üDiagnosis
üChronic pelvic pain (No cause found in 30% of patients - Newham, S Afr Med J 1996)
üMultidisciplinary / Multimodal approach
üMedication = ;
üNeural blockad= e
üPhysical therapy
üPsychological approaches
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 Analgesics for chronic pain
=
üOral rather than parenteral
üLong-acting rather than short-acting preparatio= ns
üRegular doses, not PRN
= üTime conti= ngent, not pain contingent
ü
üLimited by side effects and long term effects
üOrgan dysfunction
üTolerance and dose escalation
ü
= ü
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file:///C:/8953CAC1/PelvicPain-DrCardosa_files/master04_image004.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlhNgALAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAEAAQA1 AAoAgAAAAJnMAAIuhBF5y+0PWZq00ogzsrxPDW7eSF6hWKbqJ63ua6HwzCIt7d5YYODxGfn1OsBH AQA7 ------=_NextPart_01C7747D.731FB3E0 Content-Location: file:///C:/8953CAC1/PelvicPain-DrCardosa_files/slide0039.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Pelvic pain
Pain Clinic Management: Medications
=
&uu= ml;NSAIDs / = COX2 inhibitors
<= span style=3D'font-family:"Times New Roman";font-size:86%;layout-flow:horizonta= l'>üNot useful for CHRONIC pelvic pain
&uu= ml;OPIOIDS&#= 13;
<= span style=3D'font-family:"Times New Roman";font-size:86%;layout-flow:horizonta= l'>üWeak opioids - Codeine / Tramadol
<= span style=3D'font-family:"Times New Roman";font-size:86%;layout-flow:horizonta= l'>üStrong opioids - Morphi= ne / Oxycontin / Methadone
&uu= ml;ANTINEURO= PATHIC AGENTS
üAntidepre= ssants - amitriptyline / nortriptyline 
üAnticonvu= lsants - carbamazepine / gabapentin
------=_NextPart_01C7747D.731FB3E0 Content-Location: file:///C:/8953CAC1/PelvicPain-DrCardosa_files/slide0056.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Pelvic pain
Tramadol
&u= uml;Weak opioid <= /span>
&u= uml;Also inhibits reuptake o= f 5HT and NA
&= uuml;Useful in neuropathic pa= in
&u= uml;50-100 mg TDS - QID =
&uu= ml;Side effects - nausea/vo= miting, constipation
------=_NextPart_01C7747D.731FB3E0 Content-Location: file:///C:/8953CAC1/PelvicPain-DrCardosa_files/slide0065.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Pelvic pain
Morphine
üStrong opioid
üGold standard
üOral morphine (Sustained release, long acting)
üTitrate with aqueous (immediate release, s= hort acting) morphine??
üSide effects - same for all opioids (n/v, constipati= on)
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Oxycodone
<= span style=3D'font-family:Arial;font-size:88%;layout-flow:horizontal'>üSustained release preparation: Oxycontin
<= span style=3D'font-family:Arial;font-size:88%;layout-flow:horizontal'>üacts on mu and kappa receptors
<= span style=3D'font-family:Arial;font-size:88%;layout-flow:horizontal'>üequally as effective analgesic as morphine
<= span style=3D'font-family:Arial;font-size:86%;layout-flow:horizontal'>üOxycodone: Morph= ine 1:1.5 - 2
üBetter oral bioavailability compared to morphine
ü
ü(Kalso E, JPSM 20= 05 29:S47-56)
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file:///C:/8953CAC1/PelvicPain-DrCardosa_files/slide0062.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Pelvic pain
methadone
=
üUnique
ülong and highly variable half life
&uu= ml;Large inter-patient variability in duration of analgesia= 3;
üusually 1 day but range 12h - 150h
ücareful monitori= ng is required
ü+ NMDA receptor antagonist action
------=_NextPart_01C7747D.731FB3E0 Content-Location: file:///C:/8953CAC1/PelvicPain-DrCardosa_files/slide0063.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Pelvic pain
transdermal fentanyl
=
=
&uu= ml;
üAnalgesic equivalent dose with morphine 1:100
ü (0.1 mg Fentany= l =3D 10 mg Morphine)
&uu= ml;25 mcg, 50 mcg and 100 mcg patches available
&uu= ml;Therapeutic serum levels after 12-24 hours, Steady state in 1-3 days
üNot suitable for chronic non-cancer pain
&uu= ml;
ü
&uu= ml;
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