Follow Us On
Contact Us
info@ampainsoc.org847.375.4715
American Pain Society
4700 W Lake Ave
Glenview, IL 60025
John S. McDonald, MD
Department editor's note: This is the fourth article in a series on pelvic and abdominal pain problems in women. We have discussed the various diagnoses, the importance of a differential diagnosis list, and methods related to determining the diagnosis case illustrations of acute and chronic conditions. We have also considered the psychological implicinspecifications of chronic pelvic pain. This article focuses on the various treatment modalities available for gaining relief from the acute and chronic pelvic and abdominal pain problems that many women suffer.
In the first two articles (APS Bulletin, 5(4), p. 12; 5(6), p. 20) of this series, I discussed the reasons that gynecological patients with acute and chronic pain often receive many different diagnoses, all to no avail and without satisfactory management of the pain. The various guidelines in this article on treating pelvic and abdominal pain are not to be interpreted as the only methods of satisfactory treatment for a given disease process. However, all of the suggested treatment methods have either proved satisfactory in my experience or are commonly accepted.
The initial treatment or management steps for a patient with acute pain problems are important in both diagnosis and determination of the best treatment. The first step is a careful and complete evaluation of the problem that the patient complains of in the initial visit. The last step is a follow-up evaluation of the patient who is no longer in severe pain, to determine the effectiveness of the therapy plan and its impact on the patient's life. In common terms, this is the outcome of the treatment; it is very important in today's expectations of medical care.
There are at least 10 stages in the management of patients with acute pain disorders:
Pain scale: On a scale of 1 to 10, the patient compares her present pain to the worst pain she has ever experienced. A pain history is necessary to ascertain that the patient has experienced a sufficiently severe pain in the past to enable her to quantify the present pain.
History: A careful history includes the points that are important to the patient and the facts and features that the physician needs to know about the way the pain began, the circumstances at the time it began, the location and migration of the pain, and the changes that make the pain worse or better.
Physical examination: A general physical exam is in keeping with good medical practice and is in order unless the patient has recently had a complete physical exam by her primary care physician. If so, an exam will suffice that is limited to the area of the pain and the areas immediately adjacent. A restricted “area” exam may result in a missed diagnosis, but this risk can be minimized by examining all possible areas related to the diagnoses under consideration.
Diagnosis: The diagnosis requires a careful and detailed history, physical examination, and consideration of differential diagnoses that are inclusive enough to encompass the most likely cause of the problem. Unfortunately, in 1996, few medical schools teach the logical rule-out processes involved in the development of differential diagnoses of pain states.
Goals: Just after the development of the differential diagnosis list, and even before a definitive diagnosis, a physician can talk to the patient about goals in therapy. There are at least two immediate and end-point goals in any therapeutic plan: (a) improvement in personal and vocational functioning, and (b) reduction in pain levels. If the patient is included in the goal-setting discussion, she will feel involved in decision making as a member of the team in charge of her particular case. The patient is the most important individual in her case, and she needs to realize that. She needs some understanding of her disease process, the knowledge that there are a number of therapeutic options, and the assurance that she has the attention of concerned and interested physicians. Of course, early discussions about pain treatment results must avoid any promises of definite end points. It is unwise to tell a patient who presents with a pain score of 8/10 that by the end of therapy she can expect a 2/10 or 1/10. It makes more sense to discuss a general goal over time, in terms of reducing the beginning pain score from the severe category (7-10) to the moderate category (4-6) and, finally, to the mild category (1-3). In addition, it is important to stress functional improvement by noting the patient's level of functioning from personal and vocational standpoints. It is necessary to identify the patient's levels of personal and vocational functioning at a full 100% and then to identify the levels of functioning at the current pain score level. The dual goal, as the patient sees it, is improved function in both the personal and vocational areas and, at the same time, a reduction in pain level.
