Vanderbilt University School of Medicine
VC3 – Vanderbilt Core Clinical Curriculum

Pelvic Pain

Acute and chronic pelvic pain are common symptoms that may result from a variety of causes, including gastrointestinal, urinary, musculoskeletal, and emotional as well as gynecological conditions.

 

************************************************************************************************************************

Prerequisites

************************************************************************************************************************

Describe and discuss:

  • anatomy of the pelvis, abdomen, back, and genito-urinary system
  • pathogenesis and pathophysiology of diseases and conditions that contribute to pelvic pain
  • pharmacology of drugs used to treat pelvic pain
  • epidemiology of pelvic pain

Demonstrate:

  • ability to take a medical history and perform a physical exam
  • ability to perform a pelvic exam
  • basic communication skills

************************************************************************************************************************

Apply Medical Knowledge in the Clinical Encounter

************************************************************************************************************************

1.     Describe the clinical features that help to differentiate one etiology from another: 

  • gastrointestinal
  • urinary
  • musculoskeletal
  • psychiatric
  • gynecological

2.     Describe the signs and symptoms that suggest gynecological etiology.

3.     Describe the signs and symptoms associated with pelvic pain due to non-gynecological disease and conditions:

  • gastrointestinal
  • urinary
  • musculoskeletal
  • psychiatric

4.     Describe risk factors associated with pelvic pain.  

5.     Describe how lab studies would help in the evaluation of pelvic pain, including their indications, limitations, and cost.

6.     Describe how imaging studies would help in the evaluation of pelvic pain, including their indications, limitations, and cost.

************************************************************************************************************************

Diagnose

************************************************************************************************************************

1.     Obtain, document and present an age-appropriate medical history that differentiates among etiologies of disease.

2.     Perform a physical exam, including a pelvic exam, to establish the diagnosis and severity of disease.

3.     Generate a differential diagnosis recognizing specific history and physical exam findings that distinguish causes of pelvic pain (GI, urinary, musculoskeletal, and psychiatric as well as gynecological conditions).

4.     Recommend when to order imaging and laboratory tests, both prior to and after initiating treatment, based on the differential diagnosis. Justify ordering them and consider test cost and performance characteristics as well as patient preferences.

5.     Define the indications for and interpret (with consultation) the significance of the results of appropriate clinical tests.

6.     Perform relevant basic clinical diagnostic procedures.

7.     Record, present, research, critique, and manage clinical information.

************************************************************************************************************************

Develop a Management Plan

************************************************************************************************************************

1.     Describe and discuss indications, mechanism of action, side effects, adverse reactions, and significant interactions of medications that could be prescribed for patients with pelvic pain.

2.     Describe and discuss the indications, benefits and disadvantages of interventions and surgical therapy.

3.     Describe and compare the cost-effectiveness of:

  • various agents within each class of medications
  • interventional strategies
  • surgical approaches

4.     Select an approach to treatment for the patient with pelvic pain based on the diagnosis, evidence about treatment options, patient characteristics, and patient preferences.

5.     Formulate a prognosis for the patient with pelvic pain based on the diagnosis, the treatment plan, and the patient's characteristics.

6.     Communicate the diagnosis, treatment plan, and prognosis of the disease to patients and their families in a caring and compassionate manner, reflecting an understanding of the emotional impact of a diagnosis related to pelvic pain and its potential effect on lifestyle (work performance, sexual functioning, etc.).

7.     Provide education for the patient about his or her treatment plan.

8.     Provide counseling to patients when indicated about issues related to prevention.

9.     Refer for psychological support if indicated.

10.  Access and utilize appropriate information systems to ascertain information about health system and community resources.

11.  Plan for follow-up.

************************************************************************************************************************

Differential Diagnosis

************************************************************************************************************************

Acute and/or Chronic

GYN

  • Ectopic pregnancy
  • Abortion, spontaneous, incomplete
  • Acute salpingitis/ Chronic
  • Tubo-ovarian abscess
  • Endometritis
  • Ovarian neoplasms
  • Ovarian torsion
  • Uterine fibroids
  • Endometriosis
  • Abnormal embryology (blind uterine horn)
  • Adhesions

GI

  • Appendicitis
  • Diveticular disease
  • Meckel’s diverticulum
  • Constipation/ Hemorrhoids

IBS

  • Ulcerative colitis/ Crohn’s
  • Adhesions 

GU

  • Urinary tract infection
  • Pyelonephritis
  • Nephrolithiasis
  • Interstital cystitis 

MS

  • Symphyseal separation
  • Piriformis syndrome
  • Neuropathy 

Psychosocial

  • Sexual/physical/emotional abuse
  • Anxiety disorder
  • Depression