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Chronic Pelvic pain.

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Presentation on theme: "Chronic Pelvic pain."— Presentation transcript:

1 Chronic Pelvic pain

2 Introduction Patients with chronic pelvic pain are frequently anxious and depressed. Their marital, social, and occupational lives have usually been disrupted. About 12% to 19% of hysterectomies are performed for pelvic pain, and 30% of patients who present to pain clinics have already had a hysterectomy Approximately 60% to 80% of patients undergoing laparoscopy for chronic pelvic pain have no intraperitoneal pathology Overlapping afferent input from nearby viscera can cause a perception of referred pain, making the diagnosis of origin difficult

3 Evaluation of chronic pelvic pain
Genital Entrocoelic Musculoskeletal/neuropathic ,Carnet test Urologic The psychological component .

4 Carnet test

5 Chronic pelvic pain Differential diagnosis : Gynecologic Cyclic
Gastrointestinal Genitourinary Neurologic Musculoskeletal systemic

6 The psychological component
History of past physical ,sexual ,or emotional abuse: Childhood sexual abuse are risk factor for chronic pelvic pain Anxiety and depression

7 Endometriosis & Adhesions
Gynecologic causes Endometriosis & Adhesions There is no correlation between the location of disease and pain .40 to 60% of patients have no tenderness on examination regardless of stage. Other studies have shown that deeply infiltrating endometriosis lesions involve The rectovaginal septum and the bowel, ureters, and bladder are prostaglandin production may account for severe pain in some patients with mild disease. Endometriosis is a surgical diagnosis based on identification of characteristic lesions.

8 social and occupational disruption responded poorly to adhesionlysis
Lysis of adhesions, a subgroup of women with anxiety, depression, multiple somatic symptoms, and social and occupational disruption responded poorly to adhesionlysis Adhesions noted at the time of laparoscopy are often in the same general region of the abdomen as the source of the pelvic pain. Noncyclic abdominal pain, sometimes increased with intercourse or activity, is a common source of pain in women with adhesions.

9 Pelvic congestion Transuterine venography Signs and symptoms Bilateral lower abdominal and back pain ,secondary Dysmenorrhea, Dysparonia, AUB ,chronic fatigue, IBS , Pain usually begins with ovulation and lasts until the end of menses .

10 management Embolization or hysterectomy and salpingo- ovariectomy. Continuous OCpill low estrogen ,progestin dominant. High dose progestin, GnRH analogues , Medroxyprogesterone acetate, 30mg daily, has been found to be useful psychotherapy, behavioral pain management

11 Subacute Salpingo-oophoritis
symptoms and signs of acute infection. Atypical or partially treated infection may not be associated with fever or peritoneal signs. Subacute or atypical salpingo-oophoritis is often a sequela of chlamydia or mycoplasma infection. Abdominal tenderness, cervical motion bilateral adnexal tenderness

12 Ovarian remnant syndrome
After a difficult dissection to perform an oophorectomy . Symptoms :arise 2 to 5 years after initial oophorectomy .tender mass, Deep Dysparonia, constipation ,flank pain . Diagnosis : ultrasonography, clomid, persistent estrogenized state . Management : GnRH agonist. Surgery ,

13 Gastroenterologic causes
uterus, cervix, adnexa, lower ileum, Sigmoid colon and rectum are the same innervations . IBS is the more common causes of lower abdominal pain and may account for up to 60% for chronic pelvic pain

14 Palpable tender sigmoid colon and hard feces in the rectum
symptoms Abdominal pain, abdominal distention, excessive flatulence, alternating diarrhea and constipation, Increase pain before a bowel movement, and decrease after a bowel movement, Palpable tender sigmoid colon and hard feces in the rectum

15 Diagnosis History Physical examination CBC OCCULT BLOOD
SIGMOIDOSCOPYor Colonoscopy or Barium enema

16 Management Reassurance Stress reduction Bulk-forming agents
Low-dose tricyclic anti depressants Eliminate lactose ,sorbitol ,alcohol ,fat ,fructose ,caffeine. Dicyclomine, hycoscyamine . Tegaserod FDA aproved

17 Urologic causes Recurrent cystourethritis Urethral syndrome
Sensory urgency of uncertain cause Interstitial cystitis

18 Urethral syndrome Dysuria ,frequency ,urgency ,suprapubic discomfort ,dyspareunia ,vaginitis. Diagnosis :cystoscopy to rule out urethral diverticulum ,interstitial cystitis and cancer.

