1. Pelvic Pain

2. Acute Pelvic Pain History
Onset of pelvic symptoms
sudden vs. gradual
associated with particular activity (sex)
unilateral or bilateral
Description of pelvic symptoms
vaginal discharge, itching, burning, odor
dyspareunia
dysuria, frequency, urgency, hematuria

3. Associated abdominal sxs
nausea/vomiting
diarrhea/constipation/dyschezia
flank pain or periumbilical pain or CVA pain
Description of pain
character
nature
location
timing
Detailed menstrual history

4. Detailed sexual history Detailed gynecologic history
history of STDs/PID
history of endometriosis
history of or current IUD use, other methods of birth control used
History of previous related surgeries or hospitalizations
Obstetric history
Thorough psychosocial history
history of depression

5. Differential Diagnosis of Acute Pelvic Pain
ovarian cyst
PID
pyelonephritis
appendicitis
ectopic pregnancy
kidney stone

6. Etiology of Dyspareunia
inflammation
anatomic abnormalities
pelvic pathology
atrophy or failure of lubrication
psychological conflicts such as domestic violence or relationship problems
vaginismus

7. Incidence of Dyspareunia
Unclear
Most common cause is vulvovaginitis - infection
One 1990 study of 313 women, over 60% had experienced dyspareunia at some point in their lives
average age in this study was early 30’s

8. Etiology of Dyspareunia
Pain on insertion
Vulvovaginitis
Atrophic vulvovaginitis
Hymenal strands
scar tissue
Recent episiotomy
vaginismus (involuntary perineal muscle contractions)
Inadequate lubrication
Vulvar vestibulitis
Pudendal neuralgia

9. Pain on deep penetration
uterine prolapse
PID
endometriosis
adhesions
pelvic masses
uterine position, especially of cervix
ovarian cysts
uterine fibroids

10. Risk Factors for Dyspareunia
Menopause
Psychological factors (including restrictive sexual attitudes)
Relationship difficulties
History of sexual abuse
History of STDs
Recurrent infection (candidiasis)
Poor hygiene

11. Dyspareunia: History
Does pain occur on intromission or on deep penetration?
Does it occur after long pain-free intervals or with first intercourse or with each intercourse ?
Does changing position decrease pain?
Vaginal discharge or irritation?
Recent surgery?

12. Recent pregnancy and childbirth?
Recent trauma?
Recent unrelated pelvic pain?
Any relationship difficulties?
Able to use tampons without difficulty?
History of difficult pelvic exams?
History of sexual abuse or trauma?
Beginning to develop menopausal symptoms?

13. Physical Exam in Dyspareunia
Vvulvar/vaginal mucosa
irritation
inflammation
lesions
discharge
atrophy
hymenal remnants
Bartholin’s cyst/abscess
vestibulitis (focal irritation/inflammation of the vestibular glands)

14. Speculum exam and/or Digital exam
involuntary contraction of the perineal muscles (vaginismus)
may prohibit exam
allow patient control during pelvic exam
Bimanual exam
uterine prolapse
pelvic mass
nodularity of endometriosis
cervical motion tenderness of PID
loss of pelvic support (cystocele, rectocele)

15. Diagnostic Tests for Dyspareunia
CBC
ESR UA
SHCG
KOH/Wet prep
Cervical cultures for GC, CT
Ultrasound
Diagnostic Laparoscopy

16. Differential Diagnosis of Dyspareunia
Organic causes
vulvovaginitis
atrophic vulvovaginitis
hymenal strands
scar tissue
episiotomy
vaginismus
leiomyoma
pelvic relaxation
PID
uterine prolapse
endometriosis
adhesions
pelvic masses
Bartholin’s cyst

17. Contributing psychological factors Inappropriate sexual technique
previous sexual trauma
conflictual relationships
stress
restrictive sexual attitudes
Inappropriate sexual technique
lack of foreplay
low estrogen in oral contraceptive

18. Treatment for Dyspareunia
Psychosocial interventions
Medications for treatable etiology
HRT
water-based lubricant
treatment of infections, endometriosis, adnexal mass, leiomyoma
Surgical intervention
Progressive dilation and muscle awareness exercise

19. Chronic Pelvic Pain Persists for longer than 6 months
Significantly impacts a woman’s daily functioning and relationships
Episodic=>cyclic, recurrent pain that is interspersed with pain-free intervals
Continuous=>non-cyclic pain
Frustrates both the patient and her clinician
Many times etiology not found or treatment of presumed etiology fails: pain becomes the illness

