Chronic Pelvic Pain
Chronic Pelvic Pain: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Albert A. Meyer
Approach
A woman has an approximate 5% chance of having chronic pelvic pain in her lifetime (1). It is defined as an episodic or continuous pain that persists for 6 months or longer, sufficiently severe to have a significant impact on her lifestyle and her day-to-day function or relationships. It is less likely to be associated with an identifiable pathophysiologic disorder than is pelvic pain lasting less than 3 months.
History
As with any pain, the onset, duration, and pattern of the pain must be assessed. The location, intensity, character, and radiation are important historical elements. Aggravating or relieving factors are important, especially as they relate to the urinary, musculoskeletal, or gastrointestinal systems as well as the relationship of pain to sexual activity or menstruation. Systemic symptoms such as fatigue and anorexia are often present. A medication history (e.g., use of birth control pills or over-the-counter medications) should be obtained. The past obstetric, gynecologic, and general surgical histories are extremely important.
It should be noted that women with a history of pelvic inflammatory disease are four times more likely to develop chronic pelvic pain. The list of possibilities for the condition is substantial. A person with intestinal, sexual, urinary, musculoskeletal, and systemic symptoms may be suffering from a psychiatric disorder (e.g., depression) and an acknowledged or remote history of sexual abuse. Often this information is possible to obtain only when the provider creates an atmosphere of mutual respect and trust.
Dyspareunia is often present. Cyclic pain that is related to menstruation usually points to a gynecologic problem. Pain referred to the anterior thigh, pain associated with irregular uterine bleeding, or new onset dysmenorrhea may have a uterine or ovarian cause. Urethral tenderness, dysuria, or bladder pain suggests interstial cystitis or a urethral problem (Chapter 10.1). Pain on defecation, melana, bloody stools, or abdominal pain with alternating diarrhea and constipation can point toward pelvic floor problems, irritable bowel syndrome, or inflammatory bowel diseases.
Physical examination
A. The general condition of the patient should be noted. Does the patient look chronically ill, which may suggest a pelvic lesion or an inflammatory bowel disorder? Does the patient appear anxious, stressed, or inappropriate?
1. Can the patient point to the pain with one finger? If so, this can indicate that the pain may have a discrete source.
2. An examination of the lower back, sacral area, and coccyx, including a neuologic examination of the lower extremities, is necessary. Herniated disc, exaggerated lumbar lordosis, and spondylolisthesis can all cause pelvic pain.
3. Examine the abdomen, looking for surgical scars, distension, and palpable tenderness, particularly in the epigastrium, flank, back, or bladder.
B. A thorough pelvic examination is the most important part of the evaluation.
Testing (3)
If no obvious cause is apparent, it is reasonable to obtain a complete blood count, urine analysis, sedimentation rate, and serum chemistry profile. A pelvic ultrasound may be helpful when the pelvic examination is inconclusive. Laparoscopy is best used to diagnose a definite pelvic mass. Laparoscopy has been used extensively in the past but various studies have shown a 66% negative laparoscopy rate for patients with chronic pelvic pain. A multidisciplinary approach using medical, psychologic, environmental, and nutritional disciplines showed decreased pain after 1 year.
Diagnostic assessment
Chronic pelvic pain has a wide differential diagnosis (1). These complex problems can be assessed using a multisystems approach. Whereas gastrointestinal, gynecologic, musculoskeletal, and psychiatric conditions can cause chronic pelvic pain, a thorough gynecologic history and pelvic examination are the cornerstones of the diagnostic assessment. Few laboratory tests are helpful. A pelvic ultrasound is useful when the pelvic organs cannot be adequately assessed during the physical examination. A team approach, coordinated by a trusted family physician, can bring much relief to patients with this frustrating clinical problem.
References
1. Ryder RM. Chronic pelvic pain. Am Fam Physician 1996;54(7):2225–2232.
2. Stiege JF, Stout AL, Somkuti SG. Chronic pelvic pain in women: toward an integrative model. Obstet Gynecol Surv 1993;48:95–110.
3. Chan PD, Winkle CR, eds. Gynecology and obstetrics, 1999–2000. Laguna Hills, CA: Current Clinical Strategies Publishers; 1999:23–25.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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