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4: General Gynecology
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What information should be gathered when taking the history of the patient s pain A thorough review of systems should be performed with emphasis on urinary tract disease, bowel disease, reproductive tract disease, musculoskeletal disorders, and psychoneurologic disorders Location, intensity, quality, duration, temporal pattern, precipitating patterns (exertion, sexual activity, menses, pregnancy), radiation, and relationship to urination and defecation Somatic pain is usually localized and sharp, indicating a musculoskeletal origin Visceral pain is usually vague, aching, and difficult to localize; this may indicate an intraperitoneal or upper reproductive tract etiology What should be looked for on physical examination The physical exammination should concentrate on looking for points of localized or generalized tenderness, surgical scars, masses, and hernias The pelvic examination should focus on identifying physical findings consistent with pelvic floor dysfunction, painful bladder syndrome, endometriosis, adenomyosis, or leiomyomat Endometriosis: uterosacral ligament nodularity or thickness, cervical stenosis, lateral displacement of the cervix because of shortening of one of the ligaments Adenomyosis: slightly enlarged, globular, tender uterus on examination Leiomyomat: enlarged, mobile uterus with an irregular contour on bimanual or abdominal examination Pelvic inflammatory disease (PID): uterine tenderness or cervical motion tenderness on examination
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What characteristics of the pain should be investigated as part of the detailed history
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How do the nature and the quality of pain give a clue to the source of the pain
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What are the physical findings that suggest the following etiologies of chronic pelvic pain
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Section II: Topics in Gynecology
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Neuropathy: burning, shock-like, paresthesia, and dysesthesia Neoplasm: adnexal mass, ascites What is Carnett s sign It refers to increased local tenderness during muscle tensing by raising both legs straight up while lying supine This maneuver tightens the rectus abdominis muscles, increasing pain if there is myofascial pain (eg, trigger points, entrapped nerve, hernia, myositis), while true visceral sources of pain are associated with less tenderness when abdominal muscles are tensed Complete blood count (CBC) with differential and ESR Pregnancy test Urinalysis Occult blood test Pelvic ultrasound Chlamydia and gonorrhea infection CA-125 When should MRI or CT scan be used What is the role of laparoscopy in evaluation of women with chronic pelvic pain Only when abnormalities are found on ultrasound examination It is indicated in women who have symptoms and signs of endometriosis and/or adhesions It is also indicated in women with chronic pelvic pain who have not had relief of symptoms with nonsteroidal antiinflammatory drugs (NSAIDs) or estrogen-progestin treatment and have no strong contraindications to laparoscopic surgery It refers to laparoscopy performed under local anesthesia in which the tissues are probed and pulled with surgical instruments while the patient is asked about the severity and nature of any pain she perceives It can lead to the treatment of subtle or atypical areas of disease that might have been previously overlooked It may also help prevent surgical treatment when no painful lesions are identified
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Which laboratory and imaging tests should be ordered in a patient with chronic pelvic pain
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4: General Gynecology
Treatment
How is endometriosis-associated chronic pelvic pain treated Empirical sequential treatment with nonsteroidal anti-inflammatory drugs, oral contraceptives administered in monthly or longer cycles, GnRH agonist analogues (nafarelin, goserelin, and leuprolide), progestins (medroxy-progesterone acetate) Irritable bowel syndrome, pelvic congestion syndrome, and interstitial cystitis also respond to GnRH agonists To decrease pain from primary dysmenorrhea Currently, evidence is insufficient to substantiate efficacy of antidepressants for the treatment of chronic pelvic pain However, adding psychotherapy to medical treatment of chronic pelvic pain appears to improve response over that of medical treatment alone and should be considered Excision or destruction of endometriotic tissue, lysis of adhesions, and hysterectomy (in women who have finished childbearing) have been proposed to relieve chronic pelvic pain It is the surgical resection of the superior hypogastric plexus which innervates the cervix, uterus, and proximal fallopian tubes with afferent nociception It may be used to treat centrally located dysmenorrhea but has limited efficacy for chronic pelvic pain or pain that is not central in its location Multimodal therapy (medical therapy, surgical therapy, and behavioral/mental health treatment, along with pain consultation) is superior to treatments that emphasize a single approach
In what other sources of chronic pelvic pain are GnRH agonists effective When are oral contraceptives indicated for treatment of chronic pelvic pain What is the role of antidepressants in treatment of chronic pelvic pain
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