Chronic Pain and Illness Assessment Forms and Questionnaires
A variety of patient assessment forms and questionnaires are available for use in patients with chronic pain and illnesses. It is important to quantify the amount and location of the patient’s pain. This helps to determine the presenting level of pain and provides a baseline level for future comparison to help determine effectiveness of treatment being provided. Other questionnaires will help determine the impact of the patient’s disease on her quality of life which ultimately is what we are trying to improve.

• Numeric Pain Intensity Scale
  The numeric pain intensity scale rates the pain on a scale of 0 to 10. Zero equals no pain while 10 equals the worst imaginable pain possible. This scale can be used to give an overall high, low and average as well as the intensity of individual aspects of the pain.
  
• McGill Pain Questionnaire
  This is a multi-dimensional pain scale that uses descriptive terms to describe the pain in addition to the intensity of the pain.
  
• SF-36
  The SF-36 is a quality of life questionnaire that has been well studied and validated. This questionnaire is a widely used standard found in a variety of scientific studies. This is one of the measures of medical treatment, outcome and well being that we use at VitalCare to track our patient’s progress.
  
• Pain Diagram
  The pain diagram helps to specifically locate the area of pain. Many of our patients have multiple different pain sites. At VitalCare Institute of Health we use this instrument to help identify and quantify all of the specific pain locations prior to treatment. This provides the information necessary to follow our patients during treatment to identify efficacy of treatment.
  
• Fibromyalgia Impact Questionnaire
  This is a standard questionnaire used to determine the level of impact that fibromyalgia is having on a patients life.
  
• Toxicity Questionnaire
  The purpose of this questionnaire is to determine the overall level of toxic exposure that the patient has been exposed to in the past.
  

History and Physical Examination
History – an important step that should not be overlooked or abbreviated due to time constraints. As a physician, it is important to remember the vital contribution that can be made by the patient. While she is not a trained health care professional, she does live with her body and understands the symptoms better than anyone else. It is also important to take a detailed history, sometimes from birth, to fully understand the various factors in play in a patient’s disease condition.

Physical Examination – provides an abundant amount of information in skilled hands. A complete standard physical examination should be performed. Beyond this standard physical examination that all physicians have learned is a wealth of information waiting to be discovered. The physician should approach the patient like a detective looking for clues. This starts at the head and ends at the toes – yes we are looking for the cause or causes of pelvic pain.

The head – loss of the outer 1/3 of the eyebrows can suggest hypothyroidism

The jaw – temporomandibular joint (TMJ) problems are associated with pelvic and sacroiliac joint problems

The teeth – some feel that mercury amalgam fillings and root canals can be a focus of infection or source of heavy metal toxicity which can decrease immune function.

The mouth – the tongue can show signs of yeast overgrowth suggesting a possible imbalance of the bowel bacteria. This is known as dysbiosis which represents a breakdown of the fundamental protective lining of the bowel and thus the first line of defense of the immune system (innate immunity).

The neck – multiple areas around the neck and upper back are areas that include fibromyalgia tender points. Patients with pelvic pain and endometriosis have a higher incidence of fibromyalgia. The thyroid gland is located on the lower front neck. Hypothyroid patients often have an enlarged thyroid gland.

The mid back – mid back pain to the side of the spine can be the result of involvement of the ureter (the tube that goes from the kidney to the bladder along the back) with endometriosis or adhesions in the pelvis which can act to constrict, but rarely block, the ureter. Dilation "upstream" of this restriction can result in pain, just as dilation of the bowel with gas causes pain. Muscle spasm can cause significant pain. This rarely resolves on its own, usually requiring deep tissue massage to correct the condition.

The lower back – The lower back including the area of the sacroiliac joint which connects the hip and the coccyx (tailbone) can become inflamed and painful. This pain can be secondary to the pain in the pelvis (endometriosis, etc) which may correct after the pelvic problem is corrected. Alternatively, secondary conditions such as misalignment or instability of the SI joint may need to be treated after the primary cause of the pelvic pain is removed. Muscle spasm can cause significant pain. This rarely resolves on its own, usually requiring deep tissue massage to correct the condition.

The abdomen – A systematic approach is important for an effective exam. I start in the area that is least tender and slowly work closer to the area of most pain. The purpose of the physical examination is to obtain information, not to torture. A little sensitivity, a little extra time and a little skill can make the physical examination a humane and worthwhile experience. Often the upper abdomen is less tender and this is where I usually start.

The gallbladder is located under the right upper quadrant, the area near the ribs. I find quite a few diseased painful gallbladders. Pain with palpation in this area, usually worse with a deep breath, is known as a positive Murphy’s sign. A positive Murphy’s sign warrants a further workup of the gallbladder, including a gallbladder sonogram and a HIDA scan. There is a certain incidence of false negative tests. This means that even if all of the diagnostic tests are normal, the gallbladder can still be diseased and a source of pain. The successful resolution of this situation requires good communication with the surgeon. Pathology almost always confirms disease of the gallbladder following a cholecystectomy (surgical removal of the gallbladder) even in cases where all of the diagnostic studies were normal.

The stomach and the transverse colon are located in the area of the mid upper abdomen. The spleen is located in the left upper quadrant.

