Chapter 54 Pelvic Pain Flashcards
KEY POINTS 1. Chronic pelvic pain (CPP) usually persists for more than 6 months. Even after a thorough evaluation, the etiology of the pain may remain obscure, and inconsistency remains in the pathology of various disorders and pain. 2. The prevalence of female pelvic pain is estimated to be one in seven women of reproductive age. Internationally, the prevalence of CPP is equivalent to that of asthma, back pain, or migraine. 3. Both diagnosis and management of these patients require good in
Chronic pelvic pain (CPP) is defined as
nonmenstrual-related
pain below the umbilicus that has continued for more than 6 months.
Common causes of
CPP in men are similar to those in women and often include chronic (nonbacterial)
prostatitis, chronic orchalgia, and prostatodynia
Of patients who undergo exploratory laparoscopy, clinical
diagnosis findings include the following:
endometriosis accounts for one-third of patients, adhesions another third, and no pathology for the remaining third.
When assessing the pelvic pain patient, it is important to approach these patients
in a multidisciplinary fashion. Both diagnosis and management of these patients require good
integration and knowledge of all pelvic organ systems and other systems including musculoskeletal, neurologic, and psychiatric.
Gender-Specific Causes for Pelvic Pain- Women
Infection, endometriosis, dysmenorrhea (primary: menstruation, middleshmurtz;
secondary: fibroids, adenolysis, IUD), dyspareunia, mononeuropathies, myofascial
pain, vulvitis, cystitis, ovarian remnant syndrome, sympathetically mediated pain,
pelvic congestion, pelvic fibrosis, pelvis neurodystonia, pelvagia
Irritable bowel syndrome and other gastrointestinal disorders
Sexual/physical abuse
Cancer pain
Psychiatric disorders
Surgical procedures (adhesions)
Gender-Specific Causes for Pelvic Pain- Men
Prostatitis, chronic orchalgia, and prostatodynia,
interstitial cystitis, ureteral obstruction
Irritable bowel syndrome and other gastrointestinal
disorders
Sexual/physical abuse
Cancer pain
Psychiatric disorders
Surgical procedures (adhesions)
vascular hypothesis
It has been noted that pain may be related to dilated pelvic veins in which blood flow is markedly reduced. Pelvic venous incompetence is likely seen in 10% of women, and up to 60% of patients with this abnormality can develop pelvic congestion syndrome (PCS).
vascular hypothesis patients can find relief when the dilation is treated, such as with
foam sclerotherapy followed by coil embolization to within a centimeter of vein origin. Positive results
have also been documented with medroxyprogesterone
acetate 30 to 50 mg daily.
Organ-Specific Causes for Pelvic Pain
Reproductive
Vascular
Reproductive
-Visceral: uterus, ovaries, bladder, urethra,
-Somatic: skin, vulva, clitoris, vaginal canal
Adhesions, endometriosis,
salpingo-oophoritis, neoplasm
Vascular : Dilated pelvic vein/pelvic congestion theory
Organ-Specific Causes for Pelvic Pain
Musculocutaneous
Spinal
Musculocutaneous: Ligamentous structures, muscular (iliopsoas,
piriformis, quadrates lumborum, sacro-iliac
joint, obturator internus, pubococcygeus)
Skeletal (referred pain)
Myofascial syndrome
Pelvic floor muscle tension/spasm
Spinal:
Degenerative joint disease, disc herniation,
spondylosis, neoplasm of spinal cord/sacral
nerve, coccydynia, degenerative disease
Organ-Specific Causes for Pelvic Pain
Neurologic
Gastrointestinal
Neurologic: Neuralgia/cutaneous nerve entrapment
(surgical scar in the lower part of the
abdomen), iliohypogastric, ilioinguinal,
genitofemoral, lateral femoral cutaneous
nerve, shingles (herpes zoster infection),
spine-related nerve compressions
Gastrointestinal: Irritable bowel syndrome, abdominal
epilepsy, abdominal migraine, recurrent
small bowel obstruction, hernia
Organ-Specific Causes for Pelvic Pain
Urologic
Psychological
(psychosocial/
sexual)
Urologic: Bladder dysfunction, chronic (nonbacterial)
prostatitis, chronic orchalgia, and
prostatodynia
Psychological
(psychosocial/ sexual):
Anxiety, depression, somatization, physical
or sexual abuse, drug addiction, dependence,
family problems, sexual dysfunction
History Assessment
Pattern of onset Inciting event Quality (burning, aching, dull, sharp, cramping) Duration and progression of complaints Constant or intermittent nature Exacerbating factors (position, eating, urination, defecation, valsalva) Alleviating factors
History Assessment
Efficacy and toxicity of previous medications Association with menstrual cycle Incontinence Pregnancy Sexual activity Sudden weight loss or weight gain Breast or endocrinologic difficulties Family history of ovarian, uterine, or breast cancer
multidisciplinary team represents both the referral basis as well as the combined perspective
for sources of pain and
sources of treatment approaches: gynecologists, psychologists, physiotherapists, uro-gynecologists, gastrointerologists,
neurologists, psychiatrists, social workers, internal
medicine physicians, general surgeons, and pain medicine physicians are all involved in caring for these patients
The history must consist of a systematic review of systems assessments including
gastrointestinal, musculoskeletal,
vascular, genito-urinary, neurologic, and psychological
The physical examination must include
abdominal, pelvic,
musculoskeletal, neurologic, and psychiatric assessments
core component
of any physical exam, and especially important in the assessment of pelvic pain
The focused abdominal examination. Auscultation for sounds, bruits,
organomegaly, and palpations in four quadrants are all
components of an abdominal exam.
A pelvic examination
An experienced physician should
participate in a thorough examination of gynecologic,
urologic, and overall pelvic health
psychiatric assessment
A thorough psychosocial or psychosexual history is needed when organic diseases are excluded or coexisting psychiatric disorders are suggested.
Sufficient history must be obtained to evaluate depression, anxiety disorder, somatization, physical or sexual abuse, drug abuse or dependence, and family, marital, or sexual problems.
DIAGNOSTIC STUDIES
These exams include blood work, cultures, pregnancy testing, ultrasonography, x-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI), and diagnostic blocks.
Iliopsoas
Innervation: L1-L4
Referral Pattern: Lower abdomen, groin, anterior thigh, low back, and lateral trunk
Symptoms: Pain with hip extension and weight-bearing, especially at heel strike
Piriformis
Innervation: L5- S3
Referral Pattern: Buttock, pelvic floor, and low back
Symptoms: Pain on standing, walking, and sitting
Quadratus Lumborum
Innervation: T12-L3
Referral Pattern: Lower abdomen, anterior lateral trunk, anterior thigh, buttock, and sacroiliac joint
Symptoms: Pain in lateral low back with standing and walking
Sacroiliac Joint
Innervation: L4-S3
Referral Pattern: Posterior thigh buttock, pelvic floor, low back
Symptoms: Pain on standing and walking and a possible “catch” on one side with bending
Obturator Internus
Innervation: L3-S2
Referral Pattern: Pelvic floor, buttock, posterior thigh, and coccyx
Symptoms: “Pressure” in pelvic floor
Pubococcygeus
Innervation: S1-S4
Referral Pattern: Pelvic floor, vagina, rectum, buttock
Symptoms: Pain on sitting, dyspareunia
