3-47
Treatment
Primary: See Differential Diagnosis Chart
Primitive: Warm compresses, rest and warm baths can be helpful for many types of chronic pain. Relaxation
and meditation have helped many women deal with and decrease pain.
Patient Education
General: Most chronic pain can be successfully treated in a systematic fashion. There is no quick fix or
“magic bullet” for chronic pelvic pain. Comply with therapeutic suggestions.
Activity: As tolerated. Maintain a normal lifestyle.
Diet: As tolerated. For patients with constipation, recommend high-fiber with adequate fluids.
Medications: A three-month trial of OCPs is necessary to initiate pain suppression. They will not work
immediately.
No Improvement/Deterioration: Referral to gynecologist.
Follow-up Actions
Return evaluation: 3 months if placed on OCPs
Evacuation/Consultation Criteria: Evacuate as needed for acute pain, unclear diagnosis, unresolving pain
Symptom: GYN Problems: Vaginitis
MAJ Ann Friedmann, MC, USAGynecology may seem to be a complicated challenge for the field medic based on the simple lack of essential
equipment such as a gynecological exam table with stirrups and a vaginal speculum. Given these limitations,
proceed per Table 3-4 to diagnose and treat vaginitis. There are more complete details in the additional
sections on candida vaginitis (GYN), bacterial vaginosis (GYN) and trichomonas (STDs). Always remember
that simple vaginitis does not cause pelvic pain or systemic signs of illness such as fever, nausea and
vomiting, or pelvic pain. If these are present, the diagnosis is most likely pelvic inflammatory disease. Monitor
vaginal pH by testing secretions with urine dipsticks.
Symptom: GYN Problems: Bacterial Vaginosis
MAJ Ann Friedmann, MC, USAIntroduction: Bacterial vaginosis is caused by a vaginal overgrowth of several indigenous bacterial species.
Absolute risk factors have not been identified. Treatment of male sexual partners has not been shown to
prevent recurrence.
Subjective: Symptoms
Symptoms are localized to the vagina rather than throughout the pelvis: a gray-yellowish, thin vaginal
discharge with a foul-fishy odor made worse after intercourse; vulvar burning and irritation; pain during and
after intercourse due to vaginal irritation.
Objective: Signs
Using Basic Tools: Pelvic exam: Thin, homogenous, gray or greenish-yellow discharge adherent to side
walls of the vagina; pooled fluid in the posterior vaginal cul-de-sac; normal vaginal epithelium; amine (fishy)
odor to discharge; erythema of external genitalia; normal uterus and ovaries.
Using Advanced Tools: Lab: Examine discharge, prepare wet mount/KOH slides (see Lab Procedures), test
pH with urine dipstick. Consider STD and pregnancy evaluation.
Assessment:
Diagnosis based on the discharge having three of the following four characteristics: pH greater than 4.7;