AUS 05 History and Physical Examination

8/7/2019 AUS 05 History and Physical Examination

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How to do a History and Physicalon a Female Chronic Pelvic Pain

Patient

C. Paul Perry, MD, FACOG

Pelvic Pain CenterBirmingham, AL, USA


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PAIN

AN UNPLEASANT SENSORY ANDEMOTIONAL EXPERIENCE ASSOCIATEDWITH ACTUAL OR POTENTIAL TISSUE

DAMAGE*

* INTERNATIONAL ASSOCIATION FOR THE STUDY OF PAIN


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Why is Chronic Pelvic Painso Different?


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ACUTE vs CHRONIC PAIN

ACUTE PELVIC PAIN: SYMPTOM OFUNDERLYING TISSUE INJURY ANDDISEASE

CHRONIC PELVIC PAIN: PAIN BECOMESTHE DISEASE


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CHRONIC PELVIC PAIN

CHRONIC PAIN:PAIN LASTING6 MONTHS ORLONGER

CHRONIC PELVIC

PAIN SYNDROME:CHRONIC PELVICPAIN CAUSINGEMOTIONAL AND

BEHAVIORALCHANGES


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Viscerosomatic Convergence and

Referred Pain


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Viscerosomatic Convergence and

Pelvic Floor Myalgia


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Viscerovisceral Hyperalgesia


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Neuroinflammation

Antidromic Transmission


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Pathophysiology

Altered Pain-Processing

Repeat Stimulation of NociceptiveNeurons

1. Changes Nerve Fibers

2. Lowers Threshold

3.

Causes Peripheral Sensitization4. Exaggerates Transmission Response

5. Recruits higher and Lower Neurons

6. Produces Self-Sustaining Activation


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SOURCES OF CHRONIC

PELVIC PAIN

GYNECOLOGICAL

UROLOGICAL

GASTROINTESTINAL

MUSCULOSKELETAL

NEUROPATHIC

OTHER


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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.


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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 Septuplets1. Endometriosis, IC, PCS, VVS, PFTM, IBS

2. Fibromyalgia


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Generators

178 patients with Chronic Pelvic Pain1

134 (75%) Endometriosis

159 (89%) Interstitial Cystitis

115 (65%) had both Endometriosis

and IC1. Chung MK, Chung RP, Gordon D. Interstitial cystitis and endometriosis in

patients with chronic pelvic pain: the evil twins syndrome. JSLS2005;9:25-9.


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Necessity of Multidisciplinary

Approach


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CHRONIC PELVIC PAINMOST FREQUENTLY MISSED COMPONENTS OF

CHRONIC PELVIC PAIN

1. ABDOMINAL TRIGGER POINTS

2. VESTIBULITIS

3. PELVIC FLOOR MYALGIA

4. HERNIAS5. PELVIC CONGESTION

6. INTERSTITIAL CYSTITIS


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Pelvic Pain Assessment Forms

May be downloaded in PDF format fromweb site: www.pelvicpain.org


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History

DetailedFocusedPelvic Review of systemsBiopsychosocial Model


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International Pelvic Pain

Society Physical Form


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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


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Fibromyalgia Tender Points

(must have at least 11/18)


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Abdominal Wall Trigger Points


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Physical Examination:

Abdominal Tenderness over the

ovarian point Suggests pelvic

congestion syndrome

Pain thought to bedue to compression ofovarian veins

Ovarian

Point


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PELVIC CONGESTION


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HERNIAS INGUINAL

INDIRECT DIRECT FEMORAL

SCIATIC OBTURATOR Ventral (incisional) Others: umbilical, Spigelian, paravesical,

perineal


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INGUINAL HERNIAS


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Sciatic Hernia


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Sciatic Hernia


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OBTURATOR HERNIAS


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Q-tip Test for Vulvovestibulitis


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Pubococcygeus Screen


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Piriformis Screen


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Physical Examination: Pelvic

Traditional bimanualexamination is the

lastportion of thepelvic examination

Uterus

Adnexa

Anorectum Many layers palpated;

non-specific findingslikely


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Physical Examination: Pelvic

Traditional bimanualexamination is the

lastportion of thepelvic examination

Uterus

Adnexa

Anorectum Many layers palpated;

non-specific findingslikely


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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 andFamily

Setup Appropriate Diagnostic Studies

Explain the Reasons for Complexity

Documents

AUS 05 History and Physical Examination