Presentation is loading. Please wait.

Presentation is loading. Please wait.

1. Patients with chronic pelvic pain are frequently anxious and depressed. 2. Their marital, social, and occupational lives have usually been disrupted.

Similar presentations


Presentation on theme: "1. Patients with chronic pelvic pain are frequently anxious and depressed. 2. Their marital, social, and occupational lives have usually been disrupted."— Presentation transcript:

1

2 1. Patients with chronic pelvic pain are frequently anxious and depressed. 2. Their marital, social, and occupational lives have usually been disrupted. 3. 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 4. Approximately 60% to 80% of patients undergoing laparoscopy for chronic pelvic pain have no intraperitoneal pathology 5. Overlapping afferent input from nearby viscera can cause a perception of referred pain, making the diagnosis of origin difficult

3  Genital  Entrocoelic  Musculoskeletal/neuropathic,Carnet test  Urologic  The psychological component.

4 Carnet test

5 Differential diagnosis :  Gynecologic  Cyclic  Gastrointestinal  Genitourinary  Neurologic  Musculoskeletal  systemic

6

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

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

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

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

13 IBS is the more common causes of lower abdominal pain and may account for up to 60% for chronic pelvic pain

14 Increase pain before a bowel movement, and decrease after a bowel movement, Palpable tender sigmoid colon and hard feces in the rectum

15

16

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

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

19  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  > 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  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  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  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  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  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

27  >%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  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  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  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  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  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  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  Estrogens  Androgens  Papaverine hydrochloride  Phentolamine mesylate  Sildenafil  Apomorphine

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

36  History Sexual ; medical ; psychosocial ; physical  Laboratory testing  Duplex Doppler ultrasound

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

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

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

41  Patient and partner education  Modifying reversible causes.  Sex steroid hormones: E ²≤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  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 ß ² adrenergic antagonist promoting improvements in physical excitement.  Apomorphine a dopamine receptor produces penile erection.

43  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  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  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  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


Download ppt "1. Patients with chronic pelvic pain are frequently anxious and depressed. 2. Their marital, social, and occupational lives have usually been disrupted."

Similar presentations


Ads by Google