Therapy: Discussing an extensive treatment or therapy hierarchy with the patient helps lay out a plan for improvement, so that the patient can see the means of eventual progress. It lets the patient know there are several therapeutic possibilities, not just a single one, and it can enhance the patient's cooperation with the various therapeutic models. It is wise to go over the possibilities with the patient and to discuss how the possible pathology can be related to the anatomy in the area. The physician may use anatomical pictures to demonstrate.
Initial follow-up: Follow-up should begin just 1 week after the initial visit, either at the time of the patient's return to the clinic or during a follow-up telephone call. This is an excellent time to review the treatment hierarchy, so as to allay any disquietude that the patient may have about her treatment thus far or about the eventual goals of the therapy.
Therapy adjustment: If progress stops, as evidenced by the results of a repeat visit and examination, then the physician must make therapy adjustments to redirect the effectiveness of the medication, so as to optimize subsequent responses and follow-up question sessions.
Follow-up visits: Follow-up visits should be scheduled at the initial visit or at the time of goal-setting discussion. A reasonable follow-up schedule might call for appointments at 1 week, 2 weeks, 4 weeks, and 8 weeks after the initial visit. By definition, 3 months' duration separates acute pain from chronic pain. Some acute pain patients will shift to a chronic pain category as their pain continues and the therapy fails to achieve its goal of pain relief and improved function within the 3-month window. Every time a patient presents for follow-up in the clinic or responds by telephone to questions about her therapy, the physician should be made aware of untoward events or responses or of a deterioration of the patient's wellness. Adjustments in therapy should take place immediately, not be postponed until the next visit.
Outcome: This is the final “graduation” of the patient from the therapy regimen. The outcome criteria are the standards for measuring success or failure. They are the single most important focus from the patient's viewpoint, because originally she came to the physician with pain, a need to reduce that pain, and a need to improve her functional ability to work and enjoy life. Outcome assessment can take place whenever the clinic contacts her for follow-up queries.
Bartholinitis. Infection is the chief problem here. It often requires surgical incision and drainage to reverse the effects of inflammation and sequestration of purulent matter. Complete disruption of all communicating and infected sacs should be carried out, along with placing the patient on antibiotics (Cheetham, 1985).
Skene's urethritis. This, too, involves a set of glands lying along the urethral orifice. Usually heat applications and gentle pressure can empty the infected material, but sometimes patients may require incision and drainage and antibiotics (Dodson, Cliby, Pettavel, Keeney, & Podratz, 1995).
Herpes. The chief pain problems initially include dysuria, dyspareunia, vesicular eruptions, and groin pain, which can be treated, respectively, with suppositories, avoidance of sex, acyclovir cream, and systemic analgesics. Long-term pain can be due to actual neuropathic changes that accumulate over time. Treatment for such pain requires identification of the involved nerve or nerves and local-anesthetic blocks for pain relief trials spaced over several weeks. Some patients who are refractory to such interventions merit other methods of nerve treatment such as cryotherapy or thermolysis (Buntin, 1994).
Condyloma. In early stages, colposcopy helps make the diagnosis. Treatment consists of 5-fluorouracil until all wart activity appears neutralized. The skin will recover over a short period of time and will develop normal texture again. In some cases, larger lesions may require removal by cryotherapy, fulgeration, or surgical excision (Spitzer & Krunholz, 1992).
Vaginitis. The emphasis here is on the etiology. Possibilities include bacterial, viral, yeast, and protozoan infections. The diagnosis requires inspection, sampling of vaginal discharges, and inspection under the microscope for identification (Petersen & Pelz, 1983).
Vaginismus. Causes may be congenital, infectious, traumatic, or psychological. Since the most common by far is psychological, it is important to consult a psychologist early in the diagnosis. Some of the underlying reasons may derive from suppressed childhood-related problems. The treatment regimen is complex and demands intensive therapy (Reamy, 1982).
