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APPENDIX: Chronic Pelvic Pain: Self-assessment Multiple Choice Questions
BaillieÁre's Clinical Obstetrics and Gynaecology Vol. 14, No. 3, pp. A1±A12, 2000
doi:10.1053/beog.2000.0130, available online at http://www.idealibrary.com on
APPENDIX Chronic Pelvic Pain: Self-assessment Multiple Choice Questions L. C. Foong Consultant and Senior Lecturer Department of Obstetrics and Gynaecology, National University Hospital, Lower Kentridge Road, Singapore, 119074
For each part of each question, answer true or false. The answers are shown on page A7 with explanations. Chapter 1 1. Chronic pelvic pain (CPP): (a) only aects women. (b) is the second most common indication for laparoscopy in Britain. (c) is not associated with dyspareunia. (d) is typically cyclical in nature. (e) only aects women of reproductive age. 2. Regarding CPP: (a) the diagnosis can usually be made by taking a suciently detailed history. (b) a diagnostic laparoscopy is the gold standard investigation. (c) the cause must be non-gynaecological in the absence of visible pathology on laparoscopy. (d) the management should always include a detailed sexual history from the woman. (e) the management should always include a detailed sexual history from the partner. 3. The following diagnoses can be made from the history alone: (a) irritable bowel syndrome. (b) endometriosis. (c) bowel adhesions. (d) pelvic in¯ammatory disease. (e) nerve entrapment. 1521±6934/00/0300A1+12 $35.00/00
c 2000 Harcourt Publishers Ltd. *
A2 Appendix
4. The following are common causes of CPP: (a) ovarian remnant syndrome. (b) urethral syndrome. (c) endometriosis. (d) acute appendicitis. (e) sexual abuse. Chapter 2 1. CPP: (a) is de®ned as pain that has been present for at least 6 months. (b) leads to signi®cantly altered physical and sexual activity. (c) is much more prevalent in the USA than in the UK. (d) has an annual prevalence in UK primary care similar to asthma. (e) disappears with the onset of the menopause. 2. The following are risk factors for CPP: (a) Caucasian race. (b) marital instability. (c) increased parity. (d) higher educational status. (e) increasing age. 3. The prevalence of CPP in the community: (a) is approximately 30% (b) can be estimated by investigating hospital-based populations. (c) has almost certainly been underestimated. (d) is greater in developed than developing countries. (e) is aected by the availability of medical care. Chapter 3 1. Psychological symptoms in CPP: (a) are increased in the presence of a normal pelvis on laparoscopy. (b) are more likely the more pain complaints the woman has. (c) are proportional to the duration of pain. (d) should be treated before treating the pain. (e) are indicative of a poor prognosis. 2. The following can be used to assess the severity of CPP: (a) visual analogue scales. (b) McGill questionnaires. (c) short-form 36 health questionnaire. (d) mental health questionnaire. (e) quality-adjusted life years (QUALYs) score.
Appendix A3
Chapter 4 1. The following are useful diagnostic tests in the evaluation of CPP: (a) transabdominal ultrasound scanning. (b) magnetic resonance imaging. (c) abdominal X-ray. (d) hysterosalpingogram. (e) computed tomography. 2. Adenomyosis: (a) is a cause of CPP. (b) is best visualized with MRI. (c) is best treated medically. (d) can be eectively treated by adenomyomectomy. (e) can be eectively treated by pre-sacral neurectomy. 3. The following causes of CPP can be diagnosed using transvaginal ultrasound: (a) pelvic venous congestion. (b) adenomyosis. (c) peritoneal endometriosis. (d) bowel adhesions. (e) interstitial cystitis. 4. MRI in the diagnosis of CPP: (a) is superior to CT scanning. (b) the spatial and contrast resolution are insucient to render it a useful test in the diagnosis of CPP. (c) cannot distinguish between ®broids and adenomyosis. (d) cannot be used in women of reproductive age due to the risk of ionizing radiation. (e) is superior to ultrasonography. Chapter 5 1. Peritoneal endometriosis: (a) is the most common abnormal laparoscopic ®nding in women with CPP: (b) is the most common abnormal laparoscopic ®nding in women without CPP. (c) can usually be diagnosed at laparoscopy by visualisation alone. (d) ideally the diagnosis should always be con®rmed by peritoneal biopsy. (e) can be eectively treated by vaporization or ablation of visible lesions. 2. Endometriosis: (a) is often the cause of CPP. (b) is always seen as a ``powder-burn'' lesion. (c) may be associated with no pain symptoms at all. (d) can be underdiagnosed due to the presence of unrecognized lesions. (e) commonly presents as cribiform peritoneal defects.
