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Case History

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Image not available. A 32-year-old woman presents with a ten-year history of pelvic pain which is present most days of the month but has cyclical exacerbations. She is nulliparous, although she underwent a surgical termination of pregnancy (TOP) at age 17 years. Currently she is not in a stable relationship. Previously she had two diagnostic laparoscopies, both of which were completely normal.

What areas should you explore in the history?

What are you looking for on examination?

Are any investigations justified?

What treatment might be appropriate?

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Background

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Image not available. Chronic pelvic pain (CPP) is a symptom not a diagnosis and is defined as 'intermittent or constant pain in the lower abdomen or pelvis of at least six months' duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy'.1 It has been shown to have an annual prevalence of 38/1000 in women aged 15–73 years old, which is comparable to asthma (37/100) and back pain (41/1000).2 A number of studies have shown that many women (e.g. 25% after 3–4 years follow-up in one study) receive no diagnostic label even after multiple invasive investigations and many years.2 The symptom of CPP can be caused by pathology in a number of organ systems which overlap many specialities, contributing to diagnostic delay (see Table 4.1). Furthermore, more than one pathology can coexist and psychological factors also alter the experience of the pain. It has been shown that women with CPP have an increased incidence of negative cognitive features and emotional traits; however, it is not possible to ascertain whether these are involved in generating the chronic pain state or if they are a consequence of living with the pain and frequent attempts to justify its reality or severity to health professionals.3 A number of factors have been identified which predispose women to developing CPP,4 although the symptom occurs across all socio-economic groups. It has been shown that women want validation of their symptoms and reassurance from the consultation5 and therefore taking a history alone can be therapeutic.

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Table Graphic Jump Location
Table 4.1Possible contributory factors in CPP
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What areas should you explore in the history?

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A detailed history of the pain should be taken; however, it may be necessary to suggest to the woman that she keeps a detailed pain diary over the next one to two cycles so that patterns can be identified. The nature, location and radiation of the pain are important. Sharp ...

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