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Endometriosis and Chronic Pelvic Pain - Coggle Diagram
Endometriosis and Chronic Pelvic Pain
Chronic Pelvic Pain (CPP)
Definition
Intermittend or constant pain in the lower abdomen or pelveis of a woman of at least 6 months in duration not occuring exclusively with menstruation or intercourse and not associated with pregnancy
Epidemiology
Common symptoms - not a diagnosis
1 in 6 women
Causes
Gyanecological
Endometriosis
Adenomysosi
Adhesions related to gynae cause
Pelvic venous congestion
Other
Non-Gynaecological
IBS
Interstitial cystitis
Musculoskeletal
Central / peripheral nervous system
Psychological and social issues
Other
Assessment
History
Pattern of pain
Associated problems - bladder, bowel, psychological
Effect on movement and posture
Red-flag symptoms
Past / present sexual assault
Daily pain
Red Flag Symptoms 🚩
Rectal bleeding
New bowel symptoms over 50 y/o
New pain after menopause
Pelvic mass
Suicidal ideation
Excessive weight loss
Irregular vaginal bleeding over 40 y/o
PCB
Daily Pain Diary
2-3 mentrual cycle
Referral
Gastro
Urologist
Genitourinary
Physio
Psychologist
Psychosexual counsellor
Physical Exam
General Inspection
Abdominal and pelvic exam
Focal tenderness
Enlargement
Disortion
Tethering
Prolapse
Highly localised trigger points
Tender joints - scaroiliac / symphisis pubis
Investigations
Depends on likely cause(S)
Bloods
Serum test : CA125
Screen for infection if high risk
Bedsides
Imaging
Pelvic / TV scanning
CT
MRI
OGD / Colonoscopy / Cystoscopy
Diagnostic laparoscopy
2️⃣ Line if other therapeutic intervention fails
Managment
COC
Trial for 3-6 months before diagnostic laparoscopy
IBS: Antispasmodic
Trial and amed diet to attempt to control symptoms
Analgesia
If no other therapeutic manoevres yet to be initiated
Referral
If pain not adequately control refer to pain managemnet team / specialist pelvic pain clinic
Endometriosis
Pouch of douglas adhesions
Increased right ovary
Definition
Presence of endometrial-like tissue outside the uterus which induces a chronic inflammatory reaction
Epidemiology
10-20% women of reproductive age
Causes
Unknown but likely to be combo of:
Retrograed menstruation
Altered immune environment
Symptoms
Dysmenorrhoea
Chronic pelvic pain
Dyspareunia
Infertility
Ovulation pain - Mittleschmerz
Dyschezia - pain opening bowels
Cyclical bowel or bladder symptoms
Chronic fatigue and malaise
Phyical Examination Findings
Fixed retroverted uterus
Tender / nodular utertosacral ligaments
Visible nodules on cervix / vagina
Palpable rectal nodules
Enlarged / Tender ovaries
Diagnosis
Gold Standard 🥇
Laparoscopy and histology of visible lesions
Negative histology does not exlude
Exlude malignancy in ovarian endometriomas >3cm
Peritoneal disease - treat as much as possible at laparoscopy - diathermy Argon laser
TVUS
Exlude ovarian endometriomas - not peritoneal deposits
MRI
Identify deeply infiltrating and uterosacral disease +/- adenomyosis
Management
Medical
May commence before biopsy
Analgesia
NSAIDs
Paracetamol
Codein
COCP
C/I
Migraine with aura
Back-to-back therapy to avoid menstruation
Danazole
MOA
Synthetic androgen
Inhibits FSH / LH
Medroxyprogesterone acetate
GnRH Agonist
Need low dose addback HRT of use > 6 months
Mitigates the hypoestrogenic side effects associated with prolonged GnRH agonist therapy
Mirena (LNG-IUS)
Manages pain and symptoms
Provide contraception
Surgical
Excision
Excision > ablation
Deeply infiltrating disease - manage at specialist unit where all disease can be excised
Presurgery
Pelvic MRI
Careful preop discussion with risks of perforation, fistula, ureteric damage
3 month GnRH analogue adjunct therapy
Cystectomy
with exision of cyst wall
Laparoscopic as a one stage procedure
TH + BSO
IF family is complete
