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Chronic Pelvic Pain
Aka: Chronic Pelvic Pain
- See Also
- Chronic Pelvic Pain Causes
- Suprapubic Abdominal Pain
- Acute Pelvic Pain
- Acute Abdominal Pain
- Chronic Pelvic Pain in Men
- Pelvic Nerve Innervation
- Epidemiology
- Prevalence: 3-4% in U.K. studies up to 15% in U.S. studies
- Zondervan (1999) Br J Obstet Gynaecol 106(11):1149-55
- Mathias (1996) Obstet Gynecol 87(3): 321-7
- Causes
- Idiopathic in up to 60% of cases
- See Chronic Pelvic Pain Causes
- See Acute Pelvic Pain Causes
- See Acute Abdominal Pain Causes
- Definition
- Noncyclic pain for at least 6 months
- Severe enough to cause functional Disability
- Localized to Pelvis, sub-umbilical anterior abdominal wall or buttocks
- Symptoms: Red Flags
- Unexplained weight loss
- Hematochezia
- Perimenopausal or Postmenopausal irregular bleeding
- Postcoital bleeding
- History
- Pain History
- Localization and radiation
- Quality, intensity and duration
- Palliative and provocative factors
- Changes in pain over time
- Associated Symptoms
- Menstrual Cycle
- Abnormal bleeding (Menorrhagia, Metrorrhagia)
- Painful Menses (Dysmenorrhea)
- Altered bowel habits (Constipation, Diarrhea)
- Altered Bladder habits (Dysuria, urinary urgency, urinary frequency)
- Sexual intercourse (Dyspareunia)
- Exercise (e.g. Abdominal Wall Pain)
- Back, joint or muscle pain (myofascial pain)
- Pelvic adhesion risks
- Pelvic surgery
- Pelvic infection
- Intrauterine Device usage
- Previous evaluation and treatment by other providers
- Psychiatric History
- Mood changes and how quickly
- Physical functioning in work and activities
- Family Roles and Responsibilities with recent changes
- Sexual dysfunction
- Sexual abuse or physical abuse history (commonly associated)
- Efforts to cope with pain (Relaxation or Exercise)
- Patient and Families' interpretation of pain
- Exam: General
- Neurologic
- Stance and gait
- Posture
- Sitting position
- Abdominal exam
- Palpate anterior wall for nodularity or point tenderness
- Palpation of Urethra and Bladder trigone
- Chronic Urethritis or trigonitis
- Frequency, urgency, Dysuria without bacteruria
- Musculoskeletal
- Focal tenderness and Trigger Points
- Carnett's Sign Positive
- Post-surgical neuromas
- Entrapment in Suture with lateral Pfannenstiel
- Ilioinguinal Nerve
- Iliohypogastric Nerve
- Hernia
- Umbilical Hernia
- Inguinal Hernia
- Incisional Hernia
- Femoral Hernia
- Spigelian Hernia (Lateral margin of rectus)
- Meralgia Paresthetica
- Piriformis Syndrome
- Psoas inflammation from pelvic inflammation
- See Psoas Sign
- Exam: Pelvic Exam
- Vulvitis and vestibulitis provocative factors
- Touch vulva and distal vagina with moistened cotton tip swab
- Acetic acid
- Digital vaginal exam with 1 finger
- Patient contracts and relaxes intermittently
- Same type of pain as with intercourse?
- Press at pelvic floor (levator plate palpation)
- Pelvic floor tension myalgia increases during day
- Bimanual Exam
- Cul-de-sac palpation for nodularity or masses
- Cervical Motion Tenderness for Cervicitis
- Mild
- Endometriosis
- Adhesions
- Severe
- Pelvic Inflammatory Disease (PID)
- Retroverted Uterus associated conditions
- Endometriosis
- Pelvic adhesions
- Low Back Pain at menstruation
- Dyspareunia
- Pain elicited with palpation of fundus
- Ovarian pain (difficult to localize)
- Rectovaginal exam
- Evaluate for nodularity, posterior uterine masses, pelvic floor tenderness
- Signs of Pelvic Relaxation
- Organ prolapse (e.g. Cystocele, Uterocele, Rectocele)
- Labs
- Urine Pregnancy Test (bHCG)
- Urinalysis and Urine Culture
- Erythrocyte Sedimentation Rate
- Chlamydia Test
- Gonorrhea Test
- Imaging
- First-line: Pelvic Ultrasound
- Second-line tests: Pelvic CT or Pelvic MRI (Limited usefulness)
- Diagnostics
- Endoscopic studies may be useful in some cases
- Cystoscopy
- Colonoscopy
- Laparoscopy
- Endometriosis
- Lysis of adhesions
- Management
- See Chronic Pelvic Pain Management
- References
- Steege (1993) Chronic Pelvic Pain ACOG Video
- Howard (2003) Obstet Gynecol 101:594-611
- Ortiz (2008) Am Fam Physician 77:1535-42
- Zondervan (2001) Am J Obstet Gynecol 184:1149-55