A4 Appendix
3. At laparoscopy: (a) the presence of adhesions always signi®es previous PID. (b) in the absence of other abnormal pathology the presence of pelvic adhesions is a reliable predictor of pelvic pain. (c) the prevalence of adhesions is similar in women with and without CPP. (d) the AFS score correlates well with the duration and severity of pain. (c) adhesiolysis is an eective therapeutic measure to relieve CPP. 4. The following are recognized causes of CPP that can be diagnosed during laparoscopy: (a) corpus haemorrhagicum. (b) bleeding corpus luteum. (c) ectopic pregnancy. (d) residual ovary syndrome. (e) pelvic venous congestion. 5. In women with CPP and a negative laparoscopy: (a) this indicates there is no pelvic disease and the woman can be reassured. (b) the pain must be psychosomatic in origin. (c) neurectomy is an eective treatment option. (d) hysterectomy is an eective treatment option. (e) these women should be told preoperatively that there is a 15% chance that no diagnosis will be found at the time of laparoscopy. Chapter 6 1. Medical treatment of women with CPP using progestagens: (a) should always be the ®rst line treatment of choice. (b) may be eective in women with endometriosis. (c) is of no value in women where pelvic adhesions are the only pathology present. (d) is more eective when combined with psychotherapy. (e) can be used for long term therapy as there are few side-eects. 2. The following have been used eectively in the treatment of pain in women with CPP: (a) anti-depressants. (b) progestagen-only contraceptive pill. (c) dihydroergotamine. (d) progestagens. (e) gonadotrophin-releasing hormone analogues (GnRHa). Chapter 7 1. Operative laparoscopy in women with CPP: (a) is preferable to laparotomy. (b) all adhesions should be divided wherever visualized. (c) allows all suspicious lesions to be biopsied. (d) has resulted in endometriosis being diagnosed more frequently. (e) can be used to con®rm the cause of pain.
Appendix A5
2. Sensory innervation in the pelvis is derived from: (a) superior hypogastric plexus. (b) inferior hypogastric plexus. (c) nervi erigentes. (d) ovarian plexus. (e) obturator nerve. 3. Pelvic denervation alone has been used successfully to treat the following conditions: (a) dyspareunia. (b) dysmenorrhoea. (c) endometriosis. (d) mittelschmerz. (e) clot colic. 4. Hysterectomy in women with CPP: (a) reveals a normal uterus in approximately 35% of cases. (b) can eectively treat pelvic pain. (c) endometrial ablation should be performed instead in younger women who have not completed their family. (d) should always be combined with oophorectomy. (e) pain relief is directly related to the degree of blood loss at the time of the operation. Chapter 8 1. Chronic pelvic pain: (a) can always be attributed to organic disease. (b) can be explained by the gate control theory of pain perception. (c) always involves both physical and psychogenic components. (d) is usually not aected by social or cultural factors. (e) results in adaptive behavioural and postural changes. 2. The following are involved in the perception of pain: (a) nociception. (b) irritation. (c) somatisation. (d) internalization. (e) proprioception. 3. The following are important factors associated with CPP: (a) childhood sexual abuse. (b) childhood physical abuse. (c) schizophrenia. (d) manic depression. (e) diabetes.
A6 Appendix
Chapter 9 1. A pelvic pain clinic should ideally incorporate the following elements: (a) gynaecologist. (b) pain counsellor. (c) soft lighting. (d) psychotherapist. (e) anaesthetist. 2. Women with CPP often present with: (a) anxiety. (b) depression. (c) drug overdose. (d) anger hostility. (e) apareunia. 3. The following are used in the management of CPP: (a) neurolytic superior hypogastric plexus block. (b) trigger point injections. (c) short wave diathermy. (d) myofascial release techniques. (e) pethidine.
Appendix A7
ANSWERS Chapter 1 1. (a) False; (b) False; (c) False; (d) False; (e) False. Chronic pelvic or lower abdominal pain is a well-recognized problem in men. Pain constitutes the most common indication for laparoscopy in Britain (Chamberlain & Brown, 1978). CPP may be associated with dyspareunia or dysmenorrhoea, but it should be distinguished from them. The pain may be cyclical or continuous. Although in clinical practice most gynaecologists see women with CPP who are of reproductive age, it can in fact aect women at any age. 2. (a) False; (b) False; (c) False; (d) True; (e) False. Unlike irritable bowel syndrome, there is no consensus regarding the `typical' symptoms experienced by women with CPP. This arises because CPP has multiple causes. A laparoscopy, whilst important, shows no identi®able organic cause for pelvic pain in 40±60% of cases. Therefore, the absence of visible pathology does not exclude organic causes (eg. adenomyosis) or functional problems. Due to the high prevalence of sexual abuse in women with CPP, it is helpful to take a detailed sexual history, particularly of childhood abuse. 3. (a) True; (b) False; (c) False; (d) False; (e) False. Irritable bowel syndrome can be con®dently diagnosed from the history alone, using the Rome criteria. All the other causes may give variable and inconsistent symptoms and require further diagnostic tests to be performed. 4. (a) True; (b) True; (c) True; (d) False; (e) False. CPP may be due to gynaecological as well as non-gynaecological causes. The latter may be experienced as direct or referred pain to the appropriate dermatome. Sexual abuse, whilst commonly associated with CPP, is not a cause. Appendicitis may lead to acute but not chronic pelvic pain.
