Transcript Pelvic Pain.pps

Pelvic Pain
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
• Associated abdominal sxs
– nausea/vomiting
– diarrhea/constipation/dyschezia
– flank pain or periumbilical pain or CVA pain
• Description of pain
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character
nature
location
timing
• Detailed menstrual history
• 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
Differential Diagnosis of
Acute Pelvic Pain
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ovarian cyst
PID
pyelonephritis
appendicitis
ectopic pregnancy
kidney stone
Etiology of Dyspareunia
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inflammation
anatomic abnormalities
pelvic pathology
atrophy or failure of lubrication
psychological conflicts such as domestic
violence or relationship problems
– vaginismus
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
Etiology of Dyspareunia
• Pain on insertion
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Vulvovaginitis
Atrophic vulvovaginitis
Hymenal strands
scar tissue
Recent episiotomy
vaginismus (involuntary perineal muscle contractions)
Inadequate lubrication
Vulvar vestibulitis
Pudendal neuralgia
• Pain on deep penetration
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uterine prolapse
PID
endometriosis
adhesions
pelvic masses
uterine position, especially of cervix
ovarian cysts
uterine fibroids
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
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?
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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?
Physical Exam in Dyspareunia
• Vvulvar/vaginal mucosa
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irritation
inflammation
lesions
discharge
atrophy
• hymenal remnants
– Bartholin’s cyst/abscess
– vestibulitis (focal irritation/inflammation of the
vestibular glands)
• Speculum exam and/or Digital exam
– involuntary contraction of the perineal muscles
(vaginismus)
– may prohibit exam
– allow patient control during pelvic exam
• Bimanual exam
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uterine prolapse
pelvic mass
nodularity of endometriosis
cervical motion tenderness of PID
loss of pelvic support (cystocele, rectocele)
Diagnostic Tests for Dyspareunia
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CBC
ESR
UA
SHCG
KOH/Wet prep
Cervical cultures for GC, CT
Ultrasound
Diagnostic Laparoscopy
Differential Diagnosis of
Dyspareunia
• Organic causes
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vulvovaginitis
atrophic vulvovaginitis
hymenal strands
scar tissue
episiotomy
vaginismus
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leiomyoma
pelvic relaxation
PID
uterine prolapse
endometriosis
adhesions
pelvic masses
Bartholin’s cyst
• Inappropriate sexual
• Contributing
technique
psychological factors
– previous sexual trauma
– conflictual
relationships
– stress
– restrictive sexual
attitudes
– lack of foreplay
– low estrogen in oral
contraceptive
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
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
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
Etiologies of Chronic Pelvic Pain
• Episodic
– dyspareunia
– midcycle pelvic pain (Mittelschmerz)
– dysmenorrhea
• Continuous
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endometriosis
adenomyosis
chronic salpingitis
adhesions
loss of pelvic support
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
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
Chronic Pelvic Pain: History
• Pain duration > 6 months
• Incomplete relief by most previous
treatments, including surgery and nonnarcotic analgesics
• Significantly impaired functioning at home
or work
• Signs of depression such as early morning
awakening, weight loss, and anorexia
• 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
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
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possible neuromuscular etiology. Vomiting=>acute
process.
• 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
– 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
– 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
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
• Stool guaiac-if +, refer patient for GI w/u
• Ultrasound
• Diagnostic laparascopy
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acute or chronic salpingitis
ectopic pregnancy
hydrosalpinx
endometriosis
ovarian tumors and cysts
torsion
appendicitis
adhesions
Differential Diagnoses of
Chronic Pelvic Pain
• GI conditions
– irritable bowel syndrome
– ulcerative colitis
– diverticulosis
• Urinary tract disease
• Neuromuscular/musculoskeletal disorders
– disc problems
Treatment of Chronic Pelvic Pain
• Psychosocial interventions
• Medications
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no long-term narcotic use
NSAIDs
antidepressants
oral contraceptives
• Dietary interventions
– if patient experiences constipation, bloating,
edema, excessive fatigue, irritability, or
lethargy, or is overweight
– anticipated outcomes
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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
• Surgical interventions
– diagnostic and therapeutic laparoscopy
– hysterectomy
– presacral neurectomy - no longer advocated
• Alternative interventions
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biofeedback
stress management techniques
self-hyponosis
relaxation therapy
transcutaneous nerve stimulation (TNS)
trigger-point injections
spinal anesthesia
nerve blocks