Abdominal pain Flashcards
Differential diagnosis for abdominal pain
Gynecologic
1. Vaginal/vluvar
- vestbulitis, vuvlodynia, myofascial pelvic pain
2. Cervix
- cervicitis
3. Uterus
- degenerating fibroids, adenomyosis
4. Tubes
- TOA, salpingits, hydrosalpinx, chronic PID
5. Ovaries
- cysts, tumor, remnant syndrome
6. Misc.
- endometriosis, adhesions
Non-gyn
1. Urologic
- bladder cancer, painful bladder syndrome, urethral diverticulum, chronic UTI
2. Gastointestinal
- Chronic constipation, diverticulosis, IBS, UC, Crohn’s
3. Musculoskeletal
- pelvic floor dysfunction, fibromyalgia
4. Psychological/neurological
- depression, anxiety, PTSD, nerve entrapment
Treatment of chronic pelvic pain
Conservative
Pelvic floor PT
Cognitive behavioral therapy
Neuropathic pain meds: SNRI, gabapentin, pregabalin
Trigger point injections
Acupunture, yoga
Treatment for interstitial cystitis
Amitriptyline
Gabapentin
Antihistamines
Pentosan polysulfate (fixes GAG layer but can cause macular eye disease)
Intravesical instillation with heparin, steroids, lidocaine
Intradetrusor botox
Sacral nerve modulation
What is vulvodynia
vulvar pain for >3 months and not attributed to an identifiable cause
Treatment of endometriosis
Conservative management:
OCPs (cyclic or continuous)
Progestins (oral, injectable, LNG-IUD)
GnRH agonists or antagonists
What are GnRH agonists
Depo, leuprolide acetate
SFx: menopausal symptoms, osteoporosis if long term
Approved for 6mo, max 12mo. Consider add back therapy
What are GnRH antagonists
Elagolix (Orlissa)
Effective immediately
SFx: VMS, vaginal atrophy, bone loss
Dose: 150mg q daily for 24 months OR 200mg BID for 6 months
Endomteriosis treatment for mild pain and no endometrioma
NSAIDs and continuous OCPs or progestins
Reassess in 3-4 months
If no improvement, change OCP, 5mg norethindrone daily, or DMPA 150mg q3 months. Elagolix or GnRH antagonist is reasonable
Endometriosis treatment for severe pain
GnRH analog and add back therapy or laparoscopy