This composite diagnosis first requires identification of the involved muscles, such as the levator, the piriformis, or the coccygeus muscle groups. These often respond to attempts to relieve spasms by heat and massage or by direct, specific local injection of an anesthetic. Follow-up with muscle stretching and exercises can greatly help this painful condition and assist with recovery and prevention of repeated episodes.
Dysmenorrhea can be so severe as to be debilitating. It necessitates the use of systemic over-the-counter analgesics such as nonsteroidal antiinflammatory drugs (NSAIDs) taken regularly around the clock to maintain adequate analgesia. The patient should also receive a “rescue” medication for very severe crises (i.e., combination drugs such as darvocet or fiorinal). The use of birth control pills to suppress hormonal levels may be beneficial because they may reduce or partially eradicate the endocrine-driven aspect of the disease process. Heat or cold applications are useful during major pain periods.
Cervicitis. Colposcopic examination is vital to adequately evaluate the cervix and its superficial covering. Immediate therapy consists of cauterization, cryotherapy, or surgical excision by conization (Nuovo, Melnikow, Paliescheskey, King, & Mowers, 1995).
Ectopic pregnancy. Hemorrhage is the main problem in this disease process. Pain results from peritoneal stretch or irritation. Ultrasound can rapidly diagnose ectopic pregnancy, and laparoscopy is both diagnostic and therapeutic. In earlier days, there was no concern about tubal sacrifice, but today tubal conservation is the first concern after adequate hemostasis (Woolcott, Petchpud, O'Donnell, & Stanger, 1995).
Corpus luteum cyst. A painful hemorrhagic episode occurs when distention progresses to the point of excessive stretch of the peritoneal covering surrounding the cyst. Diagnosis requires ultrasound and confirmation with laparoscopy, which also permits definitive surgical correction.
Twisted ovarian cyst. Some ovarian cysts can enlarge to the point that local vascular supply is compromised, and this can elicit pain so severe that it merits immediate medical attention. This type of pain usually develops slowly over hours or days and presents with sharp definition and radiation to the iliac fossa. Diagnosis is by laparoscopy, and definitive therapy can be put into place with either aspiration followed by excision or by total excision of the entire cyst without aspiration if there is concern about possible malignancy.
This vascular problem involves sudden, extremely localized, severe pain with a knifelike quality. Associated free blood may appear in the abdomen with peritoneal irritation and muscular rigidity. Diagnosis can be difficult, especially if the final diagnosis is not one of the included differentials. Vascular studies are definitive, however. Surgery is indicated as soon as possible to avoid greater than necessary damage to the integrity of the nearby bowel.
The diagnosis of this bowel problem requires radiological study. The treatment is by laparotomy and excision of the involved area, if indicated. Most acute or repeated chronic pain problems result from minute outpouchings in the bowel due to local weakened wall structures. Removing damaged areas after diagnosis and after repeated episodes is important because of possible future rupture with resultant peritoneal leakage and inflammation (Vignati, Welch, & Cohen, 1995).
The management steps outlined for acute disorders apply also in approaching the patient with chronic pain problems. In the future, outcome times for chronic pain treatment may be standardized, but for the present it is suggested that follow-up at 2 months, 4 months, 6 months, 1 year, and 2 years be considered reasonable.
Vulvodynia. This disease process can cause significant psychological problems because of associated sexual dysfunction. The patient's anger is soon directed at the physician because of incorrect diagnosis or treatment regimens that fail to relieve pain and result in avoidance of sexual inactivity. Since the etiologies causing this disorder include infectious agents such as bacteria, viruses, and yeast, observation, culture, and sensitivities of the involved and inflamed tissues merit careful attention. Because some of the etiologies include lupus, lichen sclerosus and atrophicus, and plasma cell vulvitis, one needs to do superficial biopsies to rule these out. In the case of vestibulitis, or hymeneal syndrome, the diagnostic efforts must avoid speculum examination, since this maneuver elicits severe pain and thus blocks further examination. This reinforces the patient's belief that no one understands her pain or its cause and that she is locked into an endless and fruitless battle. Such patients can also develop significant operant behavioral patterns associated with vaginismus that quickly contribute to further sexual dysfunction. Touching the area of involvement with a cotton swab will show the patient that the problem is localized. A well-placed local anesthetic block can also demonstrate that help is available to relieve her pain (Lynch, 1986).