Chapter 2 1. (a) True; (b) True; (c) False; (d) True; (e) False. CPP, de®ned as pain experienced for at least 6 months, usually results in signi®cantly altered physical and sexual activity. Matthias et al reported a 3-month community prevalence amongst women aged 18±50 in the USA of 15%, but only 25% of these women had sought help from a health-care worker in that period. This compares favourably with an annual prevalence in UK primary care amongst women aged 15±73 of 3.8%, i.e. these too are women seeking advice from a primary healthcare worker.
A8 Appendix
2. (a) False; (b) True; (c) False; (d) False; (e) False. There is an increased risk of CPP in women who have been separated, widowed or divorced when compared to single women. Age also appears to in¯uence the risk, with most studies showing a reduced risk after 35 years of age. It is unclear whether race or educational status play a role. 3. (a) False; (b) False; (c) True; (d) False; (e) False. The estimated annual prevalence in the community is signi®cantly less than 30%. Hospital-based populations are highly selected and not necessarily representative of the community. The prevalence of CPP may be underestimated due to numerous factors such as under reporting of symptoms. No reliable data exist comparing CPP prevalence rates in developed and developing countries. Chapter 3 1. (a) False; (b) True; (c) False; (d) False; (e) False. There is no evidence that normal or abnormal ®ndings at laparoscopy alter the probability of depression or other mood related symptoms. Women with CPP have been shown to be more likely to somatise their experience than women with chronic pain of other types or those without pain. There is no evidence that the expression of psychological symptoms is related to outcome. 2. (a) True; (b) True; (c) True; (d) False; (e) True. The visual analogue scale and McGill pain questionnaires are the most established methods used to assess the impact and severity of pain. More recently the SF36 questionnaire and QUALY assessments have been used and are more comprehensive. Although mental health assessment is important, it does not provide a quanti®able and comparable index of pain severity. Chapter 4 1. (a) True; (b) True; (c) False; (d) False; (e) False. Ultrasound scanning is often the ®rst line diagnostic test employed as it is non-invasive and cheap. CT scans are limited in their usefulness due to non-speci®c diagnostic criteria and limited contrast resolution whilst HSGs should only be reserved for women when fertility is an issue. MRI can be used as it can eectively distinguish between normal and abnormal tissue. 2. (a) True; (b) True; (c) False; (d) False; (e) False. It has been reported that MRI accurately diagnoses adenomyosis. The condition responds poorly to medical treatment so hysterectomy is the treatment of choice. There have only been anecdotal reports of the eectiveness of excising adenomyotic lesions.
Appendix A9
3. (a) True; (b) True; (c) False; (d) False; (e) False. Ultrasound scanning has been used to diagnose pelvic venous congestion with high reported speci®city and sensitivity rates. It can visualize adenomyosis but not pelvic endometriosis unless there are ovarian endometriotic cysts. Interstitial cystitis is diagnosed following biopsy at cystoscopy. 4. (a) True; (b) False; (c) False; (d) False; (e) True. MRI is emerging as an extremely useful test due to its superior spatial and contrast resolution. Furthermore, it is non invasive and lacks ionizing radiation. The main disadvantages at present are cost and the fact that it is not a real-time investigation. Chapter 5 1. (a) True; (b) False; (c) False; (d) True; (e) True. Peritoneal endometriosis has numerous appearances, and diagnosis by visual means alone may not always be accurate. In ideal circumstances, therefore, clinicians should not rely exclusively upon visualization of the pelvis; rather, any suspicious lesions should be biopsied. It is the most common abnormal laparoscopic ®nding in women with CPP; in women without CPP adhesions are the most frequent abnormal ®nding. 2. (a) False; (b) False; (c) True; (d) True; (e) False. Endometriosis, although commonly associated with CPP may not be the cause of the pain. There is a wide variation in the appearances of typical and atypical lesions which may result in underdiagnosis. Atypical lesions such as peritoneal defects are the least likely to contain endometriosis (see Table 6) 3. (a) False; (b) False; (c) True; (d) False; (e) False. Adhesions are not speci®c to any underlying cause. The mere presence of adhesions in women with CPP is insucient to prove causation. Approximately 20% of women who have a diagnostic laparoscopy have some adhesions, whether they have CPP or not. There is little correlation between the severity of endometriosis, assessed by the AFS score, and any pain parameters. 4. (a) False; (b) False; (c) False; (d) True; (e) False. Most ovarian cysts are either asymptomatic or cause acute pain. They rarely cause chronic pelvic pain. Residual ovary syndrome is a rare cause of CPP occurring in women following hysterectomy with conservation of the ovaries. Although pelvic venous congestion may be a cause of CPP, it is not easily diagnosed on routine laparoscopy. The investigation of choice is transuterine pelvic venography.
