بسم الله الرحمن الرحیم - PowerPoint Presentation

Slide1

بسم الله الرحمن الرحیمSlide2

Associate Professor in Pediatric Urology

Kermanshah University of Medical Science

Mahmoudreza

Moradi

. MDSlide3

Pelvic PainSlide4

What Is Pelvic Pain?

If you have pain below your belly button and above your legs, it counts as pelvic pain. It can be caused by a lot of things. It may be a harmless sign that you’re fertile, a digestive disorder, or a red flag that you need to go to the hospital.Slide5

Appendicitis

If you have a sharp pain in the lower right part of your belly, are vomiting, and have a fever, it could be appendicitis. If you have these symptoms, go to the ER. An infected appendix may need surgery. If it bursts, it can spread the infection inside your body. This can cause serious complications.Slide6

Irritable Bowel Syndrome (IBS

)

Do you have belly pain, cramps, bloating, and diarrhea or constipation that keeps coming back? Talk to your doctor to figure out the problem. It could be IBS, sometimes called spastic colon. Doctors aren’t sure what causes it. Diet changes, stress management, and medications may help.Slide7

Mittelschmerz

(Painful Ovulation

)

Ever feel a painful twinge between periods? You may be feeling your body ovulate. When you do, the ovary releases an egg along with some fluid and blood. It can cause irritation. This feeling is called 

mittelschmerz

-- German for "middle" and "pain." That’s because it happens midway through your monthly cycle. The pain may switch sides from month to month. It isn't harmful and usually goes away in a few hours.Slide8

PMS and Menstrual

Cramps

You can usually feel these cramps in your lower belly or back. They typically last 1 to 3 days. Why the pain? Every month, your uterus builds up a lining of tissue. That’s where an embryo can implant and grow. If you don't get pregnant, the lining breaks down and is shed during your period. When the uterus tightens to push it out, you get a cramp. Try a heating pad and over-the-counter pain relievers to ease pain. Exercise and de-stressing can help, too. You can also talk to your doctor about PMS pain. Certain birth control pills or antidepressants may help.Slide9

Ectopic

Pregnancy

This happens when an embryo implants somewhere outside of the uterus and begins to grow. This usually happens in the fallopian tubes. Sharp pelvic pain or cramps (particularly on one side), vaginal bleeding, nausea, and dizziness are symptoms. Get medical help right away. This is a life-threatening emergency. Slide10

Sexually Transmitted

Diseases

Pelvic pain is a warning sign of some STDs. Two of the most common are chlamydia and gonorrhea (shown here through a microscope). You often get both at the same time. They don't always cause symptoms. But when they do, you may have pain when you pee, bleeding between periods, and abnormal vaginal discharge. See your doctor. It’s also important to get partners checked and treated, too, so you don’t pass the infection back and forth.Slide11

Pelvic Inflammatory Disease

This is a complication of sexually transmitted diseases. It's the No. 1 preventable cause of infertility in women. It can cause permanent damage to the uterus, ovaries, and fallopian tubes. Belly pain, fever, abnormal vaginal discharge, and pain during sex or urination can be symptoms. Get it treated right away to avoid damage. It is treated with antibiotics. In severe cases, you may need to be hospitalized. Get your partner treated, too.Slide12

Ovarian Cysts

Ovaries release eggs when you ovulate. Sometimes a follicle doesn't open to release the egg. Or it recloses after it does and swells with fluid. This causes an ovarian cyst. They’re usually harmless and go away on their own. But they may cause pelvic pain, pressure, swelling, and bloating. And if a cyst bursts or twists, it can cause sudden, severe pain, sending you to the emergency room. Doctors can spot them during a pelvic exam or ultrasound.Slide13

Uterine

Fibroids

These grow on or in the wall of the uterus. While they’re sometimes called fibroid tumors, they are not cancerous. Fibroids are common in women in their 30s and 40s. They usually don’t cause problems. But some women may have pressure in the belly, low back pain, heavy periods, painful sex, or trouble getting pregnant. Talk with your doctor if you need treatments to shrink or remove them.Slide14

