Pelvic Pain Flashcards
What is the treatment for primary dysmenorrhoea?
Continuous COCP (needs 30mcg oestrogen) + NSAIDs PRN e.g. mefenamic acid 2-3/7 prior to the withdrawal bleed +/- TXA to reduce menstrual blood loss.
- Alternative if oestrogen is contraindicated or poorly tolerated is Mirena IUS
What needs to be done if QOL is still poor after 6 months of amenorrhoea in primary dysmenorrhoea?
Laparoscopy
What are some common causes of secondary dysmenorrhoea?
Endometriosis,
PID,
Fibroids,
Polyps,
Adenomyosis
IUD
Less common causes: congenital uterine abnormalities, cervical stenosis, and ovarian pathology.
What percentage of women with chronic pelvic pain will develop IBS?
80%
What is painful bladder syndrome?
bladder wall irritation without infections.Get bladder troubles or pain most days
What percentage of women with chronic pelvic pain will develop painful bladder syndrome?
20%
What are the common symptoms of painful bladder syndrome?
Frequency,
Nocturia,
Urgency,
Pain worsening as the bladder fills and relieved by emptying, and
Dyspareunia especially in positions that place the bladder near the vagina
What treatments help with painful bladder syndrome?
Avoid/Limit foods:
- high in acid, -caffeine, chocolate and cola containing drinks; -foods high in Na or K+, -fizzy drinks including soda water; *Amitriptyline can be useful. *Other useful things: pelvic physiotherapy, cystoscopy and hydrodistension, bladder installation.
What are the symptoms of pelvic floor spasm?
Pelvic floor muscle spasm symptoms that include pain that is worse after activity, present all days of the month, worse with passing bowel motions and intercourse
How do you examine for pelvic floor spasm?
Examine the pelvic floor with the leg abducted against resistance
What is the treatment for pelvic floor spasm?
Daily stretches, ideally supported by a physio.
What is central sensitisation?
Increased responsiveness of nociceptors in the CNS to either normal or subthreshold afferent input resulting in hypersensitivity to stimuli, responsiveness to noxious stimuli, increased pain response evoked by stimuli outside the area of injury/an expanded receptive field
How many women are affected by endometriosis?
1 in 10
What are the symptoms of endometriosis and adenomyosis?
Pelvic pain, bowel issues, dysuria, painful bladder, dyspareunia, infertility/reduced fertility. Can be asx.
Adenomyosis has similar sx
What are the risk factors for endometriosis?
Fhx, short menstrual cycles, longer than normal menstruation, early menarche, low BMI, nulliparity, Mullerian anomalies, outflow obstructions e.g. cervical stenosis and transverse vaginal septum.
Can you exclude endometrosis if a ultrasound is normal?
No.
Only way to dx is laparoscopy but this should only be done if you are going to treat endometriosis found at the same time, never just for dx.
What is the treatment for endometriosis?
aim for amenorrhoea/oligomenorrhoea: High dose progesterone only contraceptive 1st line (medroxyprogestone acetate 30mg {not approved for contraception} or norithesterone 10-20mg daily{approved for contraception}) started on the first day of menses + NSAIDs + lifestyle (diet, exercise, sleep, TENs, pain psychology and specialist women’s health physio
Does hysterectomy cure endometriosis?
Not necessarily as it may be outside the uterus
What is adenomyosis?
Endometrial like tissue is present within the muscular uterine wall
Who is usually affected by adenomyosis?
older women and those following child birth
How do you diagnose adenomyosis?
USS or MRI
What is the management of adenomyosis?
Aims to reduce or eliminate the menstrual cycle with hormonal suppression; failing this a hysterectomy is required
What causes primary dysmenorrhoea?
Increased uterine prostaglandins causing increased uterine contractility and resulting ischaemia and hypoxic pain
What are the symptoms of PMS?
Depression, anxiety, irritability, loss of confidence and mood swings
Bloating and mastalgia
How do you diagnose PMS?
sx should be recorded retrospectively for 2 cycles using a sx diary before treatment is started. GnRH anaglogues can be trialed for 3 months if the sx diary is inconclusive but the dx is likely
What are the management options for PMS?
COCP (drospirenone containing are best) used continuously with the lowest dose of progesterone to limit side effects,
SSRI (1st line in severe PMS), vitamin B6 and sx management – if these fail refer to gynae.
CBT should be used especially if severe PMS.
Low dose 20mg BD Danazole in the luteal phase is effective for mastalgia – must use contraeption with this due to virilising effects on female foetuses.
GnRH analogues are highly effective in severe PMS only. If using for >6 months need hormone add back therapy with continuous MHT or tibolene. Should have yearly DEXA
What is the management for Vaginismus?
Psychosexual counselling, discuss getting aroused, vaginal dilators, oestrogen cream, vaginal lubricants, CBT
What is the treatment for pelvic floor dysfunction?
CBT, counselling pelvic physiotherapist
What is the treatment for low libido?
Reduce stress, psychosexual counselling
What is the treatment for vulvodynia?
Pelvic floor physio, CBT, topical lidocaine jelly, topical oestrogen, gabapentin
What is the treatment for postpartum dyspareunia?
Lubricants, topical oestrogen, pelvic physio
What is the treatment for anorgasmia?
Discuss genitalia, suggest self exploration/masturbation, sexual attraction to partner or fantasies, explore beliefs about sex and give permission to feel sexual
Define primary dyspareunia
Pain with intercourse since first onset of sexual activity
Define secondary dyspareunia
Pain acquired over a patient’s sexual lifetime
What are common differentials for dyspareunia?
Vaginitis and vulvovaginitis, HSV infection, vaginal atrophy, iatrogenic (medications including antidepressants, antihypertensives, COCP; radiotherapy) , inadequate lubrication, vulvodynia, endometriosis, adenomyosis, leiomyomas
What are uncommon causes of dyspareunia?
Interstitial cystitis, UTI, Bartholin gland abscess or mass, seminal plasma hypersensitivity, contact dermatitis, atopic dermatitis, imperforate hymen, vulvar dystrophies, vaginismus, tramatic perineal injuries, cervicitis, psychosexual disorder, hydrosalpinx, levator ani spasm
What should be included in a dyspareunia history?
Sexual, menstrual, obstetric, medications, general, abuse
What exams and tests should be performed initially for a patient experiencing dyspareunia?
Exam: pelvic + general physical + bimanual
Tests; STI checks, urinalysis if UTI suspected, pelvic USS if abnormal bimanual
What is the treatment for inadequate vaginal lubrication in pre and post menopausal women?
Sufficient foreplay/arousal, Vaginal moisturisers or lubricants (equivalent to OE2 in non menopausal women) or vaginal oestrogen (better for menopausal related)
