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Bloc I - Reproduction > Sept17 A3-Gynecological-Chronic-Pain > Flashcards

Sept17 A3-Gynecological-Chronic-Pain Flashcards

1
Q

most common cause of chronic pelvic pain (CPP)

A

endometriosis

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2
Q

problem in chronic pain

A
  • nociceptive signals form peripheral nerves to CNS
  • signals are interpreted by the brain as danger
  • BUT pain is not accurate indication of the danger
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3
Q

factors that can modify pain experience

A
  • mood, stress
  • environment
  • past experiences
  • meaning of pain
  • spine and brain have mechanisms to amplify or diminish pain*
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4
Q

sensitization def

A

PNS and CNS are overxited and get huge amount of synapses firing in resp to one stimulation

  • peripheral sensitization OR
  • central sensitization
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5
Q

crpss-sensitization def

A

somato-visceral or viscero-visceral convergence

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6
Q

why some people remain functional with endometriosis and some don’t

A

in certain people, the brain can adapt to a certain level but in others, there is sensitization

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7
Q

most common sx of endometriosis (BUT NOT CPP)

A

dysmenorrhea

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8
Q

(IMP) 2most imp components of central sensitization

A
  • hyperlagesia (uncomfortable stimulus becomes painful)

- allodynia (not uncomfortable stimulus becomes painful)

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9
Q

how central sensitization occurs

A

normal descending inhibitory pathwys are gone

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10
Q

pain is not a good indicator of:

A
  • the problem
  • where the problem is (bc of cross sensitization)
  • how dangerous the problem is (degree of tissue damage)
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11
Q

positive thing with chronic pain

A

neuroplasticity

  • possibility to retrain brain to desensitize
  • pain does not necessarily mean danger
  • empower the patient
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12
Q

CPP def

A

at least 3-6 months

  • episodic or constant
  • no cyclical pain like dysmenorrhea
  • in anatomic pelvis (between umbilicus and inguinal lig)
  • can cause functional disability
  • unrelated to pregnancy
  • requires tx
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13
Q

common causes of CPP (that also often coexist)

A
  • gyn (ENDOMETRIOSIS, adenomyosis, chronic pelvic infections, fibroids)
  • urologic (interstitial cystitis or painful bladder syndrome)
  • GI (IBS = irritable bowel syndrome)
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14
Q

endometriosis def

A

presence of endo glands and stroma outside of normal location

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15
Q

endometriosis most common location

A

on pelvic peritoneum

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16
Q

pathophgy of endometriosis

A
  • retrograde menstruation (most accepted theory) = endometrial cells pass through fallopian tubes and within peritoneal cavity
  • coelomic metaplasia (PMD (Muellerian duct)) from highly pluripotential coelomic epith formed endometrium in ectopic places
  • lymphatic or vascular spread
17
Q

why endometriosis happens to some women and not to others (nbr of women with retrograde menstruation >nbr with endometriosis)

A
  • immune system dysfunction contributes to genesis of endometriosis
  • NK cells, macrophages and lymphocytes usually get rid of endometrial tissue*
18
Q

hormone role in endometriosis

A

estrogen
-ectopic tissue is deficient in enzymes inactivating estrogens (progesterone responsive enzymes in normal endo)
-it expresses aromatase to make estrogen (normal endo doesn’t)
END RESULT: estrogen makes the endometriosis grow. (E = fertilizer. P = lawn mower)

19
Q

classic sx of endometriosis

A
  • severe dysmenorrhea
  • severe dyspareunia
  • chronic pelvic pain
  • dysuria
  • dyschezia (painful bowel mvmts)
20
Q

endometriosis possible PE findings

A
  • non mobile tender uterus
  • adnexal mass (endometrioma)
  • tender nodules in posterior cul de sac (Douglas)
  • can be normal PE with no pain (good inhibition in brain). but still some infertility
21
Q

how imaging helps for endometriosis

A

can only detected ADVANCED stage endometriosis or LARGE nodules using

  • pelvic US
  • MRI
22
Q

gold std (best sensitivity) to dx endometriosis

A

laparoscopy and pathologic confirmation

23
Q

why does endometriosis cause CPP

A

mostly bc of inflammation (for ex bc of pressure caused by a nodule)

24
Q

medical endometriosis tx

A
  • pain control with NSAID or tylenol)

- OCPs (stops from ovulating so no more E produced + OCP contains P), progestins, GnRH agonists

25
Q

surgical tx for endometriosis is done in who

A
  • severe pain refractory to medical management

- infertility

26
Q

do IUDs work for endometriosis?

A
  • copper IUD: no

- LNG-IUS: for endometriosis in rectouterine pouch or adenomyosis. BUT not for endometrioma

27
Q

stage 1 endometriosis on laparoscopy

A

few little spots

28
Q

stage 4 endometriosis on laparoscopy

A

major anatomical disfigurement, large ovarian lesions

29
Q

causes of dyspareunia

A 
SUPERFICIAL:
-vulvovaginal diseases such as candida, herpes, lichen sclerosus, post menopausal atrophy, lichen planus, any dermato thing causing inflammation
DEEP: 
-endometriosis
-painful bladder syndrome
-fibroids
-STIs
-PIDs
30
Q

(imp?) most common cause of longstanding dyspareunia unrelated to deep pathologies like endometriosis

A

vulvodynia and vaginismus

31
Q

vulvodynia def

A

vulvar pain. subcategorized in

  • location
  • timing
  • onset
  • temporal pattern
32
Q

most common type of vulvodynia

A

localized provoked vulvodynia (feeling of small cuts or burning at the introitus (entrance of the vagina)

33
Q

cause of vulvodynia

A
  • multifactorial
  • neurogenic inflammation
  • increased vascular permeablity and vasodilation mediated by substance P axons and serotonin
  • can occur post surgery for gyn indications or after delivery with perineal laceration or episiotomy (cut of perineum)
34
Q

most common location of localized prokoved vulvodynia (LPV)

A

5 to 7 oclock in introitus (vestibule)

35
Q

vulvodynia tx

A
  • address identifiable and tx causes like lesions
  • minimize irritants
  • pelvic floor physio
  • meds (xylocaine get, hormones, oral or topical tricyclic antidepressant or anticonvulsants)
  • interventional (injection of local anesthesia + CS)
  • surgical vestibulectomy
36
Q

vaginismus def

A
  • reflex or involuntary contraction of pelvic floor muscles at penetration which essentially closes the vaginal orifice to prevent penetration. at intercourse or while inserting anything like tampons
  • genito-pelvic pain and penetration disorder described in the DSM5 and with important physical and emotional components
37
Q

tx of vaginismus

A
  • exclude other pathologies by palpating the pelvic floor muscles
  • multidisciplinary tx (education about normal female sexual response, pelvic floor physio, reverse kegels (kegels = contract pelvis. reverse to relax)
  • sex therapy, progressive relaxation
  • vaginal suppositories of benzo or muscle relaxants

Bloc I - Reproduction (57 decks)

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