Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Pelvic Pain - University of Illinois College of Medicine
Transcript
Pelvic Pain Tracy Irwin, MD, MPH Assistant Professor University of Illinois at Chicago Definition Pain of apparent pelvic origin that has been present most of the time for at least six months and severe enough to cause functional disability or require medical or surgical treatment Obstet Gynecol Sur 1993;48:357-87 Prevalence 3.8% of women 15-73 39% complain of it in primary care settings 10% of referrals to gynecologists $880 million in direct health care costs Over $2 billion in indirect costs Br J Obstet Gynaecol 1999;106:1149-55 Obstet Gynecol 1996;87:55-7 Obstet Gynecol 1996;87:321-7 Taking a History Age, Gravity, Parity Location, Duration, Timing, Quality, Character, Alleviating and Aggravating Factors Relation to menses, Cyclic pattern Dyspareunia or Dyschezia Medications, Prior Tx, Prior Surgery Depression, Abuse Focused Physical Standing Exam – Gait, Posture, Symmetry, Trigger Points Sitting Exam – Posture, Palpation, Sensory Testing, Strength Testing Supine Exam – Leg Flexion and Raise, Abdominal Palpation, Trigger Points, Pubic Symphsis Lithotomy Exam – Inspection, Sensory Testing, Palpation of Pelvic Floor Muscles and Coccyx, Bimanual Exam, Rectovaginal Exam Systems Gynecologic Gastrointestinal Bladder Neurogenic Psychological Musculoskeletal Gynecologic Endometriosis Dysmenorrhea Leiomyomas Dyspareunia Vaginismus Adenomyosis Infectious causes Pelvic congestion syndrome Pelvic organ immobility Cancer ACOG Bulletin #51 March 2004 Level A – – – – – – Endometriosis Malignancy Ovarian Remnant Pelvic Congestion Syndrome PID Tuberculous Salpingitis Level B – Adhesions, benign cysts, fibroids, post op peritoneal cysts Level C – Adenomyosis, Dysmenorrhea, benign cysts, cervical stenosis, chronic ectopic, chronic endometritis, polyps, endosalpingiosis, IUD, mittleschmerz, prolpase Endometriosis – 7-10% of women (up to 50% in premenopausal women) – 33% of women undergoing Laparoscopy for pelvic pain will be diagnosed with endometriosis – Found in 38% of infertile women – Familial history increases risk 10x – Significant cause of morbidity Endometriosis Etiology – Retrograde menstruation – Hematogenous/lymphatogenous – Coelomic metaplasia – Immunologic dysfunction Endometriosis Laparoscopic Appearance of Endometriosis, Martin et al.1990 Endometriosis Characterisitcs – Dysmenorrhea, Dyschezia, Dyspareunia, Uterosacral Nodularity, Adnexal Mass Diagnosis – Clinical suspicion – Presence of endometrial glands in biopsy outside endometrial cavity – Relief of pain with empiric GnRH agonist – Laparoscopy Multiple appearances: red, brown, scar, white, puckering, powder burn Endometriosis Treatment – – – – – – – – – NSAID’s OCP’s Danazol GnRH analogs x 6-12 months Laparoscopic removal/destruction LUNA TAH-BSO Pain clinic/TENS units Presacral neurectomy Endometriosis GnRH Agonists – Ling et al. After 3 months of treatment pain relief seen in 81% of those treated vs. 39% of the placebo group Laparscopic Surgical Treatment – RCT 6 months 63% of treated vs. 23% of controls had a statistically significant relief of pain Presacral Neurectomy – RCTs statistically significant improvement in midline dysmenorrhea Dyspareunia – – – – – – – – – Endometriosis Adnexal masses Vulvovaginitis/STIs Chronic endometritis Vaginal dryness Vaginal atrophy Obstetrical trauma Surgical scars Vaginismus Dyspareunia Vaginismus – Definition – involuntary spasm of the muscles around the vagina – Potential Causes- abuse, trauma, psychological issues, painful intercourse in the past – Treatment Physical Therapy Biofeedback Partner Communication Anxiolyitics Pelvic Floor Anatomy Pelvic Floor Spasm/Strain Anatomy – Piriformis – Coccygeus – Levator ani Treatment – Muscle Relaxers – Physical Therapy/Biofeedback/TENS – Communication with Partner Dysmenorrhea Definition – painful periods Primary – starts within first 2-3 years of menstruation Secondary – due to underlying cause (endometriosis, PID) Treatment – – – NSAID’s OCP’s Treat underlying cause (i.e. endometriosis) Fibroids Benign tumors of uterine smooth muscle Symptoms – Pressure, Pain, Degeneration Treatment NSAID’s OCP’s Lupron Uterine Artery Embolization Exablation MRI guided U/S ablation Myomectomy Hysterectomy Fibroids Infections PID Recurrent UTI Chronic Endometritis