Pelvic Pain

Question 1

Abdominal & Pelvic Pain:

Answer 1

Common reason for seeking gynecological care.

Pain → impacts a woman’s quality of life.
Fatigue.
Tension.
Depression.

Question 2

pelvic pain

Answer 2

Many women reluctant to discuss the effect chronic pelvic pain is having on their lives:
Previous providers may have overtly or inadvertently discounted her pain.
Historically, women have been told that many gynecological problems were “all in her head”.
May be angry & frustrated → may have been seen by many providers for evaluation of pelvic pain.

Question 3

Pelvic pain can trigger many emotions centered on:

Answer 3

Sense of self as a woman.
Ability to conceive and bear children.
Feelings pertaining to sexuality.

Question 4

Very distressing to the patient experiencing pelvic pain:

Answer 4

Can usually not be resolved immediately.
Often requires extensive & increasingly invasive diagnostic testing.
After extensive testing – may come up with no physiological cause of pain.

Question 5

Clinical challenge:

Answer 5

Can be difficult to diagnose & treat.
Can be acute or chronic; may have acute pain along with chronic pain.
Very little research has been done on causes & treatment of chronic pelvic pain.

Question 6

Assessment of Pelvic Pain:

Acute pain:

Answer 6

Must be able to recognize & appropriately evaluate a potential emergency.
May require immediate MD referral.

Question 7

Assessment of Pelvic Pain:

Acute Pelvic Pain

Answer 7

Pain that has been present for hours or days.
Almost always has a direct cause.
Assess for causative factor & treat/refer appropriately

Question 8

Causes of Acute Pelvic Pain

More Common

Answer 8

Ectopic pregnancy
Spontaneous, incomplete, or threatened abortion.
Adenexal mass or cyst.
Pelvic inflammatory disease.
Appendicitis.
Urinary tract infection.

Question 9

Causes of Acute Pelvic Pain

Less Common

Answer 9

Degenerating fibroid.
Ureteral obstruction.
Intestinal obstruction.
Diverticulitis

Question 10

Chronic Pelvic Pain

Answer 10

Recurrent pelvic discomfort.
Characterized by pelvic pain present for at least 6 months:
Can be a specific diagnosis.
Can have no evidence of organic cause after thorough evaluation, including laparoscopy.
Multifactorial
May need multi-modal therapy

Question 11

Chronic pain:

Answer 11

Many visits may be needed to adequately assess pain.
Must recognize both the physical & psychological realities of woman experiencing pain:
Each woman has her own reference point for what is normal.
The cause of her pain may have both a physical and a psychological component :
Cause may be elusive & not lend itself to a simple explanation or solution.

Question 12

Causes of Chronic Pelvic Pain

Gynecologic Disorders

Answer 12

Primary dysmenorrhea.
Endometriosis.
Adenomyosis.
Adhesions.
Fibroids.
Retained ovary syndrome post hysterectomy.
Previous tubal ligation.
Chronic pelvic infection.

Question 13

Causes of Chronic Pelvic Pain

Musculoskeletal disorders

Answer 13

Myofascial pain syndrome

Question 14

Causes of Chronic Pelvic Pain GI disorders

Answer 14

Irritable bowel syndrome.

Inflammatory bowel disease.

Question 15

Causes of Chronic Pelvic Pain Urinary Tract disorders

Answer 15

Interstitial cystitis.

Nonbacterial urethritis.

Question 16

pelvic pain

differential dx- chronic pain

Answer 16

Dysmenorrhea.
Endometriosis.
Adenomyosis:
Endometrial tissue ectopically located within the myometrium.
Fairly common, occurs in over 50% or uteruses but is often asymptomatic.

Question 17

pelvic pain

differential dx- chronic pain

Answer 17

Adhesions:
May cause pelvic pain by producing abnormal adherence between adjacent organs.
More common when there has been prior pelvic infection or surgery.
Treatment – laparoscopic lysis of adhesions has been reported to reduce symptoms 40-75%.
Fibroids.

Question 18

Pelvic Pain After Pelvic Surgery:

Answer 18

Pelvic Pain After Pelvic Surgery:
“Retained ovary syndrome” – after hysterectomy; possible causes:
Pelvic adhesions, follicular cysts, hemorrhagic corpus luteum cysts.
Incidence is unknown.
Oophorectomy – only known treatment.

Question 19

pelvic pain

post tubal ligation

Answer 19

Small # women report chronic pelvic pain after procedure.
Mechanism unclear.
Possible causes:
Torsion of the ovary.
Ovarian ischemia.

Question 20

Pelvic Congestion

Answer 20

Controversial cause of pelvic pain.

Pelvic congestion – related to pelvic venous varicosities

Question 21

Psychosocial Factors – Chronic Pelvic Pain

Women with chronic pelvic pain:

Answer 21

Prevalence of childhood sexual abuse – 20-60%.
Prevalence of childhood physical abuse - @ 40%.
Tend to have a higher number of sexual partners.
May be at higher risk for depression.
May be at higher risk for somatization disorder.

Question 22

Management of Chronic Pelvic Pain

Subjective Data

Answer 22

History of present illness → ‘old cart’ system:
Onset.
Location.
Duration.
Character.
Aggravating factors.
Relieving factors.
Treatment used.

Question 23

Obtain thorough history → include psychosocial hx.

Answer 23

Effects on quality of life.
Daily activities – work, school, sexual activity.
Relationships with family, friends, coworkers.
Negative effects on emotional well-being?
Ability to follow through on course of treatment.

Question 24

Pelvic Pain Assessment Form

Answer 24

– available online from The International Pelvic Pain Society.

www.pelvicpain.org

Question 25

Objective Data

Answer 25

Chronic pain:
In absence of acute pain, thorough examination should be performed.
Observe woman’s demeanor – relaxed? Tense?
Posture – asymmetrical? Could indicate the guarding of an area or long-term discomfort.
Vital signs – may be helpful in assessing for an underlying condition related to pain.

Question 26

Objective Data

Answer 26

Evaluation of back & lower extremities – r/o musculoskeletal injury – muscle strain or stress fracture.
Abdominal examination:
Palpation
Can pain can be reproduced?
Palpate for organ enlargement or displacement, or to identify a mass or enlarged lymph nodes.
Note areas of tenderness or guarding.

Question 27

Pelvic examination:

Answer 27

Ability to perform a thorough exam can be severely limited by inordinate discomfort on the part of the woman.
Visual inspection – check for any signs of swelling, lesions, trauma or other skin changes.

Question 28

Speculum exam:

Answer 28

Observe woman’s tolerance of the insertion of the speculum – especially if she reports pain with sexual activity.
Check for presence of abnormal vaginal secretions.
Visually inspect cervix – may see protruding IUD, color change indicative of pregnancy, or presence of a polyp or other mass.

Question 29

Bimanual exam:

Answer 29

Note if discomfort at introitus or deep in vagina.
Note any cervical, adnexal, or uterine motion tenderness.
Palpate for organ dislocation or the inability to completely palpate the uterus or adnexa.
Palpate for any masses, uterine fibroids, or uterine or adnexal enlargement indicative of pregnancy.
Note vaginal muscle tone & presence of any uterine prolapse, cystocele, or rectocele.
Confirm any findings with a rectal exam & check for constipation, polyps, or masses.

Question 30

Pelvic exam

Answer 30

Palpate for any masses, uterine fibroids, or uterine or adnexal enlargement indicative of pregnancy.
Palpate for any masses, uterine fibroids, or uterine or adnexal enlargement indicative of pregnancy.
Note vaginal muscle tone & presence of any uterine prolapse, cystocele, or rectocele.
Confirm any findings with a rectal exam & check for constipation, polyps, or masses.
Note vaginal muscle tone & presence of any uterine prolapse, cystocele, or rectocele.
Confirm any findings with a rectal exam & check for constipation, polyps, or masses.

Question 31

Laboratory/Screening/Diagnostic Tests: (avoid random testing)

Answer 31

Pregnancy test.
CBC – in the absence of infectious process or concerns about anemia a CBC may not be particularly useful.
U/A or urine C&S.
Fecal occult blood test – may aid in management of an abdominal mass.
STD screening, wet mount for vaginitis.
Pelvic or abdominal ultrasound.
Transvaginal ultrasound more exact in assessment of pelvic structures.

Question 32

Management of Chronic Pelvic Pain

Answer 32

Multidisciplinary approach is most effective with attention being paid to the following areas:
Somatic symptoms.
Psychological status.
Nutritional status.
Environmental factors.
Physical exam findings.

Question 33

Medical therapy may be necessary to relieve pain.

Answer 33

NSAID’s, OC’s.
Narcotics generally not used due to high risk of developing dependency.
Research – use of antidepressants as a means of therapy.

Question 34

Surgical treatment

Answer 34

Hysterectomy with or without bilateral salpingoophorectomy.

5-20% women with idiopathic chronic pelvic pain report persistent pain for more than a year after surgery.