4: Pelvic Pain

Question 1

T/F Women experiencing chronic pelvic pain (CPP) are reported to use significantly more medications, have nongynecologic operations much more often, and are more likely to have a hysterectomy and reduced quality of life than women who do not have pelvic pain.

Answer 1

True

Question 2

What are the 3 most common findings on laparoscopy for CPP?

Answer 2

1. Endometriosis (33%)
2. Adhesions (24%)
3. Abscence of pathologic condition (35%)

Question 3

Acute pain is pain that lasts less than how many months?

Answer 3

3

Question 4

During the pelvic exam, pain with deep palpation may indicate what?

Answer 4

Endometriosis

Question 5

This type of pain is:

• “Pain with a purpose.”
• Arises from damage or injury to non-neural tissue.
• Is a result of activation of receptors.
• Serves a defense mechanism that alerts the sufferer to tissue injury (such a inflammatory pain).
• When the noxious stimulus is released, this kind of pain quickly ceases.
• This pain subsides with proper treatment and/or healing of injury.

Answer 5

Nociceptive pain

Question 6

Coarse bands of tissue that connect organs to other organs or to the abdominal wall in places where there should be no connection.

Answer 6

Adhesions

Question 7

What is treatment for mod-severe OHSS?

Answer 7

Treatment of moderate to severe disease includes careful fluid management particularly directed at maintenance of intravascular blood volume. After a few days, third-space fluid is absorbed into intravascular spaces, hemoconcentration reverses, and natural dieresis occurs. Intravenous fluids can be discontinued as oral intake of fluids becomes adequate. Complete resolution usually occurs 10 to 14 days after the initial onset of symptoms. Surgery is required in extreme cases, such as in the case of a ruptured cyst, ovarian torsion, or internal hemorrhage. Aggressive palpation of the abdomen can precipitate follicular rupture and should be avoided if OHSS is suspected.

Question 8

Mild OHSS is a self-limiting disease, and treatment should be conservative and aimed at symptoms. Medical therapy suffices for most women. Nevertheless, mild OHSS can evolve into moderate or severe disease, particularly if _____ occurs.

Answer 8

Mild OHSS is a self-limiting disease, and treatment should be conservative and aimed at symptoms. Medical therapy suffices for most women. Nevertheless, mild OHSS can evolve into moderate or severe disease, particularly if conception occurs.

Question 9

How do you differentiate abdominal wall pain from visceral sources of pain?

Answer 9

Perform the Carnett test: Ask the woman to raise her head off of the table while she is in the supine position and then have her straight-raise her legs; the clinician then palpates the area. If the woman has tenderness to palpation, the source is most likely abdominal wall pain.

Question 10

A commonly overlooked facet of the physical examination is _____ to the acute and chronic pain that the woman may have endured for years.

Answer 10

A commonly overlooked facet of the physical examination is sensitivity to the acute and chronic pain that the woman may have endured for years.

Question 11

Your patient with CPP comes to see you. You classify her pain as either gynecologic or non-gynecologic. You further classify it as cyclic or non-cyclic. Are these correct categories for labeling CPP?

Answer 11

Yes

Question 12

This type of pain can be:

• Superficial or deep.
• Sharp or dull.
• Usually localized.

Answer 12

Somatic pain

Question 13

T/F Women usually report lower levels of pain, as their pain threshold is higher. These differences usually appear during adolescence.

Answer 13

False. Women usually report higher levels of pain, as their pain threshold is higher. These differences usually appear during adolescence.

Question 14

Chronic pain is pain that lasts at least how many months?

Answer 14

6

Question 15

This mimics IBS can can present with perforations or abscesses that produce peritonitis.

Answer 15

Diverticulitis

Question 16

T/F Women with CPP and a history of physical abuse as an adolescent or an adult reported substantially greater pain-related disability compared to women reporting no abuse in these categories.

Answer 16

True

Question 17

What is the imaging study of choice for CPP?

Answer 17

US, often followed by CT

Question 18

What are 2 widely accepted forms to help with diagnosis of pelvic pain?

