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How to do a History and Physical on a Female Chronic Pelvic Pain ... - PowerPoint

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					How to do a History and Physical
on a Female Chronic Pelvic Pain
           Patient

    C. Paul Perry, MD, FACOG
        Pelvic Pain Center
      Birmingham, AL, USA
   PAIN


“AN UNPLEASANT SENSORY AND
  EMOTIONAL EXPERIENCE ASSOCIATED
  WITH ACTUAL OR POTENTIAL TISSUE
  DAMAGE”*

* INTERNATIONAL ASSOCIATION FOR THE STUDY OF PAIN
Why is Chronic Pelvic Pain
so Different?
ACUTE vs CHRONIC PAIN

ACUTE PELVIC PAIN: SYMPTOM OF
 UNDERLYING TISSUE INJURY AND
 DISEASE

CHRONIC PELVIC PAIN: PAIN BECOMES
 THE DISEASE
CHRONIC PELVIC PAIN

                       CHRONIC PELVIC
   CHRONIC PAIN:       PAIN SYNDROME:
    PAIN LASTING        CHRONIC PELVIC
    6 MONTHS OR         PAIN CAUSING
    LONGER              EMOTIONAL AND
                        BEHAVIORAL
                        CHANGES
Viscerosomatic Convergence and
Referred Pain
Viscerosomatic Convergence and
Pelvic Floor Myalgia
Viscerovisceral Hyperalgesia
Neuroinflammation
Antidromic Transmission
Pathophysiology
Altered Pain-Processing
Repeat Stimulation of Nociceptive
    Neurons
1.  Changes Nerve Fibers
2.  Lowers Threshold
3.  Causes Peripheral Sensitization
4.  Exaggerates Transmission Response
5. Recruits higher and Lower Neurons

6. Produces Self-Sustaining Activation
SOURCES OF CHRONIC
PELVIC PAIN

   GYNECOLOGICAL
   UROLOGICAL
   GASTROINTESTINAL
   MUSCULOSKELETAL
   NEUROPATHIC
   OTHER
          Concurrent Multiple Pain
                Generators
        Evil Twins
    1.        Endometriosis
    2.        Interstitial Cystitis *
        Evil Triplets
    1.        Endometriosis, IC
    2.        Pelvic Congestion Syndrome (PCS)
        Evil Quadruplets
    1.        Endometriosis, IC, PCS
    2.         Vulvovestibulitis (VVS)
    *Chung MK, Chung RP, Gordon D, Jennings C. The evil twins of chronic pain syndrome: endometriosis and interstitial
            cystitis. J Soc Laparoendosc surg 2002;6:311-14.
          Concurrent Multiple Pain
                Generators
        Evil Quintuplets
    1.     Endometriosis, IC, PCS, VVS
    2.     Pelvic Floor Tension Myalgia (PFTM)
        Evil Sextuplets
    1.     Endometriosis, IC, PCS, VVS, PFTM
    2.     Functional Bowel Disease (IBS)
        Evil Septuplets
    1.     Endometriosis, IC, PCS, VVS, PFTM, IBS
    2.     Fibromyalgia
        Concurrent Multiple Pain
              Generators

   178 patients with Chronic Pelvic Pain1
       134 (75%) Endometriosis
       159 (89%) Interstitial Cystitis
            115 (65%) had both Endometriosis
             and IC
    1. Chung MK, Chung RP, Gordon D. Interstitial cystitis and endometriosis in
       patients with chronic pelvic pain: the ”evil twins” syndrome. JSLS
       2005;9:25-9.
Necessity of Multidisciplinary
Approach
   CHRONIC PELVIC PAIN
 MOST FREQUENTLY MISSED COMPONENTS OF
            CHRONIC PELVIC PAIN
1. ABDOMINAL TRIGGER POINTS
2. VESTIBULITIS
3. PELVIC FLOOR MYALGIA
4. HERNIAS
5. PELVIC CONGESTION
6. INTERSTITIAL CYSTITIS
Pelvic Pain Assessment Forms


May be downloaded in PDF format from
 web site: www.pelvicpain.org
History


 Detailed
 Focused

 Pelvic Review of systems
 Biopsychosocial Model
International Pelvic Pain
 Society Physical Form
Physical Examination
   General Examination
   Check for Fibromyalgia
   Check Abdominal Wall
   Q-tip test for vestibulitis
   Check for Pelvic Floor Myalgia
   Single Digit Pelvic Exam
   Bimanual exam
   Rectovaginal exam
International Pelvic Pain
 Society Physical Form
International Pelvic Pain
 Society Physical Form
Fibromyalgia Tender Points
(must have at least 11/18)
Abdominal Wall Trigger Points
Physical Examination:
Abdominal
 Ovarian
                  Tenderness over the
 Point
                   “ovarian point”
                      Suggests pelvic
                       congestion syndrome
                      Pain thought to be
                       due to compression of
                       ovarian veins
PELVIC CONGESTION
HERNIAS
   INGUINAL
       INDIRECT
       DIRECT
       FEMORAL
   SCIATIC
   OBTURATOR
   Ventral (incisional)
   Others: umbilical, Spigelian, paravesical,
    perineal
INGUINAL HERNIAS
Sciatic Hernia
Sciatic Hernia
OBTURATOR HERNIAS
Q-tip Test for Vulvovestibulitis
Pubococcygeus Screen
Piriformis Screen
Physical Examination: Pelvic

                   Traditional bimanual
                    examination is the
                    last portion of the
                    pelvic examination
                       Uterus
                       Adnexa
                       Anorectum
                       Many layers palpated;
                        non-specific findings
                        likely
Physical Examination: Pelvic

                   Traditional bimanual
                    examination is the
                    last portion of the
                    pelvic examination
                       Uterus
                       Adnexa
                       Anorectum
                       Many layers palpated;
                        non-specific findings
                        likely
Cardinal Principles of Pain
Management
   Believe the Patient
   Have Realistic Goals
   Institute Adequate Pain Relief
   Identify All Pain Generators
   Lay out Game Plan for Patient and
    Family
   Setup Appropriate Diagnostic Studies
   Explain the Reasons for Complexity

				
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posted:10/17/2008
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