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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
Genital
Entrocoelic
Musculoskeletal/neuropathic ,Carnet test
Urologic
The psychological component .
Carnet test
Differential diagnosis :
 Gynecologic
 Cyclic
 Gastrointestinal
 Genitourinary
 Neurologic
 Musculoskeletal
 systemic
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.
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.
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 .
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
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
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 ,
IBS is the more common causes
of lower abdominal pain and
may account for up to 60% for
chronic pelvic pain
Increase pain before a bowel movement, and
decrease after a bowel movement,
Palpable tender sigmoid colon and hard feces
in the rectum
Recurrent cystourethritis
Urethral syndrome
Sensory urgency of uncertain cause
Interstitial cystitis
Dysuria
,frequency ,urgency
,suprapubic discomfort ,dyspareunia
,vaginitis.
Diagnosis :cystoscopy to rule out
urethral diverticulum ,interstitial cystitis
and cancer.
 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 .
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> 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,
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%)
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 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
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.
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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%)
 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
 >%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.
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 .
 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)
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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
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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.
 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)
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
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Estrogens
Androgens
Papaverine
hydrochloride
Phentolamine mesylate
Sildenafil
Apomorphine
 Psycologic
Conflict
 Issues
{ depression or anxiety
within the relationship .
relating to prior physical or sexual abuse
 Medication use .
 Physical problems { endometriosis ,atrophic
vaginitis .
History
Sexual ; medical ; psychosocial ;
physical
Laboratory testing
Duplex Doppler ultrasound
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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 .
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Antihypertensive.
Antidepressants.
Alcohol.
Cocaine.
Pelvic/perineal/genital trauma.
Genital pain.
Surgical (hysterectomy, laminectomy, vascular
bypass surgery.
Psychiatric history(depression , anxiety, sexual
trauma/abuse).
Magnifying
surgical loops and
cotton –bud evaluation .
Vestibular adenitis ,neuropathies
Para clitoral neuromas.
 CBC
.
 Lipid profiles; hypercholestrolemia,
diabetes and renal failure.
 Serum thyroid stimulating hormone.
 ACTH, FSH, LH, .
 Testosterone;.
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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.
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Supraphysiologic doses of IM testosterone.
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Methyltesterone (1.25mg/day)with esterified
estrogens(0.625 mg/day, Estratest HS)
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Oral Vasoactive agents.
Sildenafil ; has been utilized in treatment of women
with sexual arousal disorders %70 efficacy.
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Phentolamine ;a non-specific ß1 and ß² adrenergic
antagonist promoting improvements in physical excitement .
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Apomorphine a dopamine receptor produces penile erection .
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.
 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.
 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 .
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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 .