Pelvic Pain Flashcards
What is chronic pelvic pain?
-Intermittent or constant pain in the lower abdomen or pelvis of a woman of at least 6 months induration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy
1 in 4 women
Causes of chronic pelvic pain
-Gynaecological : Endometriosis, adhesions, adenomyosis, leiomyoma, pelvic congestion syndrome, ovarian cysts, pelvic inflammatory disease, malignancy
-Gastrointestinal : Adhesions, appendicitis, constipation, diverticular disease, irritable bowel syndrome, inflammatory bowel disease
-Urinary tract : Urinary tract infection, calculus, interstitial cystitis, bladder pain syndrome
-Skeletal : Degenerative joint disease, scoliosis, spondylolisthesis, osteitis pubis
-Myofascial : Fascitis, nerve entrapment syndrome, hernia
-Psychological : Somatization, psychosexual dysfunction, depression
-Neuropathic : Pudendal nerve entrapment, spinal cord neuropathies, fibromyalgia
History of chronic pelvic pain
-Pain history
=Dysmenorrhea
=Dysparunia (Superficial at entrance to vagina/ deep)
=Non cyclical pain (pelvic congestion syndrome= when standing for long time/ change in bowel function adhesions/ cysts sore always)
=Neuropathic features
=Cycle, HMB/IMB
=Bowel/bladder (on defecation and bladder distention)
-Fertility
-Fatigue/QoL (working, relationships)
-Abuse
-Past O&G
-PMH/DH/SH/FH
-Previous Ix
-Previous Rx
Examination of pelvic pain
-Inspection
-Abdominal palpation: inspection for distention or masses, tenderness, rebound and guarding, auscultation if obstruction or ileus
-Speculum (abnormal discharge or bleeding) and bimanual (uterine or adnexal enlargement if pelvic mass, fibroids, ovarian cyst, cervical excitation in ectopic pregnancy and pelvic infection)
=A fixed, immobile uterus suggests multiple adhesions, and nodules felt on the uterosacral ligaments can be a feature of endometriosis
-(Neuropathic pain features/pelvic
floor/MSK.
Epidemiology of endometriosis
-1 in 10 women
=Line peritoneum on laparoscopy
Cause of endometriosis
-Implantation theory: retrograde menstruation (tissue implants in peritoneum as endometrium refluxes into pelvis)
-Coelomic metaplasia theory: Mullerian duct/ peritoneal and pleural cavities/ ovaries
-Natural history?
Three subtypes of endometriosis
-Peritoneal superficial lesions (80%): little lesions, cannot see on scan
-Deep infiltrating lesions (5mm invasion, more fibrotic, back of uterus or pelvic side walls- rectal symptoms/ uretic obstruction)
-Ovarian endometrioma cysts (chocolate cysts)
Symptoms of endometriosis
-Fatigue/ lack of energy
-Severe period pain
-Heavy menstruation
-Pelvic pain
-Pain on defecation
-Depression/ isolation
-Infertility
-Painful urination
-Constipation and/or diarrhoea
-Painful intercourse
-Increased risk of ovarian and breast cancer, melanoma, asthma, and some autoimmune, cardiovascular, and atopic diseases
Why does endometriosis cause pain?
-Endometrial like cells respond to circulating hormones
-Inflammatory= recruitment of cells, macrophages, cytokines
=Stimulate peripheral nerve fibres
-Hypoxia in lesions after withdrawal of progesterone
-Stretch in ovarian cortex in cysts
When to suspect endometriosis
-Including young women aged 17 and under, with 1 or more:
=Chronic pelvic pain
=Period-related pain (dysmenorrhoea) affecting daily activities and QOL
=Deep pain during or after sexual intercourse
=Period-related or cyclical GI symptoms, in particular, painful bowel movement
=Period-related or cyclical urinary symptoms, in particular, blood in the urine or pain passing urine
=Infertility in association
What needs to be assessed/ discussed in suspected endometriosis?
-Circumstances, symptoms, priorities, desire for fertility, aspects of daily living, work and study, cultural background, and their physical, psychosexual and emotional needs
-Discuss keeping a pain and symptom diary
-Offer an abdominal and pelvic examination to identify abdominal masses and pelvic signs
-Consider ultrasound scan
Investigations of endometriosis
-Swabs if indicated
-MSU
-USS
=Endometrioma
=Sliding sign (adhesions)
=Deep disease
=Adenomyosis
=Other pathology
-Specialist assessment:
=MRI (deep, surgical planning)
=Cystoscopy (does it affect bladder)
=Sigmoidoscopy
Types of ultrasound in endometriosis
-Consider transvaginal ultrasound:
=to investigate suspected endometriosis even if pelvic and/or abdominal examinations are normal
=for endometriomas and deep endometriosis involving the bowel, bladder or ureter.
-Consider a transabdominal ultrasound scan of the pelvis if a TVS is not appropriate
Biomarkers of endometriosis
-Ca-125 not diagnose endometriosis
-Nothing has worked
Diagnosis of endometriosis
-Consider laparoscopy to diagnose endometriosis, even if the ultrasound was normal (gun powder lesions/ peritoneal pockets, different colours)
-During diagnostic laparoscopy, a gynaecologist with training and skills in laparoscopic surgery for endometriosis should perform a systematic inspection of the pelvis
=Sigmoid rectal
=Appendix
-If a full systematic laparoscopy is performed and is normal, explain to the woman that she does not have endometriosis and offer alternative management
