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How to do a History and Physicalon a Female Chronic Pelvic Pain
Patient
C. Paul Perry, MD, FACOG
Pelvic Pain CenterBirmingham, AL, USA
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PAIN
AN UNPLEASANT SENSORY ANDEMOTIONAL EXPERIENCE ASSOCIATEDWITH ACTUAL OR POTENTIAL TISSUE
DAMAGE*
* INTERNATIONAL ASSOCIATION FOR THE STUDY OF PAIN
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Why is Chronic Pelvic Painso Different?
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ACUTE vs CHRONIC PAIN
ACUTE PELVIC PAIN: SYMPTOM OFUNDERLYING TISSUE INJURY ANDDISEASE
CHRONIC PELVIC PAIN: PAIN BECOMESTHE DISEASE
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CHRONIC PELVIC PAIN
CHRONIC PAIN:PAIN LASTING6 MONTHS ORLONGER
CHRONIC PELVIC
PAIN SYNDROME:CHRONIC PELVICPAIN CAUSINGEMOTIONAL AND
BEHAVIORALCHANGES
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Viscerosomatic Convergence and
Referred Pain
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Viscerosomatic Convergence and
Pelvic Floor Myalgia
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Viscerovisceral Hyperalgesia
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Neuroinflammation
Antidromic Transmission
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Pathophysiology
Altered Pain-Processing
Repeat Stimulation of NociceptiveNeurons
1. Changes Nerve Fibers
2. Lowers Threshold
3.
Causes Peripheral Sensitization4. Exaggerates Transmission Response
5. Recruits higher and Lower Neurons
6. Produces Self-Sustaining Activation
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SOURCES OF CHRONIC
PELVIC PAIN
GYNECOLOGICAL
UROLOGICAL
GASTROINTESTINAL
MUSCULOSKELETAL
NEUROPATHIC
OTHER
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Concurrent Multiple Pain
Generators Evil Twins
1. Endometriosis
2. Interstitial Cystitis *
Evil Triplets
1. Endometriosis, IC
2. Pelvic Congestion Syndrome (PCS)
Evil Quadruplets
1. Endometriosis, IC, PCS
2. Vulvovestibulitis (VVS)*Chung MK, Chung RP, Gordon D, Jennings C. The evil twins of chronic pain syndrome: endometriosis and interstitial
cystitis. J Soc Laparoendosc surg 2002;6:311-14.
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Concurrent Multiple Pain
Generators Evil Quintuplets
1. Endometriosis, IC, PCS, VVS
2. Pelvic Floor Tension Myalgia (PFTM) Evil Sextuplets
1. Endometriosis, IC, PCS, VVS, PFTM
2. Functional Bowel Disease (IBS)
Evil Septuplets1. Endometriosis, IC, PCS, VVS, PFTM, IBS
2. Fibromyalgia
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Concurrent Multiple Pain
Generators
178 patients with Chronic Pelvic Pain1
134 (75%) Endometriosis
159 (89%) Interstitial Cystitis
115 (65%) had both Endometriosis
and IC1. Chung MK, Chung RP, Gordon D. Interstitial cystitis and endometriosis in
patients with chronic pelvic pain: the evil twins syndrome. JSLS2005;9:25-9.
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Necessity of Multidisciplinary
Approach
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CHRONIC PELVIC PAINMOST FREQUENTLY MISSED COMPONENTS OF
CHRONIC PELVIC PAIN
1. ABDOMINAL TRIGGER POINTS
2. VESTIBULITIS
3. PELVIC FLOOR MYALGIA
4. HERNIAS5. PELVIC CONGESTION
6. INTERSTITIAL CYSTITIS
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Pelvic Pain Assessment Forms
May be downloaded in PDF format fromweb site: www.pelvicpain.org
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History
DetailedFocusedPelvic Review of systemsBiopsychosocial Model
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International Pelvic Pain
Society Physical Form
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Physical Examination General Examination
Check for Fibromyalgia
Check Abdominal Wall
Q-tip test for vestibulitis
Check for Pelvic Floor Myalgia
Single Digit Pelvic Exam Bimanual exam
Rectovaginal exam
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International Pelvic Pain
Society Physical Form
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International Pelvic Pain
Society Physical Form
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Fibromyalgia Tender Points
(must have at least 11/18)
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Abdominal Wall Trigger Points
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Physical Examination:
Abdominal Tenderness over the
ovarian point Suggests pelvic
congestion syndrome
Pain thought to bedue to compression ofovarian veins
Ovarian
Point
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PELVIC CONGESTION
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HERNIAS INGUINAL
INDIRECT DIRECT FEMORAL
SCIATIC OBTURATOR Ventral (incisional) Others: umbilical, Spigelian, paravesical,
perineal
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INGUINAL HERNIAS
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Sciatic Hernia
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Sciatic Hernia
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OBTURATOR HERNIAS
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Q-tip Test for Vulvovestibulitis
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Pubococcygeus Screen
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Piriformis Screen
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Physical Examination: Pelvic
Traditional bimanualexamination is the
lastportion of thepelvic examination
Uterus
Adnexa
Anorectum Many layers palpated;
non-specific findingslikely
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Physical Examination: Pelvic
Traditional bimanualexamination is the
lastportion of thepelvic examination
Uterus
Adnexa
Anorectum Many layers palpated;
non-specific findingslikely
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Cardinal Principles of Pain
Management Believe the Patient
Have Realistic Goals
Institute Adequate Pain Relief
Identify All Pain Generators
Lay out Game Plan for Patient andFamily
Setup Appropriate Diagnostic Studies
Explain the Reasons for Complexity