Pelvic Pain

Front 1

1ry Vs 2ndry Dysmenorrhea ?

Back 1

Dysmenorrhea is referred to as primary when no readily identifiable cause exists. The typical age range of occurrence for primary dysmenorrhea is between 17 and 22 years, whereas secondary dysmenorrhea becomes more common as a woman ages.

Front 2

Pathophysiology of 1ry Dysmenorrhea ?

Back 2

- The etiology of primary dysmenorrhea has been attributed to uterine contractions with ischemia.
- The evidence that prostaglandins are involved in primary dysmenorrhea is convincing.
- Primary dysmenorrhea occurs during ovulatory cycles and usually appears within 6 to 12 months of the menarche. Anovulatory endometrium (without progesterone) contains little prostaglandin, and these menses are usually painless.

Front 3

Clinical features of 1ry Dysmenorrhea ?

Back 3

Box21-1 p257

Front 4

Treatment of 2ndry Dysmenorrhea ?

Back 4

Box21-2 p257

Front 5

Clinical features of 2ndry Dysmenorrhea ?

Back 5

Box21-3 p258

Front 6

Define Chronic Pelvic Pain (CPP)

Back 6

Chronic pelvic pain (CPP) refers to pelvic pain of more than 6 months' duration.

Front 7

Somatic Vs Visceral nerve fibers ?

Back 7

Painful impulses that originate in the skin, muscles, bones, joints, and parietal peritoneum travel in somatic nerve fibers, whereas those originating in the internal organs travel in visceral nerves.

Front 8

Viscerosomatic convergence ?

Back 8

Visceral pain is more diffusely spread than somatic pain because of a phenomenon called viscerosomatic convergence and the lack of a well-defined projection area in the sensory cortex for its identification.

Front 9

Variable genital tract structures' sensitivity to pain ?

Back 9

The skin of the external genitalia is exquisitely sensitive. Pain sensation is variable in the vagina, as the upper segment is somewhat less sensitive than the lower. The cervix is relatively insensitive to small biopsies but is sensitive to deep incision or to dilatation. The uterus is quite sensitive. The ovaries are insensitive to many stimuli, but they are sensitive to rapid distension of the ovarian capsule or compression during physical examination.

Front 10

How to investigate Chronic pelvic pain ?

Back 10

Laboratory studies are of limited utility in the diagnosis of CPP.
Diagnostic laparoscopy is the ultimate method of diagnosis for patients with CPP of undetermined etiology.

Front 11

Are size and pain related in Endometriosis ?

Back 11

The size and location of the endometriotic implants do not appear to correlate with the presence of pain.

Front 12

Are ovarian cysts painful ?

Back 12

- Ovarian cysts are usually asymptomatic, but episodic pain may occur secondary to rapid distention of the ovarian capsule.
- An ovary or ovarian remnant may occasionally become retroperitoneal secondary to inflammation or previous surgery, and cyst formation in these circumstances may be painful.
- Multiple recurrent hemorrhagic ovarian cysts that seem to cause pelvic pain and dyspareunia on an intermittent basis.

Front 13

Differential diagnosis of chronic pelvic pain ?

Back 13

Figure

Front 14

When do uterine myoma cause pain ?

Back 14

Uterine myomas usually do not cause pelvic pain unless they are degenerating, undergoing torsion (twisting on their pedicles), or compressing pelvic nerves. On occasion, a submucous leiomyoma may attempt to deliver via the cervix, which may cause considerable pelvic pain akin to childbirth.

Front 15

Does uterine position correlates to pelvic pain ?

Back 15

Pelvic pain is not likely to be caused by variations in uterine position, but deep dyspareunia may occasionally be associated with uterine retroversion. The pain has been ascribed to irritation of pelvic nerves by the stretching of the uterosacral ligaments as well as to congestion of pelvic veins secondary to retroversion.

Front 16

Risk factors for pelvic congestion syndrome ? Associations ?

Back 16

This entity has been described in multiparous women who have pelvic vein varicosities and congested pelvic organs.
There may be associated menorrhagia and urinary frequency.

Front 17

Mention some genitourinary pelvic pain causes

Back 17

Urinary retention, urethral syndrome, trigonitis, and interstitial cystitis are prime examples.

Front 18

Mention some gastrointestinal pelvic pain causes

Back 18

penetrating neoplasms of the gastrointestinal tract,partial bowel obstruction, diverticulitis, and hernia formation, irritable bowel syndrome, inflammatory bowel disease.

Front 19

Sensation of Acute Vs Chronic pain ?

Back 19

Figure

Front 20

Mention some excitatory and inhibitory modulators of sensation

Back 20

- Excitatory modulators include substance P, glutamate, aspartate, calcitonin gene-related peptide (CGRP), and vasoactive intestinal peptide (VIP).
- Inhibitory neuromediators include endogenous opioid peptides, norepinephrine, serotonin, and ρ-aminobutyric acid (GABA).

Front 21

Management of CPP ?

Back 21

- A therapeutic, supportive, and sympathetic (but structured) physician-patient relationship should be established. Multidisciplinary.
- In the initial stages of therapy, a trial of ovulation/menstrual suppression with the birth control pills, high-dose progestins or a gonadotropin-releasing hormone agonist (GnRH-a) may be helpful.
- NSAIDs, such as ibuprofen or naproxen, are also useful. Pharmacologic approaches to increase inhibitory neuromodulators such as norepinephrine, serotonin (5-HT), and GABA are frequently used in the form of tricyclic antidepressants or other GABA-ergic agents.
- Without proof of organic pathology or a reasonable functional explanation for the pelvic pain, a thorough psychosomatic evaluation should be carried out before a surgical corrective procedure is considered.

Front 22

Mention the causes of acute pelvic pain

Back 22

figure