15. Pelvic Pain Syndromes 2023.pptx

PELVIC PAIN SYNDROMES Clinical Medicine Lecture Kenneth L. Harris, MD 11/8/2023 objectives Lecture: Pelvic Pain Syndromes • Reading Reference: Beckmann, pp. 271-278 , 279-284 , 363-368 • Learning Objectives: a.Define and list the prevalence, pathogenesis, etiology, evaluation and management of: i....

PELVIC PAIN SYNDROMES Clinical Medicine Lecture Kenneth L. Harris, MD 11/8/2023 objectives Lecture: Pelvic Pain Syndromes • Reading Reference: Beckmann, pp. 271-278 , 279-284 , 363-368 • Learning Objectives: a.Define and list the prevalence, pathogenesis, etiology, evaluation and management of: i.chronic pelvic pain ii.dysmenorrhea iii.endometriosis iv.adenomyosis v.interstitial cystitis vi.vulvodynia vii.acute pelvic pain b.Recognize non-gynecologic etiologies of chronic pelvic pain. c.Identify the psychosocial issues associated with chronic pelvic pain. d.Differentiate physical exam findings in the evaluation of patients with pelvic pain. e.Define and list the evaluation and management for premenstrual syndrome and premenstrual dysphoric disorder. CASE PRESENTATION A 33 YO female , G0P0, presents to your office c/o pelvic pain for the past 2 years. She reports regular, painful periods that seem to be worsening. Also c/o pain with intercourse. She stopped taking birth control pills 30 months ago and has been trying to get pregnant since. CHRONIC PELVIC PAIN • Definition- noncyclic pain lasting for more than 6 months that localizes to the anatomic pelvis, anterior abdominal wall at or below the umbilicus, the lumbosacral back, or the buttocks and is of sufficient severity to cause functional disability or lead to medical care. • (Beckmanns p 281) ETIOLOGIES CHRONIC PELVIC PAIN CPP EVALUATION • Detailed history • Obtain old records • PE • Testing- imaging, GI , labs • ? Surgery- diagnostic laparoscopy • Refer to counseling CPP TREATMENT • Depends on findings – treat accordingly • If etiology is unclear – treat symptoms • NSAIDs, OCPs, Opiods, Tricyclic antidepressants, SSRI, Gabapentin , Pregabalin ( Lyrica) • Surgery- presacral neurectomy, laparascopic uterosacral nerve ablation, hysterectomy+/- BSO DYSMENORRHEA • Definition- painful menstruation • Caused by a release of prostaglandins from the sloughing endometrium. • Primary dysmenorrhea- usually appears within first 6 months of menarche. Etiology not identifiable. • Secondary dysmenorrhea- occurs later and is due to a structural or disease process of the uterus. DYSMENORRHEA • Symptoms – colicky, spasmodic, similar to labor pains • Additional symptoms- N/V, fatigue, anxiety, dizziness, diarrhea, headache ( Beckmanns p296) Dysmenorrhea: Etiology • Intramural • Extrauterine • Adenomyosis • Leiomyomata • Endometriosis • Tumors (benign and malignant) • Inflammation • Adhesions • Psychogenic • Non-gynecologic causes • Intrauterine • Polyps • IUD • Infection • Cervical stenosis Beckmann and Ling’s Obstetrics and Gynecology 9th edi DYSMENORRHEA • Evaluation • Pelvic exam • ? GC/Chl • ? Ultrasound • ? Laparoscopy • Treatment • NSAIDs • OCPs/DMPA • Alternative med- limited studies. Vit E, fish oil, exercise, acupuncture • Surgery- presacral neurectomy, LUNA, hysterectomy +/- BSO ADENOMYOSIS • Definition- endometrial glands and stroma within the myometrium • Uterus usually enlarged- often described as boggy • Etiology unclear- most cases in parous women ENDOMETRIOSIS • Definition- presence of endometrial glands and stroma outside of endometrial cavity • Prevalence – 5-10% of reproductive age women • Risks – familial, cycles < 28 days, menses > 7 days, menarche before 12y, nulliparous • Definitive diagnosis requires a biopsy ENDOMETRIOSIS PATHOGENESIS THEORIES • Retrograde menstruation- Sampson’s theory- mostly found in pelvis • Vascular/Lymphatic dissemination – Halban’s theory- would explain distant sites • Coelomic metaplasia- Meyer’s theory- multipotential cells in peritoneal cavity that develops into functional endometrial tissue ENDOMETRIOSIS SYMPTOMS • Dysmenorrhea - usually worsens over time • Dyspareunia – usually associated with uterosacral or posterior cul de sac lesions • Chronic pelvic pain • Cyclic rectal bleeding or dyschezia • Bladder or bowel