Excision of visible endometriotic lesinos +/- post-op HRT
Adjuvant Medical Treatment
Deep endometriosis: 3 month GnRH pre-op
Pot op Mirena LNG-IUS or COC for 18-24 months as 2nd prevention of dysmenorrhoea
Adenomyosis
Definition
Presence of heterotopic endometrial glands and stroma in the myometrium with adjacent smooth muscle hyperplasia
Types
Diffuse
Localised
Epidemiology
1% women of reprofuctive age
Coexist with endometriosis in 12%
Causes
Unknown or genetic componen
Possible association - disiruption of endometrial-myometrial junction
Clinical Presentation
Menorrhagia
Dysmenorrhoea
Irregular bleeding
Dyspareunia
Dyschezia
Chronic pelvic pain
Subfertility
Normal exam OR enlarged and/ or tender uterus
Diagnosis
Biopsy / Histology 🥇
Gold standard 🥇
Imaging useful to confirm diagnosis or exlude other causes
TVUS
High SE and SP - can be difficult to distinguish from fibroids
Less accurate / Higher false positives at certain times of menstrual cycle / spontaneous uterine contraction
MRI
Signs: Thickening of endomyometial junction zone >12mm
Management
Surgical
TH + BSO
Curative
May not be appropraite for all women
Medical
GnRH analogue Pre-op
Ensure pain is relieved completely with chemical suppression of ovaries - esp younger women
Analgesia
Simple
Amitriptyline / Gabapentin if neuopathic pain
Hormonal treatment
Mirena LNG-IUS
COCP
Continous progesterone tx
Continous GnRH analogues
Adhesions
Causes
2° to Infx
Surgery
Endometriosis
Management
Laparoscopic Fine Adhesiolysis
Not 1st line unless dense adhesions (risk of visceral injury)
Diagnostic laparoscopy
Pain relieve
No difference in pain scores between laparoscopic fine
adhesiolysis and diagnostic laparoscopy alone
Division of dence, vascular adhesions associated with significant pain relieve
Prevention
Careful surgical technique
Haemostasis
Minimal tissue handling
Hyaluronic acids may decrease adhesion formation - limited evidence
Bowel Related Pain
Presentation
Constipation
Diarrhoea
Nausea
Excessive flatulence
Red Flag Symptoms 🚩
PR bleed
Unexplained weight loss
New pain > 50 yo
Common cause
IBS
Rome IV Criteria
Criteria for IBS but diagnosis is clinical
Abdo pain / discomfort on ≥ 3 days in last 3 months with onset at least 6 months previous associated with at least 2:
Improvement with defecation
Onset associated with change in frequency of stool
Onset associated with change in form of stool
Rome IV Criteria
Management
Antispasmodics
Osmotic laxatives
Dietary modification
Bladder Related Pain
Diagnosis of exclusion
Pelvic pain / pressure / discomfort accompanied by urinary symptoms such as nocturia / frequency / dysuria
Red Flag Symptoms🚩
Presistent microscopic haematuria
Investigations
Baseline
Bladder diary
UTI testing
If 🚩 Red Flags
Cystoscopy
Urinary cytology
Recurrent UTI with Neg MSU
Possibilty of chronic inflammation
Investigations
Urinary ureaplasma
Chlamydia
Managment
Conservative
Diet modification
Avoid:
Citrus fruits
Yeast
Caffeine
Alcohol
Stress Management and exercise
Medical
Oral amitriptyline
Cemetidine (specialised clinicain)
+/- cystoscopy with hydrodistension / intravesical treatments - Lidocarine / Botox A
Neuromuscular Pain
Causes
Secondary to gynae pathology
Primary causes
Nerve entrapment
Epidemiology
Nerve entrapment in 3.7% after 1 Pfannensteil incision
Symphysis pubis dysfunction (SPD) can persist >6 months postnatally
Presentation
Highly localised pain
Referred pain to distrubition of nerve
Sharp / Stabbin / burning pain
Management
Physiotherapy
Psychological Factors
Common disorder in CPP
Depression
Sleep disorders
Pathophysiology
May be a consequence of pain rather than cause
Complications
Development of unhelpful behaviours
Risk Factors
Physical abuse
Sexual abuse
Management
Abuse - specialist referral and careful handling
Pyscholoical support online / via GP referral
