chronic pelvic pain Flashcards
features of chronic pelvic pain
Intermittent or constant pain
In the lower abdomen or pelvis
At least 6 months in duration
Not occurring exclusively with menstruation or intercourse and not associated with pregnancy.
pathophysiology of acute pain
resolve when tissue heals
pathophysiology of chronic pelvic pain
1) local factors at the site of pain
Chemokines and TNF ⍺ affect peripheral nerves
2) Central nervous system response- secondary to afferent pathway persistent pain lead to changes within the central nervous system which eventually magnify the original signal.
3) Visceral hyperalgesia-Alteration in visceral sensation and function.
causes of chronic pelvic pain
it can be multifactorial
adenomyosis and endometriosis IBS interstitial cystitis MSK PID adhesions nerve entrapment intrabdominal adhesions psychological and social factors - depression and sleep disorders
what is endometriosis
Presence of endometrial glands and stroma like lesions outside of the uterus
Predominantly found in the pelvis
Peritoneal lesions, superficial implants or cysts on the ovary, or deep infiltrating
as its endometrial glands it still responds to the cyclical hormones
aetiology of endometriosis
Retrograde menstruation (Sampson’s theory)
Coelomic metaplasia (Meyer’s theory)
Müllerian remnants
clinical presentation of endometriosis/adenomyosis
- Painful periods (dysmenorrhea),
- Painful intercourse (dyspareunia),
- Painful defecation (dyschezia) and
- Painful urination (dysuria)
- Heavy periods
- Lower abdominal pain persistent
- IMB and PCB
- Epistaxes , rectal bleeding
- Little correlation between symptom severity and disease severity
clinical OE of endometriosis
- Thickened uterosacral ligaments
- Fixed retroverted uterus
- Uterine - adenomysosis/ovarian - endometrial cysts enlargement
- Forniceal tenderness
- Uterine tenderness
- adnexal mass
identify abdominal masses and pelvic signs, such as reduced organ mobility and enlargement, tender nodularity in the posterior vaginal fornix, and visible vaginal endometriotic lesions.
laparoscopic signs of endometriosis
powder burn deposit
red flame lesions - pelvic peritoneal surface
scarring and adhesions
inactive
advanced you see peritoneal defects
Mx of endometriosis
treatment depends on
- fertility issues
- type and severity of symptoms
- therapies tried and failed
- expertise available and patient’s wishes
Medical Mx of endometriosis
Pain treatment
NSAIDs
hormonal treatment
stop ovulation or thin endometrium
- COCP pill or patches
- Continuous progestogen therapy (MPA) - degostrol
- GnRH analogues (nasal spray/implants) ± HRT “add-back” therapy needs to be given beyond 3 moths given wit HRT
(Danazol)
Mefenamic acid/tranexamic acid
surgical Mx of endometriosis
Laparoscopic – diathermy, laser - vaporise the endometrirtic spots
TAH + Bilateral salpingoectomy
risk of bladder, ureteric, bowel injury
risk of subtotal hysterectomy
role of HRT - if they are a young person
when do we consider pelvic MRI in endometriosis
Consider pelvic MRI to assess the extent of deep endometriosis involving the bowel, bladder or ureter.
causes of adhesions
due to PID or previous surgery
Vascular adhesions these the most painful ones
Residual ovary syndrome
Trapped ovary syndrome
Mx of adhesions
division of vascular adhesions
they can redevelop
can provide Sx relief for a few months
removal of residual ovary
what criteria is used for IBS
1) Continuous or recurrent abdominal pain or discomfort on at least 3 days a month in the last 3 months
2) Onset at least 6 months previously
3) Associated with at least two of the following:
- Improvement with defecation
- Onset associated with a change in frequency of stool
- Onset associated with a change in the form of stool.
Mx of IBS
antispasmodic- Mebeverine hydrochloride
high fibre diet for at least 3-6 months
features of MSK pain
- Joints in the pelvis
- Damage to the muscles in the abdominal wall or pelvic floor
- Pelvic organ prolapse may also be a source of pain.
- Trigger points-localised areas of deep tenderness – chronic muscle contraction
Mx of MSK pain
Analgesia, Physiotherapy, Nerve modulation and Antidepressant
MD chronic pelvic pain clinic - gynae, physio
what is nerve entrapment
- cases of scars from C section or laparotomy for hysterectomy
- A highly localised, sharp, stabbing or aching pain,
exacerbated by particular movements , and persisting beyond 5 weeks or occurring after a pain free interval
Mx of nerve entrapment
Analgesia, Physiotherapy, Nerve modulation and Antidepressant
chronic pelvic pain clinic
causes if social psychological pain
Child abuse- depression, anxiety or somatization
Examination for chronic pelvic pain
Abdominal and pelvic - speculum or bimanual
Focal tenderness
Trigger points- abdominal wall and/or pelvic floor
Enlargement, distortion or tethering, or prolapse.
Sacroiliac joints or the symphysis pubis may
Ix for chronic pelvic pain
STI Screening - adhesions or chronic inflammation
TVS -identify and assess adnexal masses - ovarian cyst, endometriotic cyst
TVS and MRI - useful tests to diagnose adenomyosis., endometriotic spots, deep ones endometrium
The role of MRI in diagnosing small deposits of endometriosis is uncertain.
Laparoscopy - second line
red flags and signs of pelvic pain
Bleeding per rectum. New bowel symptoms in patients over 50 years old (see 'Investigations', below). New pain after the menopause. Pelvic mass. Suicidal ideation. Excessive weight loss. Irregular vaginal bleeding in patients over 40 years old. Postcoital bleeding.
RFs of endometriosis
Early menarche. Late menopause. Delayed childbearing. Nulliparity. Family history. Vaginal outflow obstruction. White ethnicity. Low body mass index (BMI). Autoimmune disease (an increased prevalence of autoimmune diseases has been noted in women with surgically confirmed endometriosis) Late first sexual encounter. Smoking.
complications of endometriosis
endometriomas - ovarian cysts containing blood and endometriosis-like tissue
fertility problems adhesion formation bowel ostruction chronic pain reduced QOL
Ix of endometriosis
laparasopic - diagnostic - gold standard
transvaginal US
surgical Mx of endometriosis
- TAH+BSO (bilateral salpingo-oophorectomy =/- total hysterectomy)- for woman who have completed their families
- Risk of bladder, ureteric, bowel injury - if laparoscopic its higher
- Risk of subtotal hysterectomy- if endometriosis involving the rectum and the posterior vaginal wall; or if the ovaries are completely buried int he adhesions with a high risk to damage to the other structure, it may not be possible to remove those ovaries and the symptoms may persist
- Role of HRT- if young person may still need HRT. If a advanced form of endometriosis may need continuous HRT with no breaks to prevent any stimulation or activation of endometrial spots
