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بسم اهلل الرحمن الرحیم Pelvic Pain What Is Pelvic Pain? If you have pain below your belly button and above your legs, it counts as pelvic pain. It can be caused by a lot of things. It may be a harmless sign that you’re fertile, a digestive disorder, or a red flag that you need to go to the hospital. Appendicitis If you have a sharp pain in the lower right part of your belly, are vomiting, and have a fever, it could be appendicitis. If you have these symptoms, go to the ER. An infected appendix may need surgery. If it bursts, it can spread the infection inside your body. This can cause serious complications. Irritable Bowel Syndrome (IBS) Do you have belly pain, cramps, bloating, and diarrhea or constipation that keeps coming back? Talk to your doctor to figure out the problem. It could be IBS, sometimes called spastic colon. Doctors aren’t sure what causes it. Diet changes, stress management, and medications may help. Mittelschmerz (Painful Ovulation) Ever feel a painful twinge between periods? You may be feeling your body ovulate. When you do, the ovary releases an egg along with some fluid and blood. It can cause irritation. This feeling is called mittelschmerz -German for "middle" and "pain." That’s because it happens midway through your monthly cycle. The pain may switch sides from month to month. It isn't harmful and usually goes away in a few hours. PMS and Menstrual Cramps You can usually feel these cramps in your lower belly or back. They typically last 1 to 3 days. Why the pain? Every month, your uterus builds up a lining of tissue. That’s where an embryo can implant and grow. If you don't get pregnant, the lining breaks down and is shed during your period. When the uterus tightens to push it out, you get a cramp. Try a heating pad and overthe-counter pain relievers to ease pain. Exercise and de-stressing can help, too. You can also talk to your doctor about PMS pain. Certain birth control pills or antidepressants may help. Ectopic Pregnancy This happens when an embryo implants somewhere outside of the uterus and begins to grow. This usually happens in the fallopian tubes. Sharp pelvic pain or cramps (particularly on one side), vaginal bleeding, nausea, and dizziness are symptoms. Get medical help right away. This is a lifethreatening emergency. Sexually Transmitted Diseases Pelvic pain is a warning sign of some STDs. Two of the most common are chlamydia and gonorrhea (shown here through a microscope). You often get both at the same time. They don't always cause symptoms. But when they do, you may have pain when you pee, bleeding between periods, and abnormal vaginal discharge. See your doctor. It’s also important to get partners checked and treated, too, so you don’t pass the infection back and forth. Pelvic Inflammatory Disease This is a complication of sexually transmitted diseases. It's the No. 1 preventable cause of infertility in women. It can cause permanent damage to the uterus, ovaries, and fallopian tubes. Belly pain, fever, abnormal vaginal discharge, and pain during sex or urination can be symptoms. Get it treated right away to avoid damage. It is treated with antibiotics. In severe cases, you may need to be hospitalized. Get your partner treated, too. Ovarian Cysts Ovaries release eggs when you ovulate. Sometimes a follicle doesn't open to release the egg. Or it recloses after it does and swells with fluid. This causes an ovarian cyst. They’re usually harmless and go away on their own. But they may cause pelvic pain, pressure, swelling, and bloating. And if a cyst bursts or twists, it can cause sudden, severe pain, sending you to the emergency room. Doctors can spot them during a pelvic exam or ultrasound. Uterine Fibroids These grow on or in the wall of the uterus. While they’re sometimes called fibroid tumors, they are not cancerous. Fibroids are common in women in their 30s and 40s. They usually don’t cause problems. But some women may have pressure in the belly, low back pain, heavy periods, painful sex, or trouble getting pregnant. Talk with your doctor if you need treatments to shrink or remove them. Endometriosis In some women, the tissue that lines the uterus grows outside of it. It can happen on the ovaries, fallopian tubes, bladder, intestines, and other parts of the body. When it's time for your period, these clumps break down, but the tissue has no way to leave the body. While this is rarely dangerous, it can cause pain and form scar tissue that may make it tough to get pregnant. There are several treatment options. Pain medications, birth control pills, hormones to stop periods, surgery with small incisions, and even a hysterectomy (taking out your uterus) are options. Urinary Tract Infection Do you have to pee often, or does it hurt when you do? Or do you feel like your bladder is full? It could be a UTI. This happens when germs get into your urinary tract. Treating it quickly can keep it from it getting serious. But if it spreads to the kidneys, it can cause serious damage. Signs of a kidney infection include fever, nausea, vomiting, and