Chronic Pelvic Pain

Question 1

Chronic Pelvic pain scope

Answer 1

No pathology 39%
Endometriosis 28%
Adhesions  25%
Chronic PID  6%
Ovarian cyst 3%
Leiomyomata <1%
Pelvic varicosities <1%
Other  4%

Make sure to ask about bladder symptoms, GI symptoms, and Psych (including sexual abuse)

in scope place pt in reverse Trendelenburg for several minutes
during laparoscopy to aid in diagnosis, especially
if remainder of pelvis negative

Question 2

Carnet test

Answer 2

find point of maximal pain and press while pt is sitting up. If it get’s worse it is muscle and if it get’s better it is visceral

Question 3

Testing the obturators

Answer 3

Lateral fornices with patient pressing ipsilateral
knee in against resistance to your arm (uses
obturators and often reproduces exquisite pain for
patient, you may also be able to palpate spasticity,
trigger point)

Question 4

IC Treatment

Answer 4

 Dietary modification
 Bladder retraining
 Physical therapy
 Biofeedback
 Electrical stimulation
 Acupuncture
 Hydrodistension

IC: Pharmacologic Treatments
 Intravesical (bladder instillations)
– Pre-compounded kits with alkalinized lidocaine with
heparin and catheters for office of self-admin
available. Consider 9 treatments in first 6-8 weeks

 Oral (single or compound treatment as needed)
– Hydroxyzine 10-25 mg nightly (especially if
concomitant seasonal/environmental/food allergies)
– Amitriptyline 10-25 mg nightly (increase pain
threshold, aid sleep, elevate mood)
– Pentosan polysulfate sodium (Elmiron) 100 mg
tid(40-60% with moderate or better improvement
with prolonged use)
– Phenazopyridine as urinary analgesic prn

Question 5

IC diagnosis

Answer 5

 Pelvic pain and urgency/frequency (PUF) questionnaire (score >10
typical of IC)
 UA with microscopy/urine culture (sterile pyuria,
 Cystoscopy with hydrodistension

Or improvement with instillation

Question 6

What percent of chronic pelvic pain is IBS

Answer 6

up to 35%

Question 7

Non surgical treatments for Chronic pelvic pain

Answer 7

Empiric GnRH agonist therapy
 Abdominal or vaginal trigger point injections
 Progestin treatment for pelvic congestion syndrome
 Antidepressants
 Complementary/alternative therapies (acupuncture,
magnets to abdominal trigger points) with limited data
showing improvement

Gabapentin

Question 8

Surgical treatments for chronic pelvic pain

Answer 8

Sacral nerve stimulation
 Hysterectomy +/- BSO

no adhesiolysis except for dense adhesion

Question 9

Dysmenorrhea/Dsyperunia DDX

Answer 9

Primary dysmenorrhea
Endometriosis
Leiomyomata
Adenomyosis
Depression
Substance abuse
Intimate partner abuse