Pelvic Pain Due to Placement of the Vaginal Cuff after Hysterectomy: Case Report and Osteopathic Manipulative Approach to Treatment George J. Pasquarello
Abstract posterior thigh region. She also com- Hysterectomy is performed on more plained of some rectal pain as well as Family History than 570,000 women a year in the United right inguinal pain. She has been seen by Father died at 65 due to Emphysema. States8 with an estimated 21.2% of U.S. a Physiatrist for chronic pain treatment Mother died at 53 due to Breast CA. women having undergone the procedure14. over the past year with some minimal The most frequent indications are leio- improvement. She has been treated with O: Vitals: myomas, abnormal bleeding and chronic pain medications, which have given her Temp - 97.4oF Pulse - 88 pelvic pain3. While hysterectomy may some relief although she continues to Resp - 16 BP - 116/70 provide for the relief of chronic pelvic have persistent pain. She notes that the pain, it may also be a cause. Common pain is worse when moving her bowels General attachment sites of the vaginal cuff after though better afterward. She denies pain This is a pleasant 46 y.o.w.f. who ap- hysterectomy may include the cardinal, during intercourse though states that she pears her stated age. She has a moderately uterosacral or sacrospinous ligaments. is very sore in the inguinal and SI regions flat affect and appears to have a significant Proximity to levator ani and obturator after intercourse. She is worse with sitting amount of pain when moving from stand- internus makes injury to these muscles for long periods and feels better when ing to seated to supine positions. a risk for causing pelvic pain. A case walking. presentation of pelvic pain secondary to A recent MRI showed some de- Neuro obturator internus injury during attach- generative changes in the lumbar spine Cranial nerves 2-12 are grossly intact ment of the vaginal cuff will be described though no sign of disc pathology causing without focal sensory or motor deficits. with a review of the anatomy of the area. radiculopathy. A pelvic MRI was done DTR’s are +2/4 in the bilateral upper and After initial osteopathic evaluation and which showed no anatomic explanation lower extremities. Strength is +5/5 in the treatment, one patient had the vaginal for her pain. bilateral upper and lower extremities. cuff repositioned by the surgeon with Cervical compression test and straight leg significant improvement in pain. Fol- Past Medical History raise are negative bilaterally. Dermatomes lowup osteopathic manipulative treatment Chronic low back pain and pelvic L1-S2 and C5-T2 are intact bilaterally. alleviated most of the persistent pain pain. Babinski is downgoing bilaterally. symptoms. Past Surgical History Structural Exam Case Report Tonsillectomy and Adenoidectomy. Marked restriction is in right SI A patient presents with a 2-year Bladder suspension. Hysterectomy. Rec- joint with severe tenderness and edema history of pelvic pain after trans-vaginal tocele repair. around the SI joint and along the proxi- hysterectomy. mal insertion of the right gluteus medius AO is a 46 y.o.w.f. referred for evalu- Allergies and gluteus maximus. There is a positive ation of chronic low back and pelvic pain. COMPAZINE, THORAZINE, CEF- standing and seated flexion test on the AO states that her pain began 3 years ago TIN, DARVOCET, SOMA, INDOCIN. right. There is some tenderness and swell- after an abdominal hysterectomy was ing at the distal right multifidus insertion. done. The indication for surgery was vagi- Medications Right innominate is rotated anteriorly nal prolapse. After surgery, she developed Ultram 50 mg 6-8 q.d., Ativan 2 mg and inferiorly, L5 ERSr, L1 FRSr. Pubic a rectocele and a secondary surgery was t.i.d., Premarin 1.25 mg q.d. symphysis restriction is noted with in- done to repair this. It was after the second ferior pubic symphysis on the right. No surgery that her symptoms became more Social History tenderness is noted at the sacrococcygeal significant. She complained of burning Smokes 3 packs of cigarettes per day. ligament or along the insertion of levator pain around the area of the pelvis with Denies use of alcohol, no use of illicit ani. Focal tenderness is noted at the right some radiation into the right gluteal and drugs. Was working as a Nurse’s Aid, but lesser sciatic notch at the area of obturator is presently a housewife. December 2006 The AAO Journal/11 internus tendon. Pressure here reproduces Bony pelvis Joints all of AO’s symptoms of pain. The pain The bony pelvis is made up of the The pubic bones meet in the anterior is improved with external rotation of the sacrum and coccyx posteriorly and two midline at the pubic symphysis. The bones femur. innominate or hip bones which complete are connected by the superior and arcuate a skeletal ring and attach anteriorly in ligaments and a fibrocartilaginous disc. Assessment the midline at the pubic symphysis. The 1. Pelvic pain after hysterectomy and bony pelvis houses the pelvic organs and rectocele repair. provides structural support as a conduit 2. Low back pain with radiation into between the spine and lower extremities. right posterior thigh and gluteal region. Muscular attachments include muscles 3. Somatic dysfunction of the lumbar of the lower back, abdomen and lower spine, pelvis, sacrum and lower extremi- extremities. There is also a muscular sup- ties. port for the pelvic organs at the inferior 4. Myofascial trigger point in right aperture or pelvic outlet. obturator internus secondary to surgical The bony pelvis is divided into trauma. greater and lesser as well as true and false
