Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Differential Diagnosis of Pelvic Pain (Endometriosis and Adenomyosis) Acute Lower abdominal pain (LAP) Gynaecological causes Threatened, incomplete and septic miscarriage Ectopic pregnancy Acute salpingitis Tubal or ovarian abscess Endometritis Pelvic peritonitis Complication of an ovarian cyst: rupture, haemorrhage into a cyst, torsion Ovulation pain Retrograde menstruation Primary dysmenorrhoea Trauma to the upper genital tract following instrumentation Non-gynaecological causes Cystitis Ureteric colic Acute appendicitis Diverticulitis Bowel obstruction Mesenteric thrombosis Chronic LAP Gynaecological causes Chronic pelvic inflammatory disease (PID) Endometriosis/adenomyosis Ovarian masses – benign and malignant Complications of uterine fibroids Pelvic vascular congestion syndrome Less common gynaecological causes Unruptured ectopic pregnancy Low-grade PID Polycycstic ovary disease Varicose veins in the broad ligament Prolapsed ovaries into the pouch of Douglas Genital prolapse Non-gynaecological causes Appendiceal abscess Intra-abdominal adhesions Diverticulitis Irritable bowel syndrome Inflammatory bowel disease Malignancy of the small or large bowel Bladder dysfunction, urinary tract calculi Osteoarthritis, lumbar disc protrusion, other musculoskeletal disorders Endometriosis Definition: endometriotic tissue containing glands and epithelium is found in sites outside the endometrial cavity of the uterus, including the ovaries, the pouch of Douglas the uterosacral ligaments and the broad ligaments, and other more distant sites, e.g. lungs. Endometriosis affects up to 1 in 6 women. Pathophysiology: exact mechanism still unknown. It is probably one of/ a combination of: Retrograde menstruation Coelomic metaplasia An altered autoimmune response to menstrual blood in the peritoneal cavity. Embolic transport of endometrial cell svia the bloodstream or lymphatics. Symptoms: Pain: o Pelvic pain (most frequent sx), usually a chronic problem o Dysmenorrhoea o Dyspareunia o Other pain – ovulation pain, pain with opening bowels, passing wind or dysuria. Bleeding: o Menorrhagia o Irregular bleeding o Premenstrual spotting Other: o Bowel symptoms o Urinary symptoms o Fatigue o Mood changes o Bloating Signs: on abdominal and pelvic examination Tenderness in the pouch of Douglas, uterus and adnexa. Palpable endometriotic nodules (rare). Diagnosis: gold standard is laparoscopy to view endometrial implants within the pelvis. Other tests include ultrasound and MRI. Natural history: variable, ranging from asymptomatic to severely disabling. It may resolve with time, remain static or progress. Management: Aims include: o Resolution of pain. o Decrease in menstrual bleeding. o Preparation for pregnancy. Options: o Medical (aim to manage pain): Analgesics Hormone stabilisation Oestrogen reduction or suppression o Surgery: Laparoscopy: removal of lesions and resoration of anatomy to as normal as possible. Complete pelvic clearance (removal or uterus, tubes, ovaries and other endometriotic deposits): last resort; may not resolve all problems. Adenomyosis Definition: the occurrence of ectopic endometrial implants within the myometrium. Often coexists with endometriosis and fibroids. Typically occurs in women in their 40s. Pathophysiology: unclear; linked with uterine trauma that may break the barrier between the endometrium and myometrium, e.g. surgery, pregnancy termination and pregnancy. Diagnosis: clinical. Ultrasound and MRI may be useful. Symptoms and Signs: Dysmenorrhoea. Dyspareunia. Dyschezia (difficult or painful defaecation). Acyclical uterine bleeding. Soft, tender uterus, especially around time of menstruation on examination. Management: NSAIDs COCP Progesterone-only pills Levonorgestrel intrauterine contraceptive devices GnRH agonists Hyesterectomy (last resort) References: Women’s Health: A Core Curriculum, http://www.endometriosis.org.au