Endometriosis. Currently, the most popular treatment method is medical. Both estrogen and progesterone are suppressed by use of pituitary inhibitory hormones such as newly developed GnRh inhibitor drugs (e.g., Synarel(tm)). Surgical exploration via laparoscopy, with laser treatment of the identified endometrial implants and sometimes surgical severance of either the uterocervical plexus (LUNA procedure) or the superior hypogastric plexus (presacral neurectomy) may give permanent relief of pain (Singh et al., 1995).
Fibroids. The most common tumors of the uterus, fibroids can become painful when they outgrow their blood supply and begin to degenerate. They then require surgical removal. Diagnosis is by manual examination, further confirmed by either dilation and curettage or laparoscopy. The treatment of choice for postmenopausal women or women who do not wish to have more children is simple hysterectomy.
Chronic dysmenorrhea. NSAIDs are often the first-line treatment for this problem, which is one of the most common causes of workplace absenteeism among women. NSAID effectiveness may be due to reduction of endometrial prostaglandins. Suppression of ovulation by use of birth control pills may also be an effective treatment option. More aggressive modalities include either the use of inferior hypogastric nerve resection, which eradicates parasympathetic input to the spinal cord, or use of superior hypogastric resection surgery, which eradicates sympathetic nerve transmission upward to the spinal cord.
Pudendal neuropathy. This problem may be due to long-past nerve damage for reasons forgotten by the patient. It may be associated with a difficult delivery of a large fetus and extensive second-stage trauma from pushing for long periods of time. Or it may derive from chronic constipation with constant daily use of extensive Valsalva maneuvers to effect defecation. Other possible causes are endometrial implant growths that cause vascular damage to the pudendal nerve and surgical trauma during hysterectomy or genitourinary surgery. This condition is diagnosed only after many sessions that rule out other more common possibilities and only after point-specific identification of the involved nerve by electrical stimulation. The treatment is a series of accurately placed and optimally spaced local-anesthetic nerve blocks delivered to the damaged area over a defined time range.
Genital branch of the genital-femoral neuropathy. Here, the inguinal area and the area adjacent to the medial aspect of the upper thigh are involved, with sharp lancinating pain due to nerve damage of this major peripheral nerve as it crosses Poupart's ligament. It is accentuated by activity of any kind, due to the involvement of both lower-abdominal and upper-quadriceps muscle groups. Identification of the damaged nerve by palpation and use of electrical stimulation is the diagnostic key. A series of well-placed local-anesthetic nerve blocks will achieve gradual degradation of the pain resulting from this neuropathic entity.
In addition to the many familiar causes of pelvic pain, there are a few unusual causes. One example is the development of a hematoma in the abdominal musculature due to medication, which can cause distention and nerve compression symptoms due to a rapid developing neuropathy (Augustin, Daluzeau, Dujardin, Clement, & Denis, 1984). Another unusual cause of pelvic pain is an osteitis pubis due to excessive exercise and stretch and injury of the musculature of those muscles that insert near the front edge of the pubis (Fricker, Taunton, & Ammann, 1991). In older women or women just beginning menopause, there can be significant changes in the bone structure that may result in large amounts of calcium shifting out of the bone structure and into the serum compartment. Weakening of the bony structure can result in fractures that elicit pain due to movement during even minor exercise (Rawlings, Wilkins, Martinez, & Wilkerson, 1988).