Course of Treatment Our initial treatment included coun- terstrain to the right obturator internus, The disc is strengthened anteriorly by which immediately improved AO’s symp- the inguinal ligaments and linea alba. It toms. When she walked around the office is better developed in females and often a bit her symptoms returned, though with contains a cavity. much less severity. The sacroiliac joints are complex and Over the course of the next few provide the stability and strength in trans- weeks, she was treated several times pri- mitting weight from the vertebral column marily focusing on treating obturator in- to the lower extremities. Each joint has a ternus, restoring normal lumbar and pelvic network of anterior, posterior and interos- mechanics and decreasing related somatic seous ligaments. The iliolumbar and the dysfunction. The somatic dysfunction did segments. These divisions are helpful in anterior lumbosacral ligaments attach improve significantly although the tender- discussing the relationships of structures the lower lumbar segments to the pelvis. ness at obturator internus persisted. to the bony pelvis but there is no true The sacrotuberous and sacrospinous liga- Eventually a discussion with her sur- anatomic separation. While the primary ments attach the sacrum to the ischium. geon led to laparoscopic surgery and the function of the bony pelvis is locomotor, The sacrospinous ligament blends with attachment of the vaginal cuff was moved adaptations in the female pelvis allow for the anterior margin of the sacrotuberous. from the original site at the sacrospinous parturition. The anterior surface of the sacrospinous ligament. The greater or false pelvis consists of ligament is muscular and constitutes the After surgery, AO was seen in the the iliac flanges and sacral base cephalad coccygeus muscle, which attaches to the office and was found to have a fairly dra- to an oblique line passing through the lateral margin the coccyx.18 matic improvement in her pain symptoms. sacral promontory and the pubic crest She also had improvement in her previ- known as the lineae terminales. The iliac Viscera ously noted somatic dysfunction. flanges provide part of the lateral and pos- The major structures that occupy Over the course of the next few terior walls of the pelvis and support and the true pelvis in females include the months, OMT was focused on the lumbar protect the lower abdominal organs. rectum, uterus and bladder. The ovaries and pelvic somatic dysfunction. As her The lesser or true pelvis consists of are typically positioned in the false pelvis objective findings improved, AO became the bony structures caudad to the lineae but can be mobile. Each has an inferior more functional and was able to decrease terminals which form a more complete attachment at the pelvic diaphragm and the use of pain medications. basin to house and protect the pelvic is retroperitoneal. The peritoneum that organs. A superior and inferior aperture lies over the viscera will fold around the Review of the Pelvic Anatomy bound the true pelvis from above and structures and double over onto itself The following is a review of the anat- below respectively. The sacrum and coc- forming thickenings which function as omy of the pelvis and related structures. cyx make up the posterior border while ligamentous support. The uterus is posi- An understanding of this anatomy will be the inferior portion of the ilium, ischium, tioned between the rectum and the blad- important to appreciate the potential for pubic ramus and pubic symphysis make der and ascends into the abdomen during 18 21 injury during pelvic surgery. This discus- the lateral and anterior borders. pregnancy. sion will help clarify the possible causes of chronic pelvic pain and give some in- Uterine and cervical ligaments sight into useful treatment approaches. The uterus is connected to the blad-
