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Pelvic Pain


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An explanation of the causes of pelvic pain and its evaluation

Pelvic Pain

  1. 1. PELVIC PAINAssociate Professor Dr Hanifullah Khan
  2. 2. Objectives1. Understand the definition & terminology2. Identify the causes & form a differential diagnosis3. Clinically evaluate a patient with this problem
  3. 3. Introduction• Pelvic pain is discomfort in the lower abdomen – Below the umbilicus• may originate in – reproductive organs (cervix, uterus, uterine adnexa) – or other organs ● Urological ● Gastrointestinal ● Musculoskeletal ● Neuropathic ● Other• Sometimes the cause is unknown
  4. 4. Causes Pelvic pain Gynae Non-gynae cause cause OtherCyclical Discrete organs
  5. 5. Pelvic region
  6. 6. Female pelvis
  7. 7. Vulva
  8. 8. Definitions• Acute pelvic pain: symptom of underlying tissue injury.• Chronic pelvic pain: pain becomes the disease – Recurrent, unrelated to menses, intercourse, pregnancy Chronic pain: pain lasting 6 months or longer. Chronic pelvic pain syndrome: chronic pelvic pain causing emotional and behavioral changes.
  9. 9. Rule out pregnancy!REPRODUCTIVE AGE GROUP
  10. 10. Pain related to menstrual cyclePain related to menstrual cycle Unrelated to menstruation• Primary dysmenorrhoea • Pelvic inflammatory disease• Endometriosis • Endometriosis• PID • Fibroids• Mittleschmerz • Cysts
  12. 12. Sites
  13. 13. Peritoneal Lesions and an Ovarian Endometrioma Due to EndometriosisGiudice L. N Engl J Med 2010;362:2389-2398
  14. 14. Lesions
  15. 15. Laparoscopy
  16. 16. Symptoms• Cramping pain – may be localized or radiate• Can be continuous• Dysmenorrhoea – usually secondary• Dyspareunia• Abnormal menstruation• Infertility• Others – bowel, urinary, systemic
  17. 17. Pathophysiology of Pain and Infertility Associated with Endometriosis Giudice L. N Engl J Med 2010;362:2389-2398
  18. 18. Radiographic Images of Endometriomas Giudice L. N Engl J Med 2010;362:2389-2398
  19. 19. Major Guidelines from Professional Societies for the Diagnosis and Management of Endometriosis-Related Pain and Infertility Giudice L. N Engl J Med 2010;362:2389-2398
  20. 20. Medical and Surgical Therapies for Endometriosis-Related Pelvic Pain Giudice L. N Engl J Med 2010;362:2389-2398
  22. 22. Definition• Ectopic endometrial tissue within the myometrium• Older age group than endometriosis patients• Associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium
  23. 23. Symptoms• Similar to endometriosis and other pelvic pathology – Pain more likely to be suprapubic – More likely to have abnormal bleeding• Usually older patient• Less likely to be infertile• May have secondary infertility• Previous pregnancies or procedures to uterus• Mimic fibroids – frequently coexist
  24. 24. Pathophysiology
  25. 25. Adenomyoma
  26. 26. Adenoma & fibroids
  27. 27. Adenomyosis vs endometriosis
  28. 28. Laparoscopically Resected Uterine Adenomatoid Tumor with CoexistingEndometriosis: Case ReportNobuyuki Sakurai, MD, PhD, Yasuhiro Yamamoto, MD, Yasuyuki Asakawa, MD, PhD, Hideki Taoka, MD, Kei Takahashi, MD, PhDand Kaneyuki Kubushiro, MD, PhDJournal of Minimally Invasive GynecologyVolume 18, Issue 2, Pages 257-261 (March 2011)DOI: 10.1016/j.jmig.2010.11.009 Copyright © 2011 AAGL Terms and Conditions
  29. 29. FIBROIDS
  30. 30. Definition• Noncancerous growths of the uterus• Often appear during childbearing years• Also called fibromyomas, leiomyomas or myomas• Mostly discovered incidentally
  31. 31. Locations
  32. 32. Symptoms• Heavy menstrual bleeding – Usually cyclical – Prolonged menstrual periods — seven days or more of menstrual bleeding – More likely to be associated with anaemia• Pelvic pressure or pain• Frequent urination• Constipation• Backache or leg pains
  33. 33. Subserosal
  34. 34. Multiple fibroids
  35. 35. Pain• Rarely, a fibroid can cause acute pain – when it outgrows its blood supply• Deprived of nutrients, the fibroid degenerates• Causing pain and fever• Pedunculated fibroids can trigger pain by twisting on its stalk and cutting off its blood supply
