How to Cure Chronic Pelvic Pain
In a female patient of reproductive age, presenting with acute pelvic pain, the first distinction is whether the pain is pregnancy-related or non-pregnancy-related on the basis of a serum pregnancy test. B. In the patient with acute pelvic pain associated with pregnancy, the next step is localization of the tissue responsible for the hCG production. Transvaginal ultrasound should be performed to identify an intrauterine gestation. Ectopic pregnancy is characterized by a noncystic adnexal mass and fluid in the cul-de-sac.
Acute PID is the leading diagnostic consideration in patients with acute pelvic pain unrelated to pregnancy. The pain is usually bilateral, but may be unilateral in 10 . Cervical motion tenderness, fever, and cervical discharge are common findings. B. Acute appendicitis should be considered in all patients presenting with acute pelvic pain and a negative pregnancy test. Appendicitis is characterized by leukocytosis and a history of a few hours of periumbilical pain followed by migration of the pain to the right lower quadrant. Neutrophilia occurs in 75 . A slight fever exceeding 37.3 C, nausea, vomiting, anorexia, and rebound tenderness may be present.
Summary of Recommendations for Treatment of Chronic Pelvic Pain American College of Obstetricians and Gynecologists Endometriosis, irritable bowel syndrome (may be given empirically in women with symptoms consistent with endometriosis) Endometriosis, pelvic congestion syndrome Laparoscopic ablation resection of endometriosis Stage I-III endometriosis
Endometriosis is the most common etiology of CPP in populations with a low prevalence of sexually transmitted infections. Endometriosis is found in up to 70 percent of patients with CPP. Some Causes of Chronic Pelvic Pain by System Endometriosis Adenomyosis Leiomyomata Adhesions Ovarian cyst mass Pelvic inflammatory disease
Pelvic pain associated with severe dysmenorrhea and or pain at the time of ovulation is likely due to endometriosis or adenomyosis. Women with endometriosis report premenstrual spotting, dyspareunia, dyschezia, poor relief of symptoms with nonsteroidal anti-inflammatory drugs, progressively worsening symptoms, inability to attend work or school during menses, and the presence of pelvic pain unrelated to menses more often than women with primary dysmenorrhea.
Surgical scars, hernias, and masses should be sought. Pelvic examination should include an evaluation for physical findings consistent with endometriosis, adenomyosis, or leiomyomata. Tender areas should be identified. B. Physical findings characteristic of endometriosis are uterosacral ligament abnormalities (eg, nodularity or thickening, focal tenderness), lateral displacement of the cervix caused by endometriosis, and cervical stenosis. D. Nongynecologic physical findings that are observed more frequently among women with endometriosis are red hair color, scoliosis, and dysplastic nevi.
Women in whom a particular disease process is suspected, such as adenomyosis, uterine leiomyomata, irritable bowel syndrome, interstitial cystitis, diverticulitis, or fibromyalgia should undergo further diagnostic testing and disease-specific treatment.
Endometriosis should be considered in any woman of reproductive age who has pelvic pain. The most common symptoms are dysmenorrhea, dyspareunia, and low back pain that worsens during menses. Rectal pain and painful defecation may also occur. Other causes of secondary dysmenorrhea and chronic pelvic pain (eg, upper genital tract infections, adenomyosis, adhesions) may produce similar symptoms. Differential Diagnosis of Endometriosis Generalized pelvic pain B. Infertility may be the presenting complaint for endometriosis. Infertile patients often have no painful symptoms. C. Physical examination. The physician should palpate for a fixed, retroverted uterus, adnexal and uterine tenderness, pelvic masses or nodularity along the uterosacral ligaments. A rectovaginal examination should identify uterosacral, cul-de-sac or septal nodules. Most women with endometriosis have normal pelvic findings.
Because early cervical cancer is usually asymptomatic, establish a thorough history with particular attention to the presence of the risk factors and the woman's menstrual history. Establish a history of later symptoms of cervical cancer, including abnormal bleeding or spotting (between periods or after menopause) metrorrhagia (bleeding between normal menstrual periods) or menorrhagia (increased amount and duration of menstrual bleeding) dysparuenia and postcoital bleeding leukorrhea in increasing amounts and changing over time from watery to dark and foul and a history of chronic cervical infections. Determine if the patient has experienced weight gain or loss abdominal or pelvic pain, often unilateral, radiating to the buttocks and legs or other symptoms associated with neoplasms, such as fatigue.
