Secrets 50H

Front 1

How to diagnose endometriosis?
What are you looking for?

Back 1

Laparoscopy or laparotomy

Macroscopic black&blue lesions
+ red, red/pink, yellow/brown, white, & clear vesicular lesions
+ peritoneal defects, fibrosis, & scarring
+/- microscopic implants (do histological exam of biopsies of normal-appearing tissue)

Front 2

What are endometriomas?
What causes them?
How to diagnose?

Back 2

1) Ovarian chocolate cysts
2) Endometriosis w/in ovary
3) US, MRI, CT

Front 3

What possible future studies can be used to diagnose endometriosis?
What studies should to avoid?

Back 3

1) Possibilities include peritoneal fluid markers like cytokines, growth factors, angiogenic factors
2) For surface endometriosis, avoid imaging (useless). Also, avoid CA-125, anti-endometrial antibodies (not specific or reproducible)

Front 4

Which part of uterus is adenomyosis usually more extensive?
What does the myometrium look like?

Back 4

Posterior wall
Trabeculated

Front 5

What system is used to stage endometriosis?

Back 5

Revised American Society for Reproductive Medicine Classification of Endometriosis
Done post-op, documenting extent & location of implants & adhesions

Front 6

What are medical management options for endometriosis? (6)
What is rational behind treatment?
Which of the treatments are used as adjuncts?

Back 6

1) OCPs, Danazol, Progestins, GnRH agonists, anti-inflammatories, antidepressants
2) Suppress ovarian E2 production → decrease stimulus for endometrial growth and proliferation
3) anti-inflammatories, antidepressants

Front 7

What are surgical mgmt options for endometriosis?
(3 initial, 1 rare, 1 definitive)

Back 7

1) Excision or destruction w/ laser vaprorization
2) Electrocoagulation or thermocoagulation
3) Lysis of adhesions
4) Rare: Presacral neurectomy or uterosacral ablation to manage pain
5) Definitive: TAH + BSO + Lyse adhesions + Excise all peritoneal surface lesions & endometriomas

Front 8

What is Danazol?
What is its effect on endometriosis?

Back 8

1) Synthetic 17-α-ethinyl-testosterone derivative
2) It inhibits multiple enzymes in steriodogenesis and cytosolic hormone receptors
Causes high androgen, low estrogen environment → reduces endometrial tissue activity

Front 9

What type of bone loss is associated with long term (>6mo) GnRH agonist treatment for endometriosis?

Back 9

Trabecular
Note: Avoid this with add-back estrogen/progestin therapy!!

Front 10

Which is the best treatment for endometriosis symptoms:
Medical, surgical, or combined?

Back 10

Combined!

Front 11

What is treatment for adenomyosis? (2)

Back 11

1) OCPs + NSAIDs or GnRH agonist
2) Definitive: TAH if pt fails medical treatment

Front 12

Define chronic pelvic pain in women

Back 12

Nonspecific pelvic pain >6mo
May or may not be relieved by analgesics
Pain is associated w/ laparoscopically evident pathology, occult somatic pathology, and nonsomatic disorders.

Front 13

How common is chronic pelvic pain in women?

Back 13

Up to 10% of outpt gyn consults
Responsible for 10-35% of laparoscopies & 12% of hysterectomies in U.S.A.

Front 14

What is innervation of major pelvic organs? (overall)

Back 14

From ANS – both PSNS and SANS
Afferent pain: thru SANS w/ cell bodies in thoracolumbar distribution
PSNS is involved to a lesser extent & transmit painful stimuli

Front 15

What are spinal cord levels of the mullerian-derived organs?
(i.e., uterus, tubes, upper vagina)
Transmit via PSNS or SANS?

Back 15

1) T10, T11, T12, L1
2) SANS

Front 16

What is innervation FROM the uterus?

Back 16

Uterus → uterosacral ligaments → uterine inferior plexus → hypogastric plexus @ level of rectum & vagina

Front 17

What are spinal cord levels of the lower vagina, cervix, and lower uterine segment?
Transmit via PSNS or SANS?

Back 17

1) S2-S4
2) PSNS

Front 18

What are spinal cord levels of ovaries and distal fallopian tubes?

Back 18

T9 + T10
Have own nerve supply

Front 19

What are spinal levels of bladder, rectum, perineum, and anus?
Transmit via PSNS or SANS?