12/The AAO Journal December 2006 der, rectum and pelvic walls by thick- arise from the lateral margin of the uterus enings in the peritoneum that provide just below the lateral cornua and travel mechanical support and in some cases, laterally to the abdominal wall, through dynamic control. The ligaments are pri- the inguinal ring and attach to the mons marily made of peritoneal folds and are pubis or as far as the labia majora. The cervical ligaments are thick and strong condensations of connective tis- sue that form mechanical support for the B uterus. The pubocervical ligaments (A) A ––––––– ––––––– diverge around the urethra and attach to the posterior aspect of the pubic bones. > > The transverse cervical or cardinal liga- ments (B) extend laterally to the pelvic wall and provide significant support. The bulbs and attaches anteriorly Pubic Symphysis to the corpora cavernosus of ––––––– the clitoris. It attaches to the perineal body posteriorly and > A constricts the vaginal ori- Coronal section through the pelvis fice. Ischiocavernosus attaches along the medial border of the B pubic ramus and attaches ante- usually named by the structures that they riorly to the clitoris. Sphincter attach. The uterovesical fold (A) is made urethra surrounds the urethra of the anterior reflection of peritoneum and blends with the smooth between the uterus and bladder. The muscle of the bladder neck. rectovaginal fold (B) is made of the pos- Compressor urethra travels terior reflection of peritoneum between deep to the ischiocavernosus the rectum and posterior vaginal fornix. and medially to the urethra. The uterosacral folds are made of two C Sphincter urethrovaginalis peritoneal reflections that pass back from attaches to the perineal body the cervix uteri on each side of the rectum posteriorly and passes forward and attach to the anterior sacrum. These Superior view of cervical ligaments to either side of the vagina and are much thicker and contain fibrous tis- urethra. It is thought to play an sue and smooth muscle that provides sig- important role in continence nificant support for the uterus and cervix. uterosacral ligaments (C) are described of urine. Sphincter ani is made of three These are referred to as the uterosacral above and diverge around the rectum and layers of muscle: internus, externus and ligaments due to their thickness compared attach to the sacrum posteriorly. These superficialis. These attach to the perineal to the other folds.22 ligaments form a ring of support for the body anteriorly and the coccyx posteri- cervix. This provides a stable base for orly. It surrounds the anus and provides the uterus and a strong support for the support for its function.19 vagina.22
Muscles The muscles of the pelvis may be di- vided into categories based on function. The urogenital diaphragm is super- The broad ligaments extend from the ficial and attaches anteriorly to the pubic lateral aspect of the uterus to the lateral arch, posteriorly to the coccyx and later- TA D walls of the pelvis. They are divided into ally to the pubic and ischial rami, ischial sections named by their attachments. tuberosities and sacrotuberous ligaments. Mesosalpinx is made of the peritoneal This is a thin layer of muscle that provides fold that lies over the uterine tube. Mes- support for the urethra, vagina and anus. ovarium is made of the peritoneal fold that The superficial transverse perinei is a thin C lies over the ovary. Mesometrium is made muscular slip that attaches at the ischial of the peritoneal fold that lies over the tuberosity laterally and at the perineal B uterus. The uterine round ligaments are body in the midline. The bulbospongio- A thickenings within the mesometrium that sus attaches laterally along the vestibular Internal view of levator ani
December 2006 The AAO Journal/13 the nerve with spasm. Gemellus superior and gemellus inferior attach proximally to the ischial body and tuberosity re- spectively. Distally, their fibers blend A with obturator internus and attach to the B greater trochanter. Obturator internus attaches proximally to the anterolateral C wall of the lesser pelvis overlaying the obturator foramen. The fibers converge toward the lesser sciatic notch and form D a tendon that turns sharply and attaches Obturator internus trigger points distally to the greater trochanter. The Inferior view of levator ani tendon passes under the ischial spine at points is thought to possibly include poor The levator ani or pelvic diaphragm posture, sacroiliac dysfunction, chronic is made up of five muscles. These are hemorrhoids, chronic pelvic inflamma- named separately by their attachments tory disorders, severe falls on the coccyx, to the bony pelvis, though they func- or surgery in the pelvic region.17 Muscles tion as a group. The muscles share an of the pelvic floor may have associated attachment to a tendinous arch (TA) that trigger points causing pain to radiate to the support the muscles at the ischial spine perisacral region and the posterior thigh. posteriorly and the pubic body anteriorly. Levator ani trigger points typically cause Thus pubococcygeus (A), iliococcygeus pain to radiate to the area around the coc- (B), ischiococcygeus (C), coccygeus (D) cyx. Muscles of the urogenital diaphragm and the deep puborectalis form a mus- typically cause pain to radiate to the geni- cular sling that provides support for the talia. Obturator internus