chronic pelvic pain.pptx

8/18/2019 Chronic Pelvic Pain.pptx

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CHRONIC PELVIC PAIN

Dr. Javardo McIntoshIntern

Department of Obstetr cs and !"neco#o$"Pr ncess Mar$aret Hosp ta#%&th March '(%)


2/30

Overv e*

Introd+ct on

Ep dem o#o$"

Et o#o$"

C# n ca# Presentat on

H stor"E,am nat on

Invest $at ons

Mana$ement


3/30

Introd+ct on

Chron c pe#v c pa nInterm ttent or constant pa n n the #o*er abdomen or pe#v s of a *oman of at#east ) months n d+rat on-not occ+rr n$ e,c#+s ve#" * th menstr+at on or nterco+rse and not assoc ated* th pre$nanc"s+ c ent sever t" to ca+se f+nct ona# d sab # t" or re/+ re med ca# care

It s a s"mptom not a d a$nos s.

Ma" s $n 0cant#" mpact on a *oman1s ab # t" to f+nct on


4/30

Ep dem o#o$"

Frequency

A2ects % n 3 *omen

Most common n *omen of reprod+ct ve a$e espec a##" those a$ed ')45("ears.

Of a## referra#s to $"neco#o$ st %(6 are for pe#v c pa n

Mortality/Morbidity

CPP ma" #ead to pro#on$ed s+2er n$- mar ta# and fam #" prob#ems- #oss ofemp#o"ment or d sab # t"- and var o+s adverse med ca# react ons from# fe#on$ therap".


5/30

Et o#o$"

7he pathoph"s o#o$" of CPP s not *e## +nderstood.

A de0n t ve d a$nos s s not made for )% percent of *omen * th CPP.

Man" persons ass+me that a## chron c pe#v c pa n res+#ts from a $"neco#o$ cso+rce.

One st+d" n the 8n ted 9 n$dom fo+nd that d a$noses re#ated to the+r nar" and $astro ntest na# s"stems *ere more common than $"neco#o$ cd a$noses.:

7he fo+r most common#" d a$nosed ca+sesendometr os s- adhes ons- rr tab#e bo*e# s"ndrome ;I- and nterst t a# c"st t s

*Zondervan KT, Yudkin PL, Vessey MP, Dawes MG, Barlow DH, Kennedy SH. Pa erns o! dia"nosis and re!erral in wo#en $onsul in" !or $%roni$ &elvi$ &ain in 'K

$are. Br J Obstet Gynaecol . ())) (+ -(( /((0 1(( ( .


6/30

Ca+ses of CPP

SYSTEM DIFFERENTIAL DIAGNOSES

Gyne$olo"i$ 2d%esions, adeno#yosis, adne3al $ys s, $%roni$ endo#e ri idys#enorr%ea, endo#e riosis, "yne$olo"i$ #ali"nan$ies,leio#yo#a a &elvi$ $on"es ion syndro#e, &elvi$ in!la##adisease

Gas roin es inal 4elia$ disease, $oli is, $olon $an$er, in!la##a ory 5oweldisease, irri a5le 5owel syndro#e

Mus$uloskele al De"enera ive disk disease, !i5ro#yal"ia, leva or ani syndro#e#yo!as$ial &ain, &eri&ar u# &elvi$ &ain syndro#e, s ress!ra$ ures


7/30

Ca+ses of CPP

SYSTEM DIFFERENTIAL DIAGNOSES

Psy$%ia ri$6neurolo"i$ 25do#inal e&ile&sy, a5do#inal #i"raines, de&ression, nerveen raen , neurolo"i$ dys!un$ ion, slee& dis ur5an$esso#a i7a ion

'rolo"i$ Bladder #ali"nan$y, $%roni$ urinary ra$ in!e$ ion, in ers$ys i is, radia ion $ys i is, uroli %iasis

8 %er 9a#ilial Medi erranean !ever, %er&es 7os er, &or&%yria


8/30

H stor"

Characteristics of painNat+re

7hrobb n$- Ach n$- Interm ttent- =harp-Co# c?"