A10 Appendix
5. (a) False; (b) False; (c) False; (d) True; (e) False. The percentage of women with CPP who have no visible pathology at laparoscopy varies greatly (18±92%). In contrast, the majority of asymptomatic women (29±63%) have been found to have abnormalities generally considered to be associated with pelvic pain. A positive or negative ®nding does not therefore imply causation or normality. There are insucient data available to support neurectomy as a treatment option in women with CPP, unlike hysterectomy. Chapter 6 1. (a) False; (b) True; (c) True; (d) True; (e) False. The choice of treatment should primarily be determined by the pathology present. There is evidence to support the eectiveness of progestagens in endometriosis associated pain, but not adhesions. Farquhar et al (1989) showed that psychotherapy in conjunction with progestagens was more eective than either alone. Side eects are common with long-term use, and range from breakthrough bleeding to menopausal symptoms and osteoporosis. 2. (a) False; (b) False; (c) True; (d) True; (e) True. Neither anti-depressants nor progestagen-only contraceptive pills are eective in the long-term management of CPP. Dihydroergotamine has been shown to improve pain scores in women with pelvic venous congestion (Reginald 1989) by improving pelvic venous clearance. Medroxyprogesterone acetate and GnRH analogues have both been shown to be eective in the treatment of women with CPP. Chapter 7 1. (a) True; (b) False; (c) True; (d) True; (e) True. Laparoscopy oers multiple advantages ± it allows diagnosis, biopsy and treatment to be performed at the same time and it is associated with lower morbidity than laparotomy. There is not a strong causal link between adhesions and pelvic pain; moreover, dividing all adhesions may result in unnecessary complications. Laparoscopic conscious pain mapping under local anaesthesia can, it is claimed, be used to investigate the link between visible pathology and pain symptoms. 2. (a) True; (b) False; (c) True; (d) True; (e) False. Sensory innervation of the pelvic organs is from the superior hypogastric plexus, nervi erigentes and the ovarian plexuses. 3. (a) False; (b) True; (c) False; (d) False; (e) False. There is some evidence to suggest that dysmenorrhoea may be improved by pelvic denervation, Mittelschmerz is due to ovulation and clot colic due to menorrhagia, neither of which are aected by pelvic denervation.
Appendix A11
4. (a) False; (b) True; (c) False; (d) False; (e) False. Stovall reported that 34% of hysterectomy specimens showed pathology in women with CPP. Hysterectomy, although controversial, results in pain relief in 83±97% of women with CPP. Endometrial ablation is of no use in the treatment of CPP, as the endometrium is not the cause of the pain. The decision of whether to remove a woman's ovaries is equally controversial. Some clinicians advocate that bilateral oophorectomy in a pre-menopausal woman should only be performed following a successful therapeutic trial of a GnRH analogue and extensive counselling. Chapter 8 1. (a) False; (b) True; (c) True; (d) False; (e) True. Pain perception is multifactorial. Both social and cultural factors are known to modulate the experience and reporting of pain. The gate control theory incorporates both somatic and psychosocial factors into the understanding of pain and is therefore more appropriate than either factor alone. 2. (a) True; (b) True; (c) True; (d) True; (e) False. The initiating event of pain is usually some form of irritation, whether thermal, mechanical or chemical. This is followed by nociception (the detection or registration of the neurological event) and the eventual ``translation'' into somatic pain or its internalization as stress. Proprioception refers to the sensation of position, not pain. 3. (a) True; (b) True; (c) False; (d) False; (e) False. Childhood sexual and physical abuse appear to be strongly associated with the genesis of CPP in later life. There are no such associations with other psychiatric conditions or diabetes. Chapter 9 1. (a) True; (b) True; (c) False; (d) True; (e) True. It is well recognized that a multidisciplinary team approach is important and should incorporate both medical and paramedical specialities. The anaesthetist provides special expertise in pain management whilst a pain counsellor is able to oer advice on adaptive manouevres to overcome or modulate the pain. Psychotherapy is useful in managing CPP, particularly when given in conjunction with medical treatment. 2. (a) True; (b) True; (c) False; (d) True; (e) True. Common psychological and psychiatric symptoms in CPP include anxiety, depression, anger-hostility syndromes.