Distinguishing ACIS of the cervix from tubal metaplasia, endometriosis and microglan-dular hyperplasia may be difficult, but is important because ACIS confers a significant risk of endocervical adenocarcinoma. p16INK4a is diffusely positive in ACIS, exhibits focal positivity or is negative in tubal metaplasia, and in endometriosis there may be sometimes widespread, but noncontin-uous, scattered positivity. Microglandular hyperplasia is negative for p16INK4a (Cameron et al. 2002 Negri et al. 2003 Ishikawa et al. 2003 Murphy et al. 2004). ACIS is positive for CEA, in contrast to CEA-negative microglandular hyperplasia, tubal metaplasia or endometriosis (Cina et al. 1997). ACIS generally shows a high proliferation index with MIB-1. Tubal metaplasia, microglandular hyperplasia, and endometriosis are characterized by a low proliferation index, although some cases of endometriosis may show a moderate proliferative activity (McCluggage et al. 1995 Cina et al. 1997 Cameron et al. 2002). In...
The major cause of ectopic pregnancy is tubal damage, which can result from pelvic inflammatory disease, previous pelvic or tubal surgery, or endometriosis. Other causes may be hormonal factors that impede ovum transport and mechanically stop the forward movement of the egg in the tube, congenital anomalies of the tube, and a blighted ovum. Pelvic infections and sexually transmitted diseases (STDs), specifically chlamydia and gonorrhea, are often involved. Other risk factors include smoking, diethylbestrol exposure, T-shaped uterus, certain intrauterine devices (IUDs), and a ruptured appendix.
A woman who is sexually assaulted loses control over her life during the period of the assault. Her integrity and her life are threatened. She may experience intense anxiety, anger, or fear. After the assault, a rape-trauma syndrome often occurs. The immediate response may last for hours or days and is characterized by generalized pain, headache, chronic pelvic pain, eating and sleep disturbances, vaginal symptoms, depression, anxiety, and mood swings.
Pelvic factor infertility is caused by conditions that affect the fallopian tubes, peritoneum, or uterus. Tubal factor infertility is a common sequela of salpingitis. Appendicitis, ectopic pregnancy, endometriosis, and previous pelvic or abdominal surgery can also damage the fallopian tubes and cause adhesion formation. 2. Endometriosis is another condition involving the peritoneal cavity that is commonly associated with infertility. Uterine abnormalities are responsible for infertility in about 2 of cases. Examples of uterine abnormalities associated with infertility are congenital deformities of the uterus, leiomyomas, and intrauterine scarification or adhesions (Asherman's syndrome). 3. The mainstay of treatment of pelvic factor infertility relies on laparoscopy and hysteroscopy. In many instances, tubal reconstructive surgery, lysis of adhesions, and ablation and resection of endometriosis can be accomplished laparoscopically.
High levels of VEGFare also involved in pathologic angiogenesis and are responsible for several gynecological disorders, such as endometriosis, dysfunctional uterine bleeding, endometrial hyperplasia, and polycystic syndrome, which is known to be a leading cause of infertility.121-123 Antiangiogenic compounds are under investigation in order to provide novel therapeutic approaches for such diseases.124'125
CA 125 The preoperative evaluation of a woman with suspected ovarian cancer should include measurement of the CA 125 concentration. The serum CA 125 (normal 65 U mL) in 80 percent of women with epithelial ovarian cancer. It is also increased in patients with other malignancies, including endometrial cancer and certain pancreatic cancers in endometriosis, uterine leiomyoma, and pelvic inflammatory disease and in approximately 1 percent of healthy women.
Foci of ectocervical endometriosis 7650 0 may be located beneath the ectocervical epithelium and bulge forth as nodules (Fig. 35), grossly recognizable by the old and fresh hemorrhages in and around them (Figs. 35,36), or be located deep in the cervical wall (Figs. 37,38). These deep foci correspond in their location and structure to adenom-yosis of the myometrium. The glands are characteristically surrounded by an endome-trial-type stroma. In some instances, endocervical glands may be lined by columnar ciliated cells resulting from a ciliated cell (tubal) metaplasia (Figs. 39-42). Such glands are devoid of surrounding endometrial-type stroma and correspond to the foci of endosal-pingiosis occasionally found scattered about the small pelvis (Wells and Brown 1986). Foci of intestinal metaplasia 7332 0 may also be observed within endocervical glands. Fig. 35. Focus of endometriosis underneath ectocervical epithelium. H&E Fig. 35. Focus of endometriosis underneath ectocervical...