Onset

=+dden vs $rad+a#

Intens t"

M #d- Moderate- =evere

D+rat on

Interm ttent vs constant

@re/+enc"

Rad at on

A##ev at

post+re

mea#s

bo*e# movements

vo d n$

menstr+at on

nterco+rsemed cat ons

Menstr+a# c"c#e before- d+r

Interco+rse D+r n$ and or


9/30

H stor"

Associated SymptomsAnore, a

@at $+e

!astro ntest na# s"mptoms

D arrhea- Const pat on- Hematoche a-!as

8ro#o$ c s"mptoms

@re/+enc"- Hes tanc"- 8r$enc"-Incont nence- D"s+r a

!8

Non menstr+a# va$ na# b#eed n$

PV d schar$e

Method of contracept on

Va$ na# Dr"ness


10/30

H stor"

Past Medical/Surgicalhistory

Pe#v c Infect ons

Infert # t"

Prev o+s =+r$er es

8se of I8D

Ab+se

Ps"cho#o$ ca#-

Ph"s ca#

=e,+a#


11/30

H stor"

RED F A!S"MP#$MS

8ne,p#a ned *e $ht #oss

Hematoche a

Per menopa+sa# rre$+#ar b#eed n$-

Postmenopa+sa# va$ na# b#eed n$

Postco ta# b#eed n$


12/30

H stor"

H stor" of pe#v c s+r$er"- pe#v cnfect ons- or +se of ntra+ter ne

dev ce

Adhes ons

Non4hormona# pa n F+ct+at on Adhes ons- nterst t a# c"st t s- rr tab#e bo*e#s"ndrome- m+sc+#os?e#eta# ca+ses

Pa n F+ct+ates * th menstr+a# c"c#e Adenom"os s or endometr os s

Per menopa+sa# or postmenopa+sa#rre$+#ar va$ na# b#eed n$

Endometr a# cancer

Postco ta# b#eed n$ Cerv ca# cancer or cerv c t s ;e.$.- ch#am"d a or$onorrhea>

8ne,p#a ned *e $ht #oss ="stem c ##ness or ma# $nanc"


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Ph"s ca# E,am nat on

Can dent f"

Areas of 7enderness

Presence of masses

Other anatom ca# 0nd n$s

Norma# ph"s ca# e,am nat on does not r+#e o+t ntraabdom na# patho#o$"


15/30

Ph"s ca# e,am nat on

L thotom" e,am nat on +s+a##" nc#+desthe fo##o* n$

V s+a# nspect on of the e,terna#$en ta# a


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Co#poscop c eva#+at on of the v+#va-

vest b+#e and cerv ,

= ms retractor or s n$#e4b#adespec+#+m e,am nat on of the va$ naand pe#v c m+sc#es


17/30


Pe#v c e,am nat on

< man+a# Pe#v c e,am nat on Pa#pate for nod+#es- masses- orpo nt tenderness a#on$ the b#adderor other m+sc+#os?e#eta# str+ct+res .

Rectova$ na# e,am nat on


18/30


Carnett s s $n for pat ents * th pe#v c pa n.

7he e,am ner p#aces h s or her 0n$er on thetender area of the pat ent s abdomen and as?sthe pat ent to ra se both #e$s o2 the tab#e.

An ncrease n the pat ent s pa n d+r n$ th smane+ver s cons dered a pos t ve test.

Ind cates a m"ofasc a# ca+se of the pa n.

7h s ma" a#so nd cate that the ca+se of the pa n s* th n the abdom na# *a## ;e.$.- 0brom"a#$ a or tr $$erpo nt>.

V scera# pa n sho+#d not *orsen d+r n$ the mane+ver


19/30

Ph"s ca# e,am nat on

Ph"s ca# E,am nat on @ nd n$ Cond t on

Lac? of +ter+s mob # t" onb man+a# e,am nat on

Endometr os s- pe#v c adhes ons

Nod+#ar t" or masses onabdom na#- b man+a# pe#v c and orrecta# e,am nat on

Adenom"os s- endometr os s- hern as-ma# $nanc"- t+mors

Pa n on pa#pat on of o+ter bac?and o+ter pe#v s Abdom na# pe#v c *a## so+rce of pa n- tr $$po nts