A12 Appendix
3. (a) False; (b) True; (c) False; (d) True; (e) False. The ecacy of neurolytic hypogastric block is as yet unproven, unlike trigger point injections. Short wave diathermy is used to alleviate acute in¯ammation not chronic pain. Myofascial release techniques are useful in women with CPP and musculo-skeletal dysfunction, due for example to abnormal postures. Pethidine is addictive and not useful in the management of chronic conditions.
doi:10.1053/beog.2000.0130, available online at http://www.idealibrary.com on
APPENDIX Chronic Pelvic Pain: Self-assessment Multiple Choice Questions L. C. Foong Consultant and Senior Lecturer Department of Obstetrics and Gynaecology, National University Hospital, Lower Kentridge Road, Singapore, 119074
For each part of each question, answer true or false. The answers are shown on page A7 with explanations. Chapter 1 1. Chronic pelvic pain (CPP): (a) only aects women. (b) is the second most common indication for laparoscopy in Britain. (c) is not associated with dyspareunia. (d) is typically cyclical in nature. (e) only aects women of reproductive age. 2. Regarding CPP: (a) the diagnosis can usually be made by taking a suciently detailed history. (b) a diagnostic laparoscopy is the gold standard investigation. (c) the cause must be non-gynaecological in the absence of visible pathology on laparoscopy. (d) the management should always include a detailed sexual history from the woman. (e) the management should always include a detailed sexual history from the partner. 3. The following diagnoses can be made from the history alone: (a) irritable bowel syndrome. (b) endometriosis. (c) bowel adhesions. (d) pelvic in¯ammatory disease. (e) nerve entrapment. 1521±6934/00/0300A1+12 $35.00/00
c 2000 Harcourt Publishers Ltd. *
A2 Appendix
4. The following are common causes of CPP: (a) ovarian remnant syndrome. (b) urethral syndrome. (c) endometriosis. (d) acute appendicitis. (e) sexual abuse. Chapter 2 1. CPP: (a) is de®ned as pain that has been present for at least 6 months. (b) leads to signi®cantly altered physical and sexual activity. (c) is much more prevalent in the USA than in the UK. (d) has an annual prevalence in UK primary care similar to asthma. (e) disappears with the onset of the menopause. 2. The following are risk factors for CPP: (a) Caucasian race. (b) marital instability. (c) increased parity. (d) higher educational status. (e) increasing age. 3. The prevalence of CPP in the community: (a) is approximately 30% (b) can be estimated by investigating hospital-based populations. (c) has almost certainly been underestimated. (d) is greater in developed than developing countries. (e) is aected by the availability of medical care. Chapter 3 1. Psychological symptoms in CPP: (a) are increased in the presence of a normal pelvis on laparoscopy. (b) are more likely the more pain complaints the woman has. (c) are proportional to the duration of pain. (d) should be treated before treating the pain. (e) are indicative of a poor prognosis. 2. The following can be used to assess the severity of CPP: (a) visual analogue scales. (b) McGill questionnaires. (c) short-form 36 health questionnaire. (d) mental health questionnaire. (e) quality-adjusted life years (QUALYs) score.
Appendix A3
Chapter 4 1. The following are useful diagnostic tests in the evaluation of CPP: (a) transabdominal ultrasound scanning. (b) magnetic resonance imaging. (c) abdominal X-ray. (d) hysterosalpingogram. (e) computed tomography. 2. Adenomyosis: (a) is a cause of CPP. (b) is best visualized with MRI. (c) is best treated medically. (d) can be eectively treated by adenomyomectomy. (e) can be eectively treated by pre-sacral neurectomy. 3. The following causes of CPP can be diagnosed using transvaginal ultrasound: (a) pelvic venous congestion. (b) adenomyosis. (c) peritoneal endometriosis. (d) bowel adhesions. (e) interstitial cystitis. 4. MRI in the diagnosis of CPP: (a) is superior to CT scanning. (b) the spatial and contrast resolution are insucient to render it a useful test in the diagnosis of CPP. (c) cannot distinguish between ®broids and adenomyosis. (d) cannot be used in women of reproductive age due to the risk of ionizing radiation. (e) is superior to ultrasonography. Chapter 5 1. Peritoneal endometriosis: (a) is the most common abnormal laparoscopic ®nding in women with CPP: (b) is the most common abnormal laparoscopic ®nding in women without CPP. (c) can usually be diagnosed at laparoscopy by visualisation alone. (d) ideally the diagnosis should always be con®rmed by peritoneal biopsy. (e) can be eectively treated by vaporization or ablation of visible lesions. 2. Endometriosis: (a) is often the cause of CPP. (b) is always seen as a ``powder-burn'' lesion. (c) may be associated with no pain symptoms at all. (d) can be underdiagnosed due to the presence of unrecognized lesions. (e) commonly presents as cribiform peritoneal defects.
