Chronic pelvic pain Flashcards
How is endometriosis defined?
-Functional endometrial glands and storm are found outside the uterine cavity
-Ie ectopic endometrial tissue
-Most common site is the ovary
-An oestrogen-dependent process so symptoms occur cyclically
What is adenomyosis?
-A type of endometriosis
-Endometrial tissue is found within the myometrium
-Diagnosed on MRI
How common is endometriosis?
-5-10% of women of reproductive age
-80% of women with chronic pelvic pain
-Typically diagnosed in women in their 20s
What are some theories for the pathogenesis of endometriosis?
-Retrograde menstruation (blood flowing into the peritoneum as well as out of the cervix)
-Mesothelial cell metaplasia, lymphatic spread, haematogenous dissemination, autoimmune
What are the common sites of endometriosis?
-Peritoneum
-Pouch of Douglas (in-between vagina and rectum)
-Ovary / tubules
-Ligaments
-Bladder
-Myometrium
-Very rarely can be found in the lungs, brain, muscles
How does endometriosis present?
-Pelvic pain
-Subfertility
-Cyclic pain
–Secondary dysmenorrhoea / cyclical pelvic pain
–Deep dyspareunia
–Pain on defecation
–Urinary / rectal / anal symptoms
–Sacral back pain with menses
NB severity of symptoms does not necessarily correlate with extent of disease
What examination findings are common in endometriosis?
-Fixed, retroverted uterus (should be mobile)
-Nodular uterosacral ligaments
-Enlarged, tender adnexa
How is endometriosis diagnosed?
-Pelvic USS –> presence of endometriomas
-Laparoscopy for direct visualisation and biopsy
-Graded by location, size, depth, adhesions
How is endometriosis managed medically?
AIM = suppression of ovulation and induction of amenorrhoea
NSAIDs
-Reduce pain and menstrual flow
PROGESTINS
-Counteract oestrogen and suppress endometrial growth
OCP
-Reduce / eliminate menstrual flow and suppress ovaries
GnRH AGONISTS
-Suppress ovaries (chemical menopause)
MIRENA COIL
-Ovarian and endometrial suppression
NB treatment does not eradicate lesions but aims to improve symptoms
How is endometriosis managed surgically?
LAPAROSCOPIC SURGERY
-Excise / destroy endometriosis whilst restoring normal anatomy
-Offered to women wishing to conceive in the future and if endometrioma >4cm / pelvic adhesions suspected
-Ablation (of spots), resection (of active lesions/scar tissue), cystectomy / oopherectomy
HYSTERECTOMY + BILATERAL SALPINGO-OOPHERECTOMY
-Older women with no desires to have children
-Will need HRT
What is pelvic inflammatory disease?
-Clinical spectrum that may involve:
–Cervix, endometrium, Fallopian tubes, ovaries, uterus, broad ligaments, intraperitoneal cavity, perihepatic region
-Caused by ASCENDING INFECTION from endocervix
What can cause PID?
-Gonorrhoea and chlamydia infections
-BV-associated organisms
-Mycoplasma genitalium + mycobacterium tuberculosis
How does PID present?
-Lower abdo pain (typically bilateral)
-Fever
-Deep dyspareunia
-Abnormal vaginal bleeding
-Abnormal vaginal / cervical discharge
-Cervical motion and adnexal tenderness
-Perihepatitis - Fitz Hugh Curtis syndrome (10%)
What are you looking for on vaginal examination for PID?
-Speculum - looking for adnexal masses, vaginal discharge, cervical ectropion
-Swabs
–VVS = chlamydia + gonorrhoea
–HVS = BV, TV and candida
–EC (endocervical) = gonorrhoea culture
What are the clinical criteria to diagnose PID?
-Lower abdo pain +
One of:
-Pyrexia >38
-Leukocytosis
-ESR >15
+ One of:
-Adnexal pain
-Cervical motion tenderness
-Adnexal mass