Back 19

S2-S4
SANS and PSNS

Front 20

Fibers from the perineum and anus combine to form branches of which pelvic nerve?

Back 20

Pudendal

Front 21

What mechanisms can cause visceral pain? (6)

Back 21

1) Distention of hollow viscera
2) Sudden stretching of solid organ's capsule
3) Hypoxia or necrosis of viscera
4) Prostanoid production
5) Chemical irritation of visceral nerve endings
6) Inflammation

Front 22

What is difference btw splanchnic pelvic pain and referred pelvic pain?

Back 22

1) Splanchnic: irritable stimulus is appreciated in specific organ 2/2 tension (stretching, distention, pulling) or peritoneal irritation/inflammation
2) Referred: autonomic impulses from diseased visceral organ → irritable response w/in spinal cord. Pain is sensed in dermatomes corresponding to cells getting the impulses.

Front 23

What is DDx of gyn causes of chronic pelvic pain? (7)

Back 23

1) PID
2) Endometriosis
3) Pelvic adhesions
4) Pelvic relaxation
5) Ovarian cysts
6) Mittelschmerz
7) Adenomyosis

Front 24

What is DDx of ortho/MSK causes of chronic pelvic pain? (3)

Back 24

1) Psoas muscle pain
2) Stress fracture of pelvis
3) Abdominal wall pain

Front 25

What is DDx of urinary tract causes of chronic pelvic pain? (5)

Back 25

1) Interstitial cystitis & urethral syndrome (UTI symptoms w/o bacteruria)
2) UTI/pyelo/cystitis
3) Bladder spasms
4) Ureteral obstruction (stone)
5) Perinephric abscess (usually caused by staph)

Front 26

What is DDx of GI causes of chronic pelvic pain or lower abdominal pain? (5)

Back 26

1) IBS, IBD
2) Constipation/bowel obstruction
3) Appy, diverticulitis
4) Strangulated hernia
5) Cholecystitis, cholangitis, GD ulcers, pancreatitis

Front 27

What are the 11 most common causes of acute pain related to reproductive organs?

Back 27

1) mittelschmerz
2) Fxnal ovarian cysts
3) Intrauterine pregnancy
4) Ectopic pregnancy
5) Pelvic infections
6) Uterine tumors
7) Adnexal neoplasia
8) Ovarian torsion
9) Endometriosis
10) Adenomyosis
11) Dysmenorrhea

Front 28

What is mittelschmerz?

Back 28

Dull pressure or aching during mid-cycle in RLQ or LLQ 2/2 ovulation, ovarian capsule distention, or mild bleeding associated w/ ovulation

Front 29

What are fxnal ovarian cysts (2)?
What do each result from?
What are findings in each?
What are symptoms or complications in each?

Back 29

1) Follicular or corpus luteum
2) Follicular: 2/2 failure of egg release from mature follicle during ovulation → aching in RLQ or LLQ
Corpus luteum: cyst persisting in center of corpus luteum; may be fxnal or non, so may delay menses. Rare except in pregnancy
3) F: Enlarged cystic ovary on exam
CL: Cyst in center of CL.
4) F: Torsion w/ pain, rupture w/ pain, rupture w/ hemorrhage, or nothing (spontaneous resolution)
CL: Torsion, rupture, hemorrhage; treat w/ OCPs or laparoscopy

Front 30

How can an intrauterine pregnancy cause pelvic pain?

Back 30

Stretching the visceral peritoneum via the enlarging uterus, early uterine contractions, ovarian capsule stretching from the corpus luteum cyst, corpus luteum rupture, and threatened abortion

Front 31

How can ectopic pregnancy cause pelvic pain?

Back 31

Before and after rupture 2/2 stretching of the fallopian tube hollow viscus or peritoneal irritation from a hemoperitoneum

Front 32

Where might an ectopic pregnancy be located? (5)

Back 32

Tubes
Cervix
Ovary
Intramural
Abdominal

Front 33

How can uterine tumors (like leiomyomas or leiomyosarcomas) cause pelvic pain?

Back 33

Via torsion, necrosis, visceral peritoneum stretching, or pressure against surrounding intra-abdominal structures.

