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APGO educational topic number 39
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chronic pelvic pain chronic pelvic pain
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is a common and significant disorder of
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women that represent significant
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disability and represents 10% of all
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referrals to gynecologists the
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objectives of this video are to define
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chronic pelvic pain to define the
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prevalence and common ideologies of
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chronic pelvic pain to describe the
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symptoms and physical exam findings in a
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patient with chronic pelvic pain discuss
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evaluation and management options for
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chronic pelvic pain and to discuss the
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psychosocial issues associated with
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chronic pelvic pain let’s start with the
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basics with a definition there is no
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generally accepted definition of chronic
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pelvic pain but one proposed definition
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includes non cyclic pain that lasts for
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greater than six months that localizes
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to the anatomic pelvis the anterior
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abdominal wall at or below the umbilicus
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the lumbosacral back or the buttocks and
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is of sufficient severity to cause
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functional disability or lead to medical
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care the prevalence of chronic pelvic
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pain is 3.8 percent of women aged 15 to
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73 which is higher than the prevalence
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of migraine 2.1% and asthma 3.7 percent
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moving now to etiology x’ most often the
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pain is associated with several
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diagnoses including gynecologic and non
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gynecologic conditions the list of
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gynecological conditions is extensive
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and includes endometriosis gynecologic
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malignancies ovarian retention syndrome
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pelvic inflammatory disease adhesions
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leiomyoma – benign cystic mesothelioma
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adenomyosis cervical stenosis and
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chronic endometritis of all the
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gynecologic conditions PID in particular
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increases the risk of developing chronic
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pelvic pain 18 to 35 percent of women
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who have had PID will develop chronic
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pelvic pain the mechanism is thought to
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involve chronic inflammation adhesive
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disease and the coexistence of
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psychosocial factors the list of non
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gynecological conditions that can
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contribute to chronic pelvic pain is
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extensive however there are two that are
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worth noting irritable bowel syndrome
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and interstitial cystitis irritable
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bowel syndrome affects fifty to eighty
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percent of women with chronic pelvic
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pain it is defined as recurrent
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abdominal pain or discomfort with a
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marked change in bowel habit for at
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least six months with symptoms
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experienced on Atlee
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three days of the last three months
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interstitial cystitis is a chronic
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inflammatory condition of the bladder
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often characterized by pelvic pain
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urinary urgency frequency and
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dyspareunia let’s move now to evaluation
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it is important to note that the
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successful evaluation and treatment of a
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patient with chronic pelvic pain
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requires a patient and caring physician
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the history and physical is an important
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time in which the physician can both
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gather information and establish a
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trusting rapport remember that there is
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a significant correlation between a
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history of abuse and chronic pain during
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your history asked for a description and
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timing of the symptoms perform a
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thorough medical surgical menstrual and
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sexual history and obtain a psychosocial
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history and especially ask about
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depression depression is one of the
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several predictors of pain severity and
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is a significant indicator of
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responsiveness to treatment the physical
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examination should be directed towards
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trying to uncover possible causative
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pathologies of the pain the carnot sign
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is a tensing of the abdominal wall while
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raising the leg or chin which points to
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a myofascial component to pain also
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don’t forget to obtain cervical cultures
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the management often involves a
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multidisciplinary approach which may
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include psychiatric evaluation physical
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therapy gastroenterology urology and/or
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anesthesia if the cause of the pain is
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known then it should be treated if the
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cause of the pain is unknown then
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therapy will focus on pain relief
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medical therapy options to consider
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would be suppression of ovulation with
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oral contraception or a gnrh agonist may
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be useful also possible referral to GI
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for IBS or urology for interstitial
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cystitis surgical therapies such as
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hysterectomy should only be used after
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non gynecological causes have been ruled
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out this concludes the aapko video on
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chronic pelvic pain we have defined the
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prevalence comedy ology symptoms and
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physical exam findings as well as
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evaluation and management options for
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this common disease process