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Chronic pelvic pain..................ppt
- 1. Chronic pelvic pain Presentedby: DR Afsar tabatabai
- 2. Definition • Nonmenstrual painof 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.
- 3. Putative Pelvic PainStates • Adhesions • Pelvic inflammatory disease (PID), • endometriosis • inflammatory bowel disease • prior surgery • Painful bladders syndrome • Uterian originated pains • Psychological problems
- 4. Adhesions • Pelvic inflammatorydisease (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;
- 5. Endometriosis • little correlationbetween 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
- 6. Endometriosis • Treatment: • Firstline NSAIDs,OCP • Danazol,GnRH agonists • No response to conservative treatment surgery
- 7. 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.
- 8. Myofascial Pain(MFPS) • commonin 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
- 9. Pelvic Varicosity PainSyndrome • 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
- 10. Painful Bladder Syndrome characterizedby 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.
- 11. 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.
- 12. 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.
- 13. 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….)
- 14. 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
- 15. Pain of UterineOrigin • 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
- 16. Psychological problems Consider: • Depression •Panic attack • Anxiety
- 17. History and PhysicalExam • 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.)?
- 18. Cyclic Causes forChronic Pelvic Pain • Adenomyosis • Endometriosis • IBS • Mittelschmerz • Ovarian remnant syndrome • PVPS
- 19. Gastrointestinal Causes forChronic Pelvic Pain. • Cholecystitis Chronic appendicitis Constipation Diverticulitis IBS Inflammatory bowel disease Intermittent bowel obstruction Neoplasm Pseudomembranous enterocolitis Ulcer (duodenal, gastric)
- 20. Urologic Causes forChronic Pelvic Pain • Bacterial cystitis Detrusor dyssynergia Neoplasm PBS (interstitial cystitis) Radiation cystitis Urethral caruncle Urethral diverticulum Urethral syndrome Urolithiasis
- 21. treatment • NSAID • Anticonvalsants • Anti depressents • Narcotics
- 22.