Front 34

How can adnexal neoplasia cause pelvic pain? (4)

Back 34

Hemorrhage, necrosis, torsion, or rupture

Front 35

What is the pathogenesis of pelvic pain in ovarian torsion?

Back 35

Twists → venous blood flow ceases → ovary enlarges → arterial blood flow ceases → necrosis
Pain is usually acute, severe, and constant or intermittent. May also include n/v & diaphoresis

Front 36

What is pathogenesis of pelvic adhesions?
What is MCC of these?

Back 36

1) Adhesions happen 2/2 trauma to visceral or parietal peritoneum (2/2 operation, endometriosis, or infxn)
Can also happen w/ ischemic damage to peritoneum occurs → no fibrin lysis → fibrous adhesions occur
Foreign body granulomas can occur 2/2 talc or gauze/suture material → adhesions
2) Surgical intervention (~70%)

Front 37

How do pelvic adhesions cause pelvic pain?

Back 37

Theories include pain via mechanical stimulation (i.e., stretching) of visceral nociceptors

Front 38

How to treat pelvic adhesions?
What percent of pts see improvement of pelvic pain from this?

Back 38

1) Laparoscopic lysis
2) 65-85%. 75% of pts see continued improvement 6-12 mos after surgery

Front 39

What are causes of deep vaginal pain?
What makes it worse?
How to treat?

Back 39

1) Tender trigger points in the paracervical region or margins of the vaginal cuff after hysterectomy; pain is diffuse
2) Coitus, menses, examination
3) Inject w/ 1% procaine or 0.25% bupivacaine w/ min 3-5mm penetration of vaginal mucosa – may need to repeat 3x per week. Use diagnostic laparoscopy to r/o adhesions & endometriosis. Laser therapy for fulgurate endometriosis, lyse adhesions, transect uterosacral ligaments.

Front 40

Myofascial trigger point vs abdominal wall trigger point?

Back 40

MFTP: hyperirritable spot, usually w/in taut band of SKM or muscle fascia
AWTP: in fat or fascial planes above the aponeurosis on needle localization

Front 41

How to detect myofascial trigger points?

Back 41

Points are painful on compression (=jump sign)
May give rise to characteristic referred pain to arm, leg, or back
Tenderness
Autonomic phenomena: tearing, coryza, visual disturbances, tinnitus

Front 42

How to treat myofascial trigger points?

Back 42

Hyperstimulation
Analgesics: stretch, cold spray
Needle w/ local injection
Transcutaneous electrical nerve stimulation (TENS)
Acupuncture

Front 43

What diagnostic method can be used to distinguish visceral pathologic conditions from chronic abdominal pain of neurologic origin?

Back 43

Careful neuro assessment w/ palpating small areas of tissue:
Place needle into tissue either abdominally or vaginally
Inject saline into local tissue & reproduce same pain w/ needle tip

Front 44

T or F: Sexual abuse is associated w/ chronic pelvic pain

Back 44

TRUE

Front 45

Best approach to pt w/ chronic pelvic pain?

Back 45

1) Complete medical, social, sexual history and PEx.
2) ID trigger points & use analgesia to improve accuracy
3) Differentiate btw somatic and visceral foci of pain
4) Consider US, CT, MRI, AbdXR & Renal rads to help diagnose
5) Use minimal am't of meds
6) Limit surgery to severe, refractory cases
7) Avoid removing normal tissue
8) Offer psych consultation – multidisciplinary therapy is key!

Front 46

Which meds to use w/ chronic pelvic pain, & what are benefits or side effects?

Back 46

1) Analgesics; may be addicting
2) Antidepressants; may potentiate analgesics
3) Anxiolytics: may potentiate analgesics but may be addicting
4) GnRH agonists for endometriosis; bone loss (add back tx)

Front 47

What are the success rates for laparoscopic conservative surgery in endometriosis associated pelvic pain?
For hysterectomy for chronic pelvic pain?
For presacral neurectomy for difficult, non-responsive cases?

Back 47

1) Relief up to 6mos in 40-70% of women
2) Up to 78% (even w/o uterine pathology)
3) 50-75%, but recurrence rate is >50%

Front 48

What is laparoscopy's role in treatment for chronic pelvic pain?

Back 48

40% of laparoscopy is done to treat chronic pelvic pain
40% have diagnosable abnormalities
50% may be helped with this procedure, though