Vital signs BP 100/70 mmHg, BT ไม่ได้วัด PR 80/min, RR 20/min GAA young female, active HEENTNo pale conjunctiva, no icteric sclera, no lymphadenopathy CVSNormal S1 and S2, no murmur RSClear breath sound, no adventitious sound
Abdome n No distension, normal bowel sound, soft, not tender, no palpable mass Genitali a PV - not test Previous exam at private hospital : unremarkable Extremit ies No edema, not seen rash or skin lesion SkinNot seen skin lesion or evidence of trauma
Chronic pelvic pain Cyclic (or noncyclic) pain that lasts longer than 6 month Localized to pelvis, anterior abdominal wall, below umbilicus or buttocks Sufficient severity to cause functional disability or required medical care ACOG Committee on Practice Bulletins. ACOG Practice Bulletin No. 51. Chronic pelvic pain. Obstet Gynecol 2004; 103:589–605.
A. Physical and sexual abuse A. Physical and sexual abuse B. Gynecologic problems B. Gynecologic problems C. Non gynecologic medical problems C. Non gynecologic medical problems D. Psychologic al problems D. Psychologic al problems Bowel dysmotility Musculoske letal dysfunction Endometri osis Pelvic adhesions Dysmenorr hea and Mittelschmer z Chronic PID Depress ive disorder Somatof orm disorders
GynecologyUrologic EndometriosisInterstitial cystitis Pelvic adhesions Chronic UTI Pelvic varicosities Urethral syndrome Pelvic inflammatory diseaseUrinary calculi AdeomyosisRadiation cystitis Vulvodynia Musculoskeletal Uterine myomasMyofascial pain (abdominal wall or pelvic floor muscles) Ovarian cyst, ovarian tumorCoccygeal or low back pain Tuberculous salpingitisNerve pain GastrointestinalPsychological Irritable bowel syndrome Childhood physical or sexual abuse Inflammatory bowel diseaseEmotional abuse Chronic constipationPartner violence Colitis Malignancies DiverticulitisBladder Post operative Gynecologic AdhesionsColon Previous tubal ligation
% of CCP (controversial role of pain) Cause Acute or chronic inflammatory disorder Physico-chemical trauma (surgery)
30% of CPP (12% in combination with another pelvic pathology) Pelvic congestion syndrome (PCS) Ovarian and pelvic (internal illiac) varicies Venous incompetence, reduced venous clearance in pelvis/ reflux Unknown pathophysiology
Unknown causedLt > Rt Exacerbation of pain : during or after sexual intercourse 10-15% overactive bladder Co-existing with endometriosis Chronic pelvic, suprapubic, perineal, vulvo-vaginal pain, pressure with urinary urgency, diurnal frequency, nocturia
Functional dysmotility disorder of the bowel 65-79% of woman with CPP Uncertain etiology and multifactor pathophysiology Altered bowel motility Visceral hypersensitivity Psychosocial factor
Pattern of the pain Associated symptom and red flag sign Previous surgery, child delivery Menstrual and contraception Life situation, abuse Patient’s affect
General exam PV and focus on bladder and urethra Bimanual or rectovaginal examination Piriformis muscle Abdominal deformity “Carnett’s sign” Back and inguinal area
CPP has similar to the prevalence of migraine, asthma and low back pain (in UK) 4 most common causes of CPP are (endometriosis) pelvic adhesions, pelvic varicies, interstitial cystitis, and irritable bowel syndrome. Women with CPP have more than one cause for their pain.
Unclear what to do with the answers Unfamiliarity with treatment approaches Uncertainty about the next question Fear to offending patient Lack of obvious justification Generational obstacles Fear of sexual misconduct charge Sometimes perceived irrelevant Unfamiliarity with some sexual practices
Morbidity and motality – STDs and HIV/AIDS Symptoms of illness Treatment side effects Past may explain present problems Function potentially lifelong Dysfunctions and difficulties are common Association with health and happiness Why not? May be negligent if ignored