1. Obstetrics and Gynecology Clerkship Case Based Seminar Series
Chronic Pelvic Pain
UNC School of Medicine
Obstetrics and Gynecology Clerkship
Case Based Seminar Series

2. Objectives for Chronic Pelvic Pain
Define chronic pelvic pain
Cite the prevalence and common etiologies of chronic pelvic pain
Describe the symptoms and physical exam findings associated with chronic pelvic pain
Discuss the psychosocial issues associated with chronic pelvic pain
Discuss the steps in the evaluation and management options for chronic pelvic pain

3. Definition
Pelvic pain of more than 6 months duration that has a significant effect on daily function and quality of life
Includes reproductive and non-reproductive related pelvic pain that is primarily acyclic

4. Prevalence
Overall 15-20% of women aged 18 to 50 yrs have chronic pelvic pain that lasts > 1 year
10-30% of gynecologic visits
12-19% of hysterectomies (~ 80,000/yr.)
30% of laparoscopy indications

5. Common Etiologies
(Percentages vary widely depending on practice setting
No apparent pathology ~ 33%
Endometriosis ~ 33%
Adhesions or Chronic PID ~ 25%
Other causes ~ 9%
Gynecologic
Genitourinary
Gastrointestinal
Neuromuscular
Psychological

6. Etiology: Gynecologic
Endometriosis
Adhesions
Chronic PID
Ovarian remnant syndrome
Pelvic congestion syndrome
Recurrent hemorrhagic ovarian cysts
Myomata uteri (degenerating)
Uterine retroversion
Adenomyosis
Pelvic floor and hip muscle pain
Visceral hyperalgesia

7. Etiology: Non-Gynecologic
Genitourinary
Urinary retention
Urethral syndrome
Interstitial cystitis
Gastrointestinal
Penetrating neoplasms
Irritable bowel syndrome
Irritable bowel disease
Partial small bowel obstruction
Diverticulitis
Hernia

8. Etiology: Non-Gynecologic
Neuromuscular
Nerve entrapment syndrome
Generalized myofascial pain syndrome
Fibromyalgia
Psychological
Depression
PTSD (history of abuse/trauma)
Anxiety disorders
Personality disorder

9. Symptoms Dysmenorrhea Pain lasting > 6 months Impaired lifestyle
Dyspareunia
Pain during daily activities

10. Patient Evaluation: History
Characteristics of the pain:
Onset
Location
Duration
Radiation
Severity
Alleviating/aggravating factors
Relation to menstrual cycle
Cyclic vs. non-cyclic
Evolution over time
Responses to treatments

11. Patient Evaluation: Psychological
Psychological Evaluation
Use good clinical judgment in deciding when/if to ask about this!
History of traumatic event
History of abuse (emotional/physical/sexual)
Depression
Anxiety
Hypochondriasis
Secondary gain
Therapy/counseling about these events?
How much do they enter the patient’s thoughts on a daily basis?

12. Physical exam Observe patient’s mobility as she gets up on the table.
Palpate the entire back, but especially the paraspinous and SI joint areas
Referred pain?
Then palpate abdomen

13. Patient Evaluation: Physical Exam
Abdominal exam
Listen for bowel sounds
Ask patient to point to exact location of pain, radiation, and grade its severity (scale of 0 to 10)
Ask the patient to map and demonstrate her tender area(s) by palpating with and without abdominal wall flexion
Palpate entire abdomen with a single digit, with and w/o abdominal wall flexion (Carnett sign)
Palpate from least painful area to most painful area
Referred pain?
Carnet sign?

14. Patient Evaluation: Physical Exam
Evaluate for nerve entrapment
Trigger points
Ilioinguinal, iliohypogastric, and genitofemoral nerves
Abdominal wall and back dermatomes
Mark “jump signs” (points of motion tenderness )
Straight leg raise

15. Patient Evaluation: Physical Exam
Pelvic Exam: ask one question at a time
Vulva
General anatomy; educational exam as needed
Retract labia; walk posterior vestibule with cotton-tipped applicator in cases of dyspareunia or constant vulvar pain.
Vagina
Discharge
Epithelial quality, lesions
Cervix: Pap, cultures if indicated; Q-tip walk to evaluate sensitivity
Single digit exam: what hurts? (Order determined by history)
Cervix; motion tenderness
Bladder and urethra
Uterus, esp lower uterine segment
Adnexa
Levators, obturators, piriformi
Referral of pain? Similarity to chief complaint?: “Does this hurt? Is it like the pain you get? Does it travel anywhere?”
Single digit exam, obturator

16. Physical exam, continued
Bimanual exam: size, shape, and mobility?
Start with non-tender areas first
Make two hands almost meet, sweep caudad
Communicate with patient throughout
Describe limits of exam due to habitus, guarding
Examine to “count of 3” if patient is too uncomfortable.