A result of chromosomal defects, or in isolation. Patients with vaginal agenesis but with patent endometrial and en-docervical canals are treated with vaginoplasty to allow egress of menses. Hysterectomy is reserved for patients without a cervix, as a neocervix or uterovaginal fistula is unable to successfully sustain a pregnancy, nor can it prevent retrograde menses and endometriosis.
Elicit a detailed family history of all cancer-related illnesses, paying particular attention to the history of female relatives. The patient's descriptions of the signs and symptoms vary with the tumor's size and location symptoms usually do not occur until after tumor metastasis. The symptoms patients most commonly report are back pain, fatigue, bloating, constipation, abodomi-nal pain and urinary urgency. Most patients with ovarian cancer have at least two of these symptoms. Other symptoms include urinary frequency, abdominal distension, pelvic pressure, vaginal bleeding, leg pain, and weight loss. Pelvic discomfort and acute pelvic pain may occur, and if infection, tumor rupture, or torsion has resulted, the pain may resemble that of acute appendicitis.
Reproductive medicine encompasses all aspects of fertility including birth control and the reproductive results of aging of the reproductive organs. The utility of drugs for use as birth control agents and in the treatment of postmenopausal disorders like endometriosis is an underesearched area. 18.104.22.168 Endometriosis Endometriosis, the growth of endometrial tissue outside the uterus into 'nodules,' 'tumors,' 'lesions,' 'implants,' or 'growths,' that cause pain, infertility, and other problems, affects nearly 10 of all postmenopausal females. These endometrial growths are chiefly abdominal, being found in the ovaries, fallopian tubes, uterine ligaments supporting the area between the vagina and the rectum, the outer surface of the uterus, and the lining of the pelvic cavity. The etiology of endometriosis is unknown, but various theories exist including (1) retrograde menstruation where menstrual tissue backs up through the fallopian tubes, implants in the abdomen, and grows (2)...
The incidence of disorders and dysfunctions of the urogenital tract including the kidney are increasing with the aging of the population. Drug treatments for both bona fide organic disorders (endometriosis, prostatitis, BPH, incontinence, BOO) and those more psychologically related (sexual dysfunction) are limited in their efficacy and side effect liabilities and perhaps with new insights into potential genetic causes of these disorders, may be treated via newer targets that have a lesser impact on cardiovascular system function.
There is evidence to suggest that prostatitis may be pathologically linked to interstitial cystitis in men as both of these conditions share common symptoms. In a survey of 92 men with interstitial cystitis confirmed by the National Institute for Diabetes and Digestive and Kidney Diseases criteria, the most commonly reported initial symptoms were mild suprapubic discomfort (33 ), nocturia (15 ), urgency (15 ), dysuria (11 ), and frequency (11 ) however, after 2.5 years these symptoms had become more severe and 89 reported dysuria, 85 had urinary frequency, 82 had severe suprapubic discomfort and or urgency, and 56 had sexual dysfunction.67 The overlap between prostatitis and interstitial cystitis has led researchers to consider that they have underlying causes. In a recent study of 50 patients with prostatitis, the majority of patients were also symptomatic on an interstitial cystitis questionnaire known as the pelvic pain and urgency frequency questionnaire, and 77 with a score more...
Reproductive System DRG Category 336 Mean LOS 40 days Description Surgical Transurethral Prostatectomy with CC
Prostatitis, an inflammation of the prostate gland, is classified in four categories. Acute bacterial prostatitis is an acute, usually gram-negative, bacterial infection of the prostate gland, generally in conjunction with acute bacterial cystitis. Chronic bacterial prostatitis is a subclinical chronic infection of the prostate by bacteria that can be localized in prostatic secretions and is the most common recurrent urinary tract infection in men. Nonbacterial prostatitis is a chronic prostatitis for which there is no identifiable organism. Prostatodynia is a condition in which the patient experiences irritation and pelvic pain on voiding the symptoms suggest an acute inflammatory process, but there is no evidence of inflammatory cells in the prostatic secretions.
