Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

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M.J. Solnik and M.T. Siedhoff
Discussion
Nonacute pelvic pain represents a spectrum of disorders not unlike
many others, whereby the diagnosis remains elusive and the treatment is
fraught with episodes of trial and error. In recent years, our fundamental
understanding of pain mechanisms has helped to provide not only a better
awareness among providers who care for women, but an improved
capacity to have a positive impact on these patients who are indeed suffering.
Salient features of the historical intake along with a focused
exam, without the need for expansive diagnostic studies, often direct us
to treatment options that are typically nonsurgical and can be applied
readily. When addressing elective surgery, not all clinicians will be able
to offer each option, and so knowing when to operate and when to refer
will only enable her care. Ultimately, an honest discussion with a patient
in pain—listening to her concerns and allowing her to be active in her
care—becomes our obligation and may be therapeutic in and of itself.
Key Points
• A complete medical and psychosocial history, as well as a painoriented
physical examination, should be completed before
diagnostic laparoscopy is performed.
• Neuropathic and musculoskeletal components of chronic pelvic
pain often require treatment both before and after appropriate
pelvic surgery.
• A minimally invasive surgical approach is particularly appropriate
for chronic pain patients.
• Laparoscopic treatment of endometriosis is more effective than
diagnostic exploration alone.
• Resection of deeply infiltrating endometriosis is effective treatment
of organ-specific symptoms.
• Improvement in pain symptoms following GnRHa treatment
does not prove the existence of endometriosis. Many painful
conditions (e.g., irritable bowel, inguinal hernia) vary with the
menstrual cycle, and elimination of hormonal variation can
change symptom profile, regardless of the presence of
endometriosis.
• Complete skeletonization of the infundibulopelvic vessels,
especially in difficult oophorectomy, reduces the risk of adja-