Pelvic Pain

Anna Mae Smith, MPAS, PA-C

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
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

ovarian cyst PID pyelonephritis appendicitis ectopic pregnancy kidney stone

Etiology of Dyspareunia
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 30s

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

 Pain on deep penetration

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?

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
irritation inflammation lesions discharge atrophy
hymenal remnants

Bartholins 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
uterine prolapse pelvic mass nodularity of endometriosis cervical motion tenderness of PID loss of pelvic support (cystocele, rectocele)

Diagnostic Tests for Dyspareunia

CBC ESR UA SHCG KOH/Wet prep Cervical cultures for GC, CT Ultrasound Diagnostic Laparoscopy

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 Bartholins 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 womans 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
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 =>may suggest the severity of the pain and 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

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
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
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
biofeedback stress management techniques self-hyponosis relaxation therapy transcutaneous nerve stimulation (TNS) trigger-point injections spinal anesthesia nerve blocks