Chronic Pelvic Pain Flashcards
Differential diagnosis for chronic pelvic pain?
From passmed
Endometriosis
IBS
Ovarian cyst
Urogenital prolapse
Could remember this by the vowels - (a) E I O U
What features in Hx taking would lead you to think pelvic pain was chronic in nature?
- Intermittent or constant
- in lower abdomen or pelvis
- at least **6 months **in duration
- NOT occuring exclusively with menstruation or intercourse, and NOT associated with pregnancy
Acute pain resolves when tissues involved heal.
Why does pain persist for longer in chronic pelvic pain?
From BB slides
Additional factors contribute so pain persists:
Local factord at the site of pain (chemokines and TNF alpha) affect peripheral nerves
Persistant pain leads to changes in the CNS - so magnifies original signal
Get visceral hyperalgesia - where there is an alteration in visceral sensation and function
Pelvic pain is multifactorial.
What factors contribute to pelvic pain?
MSK pain
Social and psychological factors
PID
Intrabdominal Adhesions
IBS
Endometriosis and Adenomyosis
Interstitial cystitis
Nerve entrapment
Define endometriosis
Endometriosis is characterized by the growth of endometrium-like tissue outside the uterus. (endometrium like tissue = endometrial glands and stroma like lesions)
Deposits are most commonly distributed in the pelvis; on the ovaries, uterosacral ligaments, pouch of Douglas, rectum and sigmoid colon, bladder and distal ureter.
Endometriosis is hormone mediated (responds to cyclical hormonal changes) and is associated with menstruation.
What is adenomyosis
From BB slides
Presence of endometrial tissue within the myometrium resulting in significant pelvic pain and heavy bleeding at menstruation
Gold standard diagnosis: Diagnosed by histology after a hysterectomy
Imaging is required - USS and MRI - to give Dx (this is done before histology
Describe aetiology of endometriosis
(what theories have been explored?)
BB and NICE
Exact cause is unkown
- Retrograde menstruation (Sampson’s theory)
Endometrial cells flow backwards from uterine cavity, through the fallopian tubes and implant on pelvic organs where they can seed and grow - Coelomic metaplasia (Meyer’s theory)
cells in the pelvic and abdominal area change into endometrial type cells of the germinal epithelium. - Müllerian remnants - differentiae into endometrial tissue in the pelvis
What would be in Hx of pt with suspected endometrosis?
List distinguishing factors if you can!
- Persistant lower abdominal pain (6m+)
- Dysmenorrhea
- Dyspareunia
- Dyschezia = painful defecation
- Dysuria = painful urination
- Menorrhagia
- Rectal bleeding or epistaxis
- Intermenstrual bleeding and post coital bleeding
NICE say should suspect endometriosis if 1 or more of those ^ are presented.
In endometriosis, is there a correlation between symptom severity and disease severity?
NO! No correlation between them, for some pts it is asymptomatic
A lady has minimum - mild endometriosis. What would you expect to find when conducting a clinical examination?
- if mild = usually nothing found on examination
A lady has moderate - severe endometriosis. What would you expect to find on clinical examination?
Thickened uterosacral ligaments
Fixed retroverted uterus
Uterine/Ovarian enlargement
Forniceal tenderness (in posterior vaginal fornix)
Uterine tenderness
A woman undergoes laparoscopy. What is this?
Powder burn deposit
These are bluish/brown lesions/plaques which represent haemolysed blood encased in fibrotic tissue
A woman undergoes laparoscopy for endometriosis. What are these?
Red flame lesions
A woman undergoes laparoscopy for endometriosis. What is this?
Scarring - seen when endometriosis is not active
A lady undergoes laparoscopy for endometriosis. What are these?
Peritoneal defects - seen in the pelvic peritoneum
What does treatment for endometriosis depend on?
BB slide
- Fertility issues
- Type and severity of symptoms
- Therapies tried and therapies failed
- Expertise available
- Patients wishes
A woman with endometriosis would like to manage her condition medically.
What are the medical management options available?
Medical management aim is to suppress ovulation and growth of endometrium
COCP
Continuous progestogen therapy (MPA) - mostly desogestrol is used as it also helps with preventing ovulation.
GnRH analogues (nasal spray/implant)
* +/- HRT (“add back” therapy) - needs to be given in GnRH is used for more than 3 months
Mefenamic acid/tranexamic acid
Danazol - not used in practice anymore
Surgical management options for endometriosis?
- Laparoscopic - diathermy, laser
- total hysterectomy + bilateral salipingo-oophrectomy
What structures are at risk of being damaged with hysterectomy (management for endometriosis)?
Bladder
Ureter
Bowel
Common reason for development of adhesions?