The lower half of the abdomen is usually the location of the pain and pathology. One question that we are trying to answer is if the pain is located in the abdominal wall (neuropathy, etc.) or inside of the abdominal cavity (endometriosis, adhesions, IC, etc.). Pain that wraps around from the back, over the hip and down the right or left lower quadrant into the groin area is often a problem with the ilioinguinal nerve. There are a variety of causes and conditions that can result in damage to this nerve. It is possible that long standing pain has resulted in neuroplastisity with this nerve becoming hypersensitized. Once this happens, any stimulus of this nerve is interpreted as pain and that is the message that is sent on to the brain, even if the stimulus is not one that should evoke pain. Placing pressure on the area of the ilioinguinal nerve (re-creating the patient’s pain) and having the patient do an "abdominal crunch" will help differentiate abdominal wall neuropathy from intrabdominal pathology. As the muscle tense up, they protect the inside of the abdomen and thus the pressure of the exam. In this case the pain usually decreases. If the problem is an abdominal wall neuropathy, then the muscles tensing up place more pressure on the nerve and thus the pain gets worse.

The sigmoid colon is located in the left lower quadrant. This should be checked for the presence of impacted stool and adhesions.

Next I usually put pressure on the pubic bone. If this is tender, my level of suspension for bladder problems including interstitial cystitis is higher.

The inguinal ligament runs between the pubic bone and the crest of the hip bone. Pain in this area is suggestive but not diagnostic of an inguinal or femoral hernia

Pain associated with light touch of the skin is suggestive of an overall hyperesthesia of the abdominal wall which is a type of neuropathy.

The Lungs – pain with inspiration can suggest endometriosis in the lining of the lung. The lack of breath sounds may represent a partial pneumothorax that can occur with endometriosis.

The Extremities – Several fibromyalgia tender points are present on the extremities. Very cold hands and feet are suggestive of some disease processes. Minimal reflexes indicate further evaluation for the possibility of hypothyroidism. The length of both legs should be evaluated. If one leg is longer than the other it can throw the pelvis off and result in misalignment and pain.

The Pelvic Exam

Vulva – is the outside portion of the pelvis. This area contains the peri-urethral glands and the vestibular glands. These glands can become inflamed and painful contributing to pelvic pain in general and specifically pain with intercourse. The entire vulvar area can become painful as well. This is known as vulvodynia. The vulva should be inspected for any lesions, including abnormal lesions including herpes lesions and condyloma.

Pelvic Muscle Floor – The bottom of the pelvis, from the pubic bone to the tail bone, is comprised of a series of muscles. In patients with chronic pelvic pain, these muscles are often unconsciously tensed up. Over time these muscles commonly go into spasm forming knots. These areas of the muscle become scarred and cannot fully relax. Just like a cramp in the leg or knots in the back muscle, these areas are very painful, especially when pressure is placed on the muscle or when the muscle is stretched (as it is during intercourse). This secondary condition of pain is a result of another condition causing pain (for example endometriosis) which often persists even after the initial cause of pain is corrected. Pelvic muscle floor spasm needs to be recognized and treated when present for resolution of symptoms.

Pudendal Nerve – This nerve is located on both the right and left side of the vagina. This nerve often becomes sensitized and involve in the pain process. A pudendal nerve block is often helpful in relieving this type of pain.

Vagina – The vagina should be inspected for signs of infection, most often either yeast or bacteria. The area near the top of the vagina behind the cervix should be carefully inspected for the presence of endometriosis. Endometriosis can grow through the vagina in severe cases of invasive posterior cul-de-sac disease. The bartholins gland is located near the opening of the vagina. A cyst can develop in this area and can become infected. Atrophy (thinning) of the vagina can result in pain with intercourse. During internal examination of the vagina, pressure on the top of the vagina presses on the bladder. Patients with interstitial cystitis usually have marked tenderness in this area.

Cerivx – As the posterior cul-de-sac becomes involved with endometriosis the cervix is less mobile as a result of the fibrotic changes. The cervix becomes increasingly tender and can be a source of deep pain during intercourse (collisional dyspareunia). Nodularity of the uterosacral ligaments which arise from the back of the cervix usually represents endometriosis. This condition often results in lower back pain.

Uterus – The position, location, size and sensitivity of the uterus should be determined. In some cases, the uterus literally starts to fall out of the vagina. In mild cases, known as pelvic relaxation, the uterus descends a little bit lower into the vagina. As a result the uterus can cause pressure in the pelvis and tends to get hit during intercourse. A uterus that is tipped to the back is suggestive of posterior cul-de-sac endometriosis. If the uterus is slightly enlarged and tender to palpation this may represent adenomyosis. A fibroid uterus is usually enlarged and irregular shaped.