Ilioinguinal problems. Early articles described the phenomenon of nerve damage after surgical incision and exploration due to use of retractors, nerve stretch, and frank nerve compression (Applegate, 1972). This damage, thought to be minimal and evanescent, often proved incapacitating over time. The increasing intensity of signals generated over time is secondary to muscular motion that results in intervals of interrupted blood flow to the nerves themselves. The literature described this as iliohypogastric and ilioinguinal neuropathy.
Slocumb (1990) reported that many women who complain of pelvic pain have suffered damage to these nerves. Such patients interpret their pain as pelvic in origin, when it really originates in the low-anterior abdominal wall (in this case, along the margin of the ilioinguinal ligament, either on the right side or the left side or in some instances on both sides). Treatment requires identification of the involved nerves by palpation and then nerve stimulation followed by immediate injection of 1 ml to 2 ml of local anesthetic. Multiple tender spots that have been identified can be injected on a regular weekly schedule. The patient may fall into the responding group of patients (i.e., those who have gradually increasing intervals of pain relief after each successive local-anesthetic nerve block, until finally they are not bothered by the pain at all). I favor repeated effective blockade of the involved areas locally to the point that the dorsal root ganglion is no longer constantly bombarded with pain signals.
Iliohypogastric. This nerve descends from its origin at L-1 and L-2 and penetrates the transversalis muscle and then the internal oblique and external oblique muscle groups on its way toward the umbilicus, as it enervates the middle aspect of the lower quadrants of the abdomen. Compression and stretching maneuvers during the classic Pfannenstiel incision or during use of retractors placed in the incision to aid in visualization during exploration can damage this nerve. Such an injury can occur also during laparoscopy, due to stretch and compression caused by placement of the probes, trochars, and scope or by direct contact with the above-mentioned nerves that is overlooked by the operator during the procedure. Treatment of this nerve is the same as described above under ilioinguinal neuropathy.
It is important to begin some therapy on the patient's first visit. This can consist of administration of various systemic medications or of rest or exercise programs. Intervention should follow careful analysis of the currently used medications and recording of the successes and failures of medications and therapies tried in the past. This is a time-consuming process, but it is essential for achieving an understanding of the complete medical background of the patient. It is also necessary to have an in-depth conversation with the patient about her sleep habits and to consider the use of a low-dose antidepressant medication such as amyltriptyline (0.25 mg taken at bedtime). This regimen can decrease the reception of pain centrally and provide some badly needed sleep (Walker, Roy-Byrne, Katon, & Jemelka, 1991). Another approach to initiating therapy is to emphasize rapport, carefully outlining to the patient the various problems, the possible etiologies, the possible therapies, and how the physician and staff will support the patient through the work-up phase and the therapy phase. Some may not think of this approach as therapy, but the physician's concern and consideration, eye contact, and reaching out to display sincere concern have great value.
The foundation for treatment of noncancer pain is the use of over-the-counter, readily available drugs such as salicylates. The next step typically is to use readily available over-the-counter NSAIDs. Next are the tricyclic antidepressants, which are believed to act by blocking the uptake of serotonin and norepinephrine in the central nervous system. Next are the anticonvulsant drugs, which are effective in certain pain syndromes such as trigeminal neuralgia. Finally, opioids are an option, if all the other types of drugs have been tried. For some patients, the opioid analgesics may have fewer side effects than the tricyclic antidepressants and the anticonvulsant drugs. There is also a wide difference in the incidence of side effects among opioids such as morphine sulfate, codeine, and pentazocine, which have side effects in the range of 20%, and oxycodone, which has side effects in the range of 10%. The adverse effects usually associated with opioids are pruritus, drowsiness, nausea, vomiting, dizziness, headache, euphoria, dry mouth, and swelling.