pain in one side of the lower back. Kidney Stones These are globs of salt and minerals that your body tries to get rid of in urine. They can be as tiny as a grain of sand or as large as a golf ball. And boy can they hurt! Your urine may turn pink or red from blood. See your doctor if you think you have a kidney stone. Most will pass out of your system on their own, but some need treatment. Even if they can pass on their own, your doctor can help with pain medication and will tell you to drink lots of water. Interstitial Cystitis (IC) This condition causes ongoing pain and is related to inflammation of the bladder (illustrated here). It’s most common in women in their 30s and 40s. Doctors aren’t sure why it happens. People with severe IC may need to pee several times an hour. You might also feel pressure above the pubic area, pain when you urinate, and pain during sex. Although this can be a long-term condition, there are ways to ease the symptoms and avoid flares. Pelvic Organ Prolapse As you get older, this may happen. Your bladder or uterus drops into a lower position. It usually isn't a serious health problem, but it can be uncomfortable. You may feel pressure against the vaginal wall, or your lower belly may feel full. It may also give you an uncomfortable feeling in the groin or lower back and make sex hurt. Special exercises like Kegel’s or surgery may help. Pelvic Congestion Syndrome We’ve all seen varicose veins in legs. (This is a picture of one in the upper thigh.) They can sometimes happen in the pelvis, too. When blood backs up in veins, they become swollen and painful. This is known as pelvic congestion syndrome. It tends to hurt worse when you sit or stand. Lying down may feel better. It usually can be treated with procedures using very small incisions. Scar Tissue If you've had surgery or an infection, you could have ongoing pain from this. Adhesions are a type of scar tissue inside your body. They form between organs or structures that aren’t meant to be connected. Adhesions in your belly can cause pain and other problems, depending on where they are. In some cases, you may need a procedure or surgery to get rid of them. Vulvodynia Does it hurt when you ride a bike or have sex? If it burns, stings, or throbs around the opening of your vagina, it could be this. The feelings can be ongoing or come and go. Before you’re diagnosed with this, your doctor will rule out other causes. This isn’t caused by an infection. Treatment options range from medication to physical therapy. Chronic Pelvic Pain If you have pain that lasts at least 6 months, it’s considered chronic. It may be so bad it messes with your sleep, career, or relationships. See your doctor. Most of the conditions we've covered get better with treatment. Sometimes, even after a lot of testing, the cause of pelvic pain remains a mystery. But your doctor can still help you find ways to feel better. Prostatitis is the most common urologic diagnosis in men younger than age 50 years and the third most common urologic diagnosis in men older than age 50 years after benign prostatic hyperplasia (BPH) and prostate cancer. Definition and Classification Acute bacterial prostatitis Acute bacterial prostatitis was diagnosed when prostatic fluid was clinically purulent, systemic signs of infectious disease were present, and bacteria were cultured from prostatic fluid. Chronic bacterial prostatitis Chronic bacterial prostatitis was diagnosed when pathogenic bacteria were recovered in significant numbers from a purulent prostatic fluid in the absence of a concomitant UTI or significant systemic signs. Nonbacterial prostatitis Nonbacterial prostatitis was diagnosed when significant numbers of bacteria could not be cultured from prostatic fluid but the fluid consistently revealed microscopic purulence. Prostatodynia Prostatodynia was diagnosed in the remaining patients who had persistent pain and voiding complaints as in the previous two categories but who had no significant bacteria or purulence in the prostatic fluid. There is no validated cutoff point for the level of WBCs per high-power field that is required to differentiate an inflammatory from a noninflammatory CP/CPPS. Although the suggested limits have ranged from as low as 2 to as high as 20, the consensus appears to favor 5 to 10 WBCs/hpf in EPS as the upper level of normal. cystoscopy is indicated in patients in whom the history (e.g., hematuria), lower urinary tract evaluation (e.g., VB1 urinalysis), or ancillary studies (e.g., urodynamics) indicate the possibility of a diagnosis other than CP/CPPS. In these patients, occasionally lower urinary tract malignancy, stones, urethral strictures, bladder neck abnormalities, and so forth that can be surgically corrected are discovered. Cystoscopy can probably be justified in men refractory to standard therapy. Transrectal ultrasonography can be valuable in diagnosing medial prostatic cysts in patients with prostatitislike symptoms, diagnosing and draining prostatic abscesses, or diagnosing and draining obstructed seminal vesicles. Treatment