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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

“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
  • 10% out-patient gynecologic visits
  • 20% of laparoscopies
  • 15% of hysterectomies
  • $2.8 billion annually

15% of American women

prevalence
Prevalence

CPP

Migraine

Asthma

Back Pain

features
Features
  • 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
  • Acute pain

Pain is symptom of underlying tissue damage

  • Chronic pain

Pain itself becomes the disease

females unique design
Females - Unique Design
  • 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?

Gynecologic - extra-uterine

Gynecologic - uterine

Urologic

Musculoskeletal

Gastrointestinal

Neurologic

referred pain
Referred Pain

Ovary T10 umbilical area

Uterus T12 lower abdominal wall

Vagina L1 skin over groin

most common culprits
Most common culprits
  • Endometriosis
  • Adenomyosis
  • Interstitial cystitis
  • Irritable bowel
  • Pelvic Adhesions
endometriosis
Endometriosis
  • 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

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
  • 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

slide20

Pathogenesis of IC:Defective Urothelial Barrier

IrritatingSolutes

GAGLayer

Urothelium

Inflammation

IrritatedNerve

slide21

IC is Typically Diagnosed Late 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

slide22

IC Concurrent with Endometriosis

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
  • 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

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

irritable bowel
Irritable Bowel
  • 12% US population
  • 2:1 women
  • Peak age 30-40
  • Increased GI motility and sensitivity to stimulants
keys to treatment
Keys to Treatment
  • 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
  • Manipulation increases spinal mobility and improves blood supply by influencing the autonomic nervous system