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YEAR 4 REPRO > Chronic Pelvic Pain > Flashcards

Chronic Pelvic Pain Flashcards

1
Q

Differential diagnosis for chronic pelvic pain?

From passmed

A

Endometriosis
IBS
Ovarian cyst
Urogenital prolapse

Could remember this by the vowels - (a) E I O U

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2
Q

What features in Hx taking would lead you to think pelvic pain was chronic in nature?

A
  • 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
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3
Q

Acute pain resolves when tissues involved heal.
Why does pain persist for longer in chronic pelvic pain?

From BB slides

A

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

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4
Q

Pelvic pain is multifactorial.
What factors contribute to pelvic pain?

A

MSK pain
Social and psychological factors
PID
Intrabdominal Adhesions
IBS
Endometriosis and Adenomyosis
Interstitial cystitis
Nerve entrapment

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5
Q

Define endometriosis

A

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.

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6
Q

What is adenomyosis

From BB slides

A

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

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7
Q

Describe aetiology of endometriosis
(what theories have been explored?)

BB and NICE

A

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
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8
Q

What would be in Hx of pt with suspected endometrosis?

List distinguishing factors if you can!

A
  • 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.

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9
Q

In endometriosis, is there a correlation between symptom severity and disease severity?

A

NO! No correlation between them, for some pts it is asymptomatic

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10
Q

A lady has minimum - mild endometriosis. What would you expect to find when conducting a clinical examination?

A
  • if mild = usually nothing found on examination
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11
Q

A lady has moderate - severe endometriosis. What would you expect to find on clinical examination?

A

Thickened uterosacral ligaments
Fixed retroverted uterus
Uterine/Ovarian enlargement
Forniceal tenderness (in posterior vaginal fornix)
Uterine tenderness

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12
Q

A woman undergoes laparoscopy. What is this?

A

Powder burn deposit
These are bluish/brown lesions/plaques which represent haemolysed blood encased in fibrotic tissue

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13
Q

A woman undergoes laparoscopy for endometriosis. What are these?

A

Red flame lesions

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14
Q

A woman undergoes laparoscopy for endometriosis. What is this?

A

Scarring - seen when endometriosis is not active

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15
Q

A lady undergoes laparoscopy for endometriosis. What are these?

A

Peritoneal defects - seen in the pelvic peritoneum

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16
Q

What does treatment for endometriosis depend on?

BB slide

A
  • Fertility issues
  • Type and severity of symptoms
  • Therapies tried and therapies failed
  • Expertise available
  • Patients wishes
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17
Q

A woman with endometriosis would like to manage her condition medically.
What are the medical management options available?

A

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

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18
Q

Surgical management options for endometriosis?

A
  • Laparoscopic - diathermy, laser
  • total hysterectomy + bilateral salipingo-oophrectomy
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19
Q

What structures are at risk of being damaged with hysterectomy (management for endometriosis)?

A

Bladder
Ureter
Bowel

20
Q

Common reason for development of adhesions?

A
  • Previous surgery
  • pelvic infections
21
Q

What type of adhesions are most associated to pelvic pain?

A

Vascular adhesions
Residual ovary syndrome
Trapped ovary syndrome

22
Q

Cause of residual ovary syndrome?

A

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

23
Q

How to treat adhesions causing pelvic pain?

A

Need to divide vascular adhesions
Remove any residual ovary

24
Q

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?

A

Suppress HPA axis with GnRH analogues - this may improve the symptoms
However surgery is preferred

25
Q

What makes up 50% of chronic pelvic pain PC in primary care?

A

IBS

26
Q

What is name of criteria used for Dx of IBS?

A

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.

27
Q

Describe Rome III criteria of IBS

A
  • 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
28
Q

What are extra-intestinal features common in IBS?

A
  • lethargy
  • nausea
  • back pain
  • headache
  • gynae symptoms
  • bladder symptoms
29
Q

Medical management for IBS causing pelvic pain?

A

Mebeverine hydrochloride

30
Q

Drug class of mebeverine used in IBS

A

An antispasmodic

31
Q

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

A

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

32
Q

How would you manage a pt whose pelvic was found to be MSK pain in nature?

A
  • Analgesia
  • Physiotherapy referral
  • Nerve modulation therapy / Antidepressent
33
Q

Describe character of nerve entrapment pelvic pain

A

Highly localised
Sharp
Stabbing or aching

34
Q

What features in Hx or Ex would make you put nerve entrapment over a gynae cause of chronic pelvic pain?

A

Exacerbated by particular movements
Persisting beyond 5 weeks or occuring after a pain free interval
In Ex - Pfannenstiel incision scar

35
Q

How to manage nerve entrapment causing pelvic pain?

A

Analgesia
Physiotherapy
Nerve modulation and antidepressent med

36
Q

What social and psychological causes are there for pelvic pain?

A

Child sexual abuse
Adult sexual abuse

  • both had increased pain symptoms (dysmennorhea, dyspareunia or chronic pelvic pain) than women reporting no abuse
37
Q

How to manage women with pelvic pain due to past sexual abuse?

A

Individualised care plan - involving MDT, psychiatry, CBT etc

38
Q

What should be in your initial assessment of pt presenting with pelvic pain?

A
  • 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
39
Q

What would you do in examination for PC of pelvic pain?

A

Abdo and pelvic exam
Focal tenderness
Trigger points - abdo wall or pelvic floor
Genitalia - enlarged? Distorted? Tethering? Prolapse?
SI joints

40
Q

What invesitgations for woman presenting with pelvic pain for more than 6m?

A

STI screen
Transvaginal screen - ID and assess adnexal massess
MRI - diagnose adenomyosis
Laparoscopy

41
Q

A woman has chronic pelvic pain. What common co-morbidity could you screen for during consultation?

A

Depression - this is v common alongside chronic pelvic pain.

42
Q

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?

A

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

43
Q

Classic sign of endometriosis found on bimanual vaginal examination?

A

FIxed retroverted uterus

44
Q

Advantage and disadvantage of transvaginal ultrasound for endometriosis?

A

Adv - good at diagnosing ovarian endometriotic changes
Disadv - poor at identifying other parameters of disease

45
Q

Pathophysiology of chronic pelvic pain?

A

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

YEAR 4 REPRO (26 decks)

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