typically causes pelvic viscera and muscular resistance to pain to radiate to the anococcygeal region increased intrapelvic pressure during res- as well as the ipsilateral posterior thigh. piration and aids in venous and lymphatic the insertion of sacrospinous ligament and coccygeus. The surface of the lesser sciatic notch is covered in hyaline car- tilage and is separated from the muscle by a bursa which functions as a pulley as the muscle contracts. The body of ob- turator internus lies lateral to the pelvic diaphragm and its tendinous arch. These muscles function primarily as external 20 rotators of the hip. Piriformis trigger points Myofascial trigger points of the pelvis Obturator internus trigger points may also present as vaginal pain or a sense of A myofascial trigger point is a rectal fullness. Piriformis typically refers hyperirritable spot in a skeletal muscle pain to the buttocks, ipsilateral hip and that is associated with a hypersensitive posterior thigh.17 The pain experienced by return from the pelvic viscera and lower palpable nodule in a taut band. The spot is 19 sciatic nerve entrapment may be similar in extremities. painful and can give rise to characteristic presentation, but trigger points may occur Muscles of the lower extremity that referred pain, referred tenderness, motor independently. attach to the pelvis on its internal surface dysfunction and autonomic phenomena.16 are of particular interest for this discus- The source of activation of pelvic trigger sion. Piriformis attaches proximally to the Review of hysterectomy anterior surface of the sacrum and dis- procedure and attachment tally to the greater trochanter. It courses of vaginal cuff through the greater sciatic foramen and its Hysterectomy involves the removal fibers often blend distally with obturator of the uterus and usually the cervix. The internus and the gemelli. The relationship uterine tubes and ovaries may or may not to the sciatic nerve is often discussed as be removed depending on the situation. piriformis and can cause compression of Levator ani trigger points The procedure involves isolating and
14/The AAO Journal December 2006 disrupting the uterine and cervical liga- fore symptoms could resolve. Moving the Removing the suture was an important ments. After the uterus is removed, the suture from its attachment at sacrospinous part of relieving the strain on obturator cervical end of the vagina is oversewn ligament relieved the constant irritation internus, however compensatory changes and attached to prevent prolapse, rectocele to obturator internus. Followup OMT that had occurred over time left the or cystocele. improved pelvic mechanics and relieved patient with many dysfunctional areas. There are several options for the the trigger point causing the patient’s Subsequent treatment focused on restor- surgeon in selecting a site for vaginal cuff symptoms. ing motion to the lumbar spine and pelvis attachment. Sacrospinous ligament is a Pelvic pain has a 30-40% unknown utilizing a variety of techniques. The treat- common attachment site and is known etiology,9,12 however a search of the lit- ment was directed toward improving the as the Richter procedure. This has been erature using MEDLINE7,9,10,15 failed to underlying somatic dysfunction. As the shown to be an effective treatment for show any citations which considered an somatic dysfunction improved, AO was patients at risk for prolapse, cystocele or active trigger point as a result of suture given an exercise program focused on rectocele formation. Long-term follow-up placement. The literature focuses on hys- strengthening the muscles of the lumbar reports that demonstrate minimal prolapse terectomy as a treatment for pelvic pain spine, pelvis and lower extremities. This have made this a popular option.11 Utero- but does not typically include pelvic pain approach allowed her to regain much of sacral ligament is another common site of as a complication. One review described her decreased function. attachment. This has also been shown to nerve injury after hysterectomy,1 but most be effective in providing good support and studies focus on the incidence of prolapse Discussion limited occurrences of prolapse, cystocele as a measure of the technique’s benefit. Understanding of anatomy and doing 4 or rectocele formation. Apical vault repair The above case illustrates how the selec- a thorough structural exam is important in involves incorporation of pubocervical tion of a site for vaginal cuff placement the management of patients with chronic fascia, uterosacral ligament and rectovagi- may be a risk for causing pelvic pain by pelvic pain. This population has often nal fascia to reestablish the pericervical injuring adjacent structures. been seen by other physicians and told ring at the vaginal apex. This recreates there is no obvious cause for their pain. the anatomical relationship of the vagina Osteopathic Manipulative They are often depressed and frustrated to the