- Previous surgery
- pelvic infections
What type of adhesions are most associated to pelvic pain?
Vascular adhesions
Residual ovary syndrome
Trapped ovary syndrome
Cause of residual ovary syndrome?
Residual ovary syndrome - residual ovarian tissue present as could not be removed, or after hysterectomy, where ovaries are left in place = can result in residual ovary syndrome
How to treat adhesions causing pelvic pain?
Need to divide vascular adhesions
Remove any residual ovary
A woman has pelvic pain due to adhesions attached to residual ovary (redidual ovary syndrome). She does not want surgery. How can she be managed?
Suppress HPA axis with GnRH analogues - this may improve the symptoms
However surgery is preferred
What makes up 50% of chronic pelvic pain PC in primary care?
IBS
What is name of criteria used for Dx of IBS?
Rome III Criteria
Note: in NICE CKS, it says: In secondary care, the more restrictive ROME IV criteria for IBS are often used for diagnosis.
Describe Rome III criteria of IBS
- Continuous or recurrent abdo pain or discomfort on at least 3 days a month in last 3 months
- Onset at least 6m previously
- Associated with 2 of the following:
- improvement with defecation
- onset associated with a change in frequency of stool
- onset associated with a change in form of stool
What are extra-intestinal features common in IBS?
- lethargy
- nausea
- back pain
- headache
- gynae symptoms
- bladder symptoms
Medical management for IBS causing pelvic pain?
Mebeverine hydrochloride
Drug class of mebeverine used in IBS
An antispasmodic
Describe why MSK pain may be a differential for pelvic pain (nongynae)?
So what features would be present to make MSK pain most likely DDx
Joints in pelvis ache
Damage to muscles in abdo wall or pelvic floor - may have urinary Sx too (?)
Pelvic organ prolapse seen - may be the source of pain
Has trigger points - localised areas of deep tenderness - chronic muscle contraction here
How would you manage a pt whose pelvic was found to be MSK pain in nature?
- Analgesia
- Physiotherapy referral
- Nerve modulation therapy / Antidepressent
Describe character of nerve entrapment pelvic pain
Highly localised
Sharp
Stabbing or aching
What features in Hx or Ex would make you put nerve entrapment over a gynae cause of chronic pelvic pain?
Exacerbated by particular movements
Persisting beyond 5 weeks or occuring after a pain free interval
In Ex - Pfannenstiel incision scar
How to manage nerve entrapment causing pelvic pain?
Analgesia
Physiotherapy
Nerve modulation and antidepressent med
What social and psychological causes are there for pelvic pain?
Child sexual abuse
Adult sexual abuse
- both had increased pain symptoms (dysmennorhea, dyspareunia or chronic pelvic pain) than women reporting no abuse
How to manage women with pelvic pain due to past sexual abuse?
Individualised care plan - involving MDT, psychiatry, CBT etc
What should be in your initial assessment of pt presenting with pelvic pain?
- Hx - pattern of pain, SQITARS/SOCRATES
- Associations - psychologucal, bladder and bowel symptoms, effect of movement and posture (help rank DDx)
- Rule out red flag symptoms
- Pain diary for 2-3 months
- Effect on QofL and function
- Symptoms based diagnostic criteria - look at IBS ROME criteria
What would you do in examination for PC of pelvic pain?
Abdo and pelvic exam
Focal tenderness
Trigger points - abdo wall or pelvic floor
Genitalia - enlarged? Distorted? Tethering? Prolapse?
SI joints
What invesitgations for woman presenting with pelvic pain for more than 6m?
STI screen
Transvaginal screen - ID and assess adnexal massess
MRI - diagnose adenomyosis
Laparoscopy
A woman has chronic pelvic pain. What common co-morbidity could you screen for during consultation?
Depression - this is v common alongside chronic pelvic pain.
You take a history from a pt in Gynae clinic who has chronic pelvic pain. This pain is cyclical. Thinking about the mechanism of action, what type of medication should you prescribe?
Hormonal medication where **ovulation is suppressed ** (ie where you suppress the ovaries)
COCP can be used cyclically or back to back by running packs together
Classic sign of endometriosis found on bimanual vaginal examination?
FIxed retroverted uterus
Advantage and disadvantage of transvaginal ultrasound for endometriosis?
Adv - good at diagnosing ovarian endometriotic changes
Disadv - poor at identifying other parameters of disease
Pathophysiology of chronic pelvic pain?
Local factors at the site of pain- chemokines and TNF alpha affect peripheral nerves
CNS response- persistent pain leads to changes within CNS which eventually magnifies the original signal
Visceral hyperalgesia- alteration in visceral sensation and function