Po nt tenderness of va$ na- v+#va-or b#adder

Adhes ons- endometr os s- nerve entrapment-tr $$er po nts- v+#var vest b+# t s

Pos t ve Carnett s s $n M"ofasc a# or abdom na# *a## ca+se of pa n


20/30

Invest $at ons

In t a# test

Cerv ca# c"to#o$"

Endocerv ca# c+#t+resNe sser a $onorrhoeaeCh#am"d a

=too# hemocc+#t

8r ne st+d es8r na#"s s8r ne c+#t+reC"to#o$"


21/30

Invest $at ons

Other Invest $at ons

4o#&le e 5lood $ounInfect on- s"stem c ##ness- or ma# $nanc";e#evated decreased *h te b#ood ce##co+nt or anem a>

E=R:n!e$ ion, #ali"nan$y, sys e#i$ illness


22/30

Invest $at ons

7ransva$ na# +#traso+nd

2deno#yosis,;ndo#e riosis6endo#e rio#a,Mali"nan$y

H"sterosa#p n$o$raph"

not a 0rst4cho ce d a$nost c too#

ma" be +sef+# n pat ents * thn0#trat ve endometr os s of the +terosacra#

# $aments.

endometr a# po#"ps

Asherman s"ndrome

adenom"os s


23/30

Invest $at ons

MRI and C7

Not ro+t ne#" +sedcan he#p assess an" abnorma# t esfo+nd on +#traso+nd.

Laparoscop" +sed *hen the d a$nos s rema ns

e#+s ve after the n t a# *or?+pcan con0rm- and poss b#" treat-

s+spected endometr os sadhes ons


24/30

Mana$ement

Myofascial pain

Ph"s ca# therap"

7r $$er po nts can often be treated* th

In ect ons of a #oca# anesthet c ;e$-b+p vaca ne KMarca ne >-

a cort costero d

Muscle rela%ants

ma" prove +sef+# n pat ents * th$+ard n$- sp# nt n$- or react vem+sc#e spasms.


25/30

Mana$ement

Ph"s ca# therap" techn /+es

nc#+de hot or co#d app# cat ons-

pos t on n$- stretch n$ e,erc ses-tract on- massa$e- +#traso+ndtherap"- transc+taneo+s e#ectr ca#nerve st m+#at on ;7EN=>-

Heat- massa$e- and stretch n$ canbe +sed to a##ev ate e,cess m+sc#econtract on and pa n.

Pe#v c Foor tra n n$ a#so ma" berecommended.


26/30

Mana$ement

Pa n re#ated to the menstr+a# c"c#e

treatment a med at s+ppress n$ thec"c#e ma" he#p.

Common methods to accomp# sh th snc#+de

depot medro,"pro$esterone ;Depo4Provera>

Ora# contracept ves

< rth contro# mp#ant


27/30

Psychophysiological therapy

Reass+ranceCo+nse## n$

Co$n t ve4behav ora# therap"

Re#a,at on therap"

=tress mana$ement

Mana$ement


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Mana$ement

Pharmacotherapy

="mptomat c abort ve therap" to stop or red+ce the sever t" of the ac+tee,acerbat ons and #on$4term therap" for chron c pa n.

In t a##"- pa n ma" respond to s mp#e over4the4co+nter ;O7C> ana#$es cs s+chas paracetamo#- b+profen- asp r n- or napro,en.

If treatment res+#ts are +nsat sfactor"- the add t on of other moda# t es orthe +se of prescr pt on dr+$s s recommended.

Am tr pt"# ne and nortr pt"# ne are the tr c"c# c ant depressants +sed mostfre/+ent#" for chron c pa n.

7he se#ect ve seroton n re+pta?e nh b tors ;==RIs> F+o,et ne- paro,et ne-and sertra# ne a#so are common#" prescr bed.


29/30

Mana$ement

aparoscopy

hen endometr os s or pe#v c adhes ons are d scovered on d a$nost c#aparoscop"- the" are +s+a##" treated d+r n$ the proced+re.

&ysterectomy ma" be *arranted f

the pa n has pers sted for more than s , months

does not respond to ana#$es cs ; nc#+d n$ ant 4 nFammator" a$ents>

and mpa rs the *oman s norma# f+nct on.


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References

chronic pelvic pain.pptx

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