Chronic pelvic pain..................ppt

Chronic and acute pelvic pain

1. Chronic pelvic pain
Presented by: DR Afsar tabatabai

2. Definition
•Nonmenstrual pain of 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 Pain States
•Adhesions
•Pelvic inflammatory disease (PID),
•endometriosis
•inflammatory bowel disease
•prior surgery
•Painful bladders syndrome
•Uterian originated pains
•Psychological problems

4. Adhesions
•Pelvic inflammatory disease (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 correlation between 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:
•First line 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)
•common in 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 Pain Syndrome
•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
characterized by 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 Uterine Origin
•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 Physical Exam
•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 for Chronic Pelvic Pain
•Adenomyosis
•Endometriosis
•IBS
•Mittelschmerz
•Ovarian remnant syndrome
•PVPS

19. Gastrointestinal Causes for Chronic
Pelvic Pain.
•Cholecystitis
Chronic appendicitis
Constipation
Diverticulitis
IBS
Inflammatory bowel disease
Intermittent bowel obstruction
Neoplasm
Pseudomembranous enterocolitis
Ulcer (duodenal, gastric)

20. Urologic Causes for Chronic Pelvic Pain
•Bacterial cystitis
Detrusor dyssynergia
Neoplasm
PBS (interstitial cystitis)
Radiation cystitis
Urethral caruncle
Urethral diverticulum
Urethral syndrome
Urolithiasis

21. treatment
•NSAID
•Anti convalsants
•Anti depressents
•Narcotics

22. thank you
thank you