Ovaries and Fallopian tubes – The size, location and tenderness of the ovaries should be assessed. An ovarian cyst, including an endometrioma, results in an enlarged and usually tender ovary. If the ovary is involved in adhesions, it is usually fixed and very tender when pressure is placed on the ovary. If an ovary or fallopian tube is attached to the bowel, this often results in intensification of pain during a bowel movement. Infection of the fallopian tube as a result of Pelvic Inflammatory Disease (PID), an infection of the fallopian tubes, can result in significant damage and blockage. The tubes can then fill up with fluid and result in chronic pain

Rectal Exam – I personally do not always perform a rectal exam.This portion of the exam is unpleasant and can be skipped if it is not indicated. Some will disagree with this approach, but I try to be humane in my medical care. When a rectal exam is indicated, several conditions should be checked. Deep invasive endometriosis can be palpated in the rectovaginal septum. A rectoceole can result in difficulty in having a bowel movement and even pain with intercourse. By definition, this is a thinning of the partition between the rectum and the vagina. It is difficult to pass a bowel movement. When a patient bears down to have a bowel movement, the thin membrane between the vagina and rectum bulges into the vagina allowing the bowel movement to displace into the vaginal area rather than being displaced out of the rectum. Some women have to place their fingers into the vagina to help push the bowel movement out.

Diagnostic Tools

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

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Allergy testing – Provocation/Neutralization (P/N) testing is the method we employ for
evaluating food and hormone sensitivities. During this procedure, carefully produced skin wheals are made for each food tested. The whealing response with intradermal testing normally correlates well with the presence or absence of sensitivity to that food. Rather than just evaluating wheal response, the patient’s symptoms are considered as well during the testing. Provoking symptoms is not required, but frequently occurs in this form of testing. One food is tested at a time, rather than a whole group of them at once in order to be more precise in the diagnosis of food sensitivities.

Since the food or hormone is tested one at a time, this type of allergy testing takes longer than scratch, prick or previous forms of intradermal allergy testing. This technique of allergy testing also becomes a form of therapy. During this test procedure, a "neutralization dose" is also determined. The neutralization dose is the proper dose to alleviate the symptoms related to ingestion of the allergic food. The symptoms that are produced during testing are usually mild and rarely severe. The accuracy and reliability of P/N testing for food allergies has been documented with a multi-center double blinded randomized study (1).

Anorectal manometry – This is a useful test in patients with constipation and anal pain.
The pressures in the anal canal, the rectoanal inhibitory reflex and rectoanal excitatory reflex can be measured. Biofeedback can be useful in treating abnormal conditions detected with this test.
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Barium enema –is performed in the radiology department at the
hospital. An x-ray dye is placed in the colon and x-ray pictures of taken. This provides a picture of the colon and helps to visualize anatomic defects including masses, partial obstruction, strictures, and redundant colon. This is a moderately painful test.

Bladder Instillation in office – This is an office test to screen for interstitial cystitis.

Blood tests – Numerous blood tests are available to help in the diagnosis of pelvic pain

Body composition analysis – This measures the relative amount of muscle and fat tissue
In the body. Most of these instruments also determine the patient’s body mass index (BMI). The BMI is a measure of the patient’s weight in relation to their height. A BMI of 19 to 24 is healthy, 25 to 29 overweight and 30 & greater is considered obese. Some instruments measure the amount of water inside and outside of the cells which some studies suggest represents an overall measure of an individual’s health.

Bowel transient study – (nuclear medicine gastric emptying test) This test is done in the
nuclear medicine department at the hospital. The stomach, small bowel and colonic motility is evaluated with this test. A radioactive tracer is placed in food and tracked over several days to determine the motility of the gastrointestinal tract. A motility disorder can result in bowel dysfunction and cause pain.
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Cystoscopy with hydrodistention – This procedure is performed in the operating room.
A cystoscope is placed through the urethra and into the bladder. The bladder is filled to its maximum capacity, then drained and measured. The cystoscope is then placed back into the bladder. The presence of numerous small bleeding points (glomerulations) is indicative of interstitial cystitis.
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Defecography – Barium paste is injected into the rectum. The patient is placed in the sitting position and x-ray pictures are taken during defecation. This allows measurement of the anorectal angle at rest and with defecation. The amount of anal decent is evaluated, the function of the anal sphincter and contractility of the rectum. A rectocele can be diagnosed with this test also.

DEXA (bone density) – A DEXA of the hip and spine is considered to be the "gold standard" for bone density examination. A T-value of -1.- to -2.49 is considered to be low bone mass and defined as osteopenia. A T-value of -2.5 or greater is by definition osteoporosis. A patient who undergoes hysterectomy with removal of both ovaries should have a baseline DEXA of the hip and spine. While most physicians would probably differ, I personally would not start a GnRH agonist without a baseline DEXA. Some people have a low peak adult bone mass (their bones are not as strong as the average person) and I feel may not be good candidates for GnRH therapy for this reason.

Diagnostic laparoscopy – The laparoscope is a telescope that is a surgical instrument.
This is usually placed through the belly button while the patient is under general anesthesia in an operating room. This instrument can be very helpful in diagnosing a variety of conditions that can cause pelvic pain including endometriosis, adhesions, appendicitis, ovarian vein varicosity, inguinal hernias, pelvic congestion, pelvic relaxation, ovarian torsion, ovarian cysts, ovarian endometrioma, uterine fibroids, adenomyosis, endometriosis of the bowel, etc.
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Gallbladder ultrasound – This ultrasound is done with the patient fasting, at which time the gallbladder is full and has not contracted. The primary purpose of this exam is to look for gallstones.
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HIDA scan – This exam uses an intravenous injection of a radioactive material called Hydroxy IminoDiacetic Acid (HIDA). This helps to evaluate the ability of the gallbladder to function normally. If the ejection fraction is low, then the gallbladder is not functioning properly and may need to be removed if symptomatic.

