3- Pelvic pain (chronic pain) Flashcards
define chronic pelvic paion
‘intermittent or constant pain in the lower abdomen or pelvis of a women of at least 6 months in duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy’
- Social and psychological issues such as physical or sexual abuse are key risk factors
examples of chronic pelvic pain
- Endometriosis
- Adenomyosis
- Adhesions
- Trauma during childbirth
- Interstitial cystitis
- Social and psychological
non-gynaecological causes of chronic pelvic pain
- MSK pain
- Nerve entrapment
- IBS/ IBD
- Chronic inflammatory condition of the bladder
pathophysiology of acute vs chronic pelvic pai n
- Acute pain- resolves when tissue heals
- Chronic pain- additional factors contribute hence pain persists longer
o Chemokines and TNF alpha affecting peripheral nerves
o Visceral hyperalgesia
endometriosis background
Presence of endometrial glands and stroma outside of the uterus.
- Responds to cyclical hormonal changes and bleeds at menstruation
pathophysiology of endometriosis
- Unknown
- Retrograde menstruation
presentation of endometriosis
- Painful periods
- Painful intercourse
- Painful defecation
- Painful urination
- Heavy periods
- Persisting abdominal pain
- Rectal bleeding
on examination: endometriosis
- Thickened uterosacral ligaments
- Retroverted uterus
- Uterine/ovarian enlargement
- Uterine tenderness
- Endometrial tissue visible on speculum exam, esp in posterior fornix
investigations for endometriosis
- Pelvic US- endometriomas and chocolate cysts
- Laparoscopic surgery- gold standard
management of endometriosis
Treatment depends on:
- Fertility issues
- Severity of symptoms
- Therapies tried and failed
medical management of endometriosis
- COCP
- Continuous progestogen therapy
- GnRH analogues
- Danazol
- Mefenamic acid
medical management of endometriosis
- COCP
- Continuous progestogen therapy
- GnRH analogues
- Danazol
- Mefenamic acid
surgical management of endometriosis
- Laparoscopic- diathermy, laser
- TAH + BSO (hysterectomy and bilateral salpingo-oophorectomy )
o Risk of bladder, ureteric, bowel injury
o Risk of subtotal hysterectomy
o Role of HRT
Adenomyosis background
Presence of endometrial tissue within the myometrium (muscle layer of the myometrium)
RF for adenomyosis
- Multiparous
- Seem to resolve after menopause
cause of adenomyosis
- Not fully understood
- Multiple factors
o Sex hormones
o Trauma
o Inflammation
presentation of adenomyosis
- Dysmenorrhoea
- Menorrhagia
- Pain during intercourse
- infertility
investigations for adenomyosis
- Transvaginal US
- Gold standard- Diagnosis by histology after hysterectomy
management of adenomyosis
- Mirena coil or COCP or cyclical oral progestogens
Others:
- GnRH analogues to induce menopause like state
- Endometrial ablation
- Uterine artery embolization
- Hysterectomy
Non-contraceptive methods
- Tranexamic acid – if not painful
- Mefenamic acid- if painful (NSAID)
IBS background
“Functional bowel disorder”. This means that there is no identifiable organic disease underlying the symptoms. The symptoms are a result of the abnormal functioning of an otherwise normal bowel.
IBS RF
- Female
- Younger adults
presentation of IBS
- Diarrhoea
- Constipation
- Abdominal pain
- Bloating
- Worse after eating
- Improved by opening bowels
rome III criteria for IBS
- Continuous or recurrent abdominal pain or discomfort on at least 3 days a month in the last 3 months
- Onset at least 6 months previously
Associated with at least two of the following:
* Improvement with defecation
* Onset associated with a change in frequency of stool
* Onset associated with a change in the form of stool.
treatment of IBCS
General healthy diet and exercise
o Adequate fluid intake
o Regular small meals
o Limit caffeine and alcohol
o FODMAP
o Probiotic supplements for 4 weeks
First line medication
o Loperamide for diarrhea
o Laxatives for constipation
o Antispasmodic e.g. buscopan
Second line medication
o Tricyclic antidepressants
Third line
o SSRIs
o CBT
Interstitial cystitis background
A chronic condition causing inflammation in the bladder, resulting in lower urinary tract symptoms and suprapubic pain. It is also called bladder pain syndrome and hypersensitive bladder syndrome.
presentation of interstitial cystitis
- Suprapubic pain
- Frequency
- Urgency
- Worse on menstruation
investigations for interstitial cystitis
- Urinalysis
- Swabs for STI
- Cystoscopy for bladder cancer
- Prostate exam
findings of cystoscopy for bladder cancer
o Hunner lesion
o Granulations
management of interstitial cystitis
Supportive
- Diet e.g. caffeine and alcohol
- Stop smoking
- PFMT
- Bladder retraining
Oral medication
- Analgesia
- Antihistamine
- Anticholinergic medication e.g. oxybutynin
- Mirabegron
Intravesical medication
- Lidocaine
- Hydrodistension-
Surgical
- Cauterisation of Hunner lesions
- Botulinum toxin injection
- Electrical nerve stimulator
- Cystectomy
hydrodistension
involves filling bladder with water, to high pressure, during cystoscopy (requires general anaesthetic)- can give temporary improvement of symptoms
MSK pain
- Joints in the pelvis
- Damage to the muscles in the abdominal wall or pelvic floor
- Pelvic organ prolapse may also be a source of pain.
- Trigger points-localized areas of deep tenderness – chronic muscle contraction
- Treatment- Analgesia, Physiotherapy, Nerve modulation and Antidepressant
nerve entrapment
- Joints in the pelvis
- Damage to the muscles in the abdominal wall or pelvic floor
- Pelvic organ prolapse may also be a source of pain.
- Trigger points-localised areas of deep tenderness – chronic muscle contraction
- Treatment- Analgesia, Physiotherapy, Nerve modulation and Antidepressant
