Columbus: chronic pelvic pain Flashcards
Define chronic pelvic pain.
Noncyclic pain of 6 or more months that localizes to the pelvis, anterior abdominal wall at or below the umbilicus, lumbosacral back or butt and is of sufficient severity to cause functional disability or lead to medical care.
What is the incidence of chronic pelvic pain?
What percentage of GYN office consults are for chronic pelvic pain?
15–20% of women 18–50 will have chronic pelvic pain greater than one years duration.
10%
What is the most common gynecologic cause of chronic pelvic pain? What is the second most common cause?
What are other gynecologic causes?
Endometriosis. Adhesions.
Pelvic congestion, PID, fibroids, adenomyosis, cervical stenosis, chronic endometritis, IUD, cancer, tuberculous salpingitis, ovulatory pain, ovarian remnant syndrome, pelvic relaxation.
What are musculoskeletal causes of chronic pelvic pain?
Myofascial pain Fibromyalgia Abdominal wall hernia Disc disease Nerve entrapment or neuropathic pain Joint disease of the back hips or pubic symphysis
What percentage of people with chronic pelvic pain have normal laparoscopy?
What are some explanations for normal appearing pelvis?
40%
Endometriosis present but not identified
Chronic pelvic infection
Pelvic congestion not identified
Non-gynecologic etiology
What are psychiatric or psychosocial causes of chronic pelvic pain?
Depression Anxiety disorder Hypochondriasis Somatization Personality disorder Abuse
What are some urinary tract related causes of chronic pelvic pain?
Interstitial cystitis Urethral syndrome Incomplete emptying UTI Urethral/bladder stones Bladder carcinoma
What are some G.I. causes of chronic pelvic pain?
Irritable bowel syndrome Chronic constipation Inflammatory bowel disease Celiac disease Diverticular disease Chronic appendicitis Bowel instruction Abdominal angina Colorectal carcinoma
What are several unusual causes of chronic pelvic pain?
Porphyria Sickle cell disease Hyperparathyroidism Heavy-metal poisoning such as lead or mercury Tabes dorsalis
What are important examination considerations for chronic pelvic pain patients?
Ambulation and posture Forward bend to assess hip and shoulder blade asymmetry Standing Valsalva exam for hernias SI joint tenderness Lower extremity strength and reflexes Single finger abdominal exam Carnette's test: supine position with head lift Pelvic exam last
What history should be emphasized for chronic pelvic pain?
Exacerbating factors
PHM: G.I., urinary history; other pain syndromes such as chronic low back pain or fibromyalgia; history of injury; depression screening
Past surgical Hx: Prior surgeries or pathology
Gyn Hx: Menstrual, dyspareunia
Social Hx: Domestic violence or sexual abuse
What percentage of women will have myofascial pain in the setting of chronic pelvic pain?
What are causes of myofascial pain?
Up to 75%
Chronic local microtrauma
Typical pelvic pain posture, leg length discrepancy, high heels, holding an infant on hip, compensating for knee and back pain, heavy lifting, new exercise
Psychosocial stress with muscle tension and pain
How can myofascial pain be treated?
Heat, NSAIDs, rest, muscle relaxants
Abdominal, back and pelvic floor physical therapy
Trigger point injections
Describe the stepwise pelvic examination in chronic pelvic pain patients.
Warn patient that exam will take 1-2 minutes longer than usual.
Do speculum exam last.
Single finger exam of: introitus, urethra/bladder, levators, lateral fornices with patient pushing in with ipsilateral knee (obturators), rectovaginal (uterosacral ligaments)
How are trigger point injections performed?
4 mL 1% lidocaine with epinephrine +1 mL Kenalog 40 mg/mL
Mark trigger point with pen
Swab skin with alcohol
Keep skin on tension and quickly insert 25 gauge at acute angle to skin with multiple passes
Re-examine the patient in 10–15 minutes