Endometriosis

In some women, the tissue that lines the uterus grows outside of it. It can happen on the ovaries, fallopian tubes, bladder, intestines, and other parts of the body. When it's time for your period, these clumps break down, but the tissue has no way to leave the body. While this is rarely dangerous, it can cause pain and form scar tissue that may make it tough to get pregnant. There are several treatment options. Pain medications, birth control pills, hormones to stop periods, surgery with small incisions, and even a hysterectomy (taking out your uterus) are options.Slide15

Urinary Tract

Infection

Do you have to pee often, or does it hurt when you do? Or do you feel like your bladder is full? It could be a UTI. This happens when germs get into your urinary tract. Treating it quickly can keep it from it getting serious. But if it spreads to the kidneys, it can cause serious damage. Signs of a kidney infection include fever, nausea, vomiting, and pain in one side of the lower back.Slide16

Kidney

Stones

These are globs of salt and minerals that your body tries to get rid of in urine. They can be as tiny as a grain of sand or as large as a golf ball. And boy can they hurt! Your urine may turn pink or red from blood. See your doctor if you think you have a kidney stone. Most will pass out of your system on their own, but some need treatment. Even if they can pass on their own, your doctor can help with pain medication and will tell you to drink lots of water.Slide17

Interstitial Cystitis (IC

)

This condition causes ongoing pain and is related to inflammation of the bladder (illustrated here). It’s most common in women in their 30s and 40s. Doctors aren’t sure why it happens. People with severe IC may need to pee several times an hour. You might also feel pressure above the pubic area, pain when you urinate, and pain during sex. Although this can be a long-term condition, there are ways to ease the symptoms and avoid flares.Slide18

Pelvic Organ

Prolapse

As you get older, this may happen. Your bladder or uterus drops into a lower position. It usually isn't a serious health problem, but it can be uncomfortable. You may feel pressure against the vaginal wall, or your lower belly may feel full. It may also give you an uncomfortable feeling in the groin or lower back and make sex hurt. Special exercises like

Kegel’s

or surgery may help.Slide19

Pelvic Congestion

Syndrome

We’ve all seen varicose veins in legs. (This is a picture of one in the upper thigh.) They can sometimes happen in the pelvis, too. When blood backs up in veins, they become swollen and painful. This is known as pelvic congestion syndrome. It tends to hurt worse when you sit or stand. Lying down may feel better. It usually can be treated with procedures using very small incisions.  Slide20

Scar

Tissue

If you've had surgery or an infection, you could have ongoing pain from this. Adhesions are a type of scar tissue inside your body. They form between organs or structures that aren’t meant to be connected. Adhesions in your belly can cause pain and other problems, depending on where they are. In some cases, you may need a procedure or surgery to get rid of them.Slide21

Vulvodynia

Does it hurt when you ride a bike or have sex? If it burns, stings, or throbs around the opening of your vagina, it could be this. The feelings can be ongoing or come and go. Before you’re diagnosed with this, your doctor will rule out other causes. This isn’t caused by an infection. Treatment options range from medication to physical therapy.Slide22

Chronic Pelvic

Pain

If you have pain that lasts at least 6 months, it’s considered chronic. It may be so bad it messes with your sleep, career, or relationships. See your doctor. Most of the conditions we've covered get better with treatment. Sometimes, even after a lot of testing, the cause of pelvic pain remains a mystery. But your doctor can still help you find ways to feel better.Slide23

Chronic Pelvic Pain Syndrome

(CPPS) Slide24

Prostatitis is the

most common

urologic diagnosis in men

younger than age 50

years and the third most common urologic diagnosis in men

older than age 50

years after benign prostatic hyperplasia (

BPH

) and prostate

cancer

.Slide25

Definition and ClassificationSlide26

Acute bacterial

prostatitis was

diagnosed when prostatic fluid was clinically purulent, systemic signs of infectious disease were present, and bacteria were cultured from prostatic fluid.