Hysteroscopy; In Office – This is a diagnostic procedure performed with local anesthesia. This allows your doctor to look inside the uterus in the office. This is helpful in patients with abnormal bleeding or patients who are having difficulty getting pregnant. There are two basic types of hysteroscopes, rigid and flexible. The primary advantage of the flexible hysteroscope is less discomfort to the patient.
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Mammography – A mammogram is a screening test for breast cancer which uses low
dose x-rays. 85 to 90% of existing breast cancers are detected with mammography.
MRI for adenomyosis – An MRI can help to diagnose the presence of adenomyosis is
some cases. A diagnostic radiology test that shows images of organs and tissues using strong magnets and the absorption energy of atomic nuclei.
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Nerve blocks – A variety of nerve blocks can be performed to provide pain relief. The
use of a numbing agent and an anti-inflammatory usually helps to block the pain signal from a damaged or irritated nerve. While this is usually temporary, when using a numbing agent such as lidocaine or marcaine, repeated nerve blocks over time (weeks) often break the pain cycle and can provide permanent pain relief. The most common in-office nerve blocks are of pudendal and ilio-inguinal nerves or other abdominal wall nerves. The abdominal wall nerve blocks including the ilio-inguinal nerves can be performed without anesthesia and without pain if the right technique is used. I have watched other physicians place patients through excruciating pain because they seem to be in a hurry and use large needles. I have developed a technique that is virtually pain-free for performing these blocks. First, the solution must be injected slowly and second a very small needle (30 gauge) is used. These seemly simple points make a huge difference for the patient. The pudendal nerve block is painful in an awake patient. I have an anesthesiologist come to my office and provide monitored intravenous sedation. The patient feels no pain with this approach.

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Pain mapping with pain diagram – During this procedure, the patient details the precise location, character and intensity of the pain. The results are drawn out on a figure to help visually identify the various different pains and location.

Patient assisted laparoscopy – Uses a small 2mm laparoscope while the patient is awake but under supervision of an anesthesiologist in an operating room. The abdominal wall is numbed up and the laparoscope and a 2mm probe is carefully placed. The probe to used to palpate the internal organs and structures trying to recreate the pain. The patient helps to locate the pain during the procedure.
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SF-36 – The SF-36 is a quality of life questionnaire that has been well studied and validated. This questionnaire is a widely used standard found in a variety of scientific studies. This is one of the measures of medical treatment, outcome and well being that we use at VitalCare to track our patient’s progress. Sitz marker test – This test uses markers to determine the motility of the bowel. The patient swallows the markers. X-rays are then taken on a regular basis to follow the progress through the bowel.

Sonogram – see Ultrasound

Sonohysterogram – This is an in office procedure that combines the use of the transvaginal ultrasound with a small catheter that is placed inside of the uterus. A saline solution (salt water similar that that naturally found in the body) is injected inside the uterine cavity. This temporarily fills up the uterus with water, filling up the uterus like a balloon, allowing a clear view of the inside lining of the endometrium. Problems inside the uterus such as an endometrial polyp and a submucous fibroid can be more easily identified.

Spinal Cord Stimulator – This procedure utilizes a small electrode that sends an electrical stimulus that in essence cancels the pain signal to the brain. A trial period before permanent implantation is usually performed as a diagnostic test to determine of this is the appropriate treatment for the patient. This is effective in patients who have failed other forms of treatment, including severe cases of interstitial cystitis. This procedure is also known as a Dorsal Column Stimulator

Stool Guiac Test - A small sample of stool is placed onto a special test kit. This test
checks for the presence of microscopic blood. This test is recommended yearly starting at the age of 50 as a screening test for colon cancer.
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Ultrasound – (also known as a sonogram) uses sound waves to provide images of internal organs. The use of a transvaginal probe provides better pictures of the pelvic organs than an abdominal probe. The other advantage of the transvaginal probe is that the bladder needs to be empty as opposed to the abdominal probe which requires a full bladder. The ultrasound provides an image of the overall size and shape of the uterus, the thickness of the endometrium, the presence of fibroids, endometrial polyps, ovarian cysts, endometrial cysts of the ovary, ovarian vein varicosity, hydrosalpinx (dilated and damaged fallopian tubes) and tubal pregnancy. The ultrasound is not good at visualizing scar tissue or endometriosis. The transvaginal ultrasound is very helpful in identifying which pelvic structures are tender. The area in question can be lined up with the end of the probe, pressure applied and presence of tenderness or pain of that structure ascertained.