A4 Appendix
3. At laparoscopy: (a) the presence of adhesions always signi®es previous PID. (b) in the absence of other abnormal pathology the presence of pelvic adhesions is a reliable predictor of pelvic pain. (c) the prevalence of adhesions is similar in women with and without CPP. (d) the AFS score correlates well with the duration and severity of pain. (c) adhesiolysis is an eective therapeutic measure to relieve CPP. 4. The following are recognized causes of CPP that can be diagnosed during laparoscopy: (a) corpus haemorrhagicum. (b) bleeding corpus luteum. (c) ectopic pregnancy. (d) residual ovary syndrome. (e) pelvic venous congestion. 5. In women with CPP and a negative laparoscopy: (a) this indicates there is no pelvic disease and the woman can be reassured. (b) the pain must be psychosomatic in origin. (c) neurectomy is an eective treatment option. (d) hysterectomy is an eective treatment option. (e) these women should be told preoperatively that there is a 15% chance that no diagnosis will be found at the time of laparoscopy. Chapter 6 1. Medical treatment of women with CPP using progestagens: (a) should always be the ®rst line treatment of choice. (b) may be eective in women with endometriosis. (c) is of no value in women where pelvic adhesions are the only pathology present. (d) is more eective when combined with psychotherapy. (e) can be used for long term therapy as there are few side-eects. 2. The following have been used eectively in the treatment of pain in women with CPP: (a) anti-depressants. (b) progestagen-only contraceptive pill. (c) dihydroergotamine. (d) progestagens. (e) gonadotrophin-releasing hormone analogues (GnRHa). Chapter 7 1. Operative laparoscopy in women with CPP: (a) is preferable to laparotomy. (b) all adhesions should be divided wherever visualized. (c) allows all suspicious lesions to be biopsied. (d) has resulted in endometriosis being diagnosed more frequently. (e) can be used to con®rm the cause of pain.
Appendix A5
2. Sensory innervation in the pelvis is derived from: (a) superior hypogastric plexus. (b) inferior hypogastric plexus. (c) nervi erigentes. (d) ovarian plexus. (e) obturator nerve. 3. Pelvic denervation alone has been used successfully to treat the following conditions: (a) dyspareunia. (b) dysmenorrhoea. (c) endometriosis. (d) mittelschmerz. (e) clot colic. 4. Hysterectomy in women with CPP: (a) reveals a normal uterus in approximately 35% of cases. (b) can eectively treat pelvic pain. (c) endometrial ablation should be performed instead in younger women who have not completed their family. (d) should always be combined with oophorectomy. (e) pain relief is directly related to the degree of blood loss at the time of the operation. Chapter 8 1. Chronic pelvic pain: (a) can always be attributed to organic disease. (b) can be explained by the gate control theory of pain perception. (c) always involves both physical and psychogenic components. (d) is usually not aected by social or cultural factors. (e) results in adaptive behavioural and postural changes. 2. The following are involved in the perception of pain: (a) nociception. (b) irritation. (c) somatisation. (d) internalization. (e) proprioception. 3. The following are important factors associated with CPP: (a) childhood sexual abuse. (b) childhood physical abuse. (c) schizophrenia. (d) manic depression. (e) diabetes.
A6 Appendix
Chapter 9 1. A pelvic pain clinic should ideally incorporate the following elements: (a) gynaecologist. (b) pain counsellor. (c) soft lighting. (d) psychotherapist. (e) anaesthetist. 2. Women with CPP often present with: (a) anxiety. (b) depression. (c) drug overdose. (d) anger hostility. (e) apareunia. 3. The following are used in the management of CPP: (a) neurolytic superior hypogastric plexus block. (b) trigger point injections. (c) short wave diathermy. (d) myofascial release techniques. (e) pethidine.
Appendix A7
ANSWERS Chapter 1 1. (a) False; (b) False; (c) False; (d) False; (e) False. Chronic pelvic or lower abdominal pain is a well-recognized problem in men. Pain constitutes the most common indication for laparoscopy in Britain (Chamberlain & Brown, 1978). CPP may be associated with dyspareunia or dysmenorrhoea, but it should be distinguished from them. The pain may be cyclical or continuous. Although in clinical practice most gynaecologists see women with CPP who are of reproductive age, it can in fact aect women at any age. 2. (a) False; (b) False; (c) False; (d) True; (e) False. Unlike irritable bowel syndrome, there is no consensus regarding the `typical' symptoms experienced by women with CPP. This arises because CPP has multiple causes. A laparoscopy, whilst important, shows no identi®able organic cause for pelvic pain in 40±60% of cases. Therefore, the absence of visible pathology does not exclude organic causes (eg. adenomyosis) or functional problems. Due to the high prevalence of sexual abuse in women with CPP, it is helpful to take a detailed sexual history, particularly of childhood abuse. 3. (a) True; (b) False; (c) False; (d) False; (e) False. Irritable bowel syndrome can be con®dently diagnosed from the history alone, using the Rome criteria. All the other causes may give variable and inconsistent symptoms and require further diagnostic tests to be performed. 4. (a) True; (b) True; (c) True; (d) False; (e) False. CPP may be due to gynaecological as well as non-gynaecological causes. The latter may be experienced as direct or referred pain to the appropriate dermatome. Sexual abuse, whilst commonly associated with CPP, is not a cause. Appendicitis may lead to acute but not chronic pelvic pain.
