Chronic Pelvic Pain

Question 1

definition of chronic pelvic pain

Answer 1

non-menstrual pelvic pain ( below umbilicus) for >6 mo

Question 2

dysmenorrhea definition

Answer 2

recurrent, sever, painful cramping prior to/during menses

other symptoms: sweating, tachycardia, headache, N/V/D, tremulousness

Question 3

primary vs secondary dysmenorrhea

Answer 3

secondary has a specific pathology/cause

Question 4

primary dysmenorrhea cause

Answer 4

increased endometrial prostaglandin production

Question 5

gynecologic causes of chronic pelvic pain + dysmenorrhea

Answer 5

endometriosis (with dysmenorrhea, deep dyspareunia, dyschezia)

chronic pelvic inflammatory disease (15-35% of PID becomes chronic)

adhesions/cervical stenosis - controversial

adenomyosis (/w heavy periods + dysmenorrhea)

Question 6

4 theories of endometriosis pathophysiology

Answer 6

• retrograde mensruation
• coelomic metaplasia
• immunologic change
• hematogenous/lymphatic spread

Question 7

non gyne causes of pelvic pain

Answer 7

GI - IBS

GU - IC (/w urgency and freq, dx /w potassium sensitivity test + cystoscopy)

MSK + Neurological - entrapment, myofascial pain, low back pain

psych - depression, anxiety, personality disorders, abuse, psychosomatic. Cause or increase pain. (can also be caused by the pain)

Question 8

work-up for CPP

Answer 8

• history
• physical exam - abdo, pelvic, vulvar, vaginal, rectovaginal
• spec exam /w cervical cultures
• test depending on symptoms: US or MRI for gyne/GI (note: can’t diagnose endo /w out laparoscopy, also adeno may image normal)
• urinalysis if symptoms
• refer to urogyne/GI as needed
• +/- laparoscopy - endometriosis, other pathology

can tx for endo without definitive dx

Question 9

exam findings of endo

Answer 9

nodularity of uterosacral ligament

fixed, retroverted uterus

ovarian englargement

Question 10

exam finding of adenomyosis

Answer 10

diffusely enlarged uterus (+ not pregnant)

note: dx only on hysterectomy

Question 11

laparoscopy findings in endometriosis

Answer 11

• powder burn blue/black lesions
• red implants
• vesicles
• white plaques
• adhesions
• chocolate cysts
• mostly in ovaries, over uterus, cul de sacs, uterosacral, round, and broad lig

Question 12

tx for primary dysmenorrhea or endometriosis

Answer 12

NSAIDs (premenstrual until day 3) and hormonal contraception - cyclic or continuous or IUD

for endo: if fail or estrogen is CI, can try progestins or GnRH analogues

Question 13

results of laparoscopy in CPP

Answer 13

35% - no cause
33% - endo
24% - adhesions
5% - chronic PID
3% - ovarian cysts