Pocket ObGyn – Chronic Pelvic Pain

Dec 8, 2019 admin PHỤ KHOA, SẢN KHOA 0

Pocket ObGyn – Chronic Pelvic Pain
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Definitions and Etiology (Chapter 27. Chronic Pelvic Pain. Hopkins Manual of Gyn-OB, 4th ed. 2011)

  • Noncyclic pain, at least 6 mo duration in the abdominal wall at or below the umbilicus or in the anatomic pelvis; causes functional disability or request for medical

  • Pain is subjective & may or may not be a/w pelvic pathology or physical Requires WIDE diff, possibly team eval/approach.
  • Causes may be gastrointestinal (38%), urologic (31%), gyn (20%), musculoskeletal, neurologic, psychological (Br J Obstet Gyn 1999;106:1156)
Clinical Manifestations
  • Gastrointestinal: Diarrhea, constip, flatulence, relationship of bowel mvmts w/ pain, hematochezia
  • Urologic: Urgency, frequency, urinary incontinence, dysuria, nocturia, hematuria
  • Gyn: Vaginal bleeding/discharge, dysmenorrhea, dyspareunia, infertility
  • Neuropathic/musculoskeletal: Trauma, postural changes
Initial Workup
  • Most common diagnoses: IBS (50–80%), IC (35–85%), endometriosis (33%), adhesions (24%), psychological or sexual abuse (40–50% prevalence).
  • A detailed history & physical Obtain pain hx, medical, surgical & gyn factors, pathology, operative reports, & prior pain evals
  • Abdominal exam: Pain map, + Carnett’s sign (bilateral leg raise, or sit up; worsening pain consider musculoskeletal etiology as true visceral pain improves w/ tension of abdominal ) Exam elements directed toward suspected cause.
  • Lab: CBC, UA & cx, GC/CT, Preg test, wet prep, ESR
Diagnostic Workup/Studies
  • If physical exam findings consistent w/ mass, TVUS to evaluate pelvic mass, If abn® consider MRI or CT.
  • Diagnostic laparoscopy for endometrial implants w/ biopsies & histology (visual dx is correct only 10–90%)
  • Validated questionnaire w/ the O’Leary-Sant Interstitial Cystitis Symptom Index: If score of ³5 on screening (94% sens & 93% NPV) ® cystoscopy + for glomerulations, ulcer (8%), ¯ bladder capacity ® IC (Obstet Gynecol 2002;100:337); validity of potassium intravesical sens test is uncertain (85% positive in CPP pts evaluated in general ob/gyn office).
  • Colonoscopy as sx or exam
Treatment and Medications
  • Multidisciplinary approach
  • Empiric medical rx for the most likely Endometriosis: NSAIDs, OCPs, medroxyprogesterone acetate 30–100 mg QD, danazol for 2–9 mo or Lupron

3.75 mg QMO. If no improv in 2–3 mo ® invasive diagnostic testing. Chronic infectious etiology (~18–35% of acute PID develop CPP, sterile pyuria in urethral syn), doxycycline 100 mg BID ´ 14 d. Manual therapy of myofascial pelvic trigger points – 65–70% improv (J Urol 2001;166:2226).

  • Endometrial implants, windows, & endometriomas ® excised & fulgurated; pain relief at 1 y in 45–85%; recurrence usually at 40–50 Hysterectomy; no RCT (75% pain relief at 1-y f/u) (Obstet Gynecol 1995;86:941).

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