Presentation is loading. Please wait.

Presentation is loading. Please wait.

Pelvic Pain.

Similar presentations

Presentation on theme: "Pelvic Pain."— Presentation transcript:

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

Download ppt "Pelvic Pain."

Similar presentations

Ads by Google