Medical log. In the medical log, the patient makes notes of medications and their effects on a daily basis. Keeping a log is important, because patients too often are given medication without care pro-viders asking for feedback. Consequently, the patient remains on a dosage that may be too much or too little. Of course, the goal is to reduce the patient's level of medication, regardless of the type of drug. This approach necessitates noting progress on a return-visit basis. The individual physician may make up notebooks or design forms, but any system is workable as long as the patient is motivated to use it to record dosage, times, and effects.
Activity log. The activity log is a component of the medical log that is vital for recording progress. It can accompany the medical log or be kept separately. It is best to begin the log with an activity notation about what the patient used to do or was capable of doing prior to the onset of the pain disorder. Again, the key concept is that the patient must be motivated to keep the log. Much of the attitude that one wishes to develop is that of continued activity and function regardless of the state of the pain disorder. This instrument can be the most valuable index of the functional status of the patient and a good indicator of the progress across therapeutic trials.
Magnetic resonance imaging (MRI). MRI creates cross-sectional, high-resolution images of the body by use of combined magnetic fields and radio waves processed by sophisticated software and hardware. The advantage of MRI for evaluation of the pelvis is that the contrasting images of the tissues are superior to those produced by computed tomography (CT) scan or ultrasound. MRI distinguishes normal and abnormal tissues in ways not possible with other methods.
Ultrasound. This is the best image method currently available for early examination of the pelvis. Its advantages are lower relative cost and greater availability. It works by reflection of high-frequency sound waves off of anatomic structures. The picture formed is the result of the various acoustic densities presented to the waves during penetration. Ultrasound is useful in determining whether pelvic organs are normal and whether displacement exists due to other pathological entities.
CT scan. The CT scan is also valuable as a diagnostic tool in determining pelvic abnormality, especially in relation to bony anatomy. It is performed by taking a series of cross-sectional X rays very close together (i.e., within 1 cm). It differs from conventional X-ray studies in that a computer determines the variation in X-ray penetration of the tissues. Since the CT scan uses X rays, the picture is excellent for depicting the bony relationships and, thus, is an excellent medium for evaluating pelvic problems associated with tumor growth, tumor invasion, and distortion of the pelvic anatomy.
Laparoscopy. Laparoscopy, or peritoneoscopy, is a refinement of the old culdoscopy surgical technique (Hinney et al., 1995; Querleu & Chapron, 1995). Its advantage is considerable compared to the older method, in that it positions the patient more reasonably and permits both diagnostic and therapeutic procedures. It is the most widely applied diagnostic technique used today in gynecology, and its application obviates many operative exploratory procedures that were needed in the past. Its use does require significant experience and expertise, but it is an invaluable tool in both diagnostic and operative procedures. Laparoscopy and lysis, or vaporization of abnormalities via laser, are indicated for endometriosis and adhesions. The laser beam offers the benefit of direct focus on the exact lesion, complete destruction by the high-energy beam, and instant hemostasis at the same time.
Laparotomy, the surgical opening of the abdomen, still pertains in some circumstances, if there is concern about distorted anatomy from multiple adhesions or a definite diagnosis of a substantial mass that requires removal.
Explaining the treatment hierarchy to the patient ensures that she understands fully what is going on. In this way, she can become an informed patient who takes interest in herself and in the therapy. Delineating the following treatment regimens in detail, and usually in the order listed, helps the patient realize that there are other pathways to explore if one of the therapies fails. Patients need to know that there are many different ways of approaching therapy and that some methods work well for some patients and other methods work well for other patients.
Local-anesthetic nerve block. The local anesthetic nerve block is used initially for diagnostic purposes, but it also serves as a beginning for therapy. Using a dilute solution of bupivacaine, the affected area is infiltrated with 3 ml to 5 ml of solution. Using a 25-gauge needle minimizes patients discomfort on repeated injections. Repeating the injections at intervals effects a decrease in the input signal to the central nervous system.