Urine analysis and culture – A urine analysis checks the urine chemistry and other factors suggestive of a bladder infection. A urine culture where the urine is incubated for growth of bacteria is needed to confirm a bladder infection and a sensitivity test determines which antibiotics are effective in killing the bacteria.
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Vaginosis panel – This is a series of tests that evaluate the vagina for bacteria and yeast infection as well as a variety of different vaginal parameters.
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Wet Prep – A sample of vaginal secretions is placed on two different microscope slides, one in normal saline and one in potassium hydroxide (KOH). The slides are viewed under the microscope. The normal saline slide helps to diagnose bacterial vaginosis and the KOH slide helps to diagnose yeast infection.

Surgical Procedures & Treatment Provided by Dr.Cook and VitalCare

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

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Adhesiolysis - To cut or remove scar tissue
Appendectomy – The surgical removal of the appendix.
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Bladder suspension – This is a process by which the bladder is placed back in its anatomically correct position. Following child birth, a woman may experience urinary stress incontinence. The most common symptoms are leakage of urine when coughing, sneezing or laughing.


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-C-
Cervical conization - This procedure is similar to the LEEP procedure except that it usually removes more tissue than a LEEP procedure. A scalpel is used to perform a cervical conization .

CO2 laser of the periurethal and vestibular glands - Ablation of the periurethal (skene's) and vestibular glands with the CO2 laser. This can be performed in cases in which these glands are chronically inflamed and painful.

Cystoscopy - To look inside the bladder with a cystoscope (a small telescope).
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-D-
Diagnostic Hysteroscopy - A hysterscope is a surgical telescope, usually 3 to 5 mm in diameter. Hysteroscopes can be rigid or flexible. In the past, rigid hysteroscopes have provided better optics and thus better visualization of the inside of the uterus. They also are better if surgery needs to be performed. The optics of flexible hysteroscopes are rapidly improving and are almost as good as rigid scopes. They are much less uncomfortable if the patient is awake. The flexible hysteroscope has made office hysteroscopy practical.

Diagnostic laparoscopy – The laparoscope, a telescope that is a surgical instrument usually 5 to 10 millimeters in diameter, is usually placed through the belly button while the patient is under general anesthesia in an operating room. This instrument can be very helpful in diagnosing a variety of conditions that can cause pelvic pain including endometriosis, adhesions, appendicitis, ovarian vein varicosity, inguinal hernias, pelvic congestion, pelvic relaxation, ovarian torsion, ovarian cysts, ovarian endometrioma, uterine fibroids, adenomyosis, endometriosis of the bowel, etc. Diagnostic means that no surgical correction or treatment is performed at this surgery, only observation is being performed.

Dilation and curettage – This procedure is performed to obtain a significant amount of
endometrium. Dilation refers to dilation of the cervix and curettage is a gentle scrapping of the lining of the uterus.


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Endometrial ablation - The removal or elimination of the lining of the uterus without doing a hysterectomy. This procedure is usually performed when excessive menstrual bleeding is present. While periods are often eliminated, the goal is to reduce the monthly bleeding to a normal level. There are several techniques by which this procedure can be done. (place link to discussion of endometrial ablation and pics of novasure)
Endometrial biopsy - Taking a biopsy (piece of tissue) from the endometrium (inside lining of the uterus) which is usually done in the office. Sometimes local anesthesia is used. It is moderately uncomfortable, but short lived. Taking a couple of Motrin ahead of time helps to minimize the cramping. (Place link picture of pipelle catheter-F-
Fimbrioplasty - To surgically improve the appearance and function of the fimbria (end of the fallopian tube).
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-H-
Hernia Repair – The most common type of groin hernia is the indirect inguinal hernia. Other types include the direct inguinal hernia, femoral hernia and the obturator hernia. These hernias can cause pelvic pain, groin pain, leg pain and even back pain. Repair of the hernia involves removal of the hernia sac and repair of the defect with mesh.

Hysterosalpingogram – Radiocontrast dye is placed into the uterine cavity under fluoroscopic evaluation. The fluoroscope is like an x-ray movie camera. The dye normally flows out of the fallopian tubes. This procedure is usually mildly to moderately uncomfortable (rarely severe pain) and provides a picture of the inside of the uterine cavity and the fallopian tubes.

Hysteroscopic resection of the uterine septum - A septum is kind of like a curtain that runs down the middle of the uterine cavity. This is an abnormality that occurs at birth. A hysteroscopic resection of the uterine septum removes the septum using either hysteroscopic scissors or more commonly an electrical "resectoscope".

Hysteroscopic Tubal Ligation – Tubal ligation via the hysteroscope allows for permanent sterilization without an incision or general surgery. A small metal coil is placed up into the fallopian tube which blocks the fallopian tube. This device is known as Essure permanent birth control by conceptus.
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-I-
Intrauterine Insemination – This procedure is also known as IUI. The sperm is washed and the active portion is concentrated into a small volume. The specimen is then placed into the uterus during an office examination.

IUD placement – An intrauterine device is a type of birth control method. Placement of
this device is performed in the office during a pelvic exam. This procedure is rarely more than minimally uncomfortable.
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-L-
Laparoscopic assisted vaginal hysterectomy (LAVH) - Hysterectomy is removal of the uterus. Total is the medical term that means that the body of the uterus and the cervix is removed. During a laparoscopic assisted vaginal hysterectomy (LAVH), the lower portion of the uterus is detached from the body through the vagina and the upper portion of the uterus is detached from the body through the laparoscope.