  36. 36. Pelvic inflammatory disease/pelvic infectionPID
  37. 37. Definition• Pelvic inflammatory disease (PID) - infection of the female reproductive organs• Occurs when sexually transmitted bacteria spread from the vagina to the uterus and upper genital tract• Important to avoid because it can result in infertility or ectopic pregnancy• Prompt treatment of a sexually transmitted disease can help prevent PID.
  38. 38. Causes• Unsafe sexual practices• IUDs may increase risk of PID• Barrier method, such as a condom, reduces the risk• Bacteria may also enter the reproductive tract as a result of an IUD insertion, childbirth, miscarriage, abortion or endometrial biopsy• Most common – Chlamydia – Gut organisms – Fungal
  39. 39. Liver adhesions
  40. 40. Uterine adhesions
  41. 41. Complications• EP• Infertility• Chronic pelvic pain
  42. 42. PID
  43. 43. Symptoms• Pain in the lower abdomen and pelvis• Heavy vaginal discharge with an unpleasant odor• Irregular menstrual bleeding• Dyspareunia• Low back pain• Fever, fatigue, diarrhea or vomiting• Painful or difficult urination
  44. 44. PID Video
  45. 45. EVALUATION
  46. 46. Differential Diagnosis for Chronic Pelvic PainGynecologic Gastrointestinal•Endometriosis •Irritable bowel•Adhesions •Chronic appendicitis –Endometriosis •Inflammatory bowel disease –PID •Diverticulosis•Leiomyomata •Meckel’s diverticulum•Adenomyosis
  47. 47. HOCI• Rule out pregnancy• Gynecologic history – onset, duration, location, and character of pain – gravity, parity, menstrual history, history of STI – Severity of pain & its relationship to the menstrual cycle• Important associated symptoms – include vaginal bleeding – vaginal discharge – symptoms of hemodynamic instability (eg, dizziness, light- headedness, syncope or near-syncope)
  48. 48. Types of pain• Visceral pain• Referred Pain• Somatic Pain• Myalgia• Hyperalgesia• Neuroinflammation
  49. 49. System review• Seek symptoms suggesting possible causes – morning sickness, breast swelling or tenderness, or missed menses (pregnancy) – fever and chills (infection) – abdominal pain, nausea, vomiting, or change in stool habits (GI disorders) – urinary frequency, urgency, or dysuria (urinary disorders)
  50. 50. Past history• Note history of – Infertility – ectopic pregnancy – pelvic inflammatory disease – Urolithiasis – Diverticulitis/GI prolems• Any previous abdominal or pelvic surgery should be noted
  51. 51. Physical examination• Begins with review of vital signs for signs of instability – eg, fever, hypotension• Focus on abdominal and pelvic examinations• Begin with inspection
  52. 52. Thrombosis of the Inferior Vena Cava and Dilated Veins of the TrunkRoncato C, Lefant PY. N Engl J Med 2011;364:2535-2535.
  53. 53. Abdominal examination• Palpation for – Tenderness – Masses – peritoneal signs• Location of pain and any associated findings may provide clues to the cause• Rectal examination is done to check for tenderness, mass, and occult blood.
  54. 54. Pelvic examination• Inspection of external genitals, speculum examination, and bimanual examination• Cervix - inspected for discharge, uterine prolapse, and cervical stenosis or lesions• Bimanual examination - assess cervical motion tenderness, adnexal masses or tenderness, and uterine enlargement or tenderness
  55. 55. Investigations• Pregnancy tests• Urinalysis• Ultrasonography• Blood tests
  56. 56. Ultrasound hydosalpinx
  57. 57. Lap endometriosis
  58. 58. KEY POINTS
  59. 59. Key points1. Pelvic pain is common and may have a gynecologic or nongynecologic cause.2. Pregnancy should be ruled out in women of childbearing age.3. Quality, severity, and location of pain and its relationship to the menstrual cycle can suggest the most likely causes.4. Dysmenorrhea is a common cause of pelvic pain but is a diagnosis of exclusion
  60. 60. References• The Merck Manual – Pelvic Pain• Mayo Clinic - pain/DS0