This means that we must take a systematic, step-by-step approach to reproducing the pain through gentle palpations and physical positioning and maneuvering.
When I do an examination, I divide it into standing, sitting, supine, and lithotomy exams. The standing exam is mainly an evaluation for musculoskeletal problems, and should specifically seek evidence of abdominal, inguinal, or femoral hernias; fibromyalgia; lumbosacral disk disease; short leg syndrome; and postural abnormalities.
The supine exam consists of a series of maneuvers and tests, from active leg flexion and obturator and psoas sign testing, to abdominal palpation and groin and pubic symphysis evaluation. It is important to initially palpate the abdominal wall with a light touch—almost superficially at first—while you note hyperesthesias or hypersensitivity of the skin and check for superficial abdominal reflexes. Then use single-digit palpation to look for myofascial or trigger-point pain.
An abdominal wall-tenderness test (known as Carnett's test), in which the patient tenses her abdominal muscles while you palpate an area of tenderness, can be used to distinguish myofascial tenderness or trigger points from visceral tenderness. Pain that increases during the test is usually of myofascial origin, or comes from the abdominal wall itself. If the pain is decreased or unchanged, it likely is not myofascial.
Myofascial pain is most often related to trigger points and can be the result of hernias, hematomas, infections, or trauma.
It is important also to specifically evaluate any scars for abnormal tenderness.
Once you have moved through these components, you can finish the supine examination with a more classic approach aimed at detecting distention, masses, ascites, and other irregularities.
The most important thing to consider for the pelvic examination is that it should always be done with a single finger on a single hand. The objective is to identify focal areas of abnormal tenderness in any pelvic structure. This includes the pelvic floor muscles (levators, piriformis, obturators), rectovaginal septum, cul-de-sac, vulvar vestibule, urethra, bladder, Alcock's canal, uterosacral ligaments, cervix, lower uterine segment, uterine fundus, adnexae, pelvic ureters, anus, coccyx, and rectum.
Beyond the Physical Exam
It is then appropriate to perform laboratory and other diagnostic tests as indicated by the history and physical exam. Overall, such tests do not add much to the evaluation. They are important, however, for ruling out potentially life-threatening conditions or for verifying suspected diagnoses.
If you think your patient has interstitial cystitis, for example, you would probably move on to cystoscopy or potassium sensitivity testing. If you think your patient has endometriosis, you may perform a laparoscopy. If colorectal cancer is a concern, then referral for a colonoscopy might be the best option.
In general, we should be guided in our differential diagnosis by seeking those diagnoses for which we have the best evidence of causal or associative roles in chronic pelvic pain. These include interstitial cystitis, irritable bowel syndrome, endometriosis, depression, myofascial pain, and chronic pain syndrome. This does not mean we will never diagnose disorders for which the evidence of association with chronic pelvic pain is weak; it just means that these are not the diagnoses that we should seek initially.
We must not be surprised, moreover, when our patients have more than one diagnosis. In fact, we should anticipate and expect more than one. And more often than not, the pain itself will be a diagnosis and not just a symptom. Although it is frustrating to us and to our patients, in some cases chronic pain syndrome may be the only diagnosis that can be confirmed.
An Individual's Pain, Society's Pain
Chronic pelvic pain is a staggering problem. Medical costs have been estimated at $1–$2 billion per year. Missed work and decreased productivity are believed to affect business negatively at a cost of $15 billion per year. Chronic pelvic pain is responsible for 10% of ambulatory referrals to gynecologists, 20% of all hysterectomies for benign disease, and 40% of all laparoscopies. Moreover, 15% of women have reported chronic pelvic pain within the past 3 months.
Despite this, we as physicians do a poor job of diagnosing and managing chronic pelvic pain. Several reasons, including the following, account for this shortcoming:
▸ Chronic pelvic pain patients require a real time commitment. Because time is our greatest commodity, the lengthy process of reviewing voluminous records, taking a detailed history, and carrying out a meticulous examination can be quite exasperating for a busy practitioner.
▸ Evaluation and treatment generally reflect our training. That is, we tend to make gynecology-related diagnoses and to recommend treatment within our skill set, just as urologists and gastroenterologists would make GU- and GI-related diagnoses and treatment recommendations.