PELVIC PAIN

INTRODUCTION Pelvic pain encompasses a large proportion of gynecologic complaints. Amongst the most challenging problems. Grouped into: acute pain cyclic pain chronic pain

ACUTE PELVIC PAIN Definition: intense, sudden onset, sharp rise and short course. Pathology: viscera are relatively insensitive to pain. First perception – a vague, deep, poorly localized sensation with corresponding autonomic reflex responses. Referred pain – more localized and relates to nerve distribution or dermatome of the spinal cord segment innervating the involved viscus.

DIFFERENTIAL DIAGNOSIS Pregnancy-associated: ectopic, miscarriage Gynae: endometriosis, dysmenorrhoea, saplingitis, ovarian torsion, rupture, haemorrhage Non gynae: GIT, UTI, musculoskeletal

DIAGNOSIS EARLY DIAGNOSIS IS CRITICAL!! History: LNM x2, AUB, discharge, sexually active, contraception, previous STDs, pain, medical, surgical, GIT Sx, UT Sx. General and gynecological examination. Special investigations: FBC + diff, ESR, bHCG, U-mcs, pelvic ultrasound, AXR.

MANAGEMENT According to the diagnosis.

CHRONIC PELVIC PAIN

INTRODUCTION Frequently depressed and anxious. Marital, social and occupational lives are disrupted. Approximately 12% will opt for hysterectomies. 30% already have had a hysterectomy. 60-80% of L/scope no intraperitoneal pathology!!

DEFINITION Continuous or episodic non-cyclic ( non-menstrual) pain, that is located in the pelvis and/or lower abdomen and has persisted for at least 6 months and is severe enough to affect a woman’s daily function.

DIFFERENTIAL DIAGNOSIS Gynae Non-gynae Psycosocial GIT, UTI, musculoskeletal Psycosocial

MANAGEMENT HISTORY PAIN: nature, location, radiation, severity, aggravating and alleviating factors, effect of menstruation, stress, work, exercise, intercourse, social and occupational toll of the pain. GYNAE: AUB, discharge, infertility, SEXUAL ABUSE. ENTEROCOLIC: constipation, bowel movement.

4. MUSCULOSKELETAL: trauma, postural change 5 4. MUSCULOSKELETAL: trauma, postural change 5. UROLOGY: urgency, frequency, nocturia, incontinence, hematuria. 6. MEDICAL: porphyria 7. SURGICAL 8. Other somatic symptoms. 9. Past psychological history!

EXAMINATION Complete examination should be performed EXAMINATION Complete examination should be performed. Particular attention to abdomen,lumbosacral area and complete gynae examination. 1. Abdominal: evaluation of abdomen with tensed muscles (head raised) to differentiate between abdominal wall pain and visceral pain. Standing!! Palpating – begin with 1 finger, then deep.

2. Pelvic examination: Speculum Bi-manual – vaginisms, levator ani spasms, piriformis spasms. Bladder Rectum

SPECIAL INVESTIGATIONS Laboratory – FBC + diff, ESR, porphyria, Urine – mcs, Stool – occult blood, alb, mcs Ultrasound XR – Ba-enema, IVP Diagnostic L/scopy Psychological evaluation

TREATMENT Treat the abnormality. Medical / surgical NO APPARENT PATHOLOGY multidisciplinary therapy include the gynecologist, psychologist and anesthesiologist. This approach is very effective – 85% relief of pain.

START – trail of OC and NSAIDs – THEN multidisciplinary team. Surgical – L/scopy – diagnostic/surgery. hysterectomy, pre-sacral neurectomy.

IMPORTANT POSITIVE ATTITUDE DETECT PSYCOLOGICAL FACTORS TREAT ABNORMALITIES TREAT PAIN IMMEDIATELY AND CONTINUALLY MULTIDISCIPLINARY