Chronic Pelvic Pain Flashcards
what is chronic pelvic pain
CPP
- persistnat, noncyclicial pain percieved to be related to structures wtihin the pelvis
- occuring for at least 6 months
- sufficient to cause functional disability
potential reasons (LOTS)
- PID
- adhesions (post-op)
- endometriosis
- nerve/muscle entrapment
- IBS
- interstitial cystits
often not possible to identify the singel reasons or definitive cure; mostly there are multiple reasons for the pain
- in teh absent of a clear etiology = CPP is a complex neuromuscular psychosocial dsiorder similar to other chronic regional pain syndromes
- hyperesthesia
- allyodyina
- and pelvic flood dysfunction
Evaluation of Chronic Pelvic Pain
IPPS
history
PE
Labs
IPPS: pelvic pain society: developed detailed eval form for a systamatic review
History : pearls
- precipitating and allevating factors; response to prior tx.
- assocaitions to menses, urination, sex, defication
- location, ROS with related systems
- effects on QOL
PE gentle!!
- often there are things found on PE; but nonspecific
- singel digit exam : for trigger points
- external exam: infection, inflammation, derm or neuro issues
- pelvic flood exma: hypertonicity or tenderness
- carnett test: descide if its abd. wall pain or visceral pain: abs. wall pain will worse with the fexion of the head and flexion of teh abd. pain
- palpation lumbar and SI; sensation test for neuro
Diagnostic Tests
- limited test initially
- CBC/ES (inflammation)
- UA
- Chamyldai/GC
- pregnancy
- Pelvic US
- severe: can do a laparascopy (endometriosis etc.)
- may need other imaing depending on findings
Red Flags of Chronic Pelvic Pain Findings
History
- post-coital bleeding: cervical cancer
- postmenpasual bleeding: endometiral cancer
- postmenopoasual onset of pain: cancers
- weight loss: cancr
- hematuria: Urinary tract CA
PE
- adenxal masses: ovarian cancer
- cervical CA findings: can be seen
- rectal masses
- hematuria
- mass on US
Overall Treatment of Chronic Pelvic Pain
If underlying diagnosis is found: treat accordignly
otherwise
- emphasize patient self managemnet and improving QOL and pain control
- medications, surgical interventions, phsycial modalities and behavioral interventions
Medications
- NSAIDS
- Hormonals: OCPs, progesterones, GnRH agnits
- neropath pain: TCAs, SNRIs or gabapentin/pregabalin
- opioids: last line by pain management
Surgical Intervention
-laparascopic to treat endometrisosi
hysterectomy: last resport
nerve injections
sacrual neuromod(implantables)
Pelvic Floor PT
- super helpful!!
Behavioral thearpy
- CBT super helpful
- diagnosis and manage comorbid depression
Uterine Leiomyoma (Fiberoids)
Etiology
Symptoms
where are they
Etiology
- benign proliferations of smooth muscle tissue from the myometrium
- these are responsive to estrogen and progesterone; thus typically occuring in those of childbearing ages, and go away during menopause
Symptoms
- most asymptomatic: if this: then no treatment needed
- incidentally found
- irregualr or heavy bleeding
- reproductive issues
- mass effect on other organs
Where are they
- MC location: subserosal
- can be pedunculated, intramural
- the ones which are submucosal are the biggest concern: as they sit and disrupt the inner uterus and endometrium :impacting pregnancy and bleeding
Fiberoids
Risk factors & Protective Factors
Risk Factors
- african americans
- nonsmokers
- early menarche
- no children
- perimenopaouse
- excessive alcohol
- hypertension
Protective Factors
- increasd parituy: more # of pregnancies, less exposure to estrogen/progesteron (since youre just pregnant all the time)
- OCP use
- ingectable progestin
- smoking
OCP USe: low dosease are protective against NEW growth, but they can stimulate growth or preexisitng fibroids
Fiberoids
Symptoms and Presentation
Symptoms
- asymptomatic
- AUB: abnormal uterine bleeding is most common manifestation: because of submuscoal fibroid
- increasingly heavy periods for longer amounts of time
- postcoital spotting
- bleeding between periods
- heavy and irregular periods
- iron def. anemia because of blood loss
- dysmenorrhea (crampy!)
- peliv pain (vasuclar issu, compromise and mass effect)
- pressure-realted: contispation, hydronephrosis, venous staiss and urinary issues
PE
- depends on size and location of the fbroids
- irregular contour of uterine fundus on bimanual exam
- cobblestone protrusions: feels firm on palpation
Fiberoids
Diagnosis
Diagnosis
- pelvic US is initial study: se area of hypogenicity within a normal muscalr uterine wall
- saline sonohystogram: saline into uterus; this can help see size and shape of them and decide if its submucosal or a polyp
MRi: can help show vs. adenmoyosis or help for surgery
Fiberoids
Treament
general approach
General Approach
- if asymptomatic: no need to treat: serial US and expectant management
severe sx: decide based on age, fertilitiy desires, etc.
medications (hormonal or non)
utrine artery embolization
MRI guided US surgery
sugrical
Fiberoids: Treatment
Medication
Medication: Non-Hormonal
- good for heavy/prolonged bleeeding + anemia
- will NOt shrink tumor
- NSAIDS: antiprostoglandin effects: decrease bleed and anemia
- tranexamic acid: for heavy bleeding
Medication: Hormonal
- the symptoms will come back when stopping treatment
- OCPs: combined
- progesterone only shots
- IUD
- mifepristone
- norethindrone acetate
GnRH Agnosits: decrease estrogen and decrease tumor
- nafarelin, leuprolide, goserelin
myfembree contains
Relogolix: GnRH antagonist: indrectly lowers estrogen
estradiol/norhindrone: add-back to hormones so they dont get induced menopause
Fiberoids: Treatment
Uterine artery embolization
Uterine Artery Embolization
- IR procedure: via femoral artery: inject emoblizing agent to the uterine artery
- decreased blood supply = ischemic necrosis = degeneration of size of fiberoid
only in pt who do no desire future pregnancy: will impact the normal uterine tissue too
not used for large/peduclated ones: the embolization cagent wont cover the entire area
Fiberoids: Treatment
MR Guided Focused US surgery
MR Guided US Surgery
indicated for those who are premenopausal with desire to keep uterus
- MR: used to located & high intesnity US waves ablate the fibroid
- expensive, outpt.
Fiberoid Treatment: Surgical Management
indications
two procedures
Indications for surgery
- AUB = causing severe anemia
- severe pelvic pain
- secondary amenorrhea
- unknown: mass or fiberoid
- urinary sx.
- growing post-menopausal
- recurrent miscarriage/infertility
- rapidly increasing in size
Procedures (avoided during active pregnancy) hemorrhage risk
Myomectomy
- excisings just the mass of the fiberoid: the muscle tissue growth
- good for those who desire future pregananc/want to keep uterus
- adhesions are complications: difficult with fertility in futrue
Hysterectomy
- definative treatment of fiberoids
- ovaries are retained if looking normal & pt. is under 65
if hysterectomy not done: annually monitoring of the size/location = if post-menopausal growth (to rule of CA)
Fiberoids & Fertility Issues
vast majority of women with fibroids are able to conceive
submuosal fibroids: can impact implantation
Fibroids Increase risk for
- preterm labor/delivery
- rfetal malpresenation: because its crowdedin the uterus
- dysfunctional labor
- C-section
Ovarian Cysts
Etiology & types
Etiology
- Functional Cysts: the most common - follicular cysts or corpus luteum cysts
- Theca Lutein cysts: usually pregnancy complication
- Endometrioma chocolate cyst
