Investigations

Excluding the possibility of ongoing pelvic infection such as Chlamydia by taking endocervical swabs is often useful to allay anxiety. Ultrasound examination may be useful in identifying uterine or adnexal pathology and has been shown to be an effective means of providing reassurance [18]. The presence of dilated veins may indicate pelvic congestion [19] but a recent study using power Doppler suggested that the primary value of sonography was to identify the characteristic multicystic ovarian morphology seen in this condition [20]. Transuterine venography is of limited value in routine clinical practice but is technically simpler than selective catheterization of the ovarian vein. MRI provides the opportunity to identify adenomyosis but is not routinely indicated.

Laparoscopy is commonly undertaken as the primary investigation for CPP. The aims are to give a diagnosis but also to provide 'one-stop' treatment for endometriosis and adhesions where these are identified. This approach is cost-effective for endometriosis treatment, as the expense of a second procedure or hormonal treatment is obviated [21]. The outcomes of this approach are not as good as might be expected: confusion can arise from a 'negative' laparoscopy [22] and where pathology is identified it may be coincidental rather than causal, especially in the case of adhesions. There is a lack of evidence for laparoscopy as a factor improving outcome in hospital referral populations with at least 6 months' history of pain [23,24]. It is therefore sensible to consider deferring laparoscopy and focus on symptomatic treatment in the first instance.

Pain mapping by laparoscopy under conscious sedation can be a useful procedure, particularly where the site of pain is unilateral, allowing comparison with a 'control' area, to assess the significance of adhesions, to identify unrecognized occult inguinal or femoral hernias and, in the negative sense, to identify individuals with a generalized hyperalgesic chronic pain state for whom further surgical intervention would be hazardous. The role of this procedure remains to be clarified in the overall context of pain assessment and management but reports of experience are now available in the literature [25]. Typical operative technique includes sedation with mida-zolam and fentanyl, infiltration of puncture sites with bupivicaine, use of a 5-mm laparoscope via a subumbil-ical puncture together with a fine suprapubic port for a probe. The maximum gas pressure is reduced to around 10 mmHg to minimize discomfort in the upper abdomen. Tenderness at specific sites is recorded on a 0-10 verbal rating scale. In this writer's practice its application is limited to the small subgroup of patients whose main priority is to obtain a definitive explanation for their problem, rather than symptom relief. Overall, after gaining initial experience following early positive reports, many clinicians no longer consider pain mapping to be useful.

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Anxiety and Panic Attacks

Anxiety and Panic Attacks

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