cervical ligaments that provides Treatment Approach from trying to find an answer. Patients are good support for the cuff and helps to Osteopathic manipulative treatment turning to many types of treatment ap- prevent prolapse, cystocele or rectocele was utilized in the initial and follow-up proaches in hopes of finding a solution. formation.13 Formation of a fascial sling care of this patient. Trigger point pressure Osteopathic diagnosis and treatment from rectus sheath has been shown to be release, stretch and spray and injection provides an opportunity for patients to effective, though limited study has been are the recommended treatments for trig- get a different perspective on this type done on this approach.2 Anterior suspen- gerpoints. Although trigger points and of problem. By observing osteopathic sion attaches the vaginal cuff to the rectus Jones tenderpoints are different types of principles and searching for the anatomic sheath anteriorly and has also been shown dysfunctions, counterstrain is often effec- or physiologic cause of the problem, we to be effective.6 tive for the treatment of triggerpoints. This are more likely to find it. Osteopathic Each of these options has advantages patient was initially treated with counter- manipulative treatment is usually effec- and disadvantages. Familiarity with the strain to the right obturator internus as tive for treating trigger points causing technical aspect of a procedure is often described by Jones.5 pelvic pain. Ischemic compression or a reason for choosing a particular tech- With the patient prone, the tender- nique. Personal experience or literature trigger point pressure release is a manual point is found in the muscle belly of review may prompt a surgeon to try a treatment, which will decrease trigger obturator internus on the medial aspect new approach. point activity and improve local func- of the ischiorectal fossa. A pain scale is Although the Richter procedure has tion of tissues. If the underlying cause or established with the initial tenderness a long history of experience, it has an perpetuating factor is not addressed, the described as a 10. The thigh is internally increased risk of causing pelvic pain as trigger point will recur. Improvement of rotated until the tenderness at the palpat- a complication due to the proximity of related somatic dysfunction is imperative ing finger is described as a 3 or less. Once structures to the sacrospinous ligament. to optimizing function in the pelvis. this is achieved, the position is maintained Coccygeus arises from sacrospinous liga- In this case, treatment addressed the for 90 seconds or until a pulsation is felt at ment and could easily become included in mechanics of the lumbar spine and pelvis the point as the tissue releases. The thigh a suture attaching the cuff here. Levator in addition to the trigger point. It is critical is returned to its original position and the ani attaches to the ischial spine at the site to address these areas in patients with pel- area may be palpated to determine if any of the sacrospinous ligament and could vic pain. Pubic symphysis and sacroiliac tenderness remains. After treatment, AO also become included in a suture here. The motion are a part of the normal function reported her tenderness to be a 2 and was patient described in the above case pre- of the pelvis. Restriction of motion in more comfortable sitting and walking than sented with an obturator internus trigger these joints will cause decreased function before treatment. point that was relieved immediately with to one area and increased workload to AO’s symptoms improved for a short relaxing the muscle. Although OMT was another. It is in this way that compensa- time. Improvement of this long-standing done using several approaches, the cause tory changes can become a part of the pain helped to determine that obturator of the trigger point had to be removed be- underlying problem. internus was in fact, the cause of the pain. December 2006 The AAO Journal/15 Identifying a problem and applying 13. Ross JW. Apical vault repair, the cor- From the Archives manual treatment is not always enough to nerstone of pelvic vault reconstruction. continued from page 10 resolve a patient’s symptoms. A good re- International Urogynecological Journal lationship with other physicians involved of Pelvic Floor Dysfunction. 8(3):146- such an extent as during the paroxysm. A with a patient’s care may be an important 52. 1997. 14. Saraiya M, Lee NC, Blackman D, diagnosis can then be made much more part of management of a problem. In Morrow B, and McKenna MA. Self- easily, and the tissues corrected with less this case, it allowed the patient to have reported Papanicolaou smears and pain to the patient. the cause of the problem removed and hysterectomies among women in the The details (as to the locality treated) provided the gynecologist with a new United States. Obstetrics and Gynecol- for each form of neuralgia will be found perspective on the diagnosis and possible ogy. 98(2): 269-78. Aug 2001. under the discussion of each variety. The causes of pelvic pain. 15. Slocumb JC. Neurologic Factors in general health and diet should be consid- Chronic Pelvic Pain: Trigger Points and the Abdominal Pelvic Pain Syndrome. ered. Peterson’ says: “Morphine is, among References American Journal of Obstetrics and the alkaloids, the most frequent cause of 1. Alsever JD. Lumbosacral Plexopathy Gynecology. 