17. Patient Evaluation: Physical Exam
Pelvic Exam
Fixed retroverted uterus & uterosacral tenderness/nodularity
Endometriosis
Bilateral, tender, irregularly enlarged adnexal structures
Chronic salpingitis (PID)
Enlarged, tender, boggy uterus
Don’t forget the recto-vaginal examination!
Especially when history includes central pain, dyschezia, or dyspareunia.
To eliminate the recto-vaginal exam in such cases is malpractice.

18. Patient Evaluation: Further Studies
Laboratory
Complete blood count (CBC)
Elevated sedimentation rate (ESR) - nonspecific
Urinalysis (UA)
Urine pregnancy test (UPT)
Gonorrhea/Chlamydia
Testing
Transvaginal ultrasound (adnexal mass, uterine irregularity)
Abdominal and pelvic CT (bowel or urinary signs)
Diagnostic laparoscopy
Ultimate method of diagnosis for CPP of undetermined etiology

19. Patient Evaluation: Further Studies
Laparoscopy (% vary widely in different practice settings)
Normal pelvis
Pelvic adhesions
Non-gyn disease
Endometriosis
Fibroids
Hernias

20. Management
Make a list of contributing factors; involve family member or S.O. when possible.
Treat any underlying pathology, but don’t flog it to death.
Include treatment of contributing factors as a package deal
Establish a therapeutic, supportive, and sympathetic (but structured) physician-patient relationship
Schedule regular follow-up appointments
Patient should not be told to call ONLY if pain persists
Deters pain behavior and secondary gain

21. Management Educate, educate, educate
Reassure patient of no serious underlying pathology
Chronic v. acute pain
Educate patient to likely mechanisms of pain production
Central nervous system: centralization
Neuropathic
Muscular
Psychological (most often in reaction to pain events, not the primary etiology)

22. Management
Treating multiple components of pain has been showed to be more effective than traditional gynecologic management. This can be accomplished in a single clinic, or through collaboration among several specialists, such as
Gynecologist
Physical therapist
+ Anesthesiologist
+ Acupuncturist
Psychologist
Sex therapist

23. Management Pharmacologic therapies:
Initial trial of hormonal manipulation
Cyclic therapy/regulation of menses
Suppress ovulation (OCP, DMPA and Lupron)
Suppress menses (DMPA, high dose intrauterine progestins)
NSAIDS
Analgesics
Nonnarcotic (ASA, Acetominophen)
Narcotic – use cautiously (tolerance, dependence)
SSRI’s or SNRI’s
TCA’s, anti-epileptics
Especially for pain with neuropathic components

24. Management Surgical therapies: Anesthesia:
Guarded prognosis in patients with multiple pain syndromes
Degree of relief has uncertain relationship to amount of pathology; most can be done laparoscopically
Unilateral adnexectomy
Hysterectomy + BSO
Presacral neurectomy
Uterine suspension
Lysis of adhesions
Resection/ablation of endometriosis
Anesthesia:
Acupuncture
Nerve blocks
Trigger point injections

25. Bottom Line Concepts
Chronic pelvic pain is pelvic pain of more than 6 months duration that has a significant effect on daily function and quality of life.
It affects 15-24% of American women in varying degrees of severity and accounts for a large portion of office visit and time.
Chronic pelvic pain is caused by a variety of factors including gynecologic, genitourinary, gastrointestinal, neuromuscular, and psychological.
Diagnostic laparoscopy is the ultimate method of diagnosis for patients with chronic pelvic pain of undetermined etiology.
Multidisciplinary approach has been shown to be more effective than pharmacologic or surgical therapy alone.
Even when etiology is determined, chronic pelvic pain can be difficult to treat and patients need to be seen regularly and provided much support.

26. References and Resources
APGO, Chronic Pelvic Pain: An Integrated Approach. APGO Educational Series on Women’s Heath Issues, APGO, Washington, DC, January 2000.
APGO Medical Student Educational Objectives, 9th edition, (2009), Educational Topic 39 (p82-83).
Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 30 (p ).
Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 21 (p ).
Katz: Comprehensive Gynecology, 5th edition, (2007), Vern Katz, Gretchen Lentz, Rogerio Lobo, David Gershenson. Chapter 8.