Stump the gynecologist differential diagnosis of chronic pelvic pain
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Stump the Gynecologist: Differential Diagnosis of Chronic Pelvic Pain. Jennifer K. McDonald DO F.A.C.O.G. October 10, 2008. ACOG Definition.

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Stump the gynecologist differential diagnosis of chronic pelvic pain

Stump the Gynecologist: Differential Diagnosis of Chronic Pelvic Pain

Jennifer K. McDonald DO F.A.C.O.G.

October 10, 2008


Acog definition
ACOG Definition Pelvic Pain

“Non-cyclic pain of 6 or more months duration that localizes to the anatomic pelvis, abdominal wall at or below the umbilicus, lumbosacral back or the buttocks and is of sufficient severity to cause functional disability or lead to medical care.”


Background
Background Pelvic Pain

  • 10% out-patient gynecologic visits

  • 20% of laparoscopies

  • 15% of hysterectomies

  • $2.8 billion annually

15% of American women



Prevalence
Prevalence Pelvic Pain

CPP

Migraine

Asthma

Back Pain


Age prevalence
Age Prevalence Pelvic Pain


Features
Features Pelvic Pain

  • Present for six months or more

  • Conventional treatments have yielded little or no relief

  • Degree or pain perceived seems out of proportion to the degree of tissue damage detected by conventional means

  • Physical appearance of depression is present

  • Physical activity is increasingly limited

  • Emotional roles in the family are altered


Distinction
Distinction Pelvic Pain

  • Acute pain

    Pain is symptom of underlying tissue damage

  • Chronic pain

    Pain itself becomes the disease


Females unique design
Females - Unique Design Pelvic Pain

  • Structural changes during development

  • Pelvis widens after menarche

  • Gluteal stretching

  • Internal rotation of the femurs/lateral displacement of the patella

  • Ligamentous laxity

  • Decreased muscular tone increases lumbar lordosis and exaggerated anterior pelvic tilt

  • Pelvic organs connected through shared common nerve pathways


Where do we look
Where do we look? Pelvic Pain

Gynecologic - extra-uterine

Gynecologic - uterine

Urologic

Musculoskeletal

Gastrointestinal

Neurologic


Referred pain
Referred Pain Pelvic Pain

Ovary T10 umbilical area

Uterus T12 lower abdominal wall

Vagina L1 skin over groin


Most common culprits
Most common culprits Pelvic Pain

  • Endometriosis

  • Adenomyosis

  • Interstitial cystitis

  • Irritable bowel

  • Pelvic Adhesions


Endometriosis
Endometriosis Pelvic Pain

  • Presence of endometrial glands and stroma outside the uterus

  • No difference among ethnic groups or socioeconomic status

  • Genetic predisposition 6-10% increased risk with history of first degree relative

Dysmenorrhea Abnormal bleeding

Dyspaurenia GI complaints

Infertility Urinary complaints

Low back pain



Location location
Location Location Pelvic Pain

76% ovaries

69% posterior & anterior

cul de sac

47% posterior broad ligament

36% uterosacral ligaments

11% uterus

6% fallopian tubes

4% sigmoid colon


Interstitial cystitis
Interstitial Cystitis Pelvic Pain

  • Prevalence of bladder origin chronic pelvic pain/interstitial cystitis is much greater than previously believed

IC is a chronic inflammatory condition of the bladder characterized by irritable voiding symptoms of urgency and frequency in the absence of objective evidence of another disease that could cause the symptoms


Pathogenesis of IC: Pelvic PainDefective Urothelial Barrier

IrritatingSolutes

GAGLayer

Urothelium

Inflammation

IrritatedNerve


IC is Typically Diagnosed Pelvic PainLate in Disease Continuum

Average Time Between Initial Development of Symptoms and Diagnosis is 5 Years

See at least

5 physicians

before diagnosis

Significant suffering

and reduced QOL

InitialDevelopment of

IC Symptoms

Diagnosis of IC

2-7 years

May have

unnecessary

hysterectomy


IC Concurrent with Endometriosis Pelvic Pain

Diagnosis of Patients With CPP byCystoscopy and Hydrodistention & Laparoscopy1

10%

IC Alone

20%

Endometriosis

Alone

70%

IC and

Endometriosis

Clinicians should consider the bladder to be the source of CPP, even when endometriosis is present


Pelvic adhesions
Pelvic Adhesions Pelvic Pain

  • Distort normal blood/nerve supply

  • Decreased mobility of organs/hypoxia

  • Pelvic inflammatory disease (PID)

  • Most common Chlamydia

  • Inflammatory reaction

  • Secretion of prostaglandins


Fibromyalgia tender points
Fibromyalgia Tender Points Pelvic Pain

11 or more TP sensitivity of 88% and specificity of 81%



Irritable bowel
Irritable Bowel Pelvic Pain

  • 12% US population

  • 2:1 women

  • Peak age 30-40

  • Increased GI motility and sensitivity to stimulants


Pelvic pain assessment forms
Pelvic Pain Assessment Forms Pelvic Pain

www.pelvicpain.org


Pain diaries

www.reliefinsite.com Pelvic Pain

Pain Diaries


Keys to treatment
Keys to Treatment Pelvic Pain

  • Pain and its perception are located in the nervous system so its treatment must encompass a Mind and Body approach

  • Multiple interactive problems are most likely with CPP so it isn’t which treatment is best but which treatments

  • It usually took time for things to get to where they are so it will be take time to get them back to normal as well

  • Chronic pain affects a family not just an individual patient


How can chiropractic help
How can chiropractic help Pelvic Pain

  • Manipulation increases spinal mobility and improves blood supply by influencing the autonomic nervous system



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