3- Pelvic pain (chronic pain) Flashcards
(32 cards)
define chronic pelvic paion
‘intermittent or constant pain in the lower abdomen or pelvis of a women of at least 6 months in duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy’
- Social and psychological issues such as physical or sexual abuse are key risk factors
examples of chronic pelvic pain
- Endometriosis
- Adenomyosis
- Adhesions
- Trauma during childbirth
- Interstitial cystitis
- Social and psychological
non-gynaecological causes of chronic pelvic pain
- MSK pain
- Nerve entrapment
- IBS/ IBD
- Chronic inflammatory condition of the bladder
pathophysiology of acute vs chronic pelvic pai n
- Acute pain- resolves when tissue heals
- Chronic pain- additional factors contribute hence pain persists longer
o Chemokines and TNF alpha affecting peripheral nerves
o Visceral hyperalgesia
endometriosis background
Presence of endometrial glands and stroma outside of the uterus.
- Responds to cyclical hormonal changes and bleeds at menstruation
pathophysiology of endometriosis
- Unknown
- Retrograde menstruation
presentation of endometriosis
- Painful periods
- Painful intercourse
- Painful defecation
- Painful urination
- Heavy periods
- Persisting abdominal pain
- Rectal bleeding
on examination: endometriosis
- Thickened uterosacral ligaments
- Retroverted uterus
- Uterine/ovarian enlargement
- Uterine tenderness
- Endometrial tissue visible on speculum exam, esp in posterior fornix
investigations for endometriosis
- Pelvic US- endometriomas and chocolate cysts
- Laparoscopic surgery- gold standard
management of endometriosis
Treatment depends on:
- Fertility issues
- Severity of symptoms
- Therapies tried and failed
medical management of endometriosis
- COCP
- Continuous progestogen therapy
- GnRH analogues
- Danazol
- Mefenamic acid
medical management of endometriosis
- COCP
- Continuous progestogen therapy
- GnRH analogues
- Danazol
- Mefenamic acid
surgical management of endometriosis
- Laparoscopic- diathermy, laser
- TAH + BSO (hysterectomy and bilateral salpingo-oophorectomy )
o Risk of bladder, ureteric, bowel injury
o Risk of subtotal hysterectomy
o Role of HRT
Adenomyosis background
Presence of endometrial tissue within the myometrium (muscle layer of the myometrium)
RF for adenomyosis
- Multiparous
- Seem to resolve after menopause
cause of adenomyosis
- Not fully understood
- Multiple factors
o Sex hormones
o Trauma
o Inflammation
presentation of adenomyosis
- Dysmenorrhoea
- Menorrhagia
- Pain during intercourse
- infertility
investigations for adenomyosis
- Transvaginal US
- Gold standard- Diagnosis by histology after hysterectomy
management of adenomyosis
- Mirena coil or COCP or cyclical oral progestogens
Others:
- GnRH analogues to induce menopause like state
- Endometrial ablation
- Uterine artery embolization
- Hysterectomy
Non-contraceptive methods
- Tranexamic acid – if not painful
- Mefenamic acid- if painful (NSAID)
IBS background
“Functional bowel disorder”. This means that there is no identifiable organic disease underlying the symptoms. The symptoms are a result of the abnormal functioning of an otherwise normal bowel.
IBS RF
- Female
- Younger adults
presentation of IBS
- Diarrhoea
- Constipation
- Abdominal pain
- Bloating
- Worse after eating
- Improved by opening bowels
rome III criteria for IBS
- Continuous or recurrent abdominal pain or discomfort on at least 3 days a month in the last 3 months
- Onset at least 6 months previously
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.
treatment of IBCS
General healthy diet and exercise
o Adequate fluid intake
o Regular small meals
o Limit caffeine and alcohol
o FODMAP
o Probiotic supplements for 4 weeks
First line medication
o Loperamide for diarrhea
o Laxatives for constipation
o Antispasmodic e.g. buscopan
Second line medication
o Tricyclic antidepressants
Third line
o SSRIs
o CBT