-Menstrual endometrium -Endometriosis -Normal endocervical cells -Malignancies Retrograde ejaculation Prostate, benign and malignant Adenocarcinoma -Bladder Figure 5.4. Endometriosis ureteral washing Unexpected cells warrant careful gathering of clinical information. This sample was obtained from the ureter of a 36 year old woman who suffered from intermittent obstruction of her ureter, coincident with her menstrual cycles. (400x)
Many causes of CPP, such as endometriosis, chronic pelvic inflammatory disease, and of a pelvic mass, require a surgical procedure to determine a definitive diagnosis. In addition to providing a diagnosis of endometriosis, surgical excision of the endometriosis implants can be performed during the laparoscopy. B. Hysterectomy is effective in relieving chronic pelvic pain in some women, who have completed child bearing. C. Presacral neurectomy refers to interruption of the sympathetic innervation of the uterus. The procedure can be performed via laparoscopy or laparotomy. PSN is most effective for relieving midline pelvic pain.
Progestins are similar to combination OCPs in their effects on FSH, LH and endometrial tissue. They may be associated with more bothersome adverse effects than OCPs. Progestins are effective in reducing the symptoms of endometriosis. Oral progestin regimens may include once-daily administration of medroxyprogesterone at the lowest effective dosage (5 to 20 mg). Depot medroxyprogesterone may be given intramuscularly every two weeks for two months at 100 mg per dose and then once a month for four months at 200 mg per dose. 4. Danazol (Danocrine) has been highly effective in relieving the symptoms of endometriosis, but adverse effects may preclude its use. Adverse effects include headache, flushing, sweating and atrophic vaginitis. Androgenic side effects include acne, edema, hirsutism, deepening of the voice and weight gain. The initial dosage should be 800 mg per day, given in two divided oral doses. The overall response rate is 84 to 92 percent. Medical...
Other malignancies of the colon and rectum are rare, and include soft tissue cancers, gastrointestinal stromal tumors and extension of tumor from adjacent organs and peritoneal metastases. The differentiation between diver-ticulitis and cancer may be difficult, particularly in the sigmoid colon. The presence of fluid in the root of the sigmoid mesentery, engorgement of adjacent sigmoid mesenteric vasculature and a tethered or sawtooth lumi-nal configuration favors the diagnosis of diverticulitis. Conversely, the presence of enlarged pericolic lymph nodes, mural thickness greater than 1.5 cm, and an abrupt transition zone raises the possibility of colon cancer. Ischemic colitis may also lead to bowel wall thickening, but the clinical history (e.g. extensive atherosclerosis) and imaging findings (no enlarged lymph nodes, more gradual transition) help to differentiate. At the rectosig-moid, endometriosis may simulate colorectal cancer, but the location (often anterior, adjacent to the...
Although it is not relevant to consider all the subsequent patents awarded to Eli Lilly and Company, it is perhaps pertinent to observe that these are often patents for formulations of numerous oral preparations. These patents are illustrated by patent numbers 5,811,120 (September 22, 1998), 5,972,383 (October 26, 1999), US 6,458,811 B1 (October 1, 2002), US 6,797,719 B2 (September 28, 2004), and US 6,894,064 B2 (May 17, 2005). Each of these is a new invention for raloxifene-like analogs ''optionally containing estrogen or progestin for alleviating the symptoms of osteoporosis, lowering lipid levels, and inhibiting endometriosis, uterine fibroids, and breast cancer.''
Ill-defined low pelvic pain and painful straining at defecation (tenesmus) are frequently difficult to explain and even more difficult to treat. After evaluating for obvious sources, such as fissure, hemorrhoids, or ulcer, defecography may help to establish or exclude an anatomic etiology. For example, paradoxical contraction of pelvic muscles may explain anismus and cramping or spastic pain. Extensive perineal descent may result in stretching of the pudendal nerve that can cause a dull, aching sensation after defecation.