Laparoscopic oophorectomy - Removal of the ovary with the laparoscope.

Laparoscopic salpingectomy - Removal of the fallopian tube with the laparoscope.

Laparoscopic supracervical hysterectomy (LSH) - During a supracervical hysterectomy, the body of the uterus is removed and the cervix is left in place. The entire procedure is performed through the laparoscope. The uterus is removed from the abdomen with a morcellator. (place link to picture and discussion of morcellator - possible sponsor by gynecare the manufacturer)

Laparoscopic tubal ligation - A surgical technique where the fallopian tubes are ligated (tied off) using the laparoscope which results in permanent sterilization

LEEP procedure of the cervix - This involves removal of the surface of the cervix and abnormal cells (usually precancerous) with a wire electrode.
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-M-
Myomectomy - Surgical removal of uterine fibroids while preserving the uterus.
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Operative Laparoscopy – This includes all surgical procedures to correct or remove disease that use the laparoscope. The vast majority of operative procedures can performed as well or better than laparotomy (large incision similar to a C-section). This includes treatment of endometriosis, adhesions and hysterectomy to name a few.

Ovarian vein ligation - Tying off of the ovarian vein. This procedure is usually done to treat a symptomatic ovarian vein varicosity.

Ovariolysis - To cut or remove scar tissue that is involves the ovary or ovaries.
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-P-
Patient Assisted Laparoscopy (PAL) – Uses a small 2mm laparoscope while the patient is awake but under supervision of an anesthesiologist in an operating room. The abdominal wall is numbed up and the laparoscope and a 2mm probe is carefully placed. The probe to used to palpate the internal organs and structures to re-create the pain. The patient helps to locate the pain during the procedure.

Perineoplasty – Surgical reconstruction of the perineal area. The perineal area is located in between the vagina and the rectum. This area can become traumatized as a result of child birth.

Peripheral Nerve Block – A numbing agent such as marcaine or lidocaine is used to temporary block the pain signal from a peripheral nerve. An anti-inflammatory agent is often added in addition to the local anesthetic.
Presacral Neurectomy - Cutting or removing a portion of the presacral nerve plexus.

his plexus or group of nerves conducts the pain signal to and from the uterus and the brain. This procedure is effective in controlling pain or cramping in the middle of pelvis. This can be an effective procedure for treating severe primary dysmenorrhea.

Pudendal Nerve Block - A numbing agent such as marcaine or lidocaine is used to temporarily block the pain signal from the Pudendal nerve. An anti-inflammatory agent is often added in addition to the local anesthetic.
Pulse-Dye Laser Treatment – The pulse dye laser is selectively absorbed by red pigment. Use of this laser on the vulva is one treatment for vulvodynia. This helps to decrease the inflammatory response and often the associated pain.
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Rectocele Repair – This is also known as a posterior repair. A rectocele is defined as protrusion of the rectum into the vaginal wall. The wall in between the rectum and the vagina becomes thin and the bowel prolapses into the vagina. The most common symptom is difficulty in passing the stool from the rectum. Some women have to place their fingers into the vagina to help the stool out of the rectum. Surgical repair of the rectocele involves building up the wall in between the rectum and vagina.
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Salpingolysis - To cut or remove scar tissue that involves the fallopian tube.

Sonohysterogram – This is an in-office procedure that combines the use of the transvaginal ultrasound with a small catheter that is placed inside of the uterus. A saline solution is injected inside the uterine cavity. This temporarily fills up the uterus with water, filling up the uterus like a balloon, allowing a clear view of the inside lining of the endometrium. Problems inside the uterus such as an endometrial polyp and a submucous fibroid can be more easily identified.
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TMJ problems – Patients with pelvic pain and fibromyalgia may have a higher incidence of temporomandibular joint problems. This should be evaluated and treated by a dentist that specializes in this area.

Total abdominal hysterectomy - Hysterectomy is removal of the uterus. Total is the medical term that means that the body of the uterus and the cervix is removed. This procedure is performed with a laparotomy (bikini incision like a c-section)

Total Laparoscopic Hysterectomy – A hysterectomy is removal of the uterus. Total is the medical term that means that the body of the uterus and the cervix is removed. Total laparoscopic hysterectomy is defined as removing the uterus and cervix with laparoscopic surgery. The uterus is usually removed through the vagina.

Total vaginal hysterectomy - Hysterectomy is removal of the uterus. Total is the medical term that means that the body of the uterus and the cervix is removed. The entire operation is performed through the vagina.Transvaginal Ultrasound Guided Cyst Aspiration – An ovarian cyst can be aspirated or drained through the vagina with the aid of a transvaginal ultrasound. The ovary with a cyst is just on the other side of the vagina and can be easily accessed with a special needle that goes through a needle guide attached to the transvaginal probe. This is a moderately painful procedure which is usually performed under IV sedation.

Tubal anastomosis - This procedure re-connects the fallopian tubes usually to reverse a
tubal ligation.