20. Epidemiology of Chronic Pelvic Pain
1/3 have no obvious pelvic pathology
Different theories at various times
Popular theories that lack definite diagnostic criteria
Pelvic congestion syndrome
Retro-displacement of the uterus

21. Etiologies of Chronic Pelvic Pain
Episodic
dyspareunia
midcycle pelvic pain (Mittelschmerz)
dysmenorrhea
Continuous
endometriosis
adenomyosis
chronic salpingitis
adhesions
loss of pelvic support

22. Risk Factors for Chronic Pelvic Pain
History of childhood or adult sexual abuse or trauma
Previous pelvic surgery
Personal or family history of depression
History of other chronic pain syndromes
History of alcohol and drug abuse
Sexual dysfunction
Tendency toward somatization

23. Facts about Chronic Pelvic Pain
Comprises up to 10% of outpatient gynecologic visits
Accounts for 20% of laparoscopies
Accounts for 12% of hysterectomies
Approximately 70,000 hysterectomies are performed annually due to chronic pelvic pain

24. Chronic Pelvic Pain: History
Pain duration > 6 months
Incomplete relief by most previous treatments, including surgery and non-narcotic analgesics
Significantly impaired functioning at home or work
Signs of depression such as early morning awakening, weight loss, and anorexia

25. Pain out of proportion to pathology
Altered family roles
History of childhood abuse, incest, rape or other sexual trauma
History of substance abuse
Current sexual dysfunction
Previous consultation with one or more health care providers and dissatisfaction with their management of her condition

26. Chronic Pelvic Pain: Physical Exam
Systematic physical exam of abdominal, pelvic, and rectal areas, focusing on the location and intensity of the pain
Attempt to reproduce the pain
Check vital signs: Fever=>acute process
Note general appearance, demeanor, and gait =>may suggest the severity of the pain and possible neuromuscular etiology. Vomiting=>acute process.

27. Abdominal symptoms of more acute process
rebound tenderness (peritoneal irritation)
decreased abdominal pain on palpation with tension of the rectus muscles
straight leg raise, pain on deep palpation
decrease = pelvic origin
increase = abdominal wall or myofascial origin
inspect & note any well healed scars
palpate scars for incisional hernias

28. Speculum exam Bimanual/rectal exam
palpate for femoral & inguinal hernias
palpate for any unsuspected masses
Speculum exam
cervicitis =>source of parametrial irritation
Bimanual/rectal exam
tender pelvic or adnexal mass, abnormal bleeding, tender uterine fundus, cervical motion tenderness =>acute process such as PID, ectopic pregnancy, or ruptured ovarian cyst

29. Non-mobility of uterus => presence of pelvic adhesions
existence of adnexal mass, fullness, tenderness
cul-de-sac nodularities =>endometriosis
identify any areas that reproduce deep dyspareunia
Palpate the coccyx, both internally and externally
tenderness of coccydynia

30. Diagnostic Tests and Methods for Chronic Pelvic Pain
Should be selected discriminately as indicated by the findings of the history and physical exam
Avoid unnecessary and repetitive diagnostic testing UA
sHCG
Wet prep/KOH
Cervical cultures

31. Stool guaiac-if +, refer patient for GI w/u Ultrasound
Diagnostic laparascopy
acute or chronic salpingitis
ectopic pregnancy
hydrosalpinx
endometriosis
ovarian tumors and cysts
torsion
appendicitis
adhesions

32. Differential Diagnoses of Chronic Pelvic Pain
GI conditions
irritable bowel syndrome
ulcerative colitis
diverticulosis
Urinary tract disease
Neuromuscular/musculoskeletal disorders
disc problems

33. Treatment of Chronic Pelvic Pain
Psychosocial interventions
Medications
no long-term narcotic use
NSAIDs
antidepressants
oral contraceptives

34. Dietary interventions
if patient experiences constipation, bloating, edema, excessive fatigue, irritability, or lethargy, or is overweight
anticipated outcomes
regular BMs
decreased gas, bloating, and edema
improved energy level and stability of mood
attainment and maintenance of ideal body wt
high fiber diet
less sodium, caffeine, and carbonated beverages, refined carbohydrates & sugar in diet
low-fat foods

35. Surgical interventions
diagnostic and therapeutic laparoscopy
hysterectomy
presacral neurectomy - no longer advocated

36. Alternative interventions
biofeedback
stress management techniques
self-hyponosis
relaxation therapy
transcutaneous nerve stimulation (TNS)
trigger-point injections
spinal anesthesia
nerve blocks