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~ Chronic Pelvic Pain ~

　

Definition

  1. Chronic Pain: pain of more than 6 months’ duration
  2. Cyclic Pain: pain associated with the menstrual cycle, eg. dysmenorrhea
  3. Primary Dysmenorrhea: menstrual pain without pelvic pathology
  4. Secondary Dysmenorrhea: painful menses with underlying pathology

　

Causes of Chronic Pain

Gynecologic:

Noncyclic
  1. Adhesions most common
  2. Endometriosis causes
  3. Salpingo-oophoritis
  1. acute b. subacute
  1. Ovarian remnant syndrome
  2. Pelvic congestion syndrome (varicosities)
  3. Ovarian enoplasms
  4. Pelvic relaxation

Cyclic
  1. Primary dysmenorrhea
  2. Secondary dysmenorrhea
  1. imperforate hymen
  2. transverse vaginal septum
  3. cervical stenosis
  4. uterine anomaly
  5. intrauterine synechiae
  6. endometrial polyps
  7. uterine leomyoma
  8. adenomyosis
  9. pelvic congestion syndrome (varicosities)
  10. endometriosis
  1. Atypical cyclic
  1. endometriosis
  2. adenomyosis
  3. ovarian remnant syndrome
  4. chronic functional cyst formation

Gastrointestinal:
  1. Irritable bowel syndrome ß most common cause
  2. Ulcerative colitis
  3. Granulomatous colitis (Crohn’s disease)
  4. Carcinoma
  5. Infectious diarrhea
  6. Recurrent partial small bowel obtruction
  7. Diverticulitis
  8. Hernia
  9. Abdominal angina

10. Recurrent appendiceal colic

　

　

Genitourinary:
  1. Recurrent or relapsing cystourethritis
  2. Urethral syndrome
  3. Interstitial cystitis
  4. Carcinoma of the bladder
  5. Ureteral diverticuli or polyps
  6. Ureteral obstruction
  7. Pelvic kidney

Neurologic:
  1. Nerve entrapment syndrome
  2. Neuroma

Musculoskeletal:

Low back pain syndrome
  1. Congenital anomalies
  2. Scoliosis and kyphosis
  3. Spondylolysis
  4. Spondylolisthesis
  5. Spinal injuries
  6. Inflammation
  7. Tumors
  8. Osteoporosis
  9. Degenerative changes

10. Coccdynia

Myofascial Syndrome:

Systemic
  1. Acute intermittent porphyria
  2. Abdominal migraine
  3. Systemic lupus erythematosis
  4. Lymphoma
  5. Neurofibromatosis

　

Cyclic Pain

  1. Primary Dysmenorrhea:
  1. Causes: increased endometrial prostaglandin production
  2. Symptoms:

Ÿ Pain:

and lasting as long as 48-72 hours

  1. Signs:
  1. Diagnosis:
  1. Treatment:

? Prostaglandin synthase inhibitors: eg. NSAIDs

‚ Birth control pills

ƒ Narcotic medications: eg. hydrocodone or codeine

„ Pain management:

eg. acupuncture, transcutaneous electrical nerve stimulation,

surgery (eg. LUNA, presacral neurectomy) ç rarely used

  1. Secondary Dysmenorrhea:
  1. Causes: most common endometriosis, followed by adenomyosis and an IUD
  2. Symptoms/Signs:

Ÿ Pain:

a few days after the cessation of bleeding

  1. Diagnosis: pain diary, ultrasonography, laparoscopy
  2. Treatment:

dysmenorrhea than in primary dysmenorrhea.

　

Chronic Pain

  1. Evaluation: (Figure 14.3, p414)
  1. History:

    2. À Pain history:

    nature, location, radiation, severity, aggravating and alleviating factors,

    the effect of menstrual cycle, stress, work, exercise, intercourse, and orgasm, etc.

    Á Symptomatic history:

    a). genital: abnormal vaginal bleeding, discharge, dysmenorrhea, dyspareunia, infertility

    b). enterocelic: constipation, diarrhea, flatulence, hematochezia, bowel movement

    c). musculoskeletal: trauma, exacerbation of exercise or postural changes

    d). urologic: urgency, frequency, nocturia, dysuria, incontinence, hematuria

    Â Others

  2. Physical Examination:

À When the patient is standing:

hernia or not? both abdominal (inguinal and femoral) and pelvic (cystocele and rectocele)

Á Focus on: abdomen, lumbosacral area, ext. genitalia, vagina, uterus, adnexae

 The examination should include evaluation of the abdomen with muscles tensed

(head raised off the table or with straight leg raising) to differentiate abdominal wall and

visceral sources of pain. Abdominal wall pain is augmented and visceral pain is diminished

with the above maneuvers.

  1. 　
  2. Common Situations Associated with Chronic Pelvic Pain:

Diseases

Causes

S/S

Diagnosis

Management

Endometriosis

 　 　 　 　

Adhesion

 　

Noncyclic pain

Decreased mobility

of pelvic organs

Laparoscopy

Adhesionlysis only

when other mx.

fails

Pelvic Congestion

 　

Lower abd. Pain

2o dysmenorrhea

Dyspariunia

Transuterine

venography
  1. Hormonal suppr.

provera (5) 30mg

qd

2. Hysterectomy

Saipingo-oophoritis

 　 　 　 　

Ovarian Remnant

Syndrome

Post-ATH+BSO

Lat. pelvic pain

2-5 yrs post OP

Sono
  1. Medical:

    2. Danazol,

    High-dose prog.

    Oral contracep.

    GnRH analog

  2. Surgical:

Irritable Bowel

Syndrome

unknown

Abdominal pain

Others:

Abd. distension

Flatulence é

Diarrhea/Consti.

A diagnosis by

exclusion

Bulk-forming agent

Low-dose tricyclic

antidepressants

Urethral Syndrome

unknown

Dysuria, frequency,

and urgency

Suprapubic

pressure

A diagnosis by

exclusion
  1. Medical:

    2. Doxycycline

    Erythromycin

  2. Local estrogen

    3. for menopaused

    females

  3. Urethral

dilatation

Interstitial Cystitis

unknown

Severe dysuria,

frequency,

urgency

Pain over

suprapubic,

pelvic, urethral,

vaginal,

or perineal area.

S/S

Specific

Cystoscopic

findings
  1. Medical
  2. Hydrostatic

    3. bladder

    distension

  3. Biofeedback

or behavior

therapy

Nerve Entrapment

 　 　

Point or tenderness

 　

Myofascial Pain

 　 　

Trigger point

 　

Low Back Pain

Syndrome

 　 　 　 　

v 各疾病詳細的clinical presentation, diagnosis,與treatment見其它files.

  1. Management:

v When no pathology is apparent:

multidisciplinary therapy (gynecological, psychological, anesthesiological)

v When medical treatment fails:

À laparoscopy (lysis of adhesion, etc.)

Á presacral neurectomy

 hysterectomy

　

Filename: Chronic Pelvic Pain