Williams Gynecology, Second Edition (Schorge,Williams Gynecology), 2nd Edition

CHAPTER 11
Pelvic Pain

11–1. Depending on the type of afferent nerve fibers involved, pain may be categorized as visceral or somatic. Somatic pain stems from nerve afferents of the somatic nervous system, which innervates which of the following?

a. Muscle

b. Parietal peritoneum

c. Subcutaneous tissue and skin

d. All of the above

11–2. The following illustration describes which of the following?

Image

Reproduced, with permission, from Rogers DE, Hoffman BL: Pelvic pain. In Hoffman BL, Schorge JO, Schaffer JI, et al (eds): Williams Gynecology, 2nd ed. New York, McGraw-Hill, 2012, Figure 11-1B.

a. Dermatome map

b. Central sensitization

c. Peripheral sensitization

d. Viscerosomatic convergence

11–3. Visceral pain stems from afferent fibers of the autonomic nervous system that transmit information from the viscera and visceral peritoneum, resulting in pain described as which of the following?

a. Sharp

b. Stabbing

c. Localized

d. Generalized, dull ache

11–4. Sustained noxious stimuli can lead to persistent central sensitization and to a permanent loss of neuronal inhibition. As a result, a decreased threshold to painful stimuli remains despite resolution of the inciting stimuli. This persistence characterizes which type of pain?

a. Acute

b. Neuropathic

c. Inflammatory

d. All of the above

11–5. Acute lower abdominal pain and acute pelvic pain are common complaints. By definition, these present in general for which of the following durations?

a. <7 days

b. 1 month

c. 2 months

d. 3 consecutive months

11–6. Etiologies of acute lower abdominal and acute pelvic pain are extensive. Common etiologies of right lower quadrant pain include all EXCEPT which of the following?

a. Hepatitis

b. Urolithiasis

c. Ovarian torsion

d. Ectopic pregnancy

11–7. In addition to a thorough medical and surgical history, a verbal description of the pain experienced and its associated factors is essential. As an example, pain without diarrhea, constipation, or gastrointestinal bleeding lowers the probability of which of the following sources?

a. Urinary

b. Neurologic

c. Gynecologic

d. Gastrointestinal

11–8. The initial examination of a patient experiencing pain includes the assessment of vital signs. If intravascular hypovolemia is suspected, pulse and blood pressure assessment for orthostatic changes is required. Between lying and standing after 1 minute, which of the following values often reflect hypovolemia?

a. An unchanged pulse, systolic blood pressure decrease of 10 mm Hg

b. A pulse increase of 15 beats per minute, systolic blood pressure unchanged

c. A pulse increase of 30 beats per minute, systolic blood pressure decline of 20 mm Hg

d. A pulse decrease of 15 beats per minute, systolic blood pressure decline of 10 mm Hg

11–9. Which of the following is suggested by abdominal rebound tenderness and involuntary guarding?

a. Bowel obstruction

b. Uterine leiomyomata

c. Peritoneal irritation

d. None of the above

11–10. Cervical motion tenderness is associated with peritoneal irritation and is commonly found with which of the following?

a. Appendicitis

b. Liver disease

c. Pyelonephritis

d. Unruptured ectopic pregnancy

11–11. Your patient presents with acute lower abdominal pain, 8 weeks of amenorrhea, and vaginal spotting. She has a history of gonorrhea, and her pregnancy test result is positive. A transvaginal sonographic sagittal view of her uterus and cul-de-sac is shown here. These findings are most suggestive of which of the following?

Image

Reproduced, with permission, from Gala RB: Ectopic pregnancy. In Hoffman BL, Schorge JO, Schaffer JI, et al (eds): Williams Gynecology, 2nd ed. New York, McGraw-Hill, 2012, Figure 7-8B.

a. Hydrosalpinx

b. Hemoperitoneum

c. Corpus luteum cyst

d. Abdominal pregnancy

11–12. Chronic pelvic pain is a common gynecologic problem, and its prevalence in reproductive-aged women has been estimated at which of the following?

a. 5

b. 10

c. 15

d. 20

11–13. Many investigators, as well as the American College of Obstetricians and Gynecologists, define chronic pelvic pain. It is pain that is localized to the pelvis, infraumbilical anterior abdominal wall, or lumbosacral back or buttocks in addition to which of the following?

a. Dyspareunia

b. Cyclic pain

c. Dysmenorrhea

d. Pain leading to degrees of functional disability

11–14. Although causes of chronic pelvic pain fall within a broad spectrum, which of the following is commonly diagnosed?

a. Endometriosis

b. Interstitial cystitis

c. Irritable bowel syndrome

d. All of the above

11–15. A detailed history and physical examination are integral to diagnosing the etiology of chronic pelvic pain. A brief historical survey generally includes all EXCEPT which of the following questions?

a. Are you taking any drugs?

b. Do you believe you are imagining this pain?

c. What do you believe or fear is the cause of your pain?

d. Are you now or have you been abused physically or sexually?

