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Pelvic Pain

PATIENT WORKUP: CHRONIC PELVIC PAIN

History

Timing of pain

Pain elsewhere

Sexual history (dyspareunia)

Work history

Problems of other organ systems (GU, GI)

Infection

Previous surgery end diagnostic procedures

Previous GYN pathology

Social history

CRITICAL ITEMS Childhood

Sexually assaulted/raped

Mental health evaluation

Arrested/in detention

Didn't finish high school

ASSOCIATED ITEMS

Childhood

Used drugs

Physically abused

Witnessed physical abuse, endometrosis, endometreosis, endometriosis

p <0.05

CRITICAL ITEMS Adulthood

Moved frequently

Raped

Not working*

On welfare*

Several marriages/Live-in partners

+p<.05 *p<-.01

PATIENT WORKUP: CHRONIC PELVIC PAIN

Physical Examination

Complete physical exam

Culture for GC, Chlamydia

Pap Smear

PATIENT WORKUP: CHRONIC PELVIC PAIN

Other Studies

Psychiatric evaluation

MMPI

Laparoscopy

Biopsies where appropriate

Findings in 1,194 Patients with Chronic Pelvic Pain Undergoing Laparoscopy

NormaI pelvis 355
Normal pelvic exam  
before laparoscopy 749
No. with Abn. Lap 479 (63%)  

Cunanan et al, OB/GYN,146:587,1983

Other Studies Relating Laparoscopic Findings to Chronic Pelvic Pain

Chronic Pelvic Pain Patients and Adhesions

Pain Relief with Adhesion Lysis _

48 women with AFS Stage II-IV pelvic adhesions on laparoscopy

Pelvic and Lower Abdominal Pain

Pregnancy related

Disorders of uterus & cervix

Disorder of adnexa

Salpingitis

TOA

Endometriosis

Torsion

Ruptured follicle or CL cyst Ovarian hyperstimulation Ovarian tumor

Non-GYN Disorders

Appendicitis

Mesenteric lymphadenitis

Diverticulitis

Functional bowel syndrome

Cystitis

Trigonitis

Renal calculus

Musculoskeletal

CHRONIC PELVIC PAIN Hypothetical Subtypes

Chronic Pelvic Pain Patients:

Type 1 Age in early20's
History of childhood sexual assault
Onset of pain after onset of sexual activity
Type 2 Age in 40's to 50's
. No significant sexual assault history
Pain onset during social stress
Type 3 Age 30s to 60s
Career somatizer

CHRONIC PELVIC PAIN

(Conclusions)

Chronic Pelvic Pain Patients

Increased prevalence of psychiatric disorder particularly mood and somatization disorder

Increased frequency of sexual assault

Use somatization more frequently as a

CHRONIC PELVIC PAIN

Women, with history of sexual assault in this study had significantly:

Higher prevalence of current and lifetime depression

Higher prevalence and longer duration of chronic pelvic pain

More sexual adjustment problems

More unexplained medical symptoms

Earlier first sexual experience

CHRONIC PELVIC PAIN TREATMENT

Chronic Pelvic Pain Patients:

1.Treat the whole patient
2.Treat specific findings
3.Avoid repetitive courses of