TENS unit. This battery-powered electrical-stimulus unit delivers intermittent bursts of nonpainful current to the skin to block noxious input signals coming from the same area. The current setting is ad-justable and can be modulated by simple switches on the base control unit. One can combine use of the TENS unit with other therapies such as local-anesthetic nerve blocks. This parallel therapy can sometimes reduce the time that the patient needs to reach a level of comfort (Garrison & Foreman, 1994).
Cryotherapy. This type of treatment essentially consists of freezing the involved nerve so that it undergoes cell death and ceases to function. The machines available for such treatments include sophisticated circuitry to provide for identifying in-volved nerves and then freezing to cause destruction at the local point involved (McDowell, McFarland, & Nalli, 1994).
Abdominal catheter placement. This method is indicated if the patient is refractory to local-anesthetic block therapy. Its advantages are that it minimizes repeated painful injections, it reduces the number of visits that are necessary, and it can give continuous pain relief rather than cyclic, on-and-off pain relief (Ghia et al., 1991).
Surgical therapy. Surgical entry into the area in which repeated conservative therapeutic measures have failed is sometimes necessary due to neuroma persistence or ineffective or misdirected local-anesthetic nerve blocks. It usually consists of opening the incision and carefully inspecting the incision line and wound bed to detect any obvious pathology, such as suture placement around a nerve or an obvious collection of neuromas due to old nerve damage (Jarde, Trinquier, Pleyber, Meire, & Vives, 1995).
For the most part, chronic pain patients experience a significant decrease in function that has an impact on their personal and vocational lives. From the personal standpoint, there are social and psychological aspects, and from the vocational standpoint, there are efficiency and capability aspects. The question is: Can a carefully constructed history and physical exam and structured use of local-anesthetic blocks over a short period of time aid in determining the etiology and predicting the success of treatment of alternative modalities of nonsurgical therapy? In this article, I have attempted to point out the complexity of these patients' problems. At first, it may seem to the unwitting practitioner that a simple organic problem is the primary cause of the pain. After the initial work-up, including operative laparoscopy, MRI, laboratory studies, and psychological profile, if there is no hint of a basic underlying problem, then perhaps it is prudent to refer the patient to someone who specializes in managing chronic pain syndromes that involve the lower abdomen and pelvis.
Our pelvic pain clinic uses a general rule of thumb: There must be close coordination and communication between the physician and the psychologist, both of whom are specialists by training and by limitation of practice to pelvic pain syndromes and lower abdominal pain. The initial challenge is to get to know the patient-to become familiar with her history and develop a sense of her functional status, including her social, psychological, and sexual interactions. Our clinic uses a team approach during the initial work-up and the later therapy sessions. The team includes a physician who is board-certified in both obstetrics/gynecology and anesthesiology and a psychologist who was formerly a director at the Masters and Johnson Institute. Chronic pelvic pain patients-both male and female-are especially sensitive and have many psychological, social, physiological, and physical ramifications in regard to their pain.
Applegate, W.V. (1972). Abdominal cutaneous nerve entrapment syndrome. Surgery, 71(1), 118-124.
Augustin, P., Daluzeau, N., Dujardin, M., Clement, O., & Denis, P. (1984). Hematoma of the pyramidal muscle: A complication of anticoagulant treatment. Review of Neurolology, 140, 443-445.
Buntin, D.M. (1994). The 1993 sexually transmitted disease treatment guidelines. Seminars of Dermatology, 13(4), 269-274.
Cheetham, D.R. (1985). Bartholin's cyst: Marsupialization or aspiration? American Journal of Obstetrics and Gynecology, 152, 569-570.
Dodson, M.K., Cliby, W.A., Pettavel, P.P., Keeney, G.L., Podratz, K.C. (1995). Female urethral adenocarcinoma: Evidence for more than one tissue of origin? Gynecologic Oncology, 59(3), 352-357.
Fricker, P.A., Taunton, J.E., & Ammann, W. (1991). Osteitis pubis in athletes. Sports Medicine, 12(4), 266-279.
