Chronic Pelvic Pain

Chronic Pelvic Pain
By:Jennifer Griffin, MD
M3 Student Clerkship Lecture
University of Nebraska Medical Center

Chronic Pelvic Pain
* Definition = Pain of apparent pelvic origin that has been present most of the time for 6 months
* Difficult to diagnose.
* Difficult to treat.
* Difficult to cure.
* =Physician and patient frustration.

Just because you’re a hammer doesn’t necessarily make every problem a nail.

Chronic Pelvic Pain
* Gynecologic
* Gastrointestinal
* Urologic
* Musculoskeletal/ Pelvic Floor
* Psychological
* United Kingdom data:
o Urinary dx 30.8%
o GI dx 37.7%
o Gynecologic 20.2%
o 25-50% have >1 dx
o MC Dx = endometriosis, adhesions, IBS, IC
Getting the History
* Nature of the Pain:
o Sharp, stabbing, colicky, burning?
o Where specifically is it located?
* Timing of the Pain:
o Does it come and go or is it constant?
o Does it occur with certain activities?
o Is it related to menses?
o Is it consistent and predictable?
* Modifying factors:
o Can you do anything to make it better/ worse?

Review of Systems
* Gynecologic:
o Association with menses?
o Association with sexual activity? (be specific)
o New sexual partners/ practices?
o Symptoms of vaginal dryness / atrophy?
o Other changes in menses?
o Use of contraceptives?
o Childbirth history and any associations?
o History of pelvic infections?
o History of other gyn problems/ surgeries?
* Gastrointestinal:
o Regularity of bowel movements?
o Diarrhea/ constipation/ flatus?
o Relief with defecation?
o History of hemorrhoids/ fissures/ polyps?
o Blood in stools, melena, or mucous?
o Nausea, vomiting, or appetite change?
o Weight loss?
* Urologic:
o Pain with urination?
o History of frequent / recurrent UTIs?
o Blood in urine?
o Symptoms of urgency or incontinence?
o Difficulty voiding?
* Musculoskeletal:
o History of trauma?
o Association with back pain?
o Other chronic pain problems?
o Association with position or activity?
* Psychological:
o History of abuse (verbal/ physical/ sexual)?
o Diagnosis of psychiatric disease?
o Association with life stressors?
o Exacerbated by life stressors?
o Family/ spousal support?
Chronic Pelvic Pain
* Diagnosis
o History and Physical
o Targeted imaging studies (U/S best for gyn evaluation)
o EMB/D&C
o Laparoscopy
o Cystoscopy/ Colonoscopy
o Physical therapy evaluation
* Gynecologic Origin
o Endometriosis
o Primary Dysmenorrhea
o Leiomyomas
o Dyspareunia
o Vaginismus
o Adenomyosis
o Infectious causes
o Pelvic congestion syndrome
o Pelvic organ immobility
o Cancer
* ACOG Practice

Gyn Causes
* Cyclic:
o Primary dysmenorrhea
o Endometriosis
o Adenomyosis
o Mittleschmertz
* Non-cyclic:
o Pelvic masses
o Adhesions
o Infections
o Non-gyn causes
* Related to intercourse:
o Endometriosis
o Vaginismus
o Vaginal atrophy
o Musculoskeletal
o Any non-cyclic cause could be exacerbated.

Chronic Pelvic Pain: Cyclic
* Endometriosis
Chronic Pelvic Pain: Cyclic
* Endometriosis: Etiology
* Endometriosis: Classic Triad
* But may present with:
o Chronic pelvic pain
o Adnexal mass
* Endometriosis: Diagnosis
* Endometriosis:
* Endometriosis: Treatment
* Dysmenorrhea
* Leiomyomas
* Adenomyosis
* Dyspareunia
* Vaginismus

Chronic Pelvic Pain: Dyspareunia
* Pelvic Floor Muscle Spasm and Strain
Chronic Pelvic Pain: Non-cyclic
* Pelvic congestion syndrome
* Pelvic organ immobility
* PID
* Infectious causes
* Gynecologic malignancies
* Other Gynecologic origin:
* Treatment of Gynecologic Problems
* Urologic Origin, Level A:
o Bladder malignancy
o Interstitial Cystitis
o Radiation Cystitis
o Urethral Syndrome
* Bladder origin, Level B:
* Urologic origin, Level C:
* Urologic origin
* Urologic origin: Interstitial Cystitis
* Gastrointestinal Origin, Level A:
* IBS
* Irritable Bowel Syndrome
* IBS Treatment
* Colon carcinoma
* Constipation
* Inflammatory Bowel Disease
* Gastrointestinal origin, Level C (no Level B):
* Musculoskeletal, Level A:
* Musculoskeletal origin, Level B:
* Musculoskeletal origin, Level C:
* Other Non-Gynecologic Origin, Level A:
* Psychological
* Other Non-Gynecologic origins, level B:
* Other Non-Gynecologic origin, Level C:
Clinical Pearl of Wisdom
Pelvic Pain Treatment Triad
* Medical treatment of most likely diagnosis.
* Psychiatric evaluation and treatment.
* Pelvic physical therapy.

Case Studies
Chronic Pelvic Pain
* Conclusions:
o Thorough history and physical
o Imaging and lab studies
o Many treatment options available

Chronic Pelvic Pain.ppt

Read more...

Pelvic Pain – Dysmenorrhea and Endometriosis

Pelvic Pain – Dysmenorrhea and Endometriosis

* A 20 y.o. woman presents to her gynecologist with a 4 year history of increasing lower abdominal pain with her menses. The pain begins on the first day of her menses and lasts 2-3 days. She also complains of lower back pain and nausea. Menarche occurred at the age of 13 and her menses occur every 28 days and last 5 days. