Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Gynecologic
Endometriosis
Adhesions
Chronic PID
Ovarian remnant syndrome
Pelvic congestion syndrome
Recurrent hemorrhagic ovarian cysts
Myomata uteri (degenerating)
Uterine retroversion
Adenomyosis
Pelvic floor and hip muscle pain
Visceral hyperalgesia
Etiology: Non-Gynecologic
Genitourinary
Urinary retention
Urethral syndrome
Interstitial cystitis
Gastrointestinal
Penetrating neoplasms
Irritable bowel syndrome
Irritable bowel disease
Partial small bowel obstruction
Diverticulitis
Hernia
Etiology: Non-Gynecologic
Neuromuscular
Nerve entrapment syndrome
Generalized myofascial pain syndrome
Fibromyalgia
Psychological
Depression
PTSD (history of abuse/trauma)
Anxiety disorders
Personality disorder
Symptoms
Dysmenorrhea
Pain lasting > 6 months
Impaired lifestyle
Dyspareunia
Pain during daily activities
Patient Evaluation: History
Psychological Evaluation
Use good clinical judgment in deciding when/if to ask about
this!
History of traumatic event
History of abuse (emotional/physical/sexual)
Depression
Anxiety
Hypochondriasis
Secondary gain
Therapy/counseling about these events?
How much do they enter the patient’s thoughts on a daily
basis?
Physical exam
• Observe patient’s mobility as she gets up on
the table.
• Palpate the entire back, but especially the
paraspinous and SI joint areas
– Referred pain?
• Then palpate abdomen
Patient Evaluation: Physical Exam
Abdominal exam
Listen for bowel sounds
Ask patient to point to exact location of pain, radiation, and
grade its severity (scale of 0 to 10)
Ask the patient to map and demonstrate her tender area(s)
by palpating with and without abdominal wall flexion
Palpate entire abdomen with a single digit, with and w/o
abdominal wall flexion (Carnett sign)
Palpate from least painful area to most painful area
Referred pain?
Patient Evaluation: Physical Exam
Pelvic Exam
Fixed retroverted uterus & uterosacral tenderness/nodularity
Endometriosis
Bilateral, tender, irregularly enlarged adnexal structures
Chronic salpingitis (PID)
Enlarged, tender, boggy uterus
Don’t forget the recto-vaginal examination!
Especially when history includes central pain, dyschezia, or
dyspareunia.
To eliminate the recto-vaginal exam in such cases is malpractice.
Patient Evaluation: Further Studies
Laboratory
Complete blood count (CBC)
Erythrocyte sedimentation rate (ESR) - nonspecific
Urinalysis (UA)
Urine pregnancy test (UPT)
Gonorrhea/Chlamydia
Testing
Transvaginal ultrasound (adnexal mass, uterine irregularity)
Abdominal and pelvic CT (bowel or urinary signs)
Diagnostic laparoscopy
Ultimate method of diagnosis for CPP of undetermined etiology
Patient Evaluation: Further Studies
Pharmacologic therapies:
Initial trial of hormonal manipulation
Cyclic therapy/regulation of menses
Suppress ovulation (OCP, DMPA and GnRH)
Suppress menses (DMPA, high dose intrauterine progestins)
NSAIDS
Analgesics
Nonnarcotic (ASA, Acetominophen)
Narcotic – use cautiously (tolerance, dependence)
SSRI’s or SNRI’s
TCA’s, anti-epileptics
Especially for pain with neuropathic components
Management
Surgical therapies:
Guarded prognosis in patients with multiple pain syndromes
Degree of relief has uncertain relationship to amount of
pathology; most can be done laparoscopically
Unilateral adnexectomy
Hysterectomy + BSO
Presacral neurectomy
Uterine suspension
Lysis of adhesions
Resection/ablation of endometriosis
Anesthesia:
Acupuncture
Nerve blocks
Trigger point injections
Bottom Line Concepts
Chronic pelvic pain is pelvic pain of more than 6 months duration that
has a significant effect on daily function and quality of life.
It affects 15-24% of American women in varying degrees of severity and
accounts for a large portion of office visit and time.
Chronic pelvic pain is caused by a variety of factors including
gynecologic, genitourinary, gastrointestinal, neuromuscular, and
psychological.
Diagnostic laparoscopy is the ultimate method of diagnosis for patients
with chronic pelvic pain of undetermined etiology.
Multidisciplinary approach has been shown to be more effective than
pharmacologic or surgical therapy alone.
Even when etiology is determined, chronic pelvic pain can be difficult
to treat and patients need to be seen regularly and provided much
support.
References and Resources
APGO, Chronic Pelvic Pain: An Integrated Approach. APGO Educational Series
on Women’s Heath Issues, APGO, Washington, DC, January 2000.
APGO Medical Student Educational Objectives, 9th edition, (2009), Educational
Topic 39 (p82-83).
Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB
Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas
W Laube, Roger P Smith. Chapter 30 (p279-282).
Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology,
5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel.
Chapter 21 (p259-264).
Katz: Comprehensive Gynecology, 5th edition, (2007), Vern Katz, Gretchen
Lentz, Rogerio Lobo, David Gershenson. Chapter 8.