Diagnosing Chronic Pelvic Pain
▸ Once a diagnosis has been made, physicians have a tendency to stay with the diagnosis; they do not reinvestigate for other causes. Unfortunately, chronic pelvic pain can have multiple etiologies.
▸ Physicians can be uncomfortable initiating a discussion of abuse issues with their patients, thus omitting the evaluation of a very real aspect of chronic pelvic pain.
I have asked Dr. Fred Howard to present the first of two articles for the Master Class in gynecologic surgery. In this article, he discusses the diagnostic approach to chronic pelvic pain; in April, he will present therapeutic options.
Dr. Howard, who is associate chair for academic affairs, director of the division of gynecologic specialists, and professor of ob.gyn. at the University of Rochester (N.Y.), is a world leader in the arena of chronic pelvic pain. Not only has he authored numerous peer-reviewed journal articles and book chapters on the condition, but he is also the coeditor of one of the essential authoritative resources on the subject, “Pelvic Pain: Diagnosis and Management” (Philadelphia: Lippincott Williams & Wilkins, 2000).
Main Concepts For Evaluations
▸ Obtain a thorough and complete history in the following areas:
Pain
Gynecologic
Gastrointestinal
Urinary
Musculoskeletal
Psychological
Neurologic
Prior evaluations
Prior treatments
▸ Use a questionnaire.
▸ Direct the physical examination to “pain mapping.”
▸ Do not expect laboratory and imaging studies to add much to your evaluation:
Order tests that are needed to rule out life-threatening diseases.
Order tests that will definitively confirm your clinical diagnoses.
▸ Expect common diagnoses that have level A evidence of association with CPP:
Irritable bowel syndrome
Interstitial cystitis
Myofascial trigger points
Depression
Endometriosis
Chronic pain syndrome
▸ Expect more than one diagnosis.
▸ Appreciate that chronic pain syndrome is often a diagnosis.
▸ Do not assume that laparoscopy is essential; it is usually not needed for a diagnosis.
