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Probability diagnosis

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Gynaecological disorders, for example:

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  • endometriosis

  • dysmenorrhoea/mittelschmerz

  • pelvic adhesions

  • ovarian cyst – torsion, pressure or rupture

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Musculoskeletal disorders

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Irritable bowel syndrome

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Referred spinal pain

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Serious disorders not to be missed

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Neoplasia/cancer:

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  • lower bowel

  • cervix and uterus

  • ovary

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Vascular:

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  • internal iliac artery → claudication

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Infection:

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  • osteomyelitis

  • pelvic inflammatory disease

  • pelvic abscess

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Ectopic pregnancy

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Strangulated hernia (femoral or inguinal)

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Pitfalls (often missed)

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Endometriosis

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Constipation/faecal impaction

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Paget disease

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Stress fractures (incl. SCFE)

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Prostatitis/prostatodynia

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Misplaced IUCD

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Hernia in evolution (e.g. inguinal)

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Nerve entrapment

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Rectum: proctitis or prolapse

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Masquerades checklist

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Depression

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Spinal dysfunction

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UTI

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Is the patient trying to tell me something?

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Functional disorders possible. Psychosexual dysfunction. Pelvic congestion syndrome.

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Key clinical features

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As it is almost always seen in women rather than men the focus will be taking a history of pain associated with periods, ovulation and sexual intercourse. It is invariably linked at times with lower abdominal pain (see ‘Lower abdominal pain and pelvic pain in women’).

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   In men it is related to trauma, sporting injuries, prostatic disorders and hernias. Examination of the abdomen and pelvis is important, especially rectal and vaginal examinations.

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Key investigations

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Consider and select from:

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  • FBE

  • ESR/CRP

  • urine MC ± chlamydia PCR

  • STI tests

  • pregnancy test

  • plain X-ray

  • vaginal or pelvic ultrasound

  • colour Doppler US imaging

  • colonoscopy/flexible sigmoidoscopy

  • laparoscopy if appropriate.

  • cutaneous pain mapping

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Diagnostic tips

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  • The incidence of chronic pelvic pain (CPP) is 15% in 18–50 year old women. Endometriosis causes 33% and adhesions 24%.

  • CCP in women is the reason for 40% of gynaecological laproscopies and 15% of hysterectomies.

  • Pelvic congestion syndrome is regarded as a type of ovarian dysfunction causing unilateral pain, deep dyspareunia and postcoital aching.

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