Gynecology 5th year, 3rd lecture (Dr. Abir Mohidien Said)


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The lecture has been given on May 23rd, 2011 by Dr. Abir Mohidien Said.

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Gynecology 5th year, 3rd lecture (Dr. Abir Mohidien Said)

  1. 1. Chronic pelvic pain<br />Dr: AbirMoheidin Said<br />
  2. 2. Chronic pelvic pain<br />The pelvic pain that persists for aperior of 3 months or more to be considered chronic<br />Differentiating between acute & chronic pain is important in understanding chronic pelvic pain syndromes<br />Acute pain is most commen after experienced by patients after surgery or other soft tissue traumas, it tendes to be immediate, sever & short<br />
  3. 3. CPP<br />CPP is a common problem presenting a major challenge to healthcare professionals. This is partly due to understanding of the etiology & natural history of the disease.<br />CPP is a serious problem affecting the lives of many women during their child bearing years<br />The differential diagnosis of the underlying etiology often involves both psychological & organic factors<br />
  4. 4. Difinition<br />International Association for the Study of Pain (IASP)defines CPP as chronic or recurrent pelvic pain that has a gynaecological origin but for which no definite lesion or cause is found, absence of pathology<br />3-6 months duration which is not relieved by narcotic analgesia <br />
  5. 5. Incidence<br />13-20% of gynaecological consultations <br />52% of diagnostic laparoscopy<br />In the United States 12-16% of hysterectomies were performed for CPP<br />
  6. 6. CPP<br />Women with symptoms of pain may want to see a gynecologist if problems don‘t go away after a few days, should take a carful history & examination, followed by a pregnancy test. The absence of visible pathology in chronic pain syndromes should not form the basis for either seeking psychological explanations or questioning the reality of the patient‘s pain.<br />
  7. 7. CPP<br />Instead it is essential to approach the complexity of chronic pain from a psychophysiological perspective which recognizes the importance of the mind-body interaction. Some of the mechanisms by which the limbic system impacts on pain, & in particular myofascial pain, have been clarified by research findings in neurology & psychophysiology<br />
  8. 8. Gynaecological causes<br />PID ( cervicitis, endometritis, salpingo-oophoritis)<br />Most cases of PID are caused by sexually transmitted organisms, such as Chlamydia trachomatis & neisseriagonorrhoeae<br />Chlamydia infection may be asymptomatic & the resulting salpingitis is often referred to as (silent pelvic inflammatory disease)<br />The mechanism of CPP following PID is likely to be related to the scarring, tissue damage & adhesions<br />
  9. 9. Pelvic congestion syndrome<br />Dilated pelvic veins with delayed disappearance of dye & is a common finding in women with no apparent cause for their pelvic pain<br />Is largely confined to women in their reproductive years ( ovarian hormones, probably estrogen)<br />Standing for long period of time will increase pelvic congestion & pain <br />
  10. 10. Endometriosis<br />Presence & proliferation of endometrial tissue outside the endometrial cavity <br />The most frequent sites of implantation are the pelvic viscera & peritonium<br />Adenomyosis cause CPP , especially dysmenorrhoea,dyspareunia & CPP<br />Mechanism by swelling, stretching of the tissue as well as nerve damage secondary to scarring <br />
  11. 11. Other gyn. causes<br />Ovarian remnant syndrome following hysterectomy & BSO for sever endometriosis or PID, because of residual ovarian cortical tissue that is left in situ after difficult surgical dissection during oophorectomy<br />Ovarian cysts can causes unilateral pelvic pain<br />Retroverted uterus can sometimes contribute to Pelvic pain syndrome, however, there is still no convincing evidence that ventrosuspension is effective in relieving such symptoms<br />
  12. 12. Peritoneal adhesions<br />Responsible for pelvic pain although they are often asymptomatic<br />A single adhesion band which is under tension is likely to causes pain during certain position or during movement<br />Peritoneal adh. Can cause pain , particularly when they are extensive & involve sensitive structures like the ovary<br />Usually a complication of PID, endometriosis, appendicitis, peritonitis & previous pelvic surgery<br />
  13. 13. Gastroenterological causes<br />Irritable bowel syndrome ( 60% of referrals to gynaecologist for CPP)<br />Chronic appendicitis<br />Chronic diverticulitis<br />Colitis<br />
  14. 14. Urological causes<br />Urethral syndrome is a complex of various symptoms such as dysuria, frequency & urgency, suprapubic pelvic discomfort & dyspareunia <br />Interstitial cystitis is a chronic non-bacterial inflammation of the bladder ( hypersensitivity or hyperalgsia has been postulated as the cause of the pain<br />
  15. 15. Neurological & musculoskeletal<br />Nerve entrapment usually follows an abdominal cutaneous nerve injury spontaneously or after incisions<br />Myofascial syndrome about 15% of CPP, injection of local anesthetic can temporarily obliterate the pain<br />Low back pain syndrome, underlying aetiology can involve vascular, neuralgic, psychogenic or musculoskeletal causes<br />
  16. 16. Psychosocial causes<br />Depression & pain can be closely linked together<br />Histories of sexual & physical abuse<br />Somatization disorders<br />Anxiety<br />
  17. 17. CPP<br />
  18. 18. Management<br />Good history<br />Organic & psychological aspects<br />Investigation & treatment of organic disease<br />Clinical psychological &/or psychiatric input<br />Different healthcare professionals may play in the management , depending on the underlying etiology<br />Vaginal & cervical swabs<br />
  19. 19. Management<br />Pelvic ultrasound ( peritoneal free fluid, dilated fallopian tubes, tubo-ovarian abscess,ect)<br />Endometrial biopsy can sent for microbiological as well as histopathological<br />Hysteroscopy <br />Laparoscopy ( adhesion,leimyoma,hernia,ect)<br />Urin analysis / C&S<br />
  20. 20.
  21. 21. Management<br />Sigmoidoscopy for irritable bowel syndrome or diverticulitis<br />Radiological imaging studies to exclude any pathology<br />Cystoscopy, IV pyelogram<br />psychotherapy<br />
  22. 22. Treatment<br />Pain clinics can offer for women in whom organic pathology has been excluded<br />Alternative treatment such as acupunture,transcutaneous electrical stimulation, hypnosis, exercise .<br /> psychotherapy have been shown to achieve 71% reduction in pain<br />Anxiety & depression can also be reduced with psychosocial functioning improved, including return to work, increased social activities & improved sexual activity<br />
  23. 23. Treatment<br />Many women will benefit from a consultation with a consultation with a physical therapist, a trial of anti inflammatory medications, hormonal therapy or even neurological agents<br />A hysterectomy is sometimes performed<br />
  24. 24. Managment<br />Management of CPP is a major challenge for health service, both physical & psychological management offered by various medical & non medical health professionals, gynaecologist, psychologist, anaesthesiologist, urologist 6 gastroenterologists<br />
  25. 25. THANKS<br />