Garrison, D.W., & Foreman, R.D. (1994). Decreased activity of spontaneous and noxiously evoked dorsal horn cells during transcutaneous electrical nerve stimulation (TENS). Pain, 58, 309-315.
Ghia, J.N., Blank, J.W., & McAdams, C.G. (1991). A new interabdominis approach to inguinal region block for the management of chronic pain. Regional Anesthesia, 16, 72-78.
Hinney, B., Bertagnoli, C., Tobler-Sommer, M., Osmers, R., Wuttke, W., & Kuhn, W. (1995). Diagnosis of early ectopic pregnancy by measurement of the maternal serum to cul-de-sac fluid beta-hCG ratio. Ultrasound Obstetrics & Gynecology, 5(4), 260-266.
Jarde, O., Trinquier, J.L., Pleyber, A., Meire, P., & Vives, P. (1995). Treatment of Morton neuroma by neurectomy: Appropos of 43 cases. Revue de Chirurgie Orthopedique et Reparatrice de l'Appareil Moteur, 82(2), 142-146.
Lynch, P.J. (1986). Vulvodynia. Journal of Reproductive Medicine, 31, 773.
McDowell, J.H., McFarland, E.G., & Nalli, B.J. (1994). Use of cryotherapy for orthopaedic patients. Orthopaedic Nursing, 13(5), 21-30.
Nuovo, J., Melnikow, J., Paliescheskey, M., King, J., & Mowers, R. (1995). Cost-effectiveness analysis of five different antibiotic regimens for the treatment of uncomplicated Chlamydia trachomatis cervicitis. Journal of the American Board of Family Practice, 8(1), 7-16.
Petersen, E.E., & Pelz, K. (1983). Diagnosis and therapy of nonspecific vaginitis: Correlation between KOH-test, clue cells and microbiology. Scandinavian Journal of Infectious Diseases, 40 (Suppl.), 97-99.
Querleu, D., & Chapron, C. (1995). Complications of gynecologic laparoscopic surgery. Current Opinions in Obstetrics & Gynecology, 7(4), 257-261.
Rawlings, C.E., Wilkins, R.H., Martinez, S., & Wilkerson, R.H. (1988). Osteoporotic sacral fractures: A clinical study. Neurosurgery, 22(1), 72.
Reamy, K. (1982). The treatment of vaginismus by the gynecologist: An eclectic approach. Obstetrics & Gynecology, 59, 58-62.
Singh, K.K., Lessells, A.M., Adam, D.J., Jordan, C., Miles, W.F., MacIntyre, I.M., & Greig, J.D. (1995). Presentation of endometriosis to general surgeons: A 10-year experience. British Journal of Surgery, 82, 1349-1351.
Slocumb, J.C. (1990). Chronic somatic, myofascial, and neurogenic abdominal pelvic pain. Clinical Obstetrics and Gynecology, 33(1), 145.
Spitzer, M., & Krutnholz, B.A. (1992). Human papillomavirus-related diseases in the female patient. Urology Clinics of North America, 19(1), 71.
Vignati, P.V., Welch, J.P., & Cohen, J.L. (1995). Long-term management of diverticulitis in young patients. Diseases of the Colon and Rectum, 38, 627-629.
Walker, E.A., Roy-Byrne, P.P., Katon, W.J., & Jemelka, R. (1991). An open trial of nortriptyline in women with chronic pelvic pain. International Journal of Psychiatry and Medicine, 21(3), 245-252.
Woolcott, R., Petchpud, A., O'Donnell, P., & Stanger, J. (1995). Differential impact on pregnancy rate of selective salpingography, tubal catheterization and wire-guide recanalization in the treatment of proximal fallopian tube obstruction. Human Reproduction, 10, 1423-1426.
John McDonald is professor and chair of anesthesiology, professor of obstetrics and gynecology, and director of the Pain Control Center of The Ohio State University Medical Center in Columbus, OH.