Tuboplasty - To fix a damaged fallopian tube
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.-U-
Urethral dilation - To enlarge the urethral, the opening of the bladder Uterine suspension - To suspend or raise the uterus in the pelvis. This is most often done by placating (shortening) the round ligaments. A suture is run through the round ligament and then tied, shortening up the round ligament. The round ligament is a support structure that runs from the top of the uterus to the area of the groin.

Uterosacral Neurectomy – The uterosacral ligaments arise from the back of the cervix and to the sacrum (lower back). Cutting these ligaments is one technique to reduce the pain to the uterus. The results of this technique are mixed when used exclusively. When performed laparoscopically, this procedure is also known as a Laparoscopic Uterosacral Nerve Ablation (LUNA).
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-V-
Vulvar Biopsy – Removal of a piece of tissue from the vulvar area. This can be
performed in the office under local anesthesia. The biopsy specimen is sent to the pathologist who looks at the tissue under the microscope to determine if there are any tissue abnormalities.

Medical Treatment

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Detoxification of biotoxins and neurotoxins – Patients with endometriosis and associated chronic diseases may have been exposed to biotoxins, many of which are neurotoxic. There are several different approaches to detoxification of the body depending upon the patient’s situation. A study by the Endometriosis Association in the early 1990’s demonstrated a dose dependent correlation between the level of exposure to Dioxin and the severity of endometriosis in monkeys.

Endometriosis – Medical treatment of endometriosis is temporary and can range from the use of birth control pills to GnRH agonists (Lupron, Synarel, etc). Link to medical discussion below

Fibromyalgia – Treatment of fibromyalgia, like chronic fatigue, and be complex and time consuming. It is important to hook up with a physician that understands this disease and the various treatment options available for this condition. Treatment options will be discussed in more detail in another section of this website.

Food and hormone sensitivities – It is questionable if this condition actually represents an allergic condition or a hypersensitivity condition. Hypersensitivity to foods is one source of significant bowel symptoms. Testing with the provocation neutralization technique provides a neutralizing dose which can then be administered on a daily basis sublingually (under the tongue) to neutralize the symptoms. Unlike desensitizing allergy shots for inhalant allerigies (grass, pollen etc) the neutralizing drops do not seem to desensitize a patient to the substance or allergen. The treatment of food sensitivities involves an elimination diet, which over time usually decrease the sensitivity to the food. The patient can then slowly add the food back in on a rotating basis after a couple of months. Hormone sensitivities are treated long term with sublingual drops as symptoms dictate. It is unknown if they provide desensitization over time in addition to neutralization of the symptoms.

Hormonal treatment for DUB – If abnormal uterine bleeding is a result of hormone imbalance then addition or estrogen or progesterone may be needed. If the lining of the uterus (endometrium) is too thin, then the patient does not have enough estrogen to "heal over" the endometrium. If it is too thick this is an indication of not enough progesterone (assuming that the possibility of endometrial hyperplasia or cancer has been eliminated). Estrogen acts to stimulate growth of the endometrium and progesterone acts to stabilize the endometrium and balance the effect of estrogen. Each treatment should be tailored to the patients individual situation.
HRT – Recommendations for hormone replacement therapy have changed

significantly over the last year. In this time of changing medical knowledge, it is very important that the patient understand the facts regarding this issue, rather than media hype, in order to make the best decision for her individual situation.

Hyperlipidemia – Cardiovascular disease is a major health issue for women. A simple cholesterol or lipid profile is inadequate in determining the risk factors for heart disease. State of the art laboratory tests can provide an accurate determination of cardiovascular disease risk and proper treatment. While diet+- and exercise are important building blocks, additional treatment either in the form of conventional pharmaceutical medications or scientifically based herbal and nutraceutical treatment is available.

Hypothalamic-Pituitary-Adrenal axis – The adrenal gland secretes the body’s stress hormone cortisol. This hormone allows us to handle the day to day stress of living. A very low level of production of cortisol is known as Addison’s disease and can be life threatening and need coritsol replacement. It seems that patients who experience chronic pain can suffer from a slightly decreased production of the stress hormones, one of the causes of severe fatigue. Some of these patients may benefit from coritsol supplementation (not replacement).

Hypothyroidism – An increased incidence of low thyroid production is well documented in patients with endometriosis. Depending upon the particular deficiency these patients may benefit from replacement with thyroid hormone including Synthroid, Armour thyroid or Cytomel.

Insulin resistance – A condition where the patient’s body does not respond as readily to
the effects of insulin, can be part of many chronic illnesses including pelvic pain and endometriosis. Dr. Atkins promoted this belief over 30 years ago and at the time was thought to be out in left field by most of the medical community. Since that time the medical community has come to consensus on the validity and importance of this condition. During the summer of 2002 several medical societies, including the American Association of Clinical Endocrinologist met in Washington D.C. They concluded that "…the emergence of the Insulin Resistance Syndrome is among the most pressing problems of public health in the developed world…" It is estimated that one in three American adults has insulin resistance.

Interstitial cystitis – Treatments for interstitial cystitis are numerous and varied. I detailed discussion will be included elsewhere. In general treatment is usually medical, the most common medications are Elmiron and hydroxyzine. Bladder distention and instillation with DMSO has been approved for the treatment of IC.