Acute bacterial prostatitis Slide27

Chronic bacterial

prostatitis

was diagnosed when pathogenic

bacteria were recovered in significant numbers from a purulent prostatic fluid in the

absence of a concomitant UTI or significant systemic signs

.Chronic bacterial prostatitis Slide28

Nonbacterial

prostatitis was diagnosed when significant numbers of bacteria could not be cultured from prostatic

fluid but the fluid consistently revealed microscopic purulence.

Nonbacterial prostatitis Slide29

Prostatodynia

was diagnosed in the remaining patients who had persistent pain and voiding complaints as in the previous two categories but who had no significant bacteria or purulence in the prostatic fluid.

Prostatodynia

Slide30
Slide31
Slide32

There is

no validated cutoff point

for the level of WBCs per high-power field that is required to differentiate an inflammatory from a

noninflammatory

CP/CPPS.

Although the suggested limits have ranged from

as low as 2 to as high as 20

, the consensus appears to favor

5 to 10

WBCs/

hpf

in EPS as the upper level of normal.Slide33

cystoscopy

is indicated in patients in whom the history (e.g.,

hematuria

), lower urinary tract evaluation (e.g.,

VB1 urinalysis

), or ancillary studies (e.g., urodynamics) indicate the possibility of a diagnosis other than CP/CPPS. In these patients, occasionally lower urinary tract malignancy, stones, urethral strictures, bladder neck abnormalities, and so forth that can be surgically corrected are discovered. Cystoscopy can probably be justified in men refractory to standard therapy.Slide34

Transrectal

ultrasonography

can be valuable in

diagnosing medial prostatic cysts

in patients with

prostatitislike

symptoms, diagnosing and draining

prostatic abscesses

, or diagnosing

and draining

obstructed seminal vesicles

.Slide35
Slide36
Slide37

TreatmentSlide38

Most experts suggest therapy initially with

parenteral antibiotics

(depending

on the seriousness of the infection) followed by

oral antibiotics

with wide-spectrum antimicrobial activity.

Antibiotics Slide39

The most common drugs suggested for initial therapy are a combination of

penicillin

(i.e., ampicillin) and an

aminoglycoside

(i.e., gentamicin), second- or third-generation

cephalosporins

, or one of the

fluoroquinolones

.Slide40

The bladder neck and

prostate are

rich in a receptors, and it is hypothesized that

α-adrenergic blockade

may improve outflow obstruction, improving urinary flow and perhaps

diminishing

intraprostatic

ductal reflux.

α-adrenergic

blocker Slide41

Nonsteroidal

anti inflammatory drugs, corticosteroids, and immunosuppressive drugs

theoretically should improve the inflammatory parameters within the prostate and possibly result in a reduction of symptoms.

Anti

inflammatory Slide42

The results of a multicenter, randomized, placebo-controlled trial that randomized 100 men

to

pentosan

polysulfate

, 900 mg/day (three times the usual dose), or

placebo indicated this medication provided

modest benefit

for some

men with CPPS.

pentosan

polysulfateSlide43

The use of

α-blockers

to relax smooth muscle (see earlier discussion of α-adrenergic blockers) and

skeletal muscle relaxants

combined with adjuvant medical and physical therapies has been advocated and promoted.

skeletal muscle relaxantsSlide44

Theoretically,

antiandrogens

(including 5α-reductase inhibitors) could result in regression of prostatic glandular tissue (inflammation is believed to begin at the level of the

ductal

epithelium), improved voiding parameters (especially in older patients with BPH and prostatitis), and reduced intraprostatic ductal reflux. Finasteride cannot be recommended as a

monotherapy

except perhaps in men with associated BPH.

Antiandrogens

Slide45

Phytotherapeutic

Agents

Neuromodulator Therapy

Allopurinol

Prostatic Massage

Perineal

or Pelvic Floor Massage

Pudendal

Nerve Entrapment Therapy

Biofeedback

Acupuncture

Psychological Support

Others Slide46

Minimally Invasive Therapies

:

Balloon Dilatation

Transurethral Needle Ablation

Microwave Hyperthermia and Thermotherapy Slide47
Slide48
Slide49
Slide50

Bladder Pain Syndrome

(Interstitial Cystitis)Slide51

Bladder pain syndrome/interstitial cystitis (BPS/IC) is a condition diagnosed on a clinical basis and requiring

a

high

index of suspicion on the part of the clinician.