19 Management Doxycycline or erthromycin for 2 to 3 week .long-term low dose antimicrobial prophylaxis is often used . Local estrogen therapy for about 2 month in all postmenopausal women Uretheral dilatation .

20 Interstitial cystitis
> in women between 40 and 60 years of age . Symptoms : frequency, urgency, nocturia, Dysuria, hematuria . Suprapubic, pelvic, urethral, vaginal, or perineal pain that can be relived by emptying of the bladder . Management :diet, stress reduction, behavioral changes, anti-cholinergic, antispasmodic, and anti-inflammatory agents . Tricyclic antidepressants ,pentosan polysulfate sodium . Hydrostatic bladder distention,

21 Neurologic and musculoskeletal cause
Nerve entrapment : abdominal cutaneous nerve :ilioinguinal and iliohypogastric , femoral nerve injury . Myofascial pain syndrome . Fibromyalgia . Low-back pain syndrome . Psychological factors . Childhood physical and sexual abuse has also been noted to be more prevalent in women with chronic pelvic pain than in those with other types of pain (52% versus 12%)

22 Management of CPP Medical Therapy
A low dose of a tricyclic antidepressant, anticonvulsant, or selective serotonin/norepinephrine reuptake inhibitor is combined with cognitive behavioral therapy directed toward reducing reliance on pain medication

23 Surgical therapy of CPP
Laparoscopy :endometriosis, transection of the uterosacral ligaments %85 success rate, Lysis of adhesions : Hysterectomy : Although 19% of hysterectomies are performed to cure pelvic pain, 30% of patients presenting to pain clinics have already undergone hysterectomy without experiencing pain relief.

24 Neurologic and musculoskeletal cause
Nerve entrapment : abdominal cutaneous nerve :ilioinguinal and iliohypogastric , femoral nerve injury . Myofascial pain syndrome . Fibromyalgia . Low-back pain syndrome . Psychological factors . Childhood physical and sexual abuse has also been noted to be more prevalent in women with chronic pelvic pain than in those with other types of pain (52% versus 12%)

25 Management of CPP Medical Therapy
A low dose of a tricyclic antidepressant, anticonvulsant, or selective serotonin/norepinephrine reuptake inhibitor is combined with cognitive behavioral therapy directed toward reducing reliance on pain medication

26 Female sexual dysfunction

27 Epidemiology >%76 of women have some type of sexual dysfunction.
Prevalence :%43 in women and %31 in men. One third with sexual desire and one fourth report lack of orgasmic experiences and one fifth difficulties with vaginal lubrication. Female sexual dysfunction is associated with negative sexual relationship experiences.

28 Prevalence Increasing age lower level of educational attainment Unmarried status, poor physical or emotional health, Prior negative sexual experiences . happily married“ 63% of the women experienced sexual dysfunction .

29 Physiology of genital sexual arousal
Gonadal hormones Genital sensory information Input from higher cortical centers of cognition Spinal cord reflex (pudendal nerve. Autonomic nerve stimulation ) Endothelial release of nitric oxide (NO) Vasoactive intestinal peptide(VIP)

30 Mental Health low self-esteem, feelings of insecurity, and lost femininity. Impaired sexual desire has been noted in most studies of women with depression Lack of emotional well-being was one of the stronger predictors of sexual distress

31 Aging Some studies have shown little increase in sexual problems with age where as in others almost 40% of the sample reported reductions in responsiveness and an increased desire for nongenital sexual expression. Personality Factors . Relationships . Sexual Dysfunction in the Partner. Infertility.

