Chronic pelvic pain

Question 1

Give 4 differentials for chronic pelvic pain

Answer 1

Endometriosis & Adenomyosis
Pelvic inflammatory disease (PID)
IBS
MSK pain
Interstitial cystitis
Nerve entrapment (in scar)
Adhesions
Social + Psychological factors

Question 2

How is adenomyosis diagnosed?

Answer 2

On histology after hysterectomy

Adenomyosis = Endometrial tissue in myometrium

Question 3

Give 4 presenting features of Endometriosis

Answer 3

Dysmenorrhoea + Menorrhagia [heavy + painful periods]
Dyspareunia
Post-coital bleeding + Intermenstraul bleeding
Persistent lower abdominal pain

Dysuria
Dyschezia

Question 4

What is the examination findings for Endometriosis?

Answer 4

No abnormality detected (NAD)

Uterine/ovarian enlargement
Forinceal tenderness
Uterine tenderness (from Adenomyosis or from Adhesions)
Thickened uterosacral ligaments
Fixed retroverted uterus

Question 5

Give 2 findings on laparoscopy for Endometriosis

Answer 5

Ovarian chocolate cysts (Ovarian endometrioma)

Active endometriosis = Powder burn deposits; Red flame lesions
Inactive endometriosis = Adhesions + Scarring
Advanced endometriosis = Peritoneal defects (eg holes)

Question 6

What is the management for Endometriosis

Answer 6

Medical management (suppress ovulation):
* COCP
* Continuous progesterone therapy (Medroxyprogesterone acetate)
* GnRH analogues (+/- HRT as “add-back” therapy)
* Mefenamic acid + Tranexamic acid

Surgical management:
* Laparoscopic = Diathermy, Laser (of endometrial spots)
* Total abdominal hysterectomy + Bilateral oophorectomy (TAH + BSO)

Question 7

What are the complications of Total abdominal hysterectomy + Bilateral oophorectomy (TAH + BSO)

Answer 7

Injury to the bladder, ureter, or bowel
Bleeding, Infections, Adhesions

In endometriosis = Risk of subtotal hysterectomy (endometrial deposits in surrounding structures still)

Role of HRT (prevent Osteoporosis)

Question 8

What is the treatment for adhesions?

Answer 8

Division of vascular adhesions (may only provide temporary relief of symptoms)

Removal of the residual ovary (can help with pain)
- Can also use GnRH analogues to suppress the ovary

Question 9

What is the criteria for IBS diagnosis called?

Answer 9

ROME III criteria:
o Continuous or Recurrent abdominal pain or discomfort on at least 3 days a month in the last 3 months

o Onset at least 6 months previously

o Associated with ATLEAST 2 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 10

Give 3 investigations performed for Chronic pelvic pain

Answer 10

STI screening
Transvaginal USS (look for adnexal masses)
Transvaginal USS + MRI (look for adenomyosis)

Laparoscopy (now second line after therapeutic intervention trials)