Gynecology Book

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Chronic Pelvic Pain

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  1. See Also
    1. Pelvic Nerve Innervation
  2. Causes
    1. See Chronic Pelvic Pain Causes
  3. History
    1. Pain
      1. Localization and radiation
      2. Quality, intensity and duration
      3. Palliative and provocative factors
      4. Changes in pain over time
    2. Association:
      1. Menstrual Cycle
        1. Abnormal bleeding
        2. Menorrhagia
        3. Metrorrhagia
      2. Bowel or bladder habits
      3. Sexual intercourse
      4. Exercise
      5. Back, joint or muscle pain
    3. Previous evaluation and treatment by other providers
    4. Psychiatric History
      1. Mood changes and how quickly
      2. Physical functioning in work and activities
      3. Family Roles and Responsibilities with recent changes
      4. Sexual dysfunction
      5. Sexual abuse history
      6. Efforts to cope with pain (Relaxation or Exercise)
      7. Patient and Families' interpretation of pain
  4. Exam: General
    1. Neurologic
      1. Stance and gait
      2. Posture
      3. Sitting position
    2. Abdominal exam
      1. Musculoskeletal
        1. Focal tenderness and Trigger Points
        2. Raise head during abdominal exam
          1. Abdominal Wall Pain increases with neck flexion
      2. Post-surgical neuromas
        1. Entrapment in Suture with lateral Pfannenstiel
          1. Ilioinguinal Nerve
          2. Iliohypogastric Nerve
      3. Hernia
        1. Umbilical Hernia
        2. Inguinal Hernia
        3. Incisional Hernia
        4. Femoral Hernia
          1. Femoral canal
        5. Spigelian Hernia
          1. Lateral margin of rectus
      4. Meralgia Paresthetica
        1. Dysesthesia in lateral femoral cutaneous
        2. Lateral thigh to knee
        3. Causes: Obesity and local trauma
      5. Psoas muscle
        1. Adnexal changes and bowel adhesions
        2. Patient lies in lateral decubitus position
          1. Pain on hip extension suggests psoas inflammation
      6. Piriformis Syndrome
        1. Pain on Internal rotation of hip against resistance
        2. Associated with Fibromyalgia
  5. Exam: Pelvic Exam
    1. Vulvitis
    2. Vestibulitis provocative factors
      1. Touch with cotton tip
      2. Acetic acid
    3. Cervicitis
    4. Digital vaginal exam with 1 finger
      1. Patient contracts and relaxes intermittently
      2. Same type of pain as with intercourse?
      3. Press at pelvic floor (levator plate palpation)
        1. Pelvic floor tension myalgia increases during day
      4. Press at anterior wall
        1. Palpation of urethra and bladder trigone
        2. Chronic urethritis or trigonitis
          1. Frequency, urgency, Dysuria without bacteruria
      5. Cul-de-sac palpation
      6. Cervical Motion Tenderness
        1. Mild
          1. Endometriosis
          2. Adhesions
        2. Severe
          1. Pelvic Inflammatory Disease (PID)
      7. Retroverted Uterus associated conditions
        1. Endometriosis
        2. Pelvic adhesions
        3. Low Back Pain at menstruation
        4. Dyspareunia
        5. Pain elicited with palpation of fundus
      8. Ovarian pain (difficult to localize)
    5. Repeat vaginal exam with rectovaginal exam
    6. Pelvic Relaxation
      1. General symptoms
        1. Vague pelvic ache
        2. Sensation of pressure or Something falling out
      2. Causes
        1. Uterine Prolapse
        2. Cystocele
        3. Enterocele
        4. Rectocele
  6. Imaging and Diagnostic Testing
    1. Pelvic Ultrasound
    2. Pelvic CT or Pelvic MRI
      1. Limited usefulness
    3. Endoscopic studies sometimes helpful
      1. Cystoscopy
      2. Colonoscopy
      3. Laparoscopy
  7. References
    1. Steege (1993) Chronic Pelvic Pain ACOG Video

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