Chapter 2 1. (a) True; (b) True; (c) False; (d) True; (e) False. CPP, de®ned as pain experienced for at least 6 months, usually results in signi®cantly altered physical and sexual activity. Matthias et al reported a 3-month community prevalence amongst women aged 18±50 in the USA of 15%, but only 25% of these women had sought help from a health-care worker in that period. This compares favourably with an annual prevalence in UK primary care amongst women aged 15±73 of 3.8%, i.e. these too are women seeking advice from a primary healthcare worker.
A8 Appendix
2. (a) False; (b) True; (c) False; (d) False; (e) False. There is an increased risk of CPP in women who have been separated, widowed or divorced when compared to single women. Age also appears to in¯uence the risk, with most studies showing a reduced risk after 35 years of age. It is unclear whether race or educational status play a role. 3. (a) False; (b) False; (c) True; (d) False; (e) False. The estimated annual prevalence in the community is signi®cantly less than 30%. Hospital-based populations are highly selected and not necessarily representative of the community. The prevalence of CPP may be underestimated due to numerous factors such as under reporting of symptoms. No reliable data exist comparing CPP prevalence rates in developed and developing countries. Chapter 3 1. (a) False; (b) True; (c) False; (d) False; (e) False. There is no evidence that normal or abnormal ®ndings at laparoscopy alter the probability of depression or other mood related symptoms. Women with CPP have been shown to be more likely to somatise their experience than women with chronic pain of other types or those without pain. There is no evidence that the expression of psychological symptoms is related to outcome. 2. (a) True; (b) True; (c) True; (d) False; (e) True. The visual analogue scale and McGill pain questionnaires are the most established methods used to assess the impact and severity of pain. More recently the SF36 questionnaire and QUALY assessments have been used and are more comprehensive. Although mental health assessment is important, it does not provide a quanti®able and comparable index of pain severity. Chapter 4 1. (a) True; (b) True; (c) False; (d) False; (e) False. Ultrasound scanning is often the ®rst line diagnostic test employed as it is non-invasive and cheap. CT scans are limited in their usefulness due to non-speci®c diagnostic criteria and limited contrast resolution whilst HSGs should only be reserved for women when fertility is an issue. MRI can be used as it can eectively distinguish between normal and abnormal tissue. 2. (a) True; (b) True; (c) False; (d) False; (e) False. It has been reported that MRI accurately diagnoses adenomyosis. The condition responds poorly to medical treatment so hysterectomy is the treatment of choice. There have only been anecdotal reports of the eectiveness of excising adenomyotic lesions.
Appendix A9
3. (a) True; (b) True; (c) False; (d) False; (e) False. Ultrasound scanning has been used to diagnose pelvic venous congestion with high reported speci®city and sensitivity rates. It can visualize adenomyosis but not pelvic endometriosis unless there are ovarian endometriotic cysts. Interstitial cystitis is diagnosed following biopsy at cystoscopy. 4. (a) True; (b) False; (c) False; (d) False; (e) True. MRI is emerging as an extremely useful test due to its superior spatial and contrast resolution. Furthermore, it is non invasive and lacks ionizing radiation. The main disadvantages at present are cost and the fact that it is not a real-time investigation. Chapter 5 1. (a) True; (b) False; (c) False; (d) True; (e) True. Peritoneal endometriosis has numerous appearances, and diagnosis by visual means alone may not always be accurate. In ideal circumstances, therefore, clinicians should not rely exclusively upon visualization of the pelvis; rather, any suspicious lesions should be biopsied. It is the most common abnormal laparoscopic ®nding in women with CPP; in women without CPP adhesions are the most frequent abnormal ®nding. 2. (a) False; (b) False; (c) True; (d) True; (e) False. Endometriosis, although commonly associated with CPP may not be the cause of the pain. There is a wide variation in the appearances of typical and atypical lesions which may result in underdiagnosis. Atypical lesions such as peritoneal defects are the least likely to contain endometriosis (see Table 6) 3. (a) False; (b) False; (c) True; (d) False; (e) False. Adhesions are not speci®c to any underlying cause. The mere presence of adhesions in women with CPP is insucient to prove causation. Approximately 20% of women who have a diagnostic laparoscopy have some adhesions, whether they have CPP or not. There is little correlation between the severity of endometriosis, assessed by the AFS score, and any pain parameters. 4. (a) False; (b) False; (c) False; (d) True; (e) False. Most ovarian cysts are either asymptomatic or cause acute pain. They rarely cause chronic pelvic pain. Residual ovary syndrome is a rare cause of CPP occurring in women following hysterectomy with conservation of the ovaries. Although pelvic venous congestion may be a cause of CPP, it is not easily diagnosed on routine laparoscopy. The investigation of choice is transuterine pelvic venography.
