Based on:
1. Standardised History (Form 2a) (Form 2b if applicable), 2. Clinical Examination (Form 03), 3. Ultrasound (Form 04) (as appropriate)
DIAGNOSIS
DIAGNOSTIC CERTAINTY KEY:
10Certain, Practically certain(99 in 100 chance)6Good possibility(6 in 10 chance) 2Slight possibility(2 in 10 chance)
9Almost sure(9 in 10 chance)5Fairly good possibility(5 in 10 chance)1Very slight possibility(1 in 10 chance)
8Very probably(8 in 10 chance)4Fair possibility(4 in 10 chance) 0No chance, almost no chance(1 in 100 chance)
7Probable(7 in 10 chance)3Some possibility(3 in 10 chance)
Part A - Diagnosis
Considering all available diagnostic information:
A.1: Has a structural gynaecological cause been excluded? No Yes
Along with a possible differential diagnosis foreach condition in the table below is the cause of pain (definitions of gynaecological causes are provided on the back this page). Please indicate possible diagnosis with your level of certainty from 0 (no chance) to 10 (certain).
Absense of Structural Cause / How certain are you that this condition is causing the pelvic pain?
Circle your diagnostic certainty using the above key.
No chance / Certain
Absence of structural cause (idiopathic* or unknown) / 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Structural Gynaecological Cause
Superficial peritoneal endometriosis* / 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Deep infiltrating endometriosis* / 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Endometrioma of ovary / 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Adhesions* / 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Ovarian cysts / 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Adenomyosis / 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Fibroids / 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Other structural gynaecological cause (e.g. pelvic congestion syndrome*)
please specify...... / 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Non-Gynaecological Cause
Psychological or psychosexual cause / 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Gastrointestinal causes (e.g. IBS)
please specify...... / 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Urinary causes
please specify...... / 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Musculoskeletal causes
please specify...... / 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Neurological causes
please specify...... / 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Other pathological cause
please specify...... / 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10

*Definitions:

  • Idiopathic: A disease with an uncertain/unknown structural cause, after exclusion of other recognisable gynaecological pathology.1
  • Superficial peritoneal endometriosis:Macroscopic appearance of white lesions (scar tissue), red lesions, flamelike lesions, haemorrhagic or papular vesicles or black lesions (≤3mm in depth)2
  • Deeply infiltrating endometriosis: Infiltrating endometriosis (>3mm in depth) involving uterosacral ligaments, vagina, rectovaginal pouch, posterior vaginal fornix and the rectoperitoneal area and vital structures such as bowel (muscularis propria), ureters and bladder (muscularis propri). 3 This may include scarring and fibrosis4
  • Adhesions: Filmy avascular, dense and or vascular and cohesive bands between tissues and organs5
  • Other organic gynaecological causes:

E.g. Pelvic congestion syndrome: Chronic pelvic pain due to abnormal ovarian and pelvic varices6

References

  1. Wit J.M, Clayton P.E, Rogol A.D, Savage M.O, Saenger P.H et al. (2008) Idiopathicshort stature: Definition, epidemiology, and diagnostic evaluation. Growth hormone and IGF research. Vol 18, issue 2: 89-110.
  1. Brosen I., Donnez J., Benagano G. (1993) improving the classification of endometriosis. Hum. Reprod. 8(11): 1792-1795.

3. Chapron C., Fauconnier A., Vieira M., Barakat H., Dousset B. et al. (2003) Anatomical distribution of deeply

infiltrating endometriosis: surgical implications and proposition for a classification. Hum. Reprod.18 (1): 157-

161.

4. Maciel C, Ferreira H, Macedo R. (2007) Deeply infiltrating endometriosis; pathogenesis, diagnosis and clinical

management. Instituto de Ciências Biomédicas Abel Salazar.

5. Adhesion Scoring Group (1994) Improvement of interobserver reproducibility of adhesion scoring systems.

Fertil. Steril. 62: 984–988.

6. Kies D.D., Kim H.S., (2012) Pelvic congestion syndrome: a review of current diagnostic and minimally invasive

treatment modalities. Phlebology 27 (1): 52-7

Management Working Diagnosis and Diagnostic Plan (Form 06) Page 1 of 2 Version 1.7 – 05th July 2012