Simply put, it should be considered in the differential diagnosis of the patient presenting with chronic pelvic pain that is often exacerbated by bladder filling and associated with urinary frequency.Slide52

National Institute of Diabetes and Digestive and

Kidney Diseases (NIDDK)

Diagnostic Criteria

for Interstitial CystitisSlide53

• Duration of symptoms less than 9 months• Absence of nocturia

• Symptoms relieved by antimicrobial agents, urinary

antiseptic agents

,

anticholinergic agents, or antispasmodic agents• A frequency of urination while awake of less than 8 times per day • A diagnosis of bacterial cystitis or prostatitis within a 3-month period• Bladder or

ureteral calculi • Active genital herpesSlide54
Slide55
Slide56

Prevalence

range from 1.2 per 100,000

population and 4.5 per 100,000 females in Japan

,

to a questionnaire-based study that suggests a figure in American women of 20,000 per 100,000Slide57

All domains of female sexual function including sexually related

distress, desire, and orgasm frequency can

be affectedSlide58

DIAGNOSIS

It has now morphed largely into a

diagnosis of

chronic pain, pressure, or discomfort associated with

the bladder, usually accompanied by urinary frequency in the absence of any identifiable causeDiagnostic approaches vary widely, and

general agreement on a diagnostic algorithm remains a future goalSlide59

A presumptive diagnosis can be made merely by ruling out known causes of frequency, pain, and urgency in a patient

with compatible

chronic

symptomsOften this

will involve a complete history, physical examination, appropriate cultures, and local cystoscopy.Slide60
Slide61
Slide62

The gold standard in defining BPS/IC for research

purposes has been the NIDDK criteria.Slide63

TreatmentSlide64

Treatment Options

A) Conservative Therapy

B) Interventions:

Oral pharmacologic agents

Intravesical therapy

Surgical therapiesSlide65

Conservative Therapies

If the patients symptoms are tolerable and do not significantly impact quality of life, a policy of withholding treatment is reasonable.Slide66

Behavioral and physical therapy:

Biofeedback

pelvic floor rehabilitation

bladder training programs (progressively increasing the voiding interval over the course of weeks to months)Stress reduction, exercise, warm tub bathsThey are excellent initial interventions and have been used by some authors with some success.

 The urinary frequency and urgency components seem to respond better to these interventions than the pelvic pain component.Slide67

Dietary

Therapy

Dietary restrictions are unsupported by any literature (Campbell

)

, but EAU guideline stated that consider diet avoidance of triggering substances (GR C).Many patients do find their symptoms are adversely affected by specific foods and would do well to avoid them.

Often this includes caffeine, alcohol, artificial sweeteners, hot pepper, and beverages that might acidify the urine such as cranberry juice.Slide68

Medical

TreatmentSlide69

Amitriptyline

(EAU)

Amitriptyline

is effective for pain and related symptoms of BPS (LE 1b)

Mechanism: blockade of acetylcholine receptors, inhibition of serotonin and noradrenalin reuptake, and blockade of histamine H1 receptors. It is also an

anxiolytic agent.Median preferred dose is 50 mg in a range of 25 to 150 mg/day. The speed of onset of effect is 1 to 7 days.Drowsiness is a limiting factor with amitriptyline, and thus, nortriptyline is sometimes considered instead.Slide70

Pentosan

Polysulphate

Sodium

Oral PPS is effective for pain and related symptoms of BPS (LE 1a) and could be offered oral pentosanpolysulphate

sodium for the treatment of BPS (GR A).It is thought to repair defects in the GAG layer.Subjective improvement of pain, urgency, frequency, but not nocturia, has been reported.PPS had a more favorable effect in BPS with lesion than in non-lesion disease. Approved dosage is 100mg TDS.At 32 weeks, about half the patients responded. So a 3- to 6-month treatment trial is generally required to see symptom improvement.Slide71
Slide72