Answer 18

1. The International Pelvic Pain Society provides the Pelvic Pain Assessment Form
2. The Institute for Women in Pain provides the Initial Female Pelvic Pain Questionnaire

Question 19

When would surgical lysis of adhesions be recommended?

Answer 19

If there is evidence of bowel ostruction or infertility.

Question 20

What signs help differentiate between a higher, acute intestinal obstruction and colonic obstruction/

Answer 20

• Higher and acute obstruction presents with early vomiting
• Colonic obstruction presents with greater degree of abdominal distention and obstipation

Question 21

Occurs when an ovary is purposely left behind after hysterectomy.

Answer 21

Ovarian retention syndrome

Question 22

Which laboratory tests should be included in women with CPP?

Answer 22

1. CBC
2. ESR
3. Serologic syphilis
4. UA and urine culture (where appropriate)
5. Pregnancy test (where appropriate)
6. Vaginal smears/cultures to r/o infx
7. Stool guaiac to evaluation GA pathology
8. TSH

Question 23

_____ is considered the gold standard for evaluation of chronic pelvic pain and is used when pelvic pathology cannot be detected by physical examination or other testing; it allows direct visualization and may enable direct treatment of intra-abdominal pathology.

Answer 23

Laparoscopy is considered the gold standard for evaluation of chronic pelvic pain and is used when pelvic pathology cannot be detected by physical examination or other testing; it allows direct visualization and may enable direct treatment of intra-abdominal pathology.

Question 24

In reproductive age, which women with CPP have more pregnancies, c-sections, pelvic surgeries, pain, stress, intense physical exercise, and sadness?

Answer 24

CPP with functional constipation

Question 25

Occurs when some of the ovarian tissue is left behind after an oophorectomy.

Answer 25

Ovarian remnant syndrome

Question 26

If surgical lysis of adhesions is performed, barrier materials such as _____ or _____ can be utilized to prevent renewed adhesion formation.

Answer 26

If surgical lysis of adhesions is performed, barrier materials such as oxidized regenerated cellulose or hyaluronic acid with carboxymethylcellulose can be utilized to prevent renewed adhesion formation.

Question 27

What finding during a pelvic exam may be indicative of myofascial pain?

Answer 27

Discomfort from pressure along the pelvic floor when palpating the vagina.

Question 28

T/F Increased susceptibility to pain is linked to factors such as English as a second language, race and ethnicity, income and education, gender, age, geographic location, veterans, cognitive disabilities, surgical history, cancer diagnosis, and end-of-life status.

Answer 28

True

Question 29

Occurs when uterine blood vessels remain chronically dilated, creating reflux of blood in the ovarian veins.

Answer 29

Pelvic congestion syndrome

Question 30

Name 3 peripartal risk factors for CPP after pregnancy.

Answer 30

1. Poor MSK conditioning
2. Delivery of a large baby
3. Lumbar lordosis

Question 31

The risk of _____ among individuals with chronic pain is double that of the general population.

Answer 31

The risk of substance abuse among individuals with chronic pain is double that of the general population.

Question 32

Symptoms of increasing severity include enlarging abdominal girth, acute weight gain, and abdominal discomfort.

Answer 32

Moderate to severe ovarian hyperstimulation syndrome (OHSS)

Question 33

Cesarean birth has been linked to _____ and _____.

Answer 33

Cesarean birth has been linked to lower abdominal wall pain and adhesions.

Question 34

Ovarian hyperstimulation syndrome (OHSS) can result from treatment for _____. OHSS refers to a combination of ovarian enlargement caused by multiple ovarian cysts, whose rupture may create a shift of fluids from the intravascular spaces. This can potentially become a life-threatening complication of ovulation induction.

Answer 34

Ovarian hyperstimulation syndrome (OHSS) can result from treatment for infertility. OHSS refers to a combination of ovarian enlargement caused by multiple ovarian cysts, whose rupture may create a shift of fluids from the intravascular spaces. This can potentially become a life-threatening complication of ovulation induction.

