1. PELVIC PAIN

2. INTRODUCTION
Pelvic pain encompasses a large proportion of gynecologic complaints.
Amongst the most challenging problems.
Grouped into: acute pain
cyclic pain
chronic pain

3. ACUTE PELVIC PAIN
Definition: intense, sudden onset, sharp rise and short course.
Pathology: viscera are relatively insensitive to pain.
First perception – a vague, deep, poorly localized sensation with corresponding autonomic reflex responses.
Referred pain – more localized and relates to nerve distribution or dermatome of the spinal cord segment innervating the involved viscus.

4. DIFFERENTIAL DIAGNOSIS
Pregnancy-associated: ectopic, miscarriage
Gynae: endometriosis, dysmenorrhoea, saplingitis, ovarian torsion, rupture, haemorrhage
Non gynae: GIT, UTI, musculoskeletal

5. DIAGNOSIS EARLY DIAGNOSIS IS CRITICAL!!
History: LNM x2, AUB, discharge, sexually active, contraception, previous STDs, pain, medical, surgical, GIT Sx, UT Sx.
General and gynecological examination.
Special investigations: FBC + diff, ESR, bHCG, U-mcs, pelvic ultrasound, AXR.

6. MANAGEMENT
According to the diagnosis.

7. CHRONIC PELVIC PAIN

8. INTRODUCTION Frequently depressed and anxious.
Marital, social and occupational lives are disrupted.
Approximately 12% will opt for hysterectomies.
30% already have had a hysterectomy.
60-80% of L/scope no intraperitoneal pathology!!

9. DEFINITION
Continuous or episodic non-cyclic ( non-menstrual) pain, that is located in the pelvis and/or lower abdomen and has persisted for at least 6 months and is severe enough to affect a woman’s daily function.

10. DIFFERENTIAL DIAGNOSIS Gynae Non-gynae Psycosocial
GIT, UTI, musculoskeletal
Psycosocial

11. MANAGEMENT
HISTORY
PAIN: nature, location, radiation, severity, aggravating and alleviating factors, effect of menstruation, stress, work, exercise, intercourse, social and occupational toll of the pain.
GYNAE: AUB, discharge, infertility, SEXUAL ABUSE.
ENTEROCOLIC: constipation, bowel movement.

12. 4. MUSCULOSKELETAL: trauma, postural change 5
4. MUSCULOSKELETAL: trauma, postural change 5. UROLOGY: urgency, frequency, nocturia, incontinence, hematuria. 6. MEDICAL: porphyria 7. SURGICAL 8. Other somatic symptoms. 9. Past psychological history!

13. EXAMINATION Complete examination should be performed
EXAMINATION Complete examination should be performed. Particular attention to abdomen,lumbosacral area and complete gynae examination. 1. Abdominal: evaluation of abdomen with tensed muscles (head raised) to differentiate between abdominal wall pain and visceral pain. Standing!! Palpating – begin with 1 finger, then deep.

14. 2. Pelvic examination: Speculum Bi-manual – vaginisms, levator ani spasms, piriformis spasms. Bladder Rectum

15. SPECIAL INVESTIGATIONS Laboratory – FBC + diff, ESR, porphyria, Urine – mcs, Stool – occult blood, alb, mcs Ultrasound XR – Ba-enema, IVP Diagnostic L/scopy Psychological evaluation

16. TREATMENT Treat the abnormality. Medical / surgical
NO APPARENT PATHOLOGY
multidisciplinary therapy include the gynecologist, psychologist and anesthesiologist.
This approach is very effective – 85% relief of pain.

17. START – trail of OC and NSAIDs – THEN
multidisciplinary team.
Surgical – L/scopy – diagnostic/surgery.
hysterectomy, pre-sacral neurectomy.

18. IMPORTANT POSITIVE ATTITUDE DETECT PSYCOLOGICAL FACTORS
TREAT ABNORMALITIES
TREAT PAIN IMMEDIATELY AND CONTINUALLY
MULTIDISCIPLINARY