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48 Cards in this Set

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How to diagnose endometriosis?
What are you looking for?
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)
What are endometriomas?
What causes them?
How to diagnose?
1) Ovarian chocolate cysts
2) Endometriosis w/in ovary
3) US, MRI, CT
What possible future studies can be used to diagnose endometriosis?
What studies should to avoid?
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)
Which part of uterus is adenomyosis usually more extensive?
What does the myometrium look like?
Posterior wall
Trabeculated
What system is used to stage endometriosis?
Revised American Society for Reproductive Medicine Classification of Endometriosis
Done post-op, documenting extent & location of implants & adhesions
What are medical management options for endometriosis? (6)
What is rational behind treatment?
Which of the treatments are used as adjuncts?
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
What are surgical mgmt options for endometriosis?
(3 initial, 1 rare, 1 definitive)
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
What is Danazol?
What is its effect on endometriosis?
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
What type of bone loss is associated with long term (>6mo) GnRH agonist treatment for endometriosis?
Trabecular
Note: Avoid this with add-back estrogen/progestin therapy!!
Which is the best treatment for endometriosis symptoms:
Medical, surgical, or combined?
Combined!
What is treatment for adenomyosis? (2)
1) OCPs + NSAIDs or GnRH agonist
2) Definitive: TAH if pt fails medical treatment
Define chronic pelvic pain in women
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.
How common is chronic pelvic pain in women?
Up to 10% of outpt gyn consults
Responsible for 10-35% of laparoscopies & 12% of hysterectomies in U.S.A.
What is innervation of major pelvic organs? (overall)
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
What are spinal cord levels of the mullerian-derived organs?
(i.e., uterus, tubes, upper vagina)
Transmit via PSNS or SANS?
1) T10, T11, T12, L1
2) SANS
What is innervation FROM the uterus?
Uterus → uterosacral ligaments → uterine inferior plexus → hypogastric plexus @ level of rectum & vagina
What are spinal cord levels of the lower vagina, cervix, and lower uterine segment?
Transmit via PSNS or SANS?
1) S2-S4
2) PSNS
What are spinal cord levels of ovaries and distal fallopian tubes?
T9 + T10
Have own nerve supply
What are spinal levels of bladder, rectum, perineum, and anus?
Transmit via PSNS or SANS?
S2-S4
SANS and PSNS
Fibers from the perineum and anus combine to form branches of which pelvic nerve?
Pudendal
What mechanisms can cause visceral pain? (6)
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
What is difference btw splanchnic pelvic pain and referred pelvic pain?
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.
What is DDx of gyn causes of chronic pelvic pain? (7)
1) PID
2) Endometriosis
3) Pelvic adhesions
4) Pelvic relaxation
5) Ovarian cysts
6) Mittelschmerz
7) Adenomyosis
What is DDx of ortho/MSK causes of chronic pelvic pain? (3)
1) Psoas muscle pain
2) Stress fracture of pelvis
3) Abdominal wall pain
What is DDx of urinary tract causes of chronic pelvic pain? (5)
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)
What is DDx of GI causes of chronic pelvic pain or lower abdominal pain? (5)
1) IBS, IBD
2) Constipation/bowel obstruction
3) Appy, diverticulitis
4) Strangulated hernia
5) Cholecystitis, cholangitis, GD ulcers, pancreatitis
What are the 11 most common causes of acute pain related to reproductive organs?
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
What is mittelschmerz?
Dull pressure or aching during mid-cycle in RLQ or LLQ 2/2 ovulation, ovarian capsule distention, or mild bleeding associated w/ ovulation
What are fxnal ovarian cysts (2)?
What do each result from?
What are findings in each?
What are symptoms or complications in each?
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
How can an intrauterine pregnancy cause pelvic pain?
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
How can ectopic pregnancy cause pelvic pain?
Before and after rupture 2/2 stretching of the fallopian tube hollow viscus or peritoneal irritation from a hemoperitoneum
Where might an ectopic pregnancy be located? (5)
Tubes
Cervix
Ovary
Intramural
Abdominal
How can uterine tumors (like leiomyomas or leiomyosarcomas) cause pelvic pain?
Via torsion, necrosis, visceral peritoneum stretching, or pressure against surrounding intra-abdominal structures.
How can adnexal neoplasia cause pelvic pain? (4)
Hemorrhage, necrosis, torsion, or rupture
What is the pathogenesis of pelvic pain in ovarian torsion?
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
What is pathogenesis of pelvic adhesions?
What is MCC of these?
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%)
How do pelvic adhesions cause pelvic pain?
Theories include pain via mechanical stimulation (i.e., stretching) of visceral nociceptors
How to treat pelvic adhesions?
What percent of pts see improvement of pelvic pain from this?
1) Laparoscopic lysis
2) 65-85%. 75% of pts see continued improvement 6-12 mos after surgery
What are causes of deep vaginal pain?
What makes it worse?
How to treat?
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.
Myofascial trigger point vs abdominal wall trigger point?
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
How to detect myofascial trigger points?
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
How to treat myofascial trigger points?
Hyperstimulation
Analgesics: stretch, cold spray
Needle w/ local injection
Transcutaneous electrical nerve stimulation (TENS)
Acupuncture
What diagnostic method can be used to distinguish visceral pathologic conditions from chronic abdominal pain of neurologic origin?
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
T or F: Sexual abuse is associated w/ chronic pelvic pain
TRUE
Best approach to pt w/ chronic pelvic pain?
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!
Which meds to use w/ chronic pelvic pain, & what are benefits or side effects?
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)
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?
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%
What is laparoscopy's role in treatment for chronic pelvic pain?
40% of laparoscopy is done to treat chronic pelvic pain
40% have diagnosable abnormalities
50% may be helped with this procedure, though