149:536-543. 1984. insanity. It is a sad commentary on the After Gynecologic Surgery: Case 16. Travell J, Simons D, and Simons L. heedlessness of some medical men, but Report and Review of the Literature. Myofascial pain and dysfunction: The the family physician is responsible, in American Journal of Obstetrics and Trigger Point Manual, Vol. 1, Upper almost every case, for the development Gynecology. 174(6). Jun 1996. Half of the Body. p 5. 1999. of the morphine habit and its far-reach- 2. Barrington JW and Calvert JP. Vaginal 17. Travell J and Simons D. Myofascial vault suspension for prolapse after hys- Pain and Dysfunction: The Trigger ing consequences. It should be looked terectomy using an autologous fascial Point Manual, Vol. 2 ,The Lower Ex- upon as a sin to give a dose of morphine sling of rectus sheath. British Journal tremities. pp 110-131. 1992. for insomnia or for any pain (such as of Obstetrics and Gynecology. 105(1): 18. Williams P and Bannister L. Gray’s neuralgia, dysmenorrhea, rheumatism) 83-6. Jan 1998. Anatomy, 38th Edition. The Anatomical which is other than extremely severe and 3. Carlson KJ, Miller BA, and Fowler FJ, Basis of Medicine and Surgery. pp 669- transient.” R Jr. The Maine Women’s Health Study: 678. I. Outcomes of Hysterectomy. Obstet- 19. Williams P and Bannister L. Gray’s rics and Gynecology. 83(4): 556-65. Anatomy, 38th Edition. The Anatomical Apr 1994. Basis of Medicine and Surgery. pp 831- 4. Jenkins VR. Uterosacral ligament 835. fixation for vaginal vault suspension 20. Williams P and Bannister L. Gray’s CME QUIZ in uterine and vaginal vault prolapse. Anatomy, 38th Edition. The Anatomical The purpose of the quiz found American Journal of Obstetrics and Basis of Medicine and Surgery. pp 877- on the next page is to provide a con- Gynecology. 177(6): 1337-43. Dec 1997. 879. venient means of self-assessment for 5. Jones L, Kusunose R, and Goering E. 21. Williams P and Bannister L. Gray’s your reading of the scientific content th Jones Strain-Counterstrain. p 90. 1995. Anatomy, 38 Edition: The Anatomi- in the “Pelvic Pain Due to Placement 6. Juma S. Anterior vaginal suspension for cal Basis of Medicine and Surgery. pp of the Vaginal Cuff after Hysterec- vaginal vault prolapse. Technical Urol- 1861-1871. ogy. 1(3):150-6. 1995. 22. Williams P and Bannister L. Gray’s tomy: Case Report and Osteopathic 7. Klein T. Office Gynecology for the Anatomy. 38th Edition. The Anatomi- Manipulative Approach to Treat- Primary Care Physician – Part II: Pel- cal Basis of Medicine and Surgery. pp ment” by George J. Pasquarello, vic Pain, Vulvar Disease, Disorders of 1874-1875. DO, FAAO and and “Non-Operative Menstruation, Premenstrual Syndrome Management of Spinal Stenosis” by and Breast Disease. Medical Clinics of Note: All images are a part of the Philip E. Greenman DO, FAAO. For North America. 80(2). Mar 1996. 8. Kramer MG and Reiter RC. Hyster- Lippincott, Williams and Wilkins Lifeart each of the questions, place a check ectomy: Indications, Alternatives and Grant’s Atlas and Dissector Image Col- mark in the space provided next to Predictors. American Family Physician. lection or the Mediclip Manual Medicine your answer so that you can easily 55(3):827-34. Feb 15, 1997. Collection. The author has a limited verify your answers against the cor- 9. Miller. Urogenital Pain Syndromes. license for use of these images for pre- rect answers that will be published in th Anesthesia 5 Edition. pp 1955-1956. sentation and/or publication. the March 2007 issue of the AAOJ. 2000. To apply for Category 2-B CME 10. Montgomery K and Moulton A. Ap- Accepted for Publication: March 2002 credit, transfer your answers to the proach to the Patient with Menstrual or Updating as neccessary has been done rd AAOJ CME Quiz Application Form Pelvic Pain. Primary Care Medicine 3 by the author. Edition. pp 615-618. 1995. answer sheet on the next page. The 11. Richter K and Albrich W. Long-term AAO will record the fact that you results following fixation of the vagina Address Correspondence to: submitted the form for Category 2-B on the sacrospinal ligament by the George J. Pasquarello, DO, FAAO CME credit and will forward your vaginal route. American Journal of Ob- 1351 S. County Trl., Bldg. 2 test results to the AOA Division of stetrics and Gynecology. 141(7): 811-6. Dec 1, 1981. East Greenwich, RI 02818 CME for documentation. 12. Rosen. Emergency Medicine.Concepts E-mail: [email protected] R and Clinical Practice, 4th Edition. pp 2302-03. 1998. 16/The AAO Journal December 2006