Chronic pelvic pain Presented by: - PowerPoint Presentation

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Chronic pelvic pain

Presented by:

DR

Afsar

tabatabai

Definition

Nonmenstrual pain of 6 months duration or greater, localized to the pelvis, anterior abdominal wall below the pelvis, or lower back, severe enough to result in functional disability or require medical or surgical treatment.

Putative Pelvic Pain States

Adhesions

Pelvic inflammatory disease (PID),

endometriosis

inflammatory bowel disease

prior surgery

Painful bladders syndrome

Uterian originated pains

Psychological problems

Adhesions

Pelvic inflammatory disease (PID), endometriosis, inflammatory bowel disease, or prior surgery may cause adhesions; yet, in up to 50% of cases, there may be no significant antecedent event

while some case series have shown benefit to adhesiolysis, others have shown no treatment benefit

;

Endometriosis

little correlation between the extent of disease present and the degree of pain

several appearances ranging from the more typical powder burn,blue-gray lesions to atypical lesions that may be clear, red, or white.

Associated Symptoms

:

cyclic pelvic pain

dysmenorrhea.

Tenesmus involving the rectosigmoid colon.

dyspareunia

or ovarian mass (endometrioma).

Pain may precede the menses, occur with menses, and continue after menses

Endometriosis

Treatment:

First line NSAIDs,OCP

Danazol,GnRH agonists

No response to conservative treatment surgery

Pelvic Inflammatory Disease

can be a cause of acute pain, or even asymptomatic.

mechanisms for pain:

inflammation and distension of the fallopian tubes.

hydrosalpinx will sometimes persist for months or years and may cause CPP.

Myofascial Pain(MFPS)

common in patients with a history of trauma or multiple surgeries and is often overlooked as a cause for CPP.

Patterns of pain:

localized, reproducible, hyperirritable trigger points within a muscle

Treatment:

icing, stretching exercises, and injection with local anesthesia,physical therapy

Pelvic Varicosity Pain Syndrome

worsen throughout the day

Dyspareunia

Post coital pain

Mechanism:

Increasing in vein diameters

substance P and calcitonin gene-related peptide

Treatment:

GnRH agonists

Medroxiprogesteron acetate

surgery

Painful Bladder Syndrome

characterized by urgency, frequency, or pain in the absence of a urinary tract infection or malignancy.

Diagnosis:

distending the bladder cystoscopically under anesthesia

Treatment:

diet, exercise, smoking cessation, transcutaneous electrical nerve stimulation, bladder training, medications, bladder distention, or bladder instillation.

Irritable Bowel Syndrome

(Rome III criteria):

- recurrent abdominal pain or discomfort that is present for at least 3 months

- with onset at least 6 months previous

and at least two of the following clinical features:

(a) improvement with defecation

(b) onset associated with a change in frequency of stool

(c) onset associated with a change in the form (appearance) of stools.

Irritable bowel syndrome

Mechanism:

visceral hyperalgesia

infection

imbalance of neurotransmitters

psychologic factors

Treatment:

Treating symptoms

In pain prodominance: tricyclic antidepressants, NSAIDs, anticholinergics, calcium channel blockers, and in some cases opioids.

Ovarian Remnant Syndrome

a history of extensive endometriosis or pelvic inflammatory processes resulting in a technically difficult oophorectomy

DX:

FSH,LH are at normal range.

Ultrasonography

Treatment:

Surgery(removing all ovarian tissue….)

Residual Ovary Syndrome

Mechanism:

cyclical expansion of the ovary encased in adhesions

chronic lower abdominal pain,

dyspareunia

, and radiation of pain to the back or anterior thigh

A tender mass may be palpated on bimanual exam

Treatment:

Bilateral oophorectomy

Pain of Uterine Origin

Adenomyosis

Chronic endometritis

Degenerating leiomyomata

PVPS

Cervical stenosis

Intrauterine contraceptive device

Hysterectomy may be indicated in the absence of pathology in patients who have concluded childbearing and who have not responded to conservative therapy

Psychological problems

Consider:

Depression

Panic attack

Anxiety

History and Physical Exam

Characterists:What does the pain feels like? (sharp, dull, crampy, etc.)

Onset: Was the pain onset sudden or gradual? Is it cyclic or constant?

Location:Is the pain localized or diffuse?

Duration:How long has the pain been present, and how has it changed over time?

Exacerbation:What activities or movements make the pain worse?

Relief:What medication, activities, and positions make the pain better?

Radiation:Does the pain radiate anywhere (back, groin, flank, etc.)?

Cyclic Causes for Chronic Pelvic Pain

Adenomyosis

Endometriosis

IBS

Mittelschmerz

Ovarian remnant syndrome

PVPS

Gastrointestinal Causes for Chronic Pelvic Pain.

Cholecystitis

Chronic appendicitis

Constipation

Diverticulitis

IBS

Inflammatory bowel disease

Intermittent bowel obstruction

Neoplasm

Pseudomembranous enterocolitis

Ulcer (duodenal, gastric)

Urologic Causes for Chronic Pelvic Pain

Bacterial cystitis

Detrusor dyssynergia

Neoplasm

PBS (interstitial cystitis)

Radiation cystitis

Urethral caruncle

Urethral diverticulum

Urethral syndrome

Urolithiasis

treatment

NSAID

Anti convalsants

Anti depressents

Narcotics

thank you

thank you