Antibiotics Most experts suggest therapy initially with parenteral antibiotics (depending on the seriousness of the infection) followed by oral antibiotics with wide-spectrum antimicrobial activity. The most common drugs suggested for initial therapy are a combination of penicillin (i.e., ampicillin) and an aminoglycoside (i.e., gentamicin), second- or third-generation cephalosporins, or one of the fluoroquinolones. α-adrenergic blocker The bladder neck and prostate are rich in a receptors, and it is hypothesized that αadrenergic blockade may improve outflow obstruction, improving urinary flow and perhaps diminishing intraprostatic ductal reflux. Anti inflammatory Nonsteroidal anti inflammatory drugs, corticosteroids, and immunosuppressive drugs theoretically should improve the inflammatory parameters within the prostate and possibly result in a reduction of symptoms. pentosan polysulfate The results of a multicenter, randomized, placebo-controlled trial that randomized 100 men to pentosan polysulfate, 900 mg/day (three times the usual dose), or placebo indicated this medication provided modest benefit for some men with CPPS. skeletal muscle relaxants The use of α-blockers to relax smooth muscle (see earlier discussion of αadrenergic blockers) and skeletal muscle relaxants combined with adjuvant medical and physical therapies has been advocated and promoted. Antiandrogens Theoretically, antiandrogens (including 5α-reductase inhibitors) could result in regression of prostatic glandular tissue (inflammation is believed to begin at the level of the ductal epithelium), improved voiding parameters (especially in older patients with BPH and prostatitis), and reduced intraprostatic ductal reflux. Finasteride cannot be recommended as a monotherapy except perhaps in men with associated BPH. Others • • • • • • • • • Phytotherapeutic Agents Neuromodulator Therapy Allopurinol Prostatic Massage Perineal or Pelvic Floor Massage Pudendal Nerve Entrapment Therapy Biofeedback Acupuncture Psychological Support Minimally Invasive Therapies: Balloon Dilatation Transurethral Needle Ablation Microwave Hyperthermia and Thermotherapy Bladder pain syndrome/interstitial cystitis (BPS/IC) is a condition diagnosed on a clinical basis and requiring a high index of suspicion on the part of the clinician. Simply put, it should be considered in the differential diagnosis of the patient presenting with chronic pelvic pain that is often exacerbated by bladder filling and associated with urinary frequency. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Diagnostic Criteria for Interstitial Cystitis • Duration of symptoms less than 9 months • Absence of nocturia • Symptoms relieved by antimicrobial agents, urinary antiseptic agents, anticholinergic agents, or antispasmodic agents • A frequency of urination while awake of less than 8 times per day • A diagnosis of bacterial cystitis or prostatitis within a 3month period • Bladder or ureteral calculi • Active genital herpes Prevalence range from 1.2 per 100,000 population and 4.5 per 100,000 females in Japan , to a questionnaire-based study that suggests a figure in American women of 20,000 per 100,000 All domains of female sexual function including sexually related distress, desire, and orgasm frequency can be affected DIAGNOSIS It has now morphed largely into a diagnosis of chronic pain, pressure, or discomfort associated with the bladder, usually accompanied by urinary frequency in the absence of any identifiable cause Diagnostic approaches vary widely, and general agreement on a diagnostic algorithm remains a future goal A presumptive diagnosis can be made merely by ruling out known causes of frequency, pain, and urgency in a patient with compatible chronic symptoms Often this will involve a complete history, physical examination, appropriate cultures, and local cystoscopy. The gold standard in defining BPS/IC for research purposes has been the NIDDK criteria. Treatment Options A) Conservative Therapy B) Interventions: 1. Oral pharmacologic agents 2. Intravesical therapy 3. Surgical therapies Conservative Therapies If the patients symptoms are tolerable and do not significantly impact quality of life, a policy of withholding treatment is reasonable. Behavioral and physical therapy: Biofeedback pelvic floor rehabilitation bladder training programs (progressively increasing the voiding interval over the course of weeks to months) Stress reduction, exercise, warm tub baths They are excellent initial interventions and have been used by some authors with some success. The urinary frequency and urgency components seem to respond better to these interventions than the pelvic pain component. Dietary Therapy Dietary restrictions are unsupported by any literature (Campbell) , but EAU guideline stated that consider diet avoidance of triggering substances (GR C). Many patients do find their symptoms are adversely affected by specific foods and would do well to avoid them. Often this includes caffeine, alcohol, artificial sweeteners, hot pepper, and beverages that might acidify the urine such as cranberry