pain • Tender nodule in abdominal incision ENDOMETRIOSIS COMPLICATIONS • Dysmenorrhea • Pelvic pain • Abnormal uterine bleeding • Infertility • Back pain • Rectal bleeding EVALUATION • PE- may be normal. • Labs- not much help• Classic finding is uterosacral nodularity. usually ruling out other • Pelvic mass causes. • Immobile or fixed adnexa or uterus • UPT,GC/Chl, CBC, U/A • CA125 may be elevated • Imaging- endometrioma (ground glass appearance) on u/s. Chocolate cyst ENDOMETRIOSIS MEDICAL TREATMENTS • Can start treatment if endometriosis is suspected but not proven • OCPs- usually taken continuously • Progesterone- depo medroxy progesterone acetate(DMPA) given IM or oral progestins • Lupron Depo (leuprolide) - GnRH agonist-IM injection - causes temporary medical menopause- usually also treat with “ add back therapy”- usually also given estrogen or progesterone or both to minimize symptoms • Orilissa (elagolix) – GnRH antagonist- oral • Levonorgestrel IUD- eg Mirena • Androgens – danazol – not used as much now secondary to its ENDOMETRIOSIS SURGICAL TREATMENTS • Laparoscopy • Laparotomy • Hysterectomy +/- BSO Interstitial Cystitis   Effects about 700,000 people in the US, 90% of which are women, with an average age of 40 years old Chronic inflammatory condition of detrusor musculature caused by “potholes” in the inner (GAG) lining of the bladder Slide borrowed from Dr. Cathy Callahan, MD. VCOM-Va Interstitial Cystitis • Pain constant, dull in nature • exacerbations caused by heavy activity, intercourse and certain foods (caffeine, ETOH, dairy, citrus fruits, nuts, etc.) • Hallmark symptoms: • urinary frequency, nocturia, hematuria, incomplete emptying • dyspareunia, post-coital dysuria, • Pelvic Pain and Urinary Frequency Questionnaire (PUF) help with diagnosis Slide borrowed from Dr. Cathy Callahan,MD-VCOM Interstitial Cystitis • Physical exam findings – pain concentrated anteriorly/over bladder • Diagnosis presumptive but objectively through potassium sensitivity test, cystoscopy • Treatment initially with diet modification • Other treatments include Elmiron (pentosan polysulfate sodium), antihistamines, SSRI’s, bladder instillation therapies, cystoscopy with hydrodistension, cystectomy Slide borrowed from Dr. Cathy Callahan,MD-VCOM-Va VULVODYNIA • Definition • Vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific identifiable, neurologic disorder. • Pain may be so intense intercourse is impossible • Type of neuropathic pain • 12-15% of US women • Typical onset age 18 -25 • Risks: NOT associated with STI or physical abuse - Latina women - History of vaginitis - oral contraceptive use • Often not diagnosed - Most patients visit > 6 doctors before diagnosis is established Slide borrowed from Dr. Cathy Callahan, MD- VCOM- VULVODYNIA • Thorough history • Location • Chronicity • Provoked or unprovoked • Cotton-tipped swab test • Apply gentle pressure around the exterior portion of the vestibule using a cottontipped swab in a clock-wise fashion, but each application should alternate across the vestibule • Medication • Local analgesia: Lidocaine gel • Gabapentin • amitriptyline • venlafaxine • Physical therapy • Acute pelvic pain • History- ? onset, duration, description associated symptoms- eg. N/V/D, GI/GU symptoms,F/C, vaginal bleeding, discharge ? Contraception , h/o STDs, similar pain PMH- prior surgeries ACUTE PELVIC PAIN P. Kruszka,MD; S. Kruszka,DO; Am Fam Physician.2010;82(2):141-1 CASE PRESENTATION • A 33 YO female , G0P0, presents to your office c/o pelvic pain for the past 2 years. She reports regular, painful periods that seem to be worsening. Also c/o pain with intercourse. She stopped taking birth control pills 30 months ago and has been trying to get pregnant since. • PE- normal except uterosacral nodularity • Ultrasound 3 cm right adnexal mass- cyst has a ground glass appearance CASE PRESENTATION Ultrasound 3 cm right adnexal mass- cyst has a ground glass appearance CASE PRESENTATION • Discussed options- decided to proceed with laparoscopy references • Williams Gynecology, 3rd edition, p 230-274 • Obstetrics and Gynecology , Beckmann and Ling’s 8th edition • P. Kruszka,S.Kruszka: Am Fam Physician.2010;82(2):141-147