A10 Appendix
5. (a) False; (b) False; (c) False; (d) True; (e) False. The percentage of women with CPP who have no visible pathology at laparoscopy varies greatly (18±92%). In contrast, the majority of asymptomatic women (29±63%) have been found to have abnormalities generally considered to be associated with pelvic pain. A positive or negative ®nding does not therefore imply causation or normality. There are insucient data available to support neurectomy as a treatment option in women with CPP, unlike hysterectomy. Chapter 6 1. (a) False; (b) True; (c) True; (d) True; (e) False. The choice of treatment should primarily be determined by the pathology present. There is evidence to support the eectiveness of progestagens in endometriosis associated pain, but not adhesions. Farquhar et al (1989) showed that psychotherapy in conjunction with progestagens was more eective than either alone. Side eects are common with long-term use, and range from breakthrough bleeding to menopausal symptoms and osteoporosis. 2. (a) False; (b) False; (c) True; (d) True; (e) True. Neither anti-depressants nor progestagen-only contraceptive pills are eective in the long-term management of CPP. Dihydroergotamine has been shown to improve pain scores in women with pelvic venous congestion (Reginald 1989) by improving pelvic venous clearance. Medroxyprogesterone acetate and GnRH analogues have both been shown to be eective in the treatment of women with CPP. Chapter 7 1. (a) True; (b) False; (c) True; (d) True; (e) True. Laparoscopy oers multiple advantages ± it allows diagnosis, biopsy and treatment to be performed at the same time and it is associated with lower morbidity than laparotomy. There is not a strong causal link between adhesions and pelvic pain; moreover, dividing all adhesions may result in unnecessary complications. Laparoscopic conscious pain mapping under local anaesthesia can, it is claimed, be used to investigate the link between visible pathology and pain symptoms. 2. (a) True; (b) False; (c) True; (d) True; (e) False. Sensory innervation of the pelvic organs is from the superior hypogastric plexus, nervi erigentes and the ovarian plexuses. 3. (a) False; (b) True; (c) False; (d) False; (e) False. There is some evidence to suggest that dysmenorrhoea may be improved by pelvic denervation, Mittelschmerz is due to ovulation and clot colic due to menorrhagia, neither of which are aected by pelvic denervation.
Appendix A11
4. (a) False; (b) True; (c) False; (d) False; (e) False. Stovall reported that 34% of hysterectomy specimens showed pathology in women with CPP. Hysterectomy, although controversial, results in pain relief in 83±97% of women with CPP. Endometrial ablation is of no use in the treatment of CPP, as the endometrium is not the cause of the pain. The decision of whether to remove a woman's ovaries is equally controversial. Some clinicians advocate that bilateral oophorectomy in a pre-menopausal woman should only be performed following a successful therapeutic trial of a GnRH analogue and extensive counselling. Chapter 8 1. (a) False; (b) True; (c) True; (d) False; (e) True. Pain perception is multifactorial. Both social and cultural factors are known to modulate the experience and reporting of pain. The gate control theory incorporates both somatic and psychosocial factors into the understanding of pain and is therefore more appropriate than either factor alone. 2. (a) True; (b) True; (c) True; (d) True; (e) False. The initiating event of pain is usually some form of irritation, whether thermal, mechanical or chemical. This is followed by nociception (the detection or registration of the neurological event) and the eventual ``translation'' into somatic pain or its internalization as stress. Proprioception refers to the sensation of position, not pain. 3. (a) True; (b) True; (c) False; (d) False; (e) False. Childhood sexual and physical abuse appear to be strongly associated with the genesis of CPP in later life. There are no such associations with other psychiatric conditions or diabetes. Chapter 9 1. (a) True; (b) True; (c) False; (d) True; (e) True. It is well recognized that a multidisciplinary team approach is important and should incorporate both medical and paramedical specialities. The anaesthetist provides special expertise in pain management whilst a pain counsellor is able to oer advice on adaptive manouevres to overcome or modulate the pain. Psychotherapy is useful in managing CPP, particularly when given in conjunction with medical treatment. 2. (a) True; (b) True; (c) False; (d) True; (e) True. Common psychological and psychiatric symptoms in CPP include anxiety, depression, anger-hostility syndromes.
A12 Appendix
3. (a) False; (b) True; (c) False; (d) True; (e) False. The ecacy of neurolytic hypogastric block is as yet unproven, unlike trigger point injections. Short wave diathermy is used to alleviate acute in¯ammation not chronic pain. Myofascial release techniques are useful in women with CPP and musculo-skeletal dysfunction, due for example to abnormal postures. Pethidine is addictive and not useful in the management of chronic conditions.