Another study reported 30 patients with a minimum 5-year follow-up (range 61-122 months) found a mean stool frequency of 2.5 per day (range 1-6).26 Four patients required regular medications, two for constipation and two for diarrhea. Twenty-five patients (83 ) reported perfect continence and the remainder had less than one incontinent episode per month. Four patients complained of pelvic pain, three of whom had pain before surgery but noted a decrease in intensity since the operation. Seven patients (23 ) experienced persistent bloating after surgery. All of the above functional results were improved when compared with the results at 27 months' follow-up. All patients regarded their outcome as excellent.
Prostatitis is an extremely common condition, which is classified into several subgroups. Acute bacterial prostatitis is the result of an acute pathogenic infection and can lead to chronic bacterial prostatitis. Chronic nonbacterial prostatitis, or chronic pelvic pain syndrome (CPPS), is a multifactorial condition that may be linked to other conditions such as bladder neck obstruction, urethral stricture, detrusor sphincter, dyssynergia, or dysfunctional voiding. Nonculturable organisms and sexually transmitted infections (e.g., Chlamydia trachomonas) are also possible causes. Figure 17 The role of immunologic, endocrine, neurologic, and psychologic factors in the development of chronic pelvic pain syndrome (CPPS) INF, interferon IGF, insulin-like growth factor IL, interleukins NGF, nerve growth factor TNF, tumor necrosis factor. (Reproduced with kind permission from Pontari, M. A. Ruggieri, M. R. J. Urol. 2004, 172, 839-845.)
However, clinical studies do not support its claimed benefits. Androstenedione does not increase muscle strength or muscle size. Androstenedione does not appear to increase testosterone levels on a long-term basis. It does increase estrogen levels, which may increase the risk of conditions and cancers that are sensitive to this hormone, including endometriosis, uterine fibroids, and cancers of the breast, uterus, ovaries, and prostate. Androstenedione decreases levels of HDL, the good form of cholesterol, and may thereby increase the risk of heart disease and stroke. Multiple other possible side effects may occur with androstenedione.
Laparotomy revealed extensive pelvic endometriosis with widespread adhesions involving ovaries, an enlarged uterus, and upper rectum. There were hard spherical masses involving the sigmoid and lower descending colon causing rotation and constriction, and similar pathology was noted in a short segment of terminal ileum. Hysterectomy with excision of uterine adnexa was performed. The disease in the ileum and colon was removed with a double resection, and the 2 anastomoses were performed with a single layer of interrupted sutures.
With dyssynergia, voiding dysfunction, and pelvic pain. Jacobson's progressive muscle relaxation strategy indicated that after a muscle tenses, it automatically relaxes more deeply when released.21 This strategy is used to assist with hypertonia, placing emphasis on awareness of decreased muscle activity viewed on the screen as the PFM becomes more relaxed. This repetitive contract-relax sequence of isolated pelvic muscle contractions also facilitates discrimination between muscle tension and muscle relaxation. Some patients, usually women, have a greater PFM descent with straining during defecation associated with difficulty in rectal expulsion. Pelvic floor weakness may result in intrarectal mucosal intussusception or rectal prolapse, which contributes to symptoms of constipation. Furthermore, the PFM may not have the ability to provide the resistance necessary for extrusion of solid stool through the anal canal.16
Endometriosis endometrial glands outside the uterus (ectopic). Patients usually are nulli-parous and over 30 with the following symptoms dysmenorrhea, dyspareunia (painful intercourse), dyschezia (painful defecation), and or perimenstrual spotting.The most common site is the ovaries (look for tender adnexae in an afebrile patient), followed by the broad or uterosacral ligament (classic signs are nodularities on physical exam and sequela of retroverted uterus), and peritoneal surface. The gold standard of diagnosis is laparoscopy with visualization of endometriosis. 1. Endometriosis is the most likely ,cause of infertility in a menstruating woman over age of 30 (in the absence of a PID history). 4. Tubal uterine evaluation is done by a hysterosalpingogram. History may suggest a tubal problem (PID, previous ectopic pregnancy) or a uterine problem (previous D&C may cause intrauterine synechiae, history of fibroids or endometriosis symptoms). 6. Laparoscopy is a last resort or is done in...
51 Tips for Dealing with Endometriosis
Do you have Endometriosis? Do you think you do, but aren’t sure? Are you having a hard time learning to cope? 51 Tips for Dealing with Endometriosis can help.