juice. Medical Treatment Amitriptyline (EAU) Amitriptyline is effective for pain and related symptoms of BPS (LE 1b) Mechanism: blockade of acetylcholine receptors, inhibition of serotonin and noradrenalin reuptake, and blockade of histamine H1 receptors. It is also an anxiolytic agent. Median preferred dose is 50 mg in a range of 25 to 150 mg/day. The speed of onset of effect is 1 to 7 days. Drowsiness is a limiting factor with amitriptyline, and thus, nortriptyline is sometimes considered instead. Pentosan Polysulphate Sodium Oral PPS is effective for pain and related symptoms of BPS (LE 1a) and could be offered oral pentosanpolysulphate sodium for the treatment of BPS (GR A). It is thought to repair defects in the GAG layer. Subjective improvement of pain, urgency, frequency, but not nocturia, has been reported. PPS had a more favorable effect in BPS with lesion than in non-lesion disease. Approved dosage is 100mg TDS. At 32 weeks, about half the patients responded. So a 3- to 6-month treatment trial is generally required to see symptom improvement. Anti-Histamins Hydroxyzine: No significant response was found in an NIDDK placebo-controlled trial. It has limited efficacy in BPS (LE 3). Cimetidine: (Campbell) Uncontrolled studies show improvement of symptoms in two thirds of patients taking it in divided doses totaling 600 mg. Cimetidine is a common treatment in the United Kingdom, where over a third of patients reported having used it. (EAU) Limited data exist on effectiveness of cimetidine in BPS (LE 2b) and it can be considered as a valid oral option before invasive treatments (GR B) Antibiotics Antibiotics have no role in BPS due to the lack of evidence (EAU). There is no evidence to suggest that antibiotics have a place in the therapy for BPS in the absence of a culture-documented infection. Nevertheless, it would not be unreasonable to treat patients with one empirical course of antibiotic (Doxy is recommended) if they have never been on an antibiotic for their urinary symptoms (Campbell). Immunosuppressants Cyclosporin A: might be used in BPS but adverse effects are significant and should be carefully considered (GR B). Initial evaluation of cyclosporin A and methotrexate showed good analgesic effect but limited efficacy for urgency and frequency. Azathioprine treatment has resulted in disappearance of pain and urinary frequency. In an aborted multicenter randomized placebo-controlled NIDDK trial, mycophenolate mofetil (Cellcept 1 to 2 g/day in divided doses) failed to show efficacy in the treatment of symptoms of refractory BPS/IC. Analgesics Urologists should preferably use analgesics in collaboration with pain clinics. The long-term, appropriate use of pain medications forms an integral part of the treatment of a chronic pain condition such as IC. Many non-opioid analgesics including acetaminophen and the NSAIDs and even antispasmodic agents have a place in therapy along with agents designed to specifically treat the disorder itself. Others Corticosteroids are not recommended in the management of patients with BPS because of a lack of evidence (GR C). Gabapentin might be considered for oral treatment of BPS (GR C). Prostaglandins (e.g. misoprostol): are not recommended. Insufficient data on BPS, adverse effects are considerable (GR C). Duloxetine: inhibits both serotonin and noradrenaline reuptake. Duloxetin shows no efficacy, and tolerability is poor (LE 2b) L-Arginine: The body of evidence does not support the use of L-arginine for the relief of symptoms of IC. Nifedipine. inhibits smooth muscle contraction and cellmediated immunity. In one pilot study, with use of 30 mg daily within 4 months, 50% of patients showed at least a 50% decrease in symptom scores and 3 of the 5 were asymptomatic. No further studies have been reported. Montelukast: In a pilot study, with 10 mg of montelukast daily for 3 months, frequency, nocturia, and pain improved dramatically in 80% of the patients. Tanezumab is a humanised monoclonal antibody that specifically inhibits nerve growth factor (NGF). It should only be used in clinical trials. Intravesical treatment Intravesical drugs are administered due to poor oral bioavailability establishing high drug concentrations at the target, with few systemic side-effects. Disadvantages include the need for intermittent catheterization, which can be painful in BPS patients, cost, and risk of infection. Oxybutynin Intravesical oxybutynin combined with bladder training improves functional bladder capacity, volume at first sensation, and cystometric bladder capacity. However, the effect on pain has not been reported. Bladder Hydrodistention Following diagnostic hydrodistention, therapeutic hydrodistention may be performed. This is usually performed at 80-100 cm water for 810 minutes. Although bladder hydrodistension is a common treatment for BPS, the scientific justification is scarce. It can be a part of the diagnostic evaluation, but has a limited therapeutic role. Bladder distension should only be used as diagnostic (LE 3) and is is not recommended as a treatment of BPS (GR C). .