Question 35

T/F Many women with pelvic pain have more than one diagnosis as the possible cause of their pain, and women who have multiple diagnoses related to pelvic pain have been shown to suffer greater pain than their counterparts who have one diagnostic cause.

Answer 35

True

Question 36

Which disease/processes are better identified with CT?

Answer 36

1. Appendicitis
2. Endometriosis
3. Endometriomas
4. Adhesions
5. Neoplastic processes

Question 37

What is medical treatment for adhesions?

Answer 37

1. If symptoms are exacerbated during specific portions of the menstrual cycle (e.g., menses, luteal phase, follicular phase), then medical therapy should be considered with use of hormonal suppression of the cycle.
2. If symptoms are constant, then use of nonsteroidal anti-inflammatory drugs (NSAIDs) and other forms of analgesics should be considered, with possible referral to a pain specialist

Question 38

T/F Many clinicians treat CPP empirically becuase the causes of CPP are not well established.

Answer 38

True

Question 39

This type of pain is:

• “Pain without purpse.”
• Arises as a direct consequence of a lesion or disease affecting the somatosensory system.
• Occurs when noxious stimuli have sustained action, producing continuous central sensitization and loss of neuronal inhibition that becomes permanent.
• Decreased pain threshold results.
• In CPP, this pain presents as burning, paresthesia, or lancing pain.

Answer 39

Neuropathic pain

Question 40

The pathophysiology involved is unclear, but the syndrome is believed to result from a malfunction or absence of functional valves within ovarian veins, resulting in retrograde blood flow and venous dilation.

Answer 40

Pelvic congestion syndrome

Question 41

The myriad of symptoms range from mild intermittent abdominopelvic pain to constant pain with gastrointestinal (constipation, bloating, dyschezia), gynecologic (dyspareunia, dysmenorrhea, focal lateral or central pelvic and adnexal pain), and musculoskeletal symptoms (abdominal wall tenderness).

Answer 41

Adhesions

Question 42

Which ovarian cyst is the most likely to rupture and mimics ectopic pregnancy?

Answer 42

Corpus luteum cyst

Question 43

A pregnancy where both an ectopic and intrauterine (normal) pregnancy occur at the same time.

Answer 43

Heterotopic pregnancy

Question 44

What are the 2 main sources of pelvic pain?

Answer 44

1. Visceral
   
   1. Gynecologic
   2. GU
   3. GI
2. Somatic
   
   1. Pelvic bones
   2. Ligaments
   3. Muscles
   4. Fascia

Question 45

What is the most common cause of pelvic pain in adolescents?

Answer 45

Gynecologic (interestingly, pelvic pain is more likely to be of gynecologic, rather than GI/IBS, in this age group)

Question 46

This type of pain can be:

• Transmitted through the autonomic nervous system.
• Dull or crampy.
• Poorly localized.
• Possible N/V and sweating.

Answer 46

Visceral pain

Question 47

T/F Men and women experience pain in a similar fashion.

Answer 47

False. There is no longer any debate about whether there are sex and gender differences in pain. The evidence reveals that they do, indeed, exist.

Question 48

How can you improve pain mapping during a digital pelvic exam?

Answer 48

Through use of a tenderness-guided endovaginal ultrasound (EVUS) examination. This technique entails use of the EVUS probe as an extension of the clinician’s digit to palpate difficult-to-reach structures while also imaging the anatomic landmarks to confirm the structure that is being palpated. EVUS examination is especially useful in making the differential diagnosis of endometriosis.

Question 49

A technique performed under local anesthesia during laparoscopy. During this procedure, the woman remains awake and can be questioned about her pain.

Answer 49

Conscious pain mapping

Question 50

3 causes of adhesions.

Answer 50

1. Surgeries
2. Infection
3. Endometriosis

Question 51

In nearly half of all women with CPP, their condition will be due to _____ and _____.

Answer 51

In nearly half of all women with CPP, their condition will be due to pelvic inflammatory disease and lower genital tract infections (e.g., cervicitis, candidiasis, Bartholin’s abscess).

Question 52

What is the most common source of acute pelvic pain in women?

Answer 52

Appendicitis