Tuberculous Salpingitis Gynecologic Cancer Cervix Uterine Ovarian Psychologic 40-50% have history or sexual abuse Domestic Violence Relationship/Communication Issues Treatment – Counseling (Individual +/- couples) – TCA – SSRIs Psychologic Causes Somatization Disorder – Complaints begin before 30 y/o, occur over several years, seek treatment or impair social, occupational, or other functions. – Need 4 Pain Symptoms, 2 GI symptoms, 1 sexual symptom, 1 pseudoneurological symptom – Treatment Counseling Treatment of underlying mood disorder SSRIs Urologic Causes Level A – – – – Interstitial Cystitis Bladder Malignancy Radiation Cystitis Urethral Syndrome Level B – Detrusor Dysynergy – Urethral Diverticulum Level C – – – Chronic UTI Recurrent, Acute UTI Urolithiasis Urologic Causes Evaluation Urinalysis Urine culture Urine cytology Cystourethroscopy +/- hydrodistension IVP Urologic Causes Interstitial Cystitis – Sx – Urgency, Frequency, Constant Suprapubic Pain – Dx – Cystoscopy – Hydrodistension, decreased bladder capacity – Tx – Avoid Acidic Foods, Antihistamines, TCA, Intravesicular DMSO, Capsaicin or BCG, Elmiron Interstitial Cystitis Gastrointestinal Causes Level A – Irritable Bowel Syndrome – Constipation – Inflammatory Bowel Disease Ulcerative Colitis or Crohn’s Disease – Colon Cancer Level C – Colitis – Chronic Intermittent Bowel Obstruction – Diverticular Disease Gastrointestinal Causes Irritable Bowel Syndrome – No biochemical, inflammatory or mechanical reason – 12% U.S. population – 2:1 women : men – Peak age 30-40’s – Rare >50 y/o – Associated with stress – Increased gut motility and sensitivity to stimulants Gastrointestinal Causes Irritable Bowel Syndrome Treatment – Dietary changes (decreased caffeine, fat, eliminate lactose, sorbitol and fructose, increased fiber) – Decrease stress – Cognitive psychotherapy – Medications: Antidiarrheals (e.g. Loperamide) Antispasmodics (e.g. Bentyl, Belladona) Anti-Gas (e.g. Beano, Simethicone) Peppermint Oil TCA’s Serotonin receptors 3 or 4 agonists (e.g. Lotronex (3), Zelnorm (4)) Gastrointestinal Causes Constipation – Medical Causes – Neurological Disorders Multiple Sclerosis Parkinson's disease Chronic Idiopathic Intestinal Pseudo-obstruction Stroke Spinal Cord Injuries – Metabolic and Endocrine Disorders Diabetes Uremia Hypercalcemia Hypothyroidism – Systemic Disorders Amyloidosis Lupus Scleroderma Gastrointestinal Causes Constipation – Other Causes – – – – – – – – – – Lack of dietary fiber Lack of physical activity (especially in the elderly) Medications (narcotics) Milk Changes in life or routine such as pregnancy, aging, and travel Abuse of laxatives Ignoring the urge to have a bowel movement Dehydration Problems with the colon and rectum Problems with intestinal function (chronic idiopathic constipation) Gastrointestinal Causes Constipation – Treatment – Adequate Water Intake – Adequate Fiber Intake Diet – ADA recommends 20-35 grams/day Supplements – Fibercon, Benefiber, Metamucil – Stool Softeners - Colace – Laxatives Stimulants – Dulcolax, Senokot Osmotics – Miralax – Lubricants – Fleets Enema – Serotonin Agonist – Zelnorm – Biofeedback Musculoskeletal Causes Level A – – – – – Abdominal wall myofascial pain (trigger points) Chronic coccygeal or back pain Faulty or poor posture Fibromyalgia Neuralgia of iliohypogastric, ilioinguinal, and/or genitofemoral nerves – Pelvic floor myalgia (levator ani or piriformis syndrome) – Peripartum pelvic pain syndrome Level B – Herniated nucleus pulposus, Neoplasia of spinal cord or sacral nerve Level C – Compression of lumbar vertebrae, Degenerative joint disease, Hernias, Strains and Sprains, Spondylosis Musculoskeletal Causes Fibromyalgia – Long term widespread pain in muscles, tendons and ligaments without weakness – Linked to fatigue, headache, morning stiffness, sleep disturbance, anxiety, depression – Associated with trigger points – Dx – 3 months of pain and pain in 11/18 trigger points Musculoskeletal Causes Fibromyalgia Trigger Points Musculoskeletal Causes Fibromyalgia – Treatment – Lifestyle Changes (exercise) – NSAIDs – Anti-Depressants (tricyclics – Physical Therapy – Neurontin – Cognitive Behavioral Therapy Chronic Pelvic Pain Conclusion – Diverse causes in many different organ systems – May treat underlying disease, or may just treat pain itself as a diagnosis – Clinicians need to be patient and empathetic