11–16. Abdominal pain elicited with elevation of the head and shoulders while tensing the abdominal wall muscles is typical of anterior abdominal wall pathology and is termed which of the following?

a. Carnett sign

b. Iliopsoas test

c. Straight leg test

d. Trendelenburg test

11–17. During the physical examination for chronic pelvic pain, the technique shown here should be included. Nodularity may be found most commonly with which of the following?

Image

Reproduced, with permission, from Pearson MJ, Hoffman BL: Well woman care. In Hoffman BL, Schorge JO, Schaffer JI, et al (eds): Williams Gynecology, 2nd ed. New York, McGraw-Hill, 2012, Figure 1-9.

a. Chronic ectopic pregnancy

b. Endometriosis or neoplasia

c. Pelvic inflammatory disease

d. Uterine or cervical leiomyomas

11–18. In patients with combined urinary and chronic pelvic pain symptoms, which of the following tests is typically advised?

a. Cystoscopy

b. Cystometrics

c. Retrograde cystourethrography

d. Computed tomography scanning of the abdomen and pelvis

11–19. During laparoscopy for chronic pelvic pain, the following are identified in the upper abdomen and pelvis, respectively. These are most consistent with which of the following?

Image

Figure A: Photograph contributed by Dr. David Rogers. Figure B: Photograph contributed by Dr. Kevin Doody. Reproduced, with permission, from Hoffman BL: Pelvic mass. In Schorge JO, Schaffer JI, Halvorson LM, et al (eds): Williams Gynecology, 1st ed. New York, McGraw-Hill, 2008, Figure 9-17.

a. Endometriosis

b. Chronic appendicitis

c. Salpingitis isthmic nodosum

d. Prior pelvic inflammatory disease

11–20. Medical management of chronic pelvic pain in patients in whom pathology is not identifiable may be directed toward dominant symptoms using which of the following?

a. Hormonal suppression

b. Antidepressants and anticonvulsants

c. Analgesics such as nonsteroidal anti-inflammatory drugs

d. All of the above

11–21. Surgical hysterectomy may serve as a treatment of chronic pelvic pain. In patients with no identified pelvic pathology, surgery fails to resolve pain in what percentage of these women?

a. 10

b. 20

c. 30

d. 40

11–22. Which of the following terms describes cyclic menstrual pain without identifiable associated pathology?

a. Adenomyosis

b. Primary dysmenorrhea

c. Secondary dysmenorrhea

d. Menstrual outlet obstruction

11–23. Primary dysmenorrhea is positively associated with which of the following?

a. Smoking

b. Early age at menarche

c. Increased body mass index

d. All of the above

11–24. The pathophysiology of primary dysmenorrhea is initiated by endometrial sloughing, during which endometrial cells release what substance that stimulates myometrial contractions and ischemia?

a. Estrogen

b. Follicle-stimulating hormone (FSH) and luteinizing hormone (LH)

c. Progesterone

d. Prostaglandins

11–25. Dyspareunia is a frequent gynecologic complaint noted in up to 20 percent of U.S. women and can be subclassified as insertional or deep. Which of the following is commonly associated with deep dyspareunia?

a. Vulvodynia

b. Endometriosis

c. Poor vaginal lubrication

d. All of the above

11–26. Patient complaints suggestive of interstitial cystitis commonly include all EXCEPT which of the following?

a. Hematuria

b. Urinary urgency

c. Urinary frequency

d. Stress urinary incontinence

11–27. Direct hernias commonly bulge through Hesselbach triangle, whose boundaries shown here include all EXCEPT which of the following?

Image

Reproduced, with permission, from Corton MM: Anatomy. In Hoffman BL, Schorge JO, Schaffer JI, et al (eds): Williams Gynecology, 2nd ed. New York, McGraw-Hill, 2012, Figure 38-4.

a. Inguinal ligament

b. Inferior epigastric artery

c. Superficial epigastric artery

d. Lateral border of rectus abdominis muscle

11–28. Treatment options for pelvic muscle trigger points include all EXCEPT which of the following?

a. Biofeedback

b. Hysterectomy

c. Muscle relaxants

d. Trigger point needling

11–29. Chronic lower anterior abdominal wall pain may follow this incision and may be linked to nerve entrapment of all EXCEPT which of the following nerves?

Image

Reproduced, with permission, from Hoffman BL: Surgeries for benign gynecologic conditions. In Schorge JO, Schaffer JI, Halvorson LM, et al (eds) Williams Gynecology, 1st ed. New York, McGraw-Hill, 2008, Figure 41-2.1.

a. Femoral

b. Ilioinguinal

c. Genitofemoral

d. Iliohypogastric

Chapter 11 ANSWER KEY

Image