chronic pelvic pain

Question 1

features of chronic pelvic pain

Answer 1

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.

Question 2

pathophysiology of acute pain

Answer 2

resolve when tissue heals

Question 3

pathophysiology of chronic pelvic pain

Answer 3

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.

Question 4

causes of chronic pelvic pain

Answer 4

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

Question 5

what is endometriosis

Answer 5

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

Question 6

aetiology of endometriosis

Answer 6

Retrograde menstruation (Sampson’s theory)

Coelomic metaplasia (Meyer’s theory)

Müllerian remnants

Question 7

clinical presentation of endometriosis/adenomyosis

Answer 7

• 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

Question 8

clinical OE of endometriosis

Answer 8

• 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.

Question 9

laparoscopic signs of endometriosis

Answer 9

powder burn deposit
red flame lesions - pelvic peritoneal surface

scarring and adhesions
inactive

advanced you see peritoneal defects

Question 10

Mx of endometriosis

Answer 10

treatment depends on

• fertility issues
• type and severity of symptoms
• therapies tried and failed
• expertise available and patient’s wishes

Question 11

Medical Mx of endometriosis

Answer 11

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

Question 12

surgical Mx of endometriosis

Answer 12

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

Question 13

when do we consider pelvic MRI in endometriosis

Answer 13

Consider pelvic MRI to assess the extent of deep endometriosis involving the bowel, bladder or ureter.

Question 14

causes of adhesions

Answer 14

due to PID or previous surgery
Vascular adhesions these the most painful ones
Residual ovary syndrome
Trapped ovary syndrome

Question 15

Mx of adhesions

Answer 15

division of vascular adhesions
they can redevelop
can provide Sx relief for a few months

removal of residual ovary

Question 16

what criteria is used for IBS

Answer 16

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.

Question 17

Mx of IBS

Answer 17

antispasmodic- Mebeverine hydrochloride

high fibre diet for at least 3-6 months

Question 18

features of MSK pain

Answer 18

• 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

Question 19

Mx of MSK pain

Answer 19

Analgesia, Physiotherapy, Nerve modulation and Antidepressant
MD chronic pelvic pain clinic - gynae, physio

Question 20

what is nerve entrapment

Answer 20

• 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

Question 21

Mx of nerve entrapment

Answer 21

Analgesia, Physiotherapy, Nerve modulation and Antidepressant

chronic pelvic pain clinic

Question 22

causes if social psychological pain

Answer 22

Child abuse- depression, anxiety or somatization

Question 23

Examination for chronic pelvic pain

Answer 23

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

Question 24

Ix for chronic pelvic pain

Answer 24

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

Question 25

red flags and signs of pelvic pain

Answer 25

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.

Question 26

RFs of endometriosis

Answer 26

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.

Question 27

complications of endometriosis

Answer 27

endometriomas - ovarian cysts containing blood and endometriosis-like tissue

fertility problems
adhesion formation
bowel ostruction
chronic pain
reduced QOL

Question 28

Ix of endometriosis

Answer 28

laparasopic - diagnostic - gold standard

transvaginal US

Question 29

surgical Mx of endometriosis

Answer 29

• 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