Pelvic Pain

Question 1

What is the treatment for primary dysmenorrhoea?

Answer 1

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

Question 2

What needs to be done if QOL is still poor after 6 months of amenorrhoea in primary dysmenorrhoea?

Answer 2

Laparoscopy

Question 3

What are some common causes of secondary dysmenorrhoea?

Answer 3

Endometriosis,
PID,
Fibroids,
Polyps,
Adenomyosis
IUD
Less common causes: congenital uterine abnormalities, cervical stenosis, and ovarian pathology.

Question 4

What percentage of women with chronic pelvic pain will develop IBS?

Answer 4

80%

Question 5

What is painful bladder syndrome?

Answer 5

bladder wall irritation without infections.Get bladder troubles or pain most days

Question 6

What percentage of women with chronic pelvic pain will develop painful bladder syndrome?

Answer 6

20%

Question 7

What are the common symptoms of painful bladder syndrome?

Answer 7

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

Question 8

What treatments help with painful bladder syndrome?

Answer 8

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.

Question 9

What are the symptoms of pelvic floor spasm?

Answer 9

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

Question 10

How do you examine for pelvic floor spasm?

Answer 10

Examine the pelvic floor with the leg abducted against resistance

Question 11

What is the treatment for pelvic floor spasm?

Answer 11

Daily stretches, ideally supported by a physio.

Question 12

What is central sensitisation?

Answer 12

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

Question 13

How many women are affected by endometriosis?

Answer 13

1 in 10

Question 14

What are the symptoms of endometriosis and adenomyosis?

Answer 14

Pelvic pain, bowel issues, dysuria, painful bladder, dyspareunia, infertility/reduced fertility. Can be asx.
Adenomyosis has similar sx

Question 15

What are the risk factors for endometriosis?

Answer 15

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.

Question 16

Can you exclude endometrosis if a ultrasound is normal?

Answer 16

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.

Question 17

What is the treatment for endometriosis?

Answer 17

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

Question 18

Does hysterectomy cure endometriosis?

Answer 18

Not necessarily as it may be outside the uterus

Question 19

What is adenomyosis?

Answer 19

Endometrial like tissue is present within the muscular uterine wall

Question 20

Who is usually affected by adenomyosis?

Answer 20

older women and those following child birth

Question 21

How do you diagnose adenomyosis?

Answer 21

USS or MRI

Question 22

What is the management of adenomyosis?

Answer 22

Aims to reduce or eliminate the menstrual cycle with hormonal suppression; failing this a hysterectomy is required

Question 23

What causes primary dysmenorrhoea?

Answer 23

Increased uterine prostaglandins causing increased uterine contractility and resulting ischaemia and hypoxic pain

Question 24

What are the symptoms of PMS?

Answer 24

Depression, anxiety, irritability, loss of confidence and mood swings
Bloating and mastalgia

Question 25

How do you diagnose PMS?

Answer 25

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

Question 26

What are the management options for PMS?

Answer 26

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

Question 27

What is the management for Vaginismus?

Answer 27

Psychosexual counselling, discuss getting aroused, vaginal dilators, oestrogen cream, vaginal lubricants, CBT

Question 28

What is the treatment for pelvic floor dysfunction?

Answer 28

CBT, counselling pelvic physiotherapist

Question 29

What is the treatment for low libido?

Answer 29

Reduce stress, psychosexual counselling

Question 30

What is the treatment for vulvodynia?

Answer 30

Pelvic floor physio, CBT, topical lidocaine jelly, topical oestrogen, gabapentin

Question 31

What is the treatment for postpartum dyspareunia?

Answer 31

Lubricants, topical oestrogen, pelvic physio

Question 32

What is the treatment for anorgasmia?

Answer 32

Discuss genitalia, suggest self exploration/masturbation, sexual attraction to partner or fantasies, explore beliefs about sex and give permission to feel sexual

Question 33

Define primary dyspareunia

Answer 33

Pain with intercourse since first onset of sexual activity

Question 34

Define secondary dyspareunia

Answer 34

Pain acquired over a patient’s sexual lifetime

Question 35

What are common differentials for dyspareunia?

Answer 35

Vaginitis and vulvovaginitis, HSV infection, vaginal atrophy, iatrogenic (medications including antidepressants, antihypertensives, COCP; radiotherapy) , inadequate lubrication, vulvodynia, endometriosis, adenomyosis, leiomyomas

Question 36

What are uncommon causes of dyspareunia?

Answer 36

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

Question 37

What should be included in a dyspareunia history?

Answer 37

Sexual, menstrual, obstetric, medications, general, abuse

Question 38

What exams and tests should be performed initially for a patient experiencing dyspareunia?

Answer 38

Exam: pelvic + general physical + bimanual
Tests; STI checks, urinalysis if UTI suspected, pelvic USS if abnormal bimanual

Question 39

What is the treatment for inadequate vaginal lubrication in pre and post menopausal women?

Answer 39

Sufficient foreplay/arousal, Vaginal moisturisers or lubricants (equivalent to OE2 in non menopausal women) or vaginal oestrogen (better for menopausal related)