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Pelvic Pain. Acute Pelvic Pain History Onset of pelvic symptoms –sudden vs. gradual –associated with particular activity (sex) –unilateral or bilateral.

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Presentation on theme: "Pelvic Pain. Acute Pelvic Pain History Onset of pelvic symptoms –sudden vs. gradual –associated with particular activity (sex) –unilateral or bilateral."— 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 –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 –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

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