Anti-

Histamins

Hydroxyzine

:

No significant response was found in an NIDDK placebo-controlled trial. It has limited

efficacy in BPS (LE 3).Cimetidine:(Campbell) Uncontrolled studies show improvement of symptoms in two thirds of patients taking it in divided doses totaling 600 mg. Cimetidine is a common treatment in the United Kingdom, where over a third of patients reported having used it.(EAU) Limited data exist on effectiveness of cimetidine in BPS (LE 2b) and it can be considered as a valid oral option before invasive treatments (GR B)Slide73

Antibiotics

Antibiotics have no role in BPS due to the lack of evidence (EAU).

There is no evidence to suggest that antibiotics have a place in the therapy for BPS in the absence of a culture-documented infection.

Nevertheless, it would not be unreasonable to treat patients with

one empirical course of antibiotic (Doxy is recommended) if they have never been on an antibiotic for their urinary symptoms (Campbell).Slide74

Immunosuppressants

Cyclosporin

A:

might be used in BPS but adverse effects are significant and should be carefully considered (GR B).

Initial evaluation of cyclosporin A

and methotrexate showed good analgesic effect but limited efficacy for urgency and frequency.Azathioprine treatment has resulted in disappearance of pain and urinary frequency. In an aborted multicenter randomized placebo-controlled NIDDK trial, mycophenolate mofetil (Cellcept 1 to 2 g/day in divided doses) failed to show efficacy in the treatment of symptoms of refractory BPS/IC.Slide75

Analgesics

Urologists should preferably use analgesics in collaboration with pain clinics.

The long-term, appropriate use of pain medications forms an integral part of the treatment of a chronic pain condition such as IC.

Many non-

opioid analgesics including acetaminophen and the NSAIDs

and even antispasmodic agents have a place in therapy along with agents designed to specifically treat the disorder itself.Slide76

Others

Corticosteroids

are not recommended in the management of patients with BPS because of a lack of evidence (GR C).

Gabapentin

might be considered for oral treatment of BPS (GR C).

Prostaglandins (e.g. misoprostol): are not recommended. Insufficient data on BPS, adverse effects are considerable (GR C).Duloxetine: inhibits both serotonin and noradrenaline reuptake. Duloxetin shows no efficacy, and tolerability is poor (LE 2b)Slide77

L-

Arginine

:

The body of evidence does not support the use of L-

arginine for the relief of symptoms of IC.Nifedipine. inhibits smooth muscle contraction and cell-mediated immunity. In one pilot study, with use of 30 mg daily within 4 months, 50% of patients showed at least a 50% decrease in symptom scores and 3 of the 5 were asymptomatic. No further studies have been reported.

Montelukast: In a pilot study, with 10 mg of montelukast daily for 3 months, frequency, nocturia, and pain improved dramatically in 80% of the patients.Tanezumab is a humanised monoclonal antibody that specifically inhibits nerve growth factor (NGF). It should only be used in clinical trials.Slide78

Intravesical treatment

Intravesical

drugs are administered due to poor oral bioavailability establishing high drug concentrations at the target, with few systemic side-effects.

Disadvantages include the need for intermittent catheterization, which can be painful in BPS patients, cost, and risk of infection.Slide79
Slide80
Slide81

Oxybutynin

Intravesical

oxybutynin

combined with bladder training improves functional bladder capacity, volume at first sensation, and cystometric bladder capacity.

However, the effect on pain has not been reported.Slide82

Bladder

Hydrodistention

Following diagnostic

hydrodistention

, therapeutic hydrodistention may be performed. This is usually performed at 80-100 cm water for 8-10 minutes.

Although bladder hydrodistension is a common treatment for BPS, the scientific justification is scarce. It can be a part of the diagnostic evaluation, but has a limited therapeutic role.Bladder distension should only be used as diagnostic (LE 3) and is is not recommended as a treatment of BPS (GR C).Slide83

با سپاس...