Vulvodynia – Vulvodynia or vulvar vestibulitis is a condition that is poorly understood.
The precise pathophysiology is unknown and there is no cure. There are multiple medical and surgical treatments available. Common treatments involve the avoidance of chemicals and substances which can irritate the vulva. Other conditions to consider include food sensitivities and interstitial cystitis. Medical treatment includes the use of tricyclic antidepressants (for their pain relieving properties not their antidepressants effects) such as Elavil, anticonvulsants (e.g. Neurontin), nerve blocks, biofeedback and physical therapy as discussed above.

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Bowel resection for endometriosis – Usually endometriosis can be removed from the surface of the bowel without the need to actually remove a portion of the bowel. In severe cases, a portion of the bowel has been replaced with endometriosis. To fully remove the endometriosis, a portion of the bowel must be removed. The most common area of bowel that is involved with endometriosis is the rectum, low in the pelvis. Other areas of the bowel including the small bowel and the appendix can also be involved. If the patient has undergone bowel preparation preoperatively, the bowel resection can be performed at the time of the surgery with a re-anastomosis. A bowel resection is usually performed through a laparotomy and requires a longer stay in the hospital.

Bowel resection for redundant colon – A bowel resection for redundant colon is performed in a similar manner to that for endometriosis. Most often a portion of the sigmoid is removed, but depending upon the specific situation, part of the transverse and descending colon may be removed.

Cholecystectomy – Also known as removal of the gallbladder, this procedure can almost always be performed through the laparoscope

Colonoscopy – A colonoscopy is a long flexible fiber optic tube which is placed up through the colon. This is usually performed under IV sedation as it is quite uncomfortable. This procedure allows for visualization of the inside of the colon. Polyps of the colon can be precancerous. Fortunately these can be removed before they ever turn into cancer. Screening evaluation for polyps is recommended after 50 years of age. Rarely, endometriosis can be seen at colonoscopy. Usually, the inside lining of the colon looks normal even if there is full thickness involvement of endometriosis.

Correction of osteonecrosis of the jaw – Neuralgia induced osteonecrosis of the jaw is a condition that some feel can result in systemic symptoms including pelvic pain. This condition can result from decreased blood flow and necrosis of the jaw.

Dorsal Column Stimulator – This procedure utilizes a small electrode that sends an electrical stimulus that in essence cancels the pain signal to the brain. A trial period before permanent implantation is usually performed as a diagnostic test to determine of this is appropriate treatment for the patient. This is effective in patients who have failed other forms of treatment, including severe cases of interstitial cystitis.

Sigmoidoscopy – A sigmoidoscope allows visualization of the sigmoid colon. The sigmoid colon is the lower portion of the colon located in the pelvis. This is a less invasive procedure than a colonoscopy and is used as a more frequent screening tool.

Acupuncture – Is a treatment which may help with relief of painful periods, pelvic pain
and other associated conditions. This form of treatment has been practiced in the far east for thousands of years. A recent study in traditional western literature demonstrated an increase pregnancy rate with In Vitro Fertilization (IVF) with the use of acupuncture. Acupuncture is supposed to work with the body’s Qi (pronounced "Chee) which is an energy that is thought to flow through channels in the body. These channels are known as Meridians. Acupuncturists believe that a disturbance in a meridian can result in disruption of flow of Qi and result in disease.

Chiropractic care – Chronic pain can result in muscle spasm and misalignment of the joints. Misalignment of the spinal column is referred to as subluxation. The subluxation can cause pressure on a nerve and thus pain.

Chiropractic care in combination with deep tissue massage can be helpful for some types of back pain. Sacral iliac joint pain can sometimes benefit form chiropractic treatment.

Message therapy – Deep tissue message therapy is particularly useful for fibrosis, and knots in the back muscles. Most of us probably keep some of our built up tension in our back muscles. Patients with chronic pain have one more reason to have their back in knots. This can be both a result and contributing cause to the chronic pain. Deep tissue message helps to break up the scar tissue and fibrosis in the muscles (both upper and lower back). This will help to remove a source of pain once this condition is corrected.

Pelvic muscle floor biofeedback – Biofeedback can help in the treatment of pelvic
muscle floor spasm. Muscle that has been in spasm for a long time tends to neither contract all of the way, nor relax all of the way. Use of the biofeedback can help to isolate these muscles and help facilitate the patient relaxation of the muscle by the patient.

Physical therapy – Physical therapy of the pelvic muscle floor can provide therapy required for resolution of some patients problems. This usually required transvaginal deep tissue work to get to the effected muscles. The expertise of the physical therapist is paramount in successful treatment. Contacts for the American Physical Therapy Association is listed on the Resources and Links page.

Sacral iliac joint stabilization – This treatment is usually provided through a chiropractor
office. Stabilization of this joint may be helped with use of a sacral iliac belt which helps to stabilize the joint.

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Updated November 5, 2006

This page and all of the contents are Copyright © 1996-2006 by VitalCare Institute of Health

The information contained on this web page is considered informational and is not intended as medical advice. You should seek the advice and care of your local physician. Information on this web site is subject to change without any notice. The information on this web page may include technical inaccuracies or typographical errors.