32 The AFUD Classifications of Female Sexual Dysfunction .
1. Sexual desire disorders A. Hypoactive sexual desire disorder: B. Sexual aversion disorder II. Sexual arousal disorder III. Orgasmic disorder IV. Sexual pain disorders A. Dyspareunia B. Vaginismus C. Other sexual pain disorders (non-coital)

33 Drugs with negative sexual effects
Antihypertensives: β-blockers, thiazides ● Antidepressants: serotonergic antidepressants ● Lithium ● Antipsychotics ● Antihistamines ● Narcotics ● Benzodiazepines ● Oral contraceptives and oral estrogen therapy ● Gonadotropin-releasing hormone (GnRH)agonist ● Spironolactone ● Cocaine ● Alcohol ● Anticonvulsants

34 In vivo animal studies Estrogens Androgens Papaverine hydrochloride
Phentolamine mesylate Sildenafil Apomorphine

35 Etiology of FSD Conflict within the relationship .
Psycologic { depression or anxiety Conflict within the relationship . Issues relating to prior physical or sexual abuse Medication use . Physical problems { endometriosis ,atrophic vaginitis .

36 Diagnosis of FSD History Sexual ; medical ; psychosocial ; physical
Laboratory testing Duplex Doppler ultrasound

37 History Sexual history; sexual desire. arousal & orgasmic capabilities. Chronic medical history; diabetes. Anemia. Renal failure . Neurologic illness ;spinal cord injury. MS. Lumbosacral disk disease . Endocrinologic illness; hypogonadism. Hyperprolactinemia. Thyroid disease. Atherosclerotic vascular risk factors; hypercholesterolemia. Hypertension. Diabetes. Smoking and family history .

38 Drug use Antihypertensive. Antidepressants. Alcohol. Cocaine.
Pelvic/perineal/genital trauma. Genital pain. Surgical (hysterectomy, laminectomy, vascular bypass surgery. Psychiatric history(depression , anxiety, sexual trauma/abuse).

39 Physical examination Magnifying surgical loops and cotton –bud evaluation . Vestibular adenitis ,neuropathies Para clitoral neuromas.

40 Laboratory testing CBC .
Lipid profiles; hypercholestrolemia, diabetes and renal failure. Serum thyroid stimulating hormone. ACTH, FSH, LH, . Testosterone;.

41 Treatment of female sexual dysfunction
Patient and partner education Modifying reversible causes. Sex steroid hormones: E²≤50pg/ml , Androgen insufficiency, transdermal testosterone , DHEA. Hyperprolactinemia . Iatrogenic/drug-induced ;SSRIs, neuroleptics, and antipsychotics ;GnRh-agonist ,antiandrogens, Psychogenic . Genital pain>%14 neuromas and vestibular adenitis.

42 First line therapy Supraphysiologic doses of IM testosterone.
Methyltesterone (1.25mg/day)with esterified estrogens(0.625 mg/day, Estratest HS) Oral Vasoactive agents. Sildenafil ; has been utilized in treatment of women with sexual arousal disorders %70 efficacy. Phentolamine ;a non-specific ß1 and ß² adrenergic antagonist promoting improvements in physical excitement . Apomorphine a dopamine receptor produces penile erection .

43 Androgen insufficiency,
Androgen replacement in women with sexual dysfunction is associated with changes in the external genitalia, including increased sensitivity, engorgement, and hypertrophy of the clitoris and vulvar hyperemia.

44 Topical Vasoactive agents
Alprostadil ;0.2% gel over the clitoris %72 in sexual arousal disorders. Intravaginal prostaglandin E1 induce vaginal excitement. Phentolamine vaginal solution with ERT. Physiologic testosterone therapy : transdermal patch, ointment %1 . Vacuum devices; EROS FDA approved. Sexual therapy.

45 Potential risks of androgen therapy
Hirsutism Acne Irreversible deepening of the voice . Adverse changing in liver function and lipid levels . Androgen therapy may pose the same risks as estrogen therapy .

46 Indications for referral
Pelvic/ perineal trauma . Traumatic pudendal neuropathy or hysterectomy. Neuromas ,vestibular adenitis. Myofascial pain syndrome. Aortic aneurysm ,bulbosacral disk. Endocrinopathies . Refractory depression. Transsexualism. Medico legal reasons .

47


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