B8.057 Prework: Pelvic Pain Flashcards
6 major sources of the origin of chronic pelvic pain (CPP)
- gynecological
- psychological
- myofascial
- MSK
- urological
- GI
gyn diseases causing CPP
endometriosis adhesions (chronic PID) leiomyoma pelvic congestion syndrome adenomyosis
GI diseases causing CPP
IBS diverticulitis diverticulosis chronic appendicitis Meckel's diverticulum
GU diseases causing CPP
interstitial cystitis
abnormal bladder function (bladder dyssynergia)
chronic urethritis
myofascial diseases causing CPP
fasciitis
nerve entrapment syndrome
trigger points
hernias (inguinal, femoral, spigelian, umbilical, incisional)
skeletal diseases causing CPP
scoliosis
L1-L2 disk disorders
spondylolithesis
osteitis pubis
psych disorders causing CPP
somatization
psychosexual dysfunction
depression
detailed history needed for workup of CPP
characteristics of pain
med/surg history
complete gyn history (menarche, pregnancy, delivery complications, dysparenia, sexual assault, trauma)
detailed ROS w focus on repro, GI, MSK, uro, and neuropsych
consider age carefully
targeted physical for CPP
abdominal, pelvic, bimanual
pelvic exam for CPP
visual inspection for redness, discharge, lesions, fissures, excoriations, and other abnormalities
moistened cotton swab can be used to evaluate the vulva and vestibule for localized tenderness
manual pelvic exam for CPP
begin with a single digit; note tenderness or spasm
palpate levator ani muscles directly for tone and tenderness
evaluate pelvic floor
bimanual exam assessing uterine size and tenderness, nodularity, or a fixed, immobile uterus
carnett test
place finger on painful abdominal site to determine whether pain increases when rectus abdominis muscles are contracted (when legs or head are raised)
myofascial pain can increase while visceral may decrease
what is dysmenorrhea
severe, painful cramping sensation in the lower abdomen, often accompanied by other symptoms - all occurring just before or during menses
symptoms associated with dysmenorrhea
sweating tachycardia headaches nausea/vomiting diarrhea tremulousness
primary dysmenorrhea
no obvious pathological condition
onset < 20 years old
pathogenesis of dysmenorrhea
elevated PGF2a produced by secretory endometrium (increased uterine contractility)
treatment of dysmenorrhea
NSAIDS (prostaglandin synthase inhibitors) are first line
others: OCPs, other analgesics
etiologies of secondary dysmenorrhea
cervical stenosis endometriosis and adenomyosis uterine fibroids pelvic infection adhesions
symptoms of secondary dysmenorrhea
aching pain in the abdomen
feeling of pressure in the abdomen
pain in hips, lower back, and inner thighs
painful cramping, reproductive dysfunction/infertility
cervical stenosis
severe narrowing of cervical canal may impede menstrual outflow
- can cause and increase in intrauterine pressure during menses
- can lead to endometriosis
- can cause hematometra
symptoms of cervical stenosis
scant menstrual flow
severe cramping throughout menses
diagnosis of cervical stenosis
inability to pass a thin probe through cervical os or hypersalpingogram demonstrates thin cervical canal
treatment of cervical stenosis
cervical dilation via d&c or laminaria placement
symptoms of endometriosis
can be variable and unpredictable
- some asymptomatic
- dysmenorrhea
- CPP
- deep dyspareunia
- sacral backache w menses
- dysuria +/- hematuria (bladder involvement)
- dysuria +/- hematochezia
how do endometriotic lesions affect fertility
affect ovaries and endometrium leading to poor oocyte quality and implantation failure
epidemiology of endometriosis
7-10% of general pop 20-50% of infertile women 70-85% of women with CPP no racial predisposition familial association with almost 10x increased risk of endometriosis if affected 1st degree relative
pathogenesis of endometriosis
possibilities:
- retrograde menstruation
- hematogenous or lymphatic spread
- coelomic metaplasia
- immunological factors play a role
important symptoms supporting diagnosis of endometriosis
infertility
premenstrual spotting
why is it hard to diagnose endometriosis?
pelvic exam could be inconclusive
only definite diagnosis is my laparoscopic excision of the lesions and histology
what characteristics of lesions correlates best with severity of endometriosis
NOT extent of visible lesions
depth of infiltration
meds for endometriosis
progestins OCPs NSAIDs GnRH agonists (most expensive) danazol
how do GnRH agonists work for endometriosis
create a state of relative E deficiency
- vasomotor side effects and potential decrease in bone density
- no data beyond 1 year
danazol for endometriosis
as effective as GnRH agonist, but with increased side effects
reduces estrogen production
surgical treatment for endometriosis
laparoscopic removal of lesions is effective and improves fertility
-high rate of recurrence
hysterectomy is curative surgical method
-consider reproductive age, desire to have children
uterine fibroids
benign tumors that develop from muscle tissue of the uterus
hyperproliferation
epidemiology of fibroids
most common in women 30-40, but can occur at any age
more common in AA women
symptoms of fibroids
changes in menstruation -longer, more frequent, or heavy periods menstrual pain (cramps) vaginal bleeding at times other than menstruation anemia
pain caused by uterine fibroids
in abdomen and lower back
-often dull, heavy, and aching
-may be sharp
during sex, pressure
difficulty urinating or frequent urination
constipation, rectal pain, difficult bowel movements
abdominal cramps
physical exam findings with uterine fibroids
enlarged uterus and abdomen
miscarriages
infertility
acute pain from fibroids
fibroids that are attached to the uterus by a stem may twist and can cause pain, nausea and fever
fibroids that grow rapidly or start to break down may also cause pain
diagnosis of fibroids
pelvis US
pelvic bimanual
treatment of fibroids
hysterectomy
myomectomy
uterine artery embolization
OCs, NSAIDs, GnRH agonists prior to surgery
effects of fibroid treatment on fertility
hysterectomy advances age of menopause
all other also affect fertility
etiology of fibroids
unknown may be: steroid hormones (E2/P4) obesity, parity, race mutations/translocations -HMG2A, MED12, GHD, TSC2 TGFB, ECM dysregulation
causes of PID
STIs -neisseria gonorrhea -chlamydia trachomatis -mycoplasma genitalium douching can increase risk
symptoms and sequelae of PID
can be asymptomatic
can predispose to infertility, ectopic pregnancy, or cause chronic pain
minimum clinical criteria for PID
cervical motion tenderness OR uterine tenderness OR adnexal tenderness
additional clinical criteria to enhance/support a diagnosis of PID
oral temp >101 F
abnormal cervical mucopurulent discharge or cervical friability
presence of abundant numbers of WBC on microscopy of vaginal fluid
elevated ESR
elevated CRP
lab documentation of cervical infection with chlamydia or gonorrhea by NAAT
most specific criteria for PID
endometrial biopsy with histo evidence of endometritis
transvaginal sonography or MRI showing thickened, fluid filled tubes with or without pelvic fluid or tubo ovarian complex
laparoscopic findings consistent with PID
treatment of PID
cefotetan 2 g IV every 12 hr + doxycycline 100 mg orally or IV every 12 hr
OR
cefoxitin 2 g IV every 6 hr+ doxycycline 100 mg orally or IV every 12 hr
OR
clindamycin 900 mg IV every 8 hr + gentamicin loading dose IV or IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) every 8 hours
unique symptoms of interstitital cystitis
chronic bladder pain
urinary urgency/frequency
pelvic tenderness
unique symptoms of IBS
altered bowel function
women > men
diarrhea and constipation
unique symptoms of IBD
fatigue
weight loss
fever
diarrhea with crampy abdominal pain
unique symptoms of fibromyalgia
widespread pain
fatigue
memory problems
sleep dysfunction
RED FLAG SYMPTOMS of CPP
postcoital bleeding > cervical cancer
postmenopausal bleeding > endometrial cancer
postmenopausal onset of pain > malignancy
unexplained weight loss > malignancy, systemic illness
adnexal mass > ovarian neoplasm
gross or microscopic hematuria > severe interstitial cystitis, urinary system malignancy
mass on US > malignancy
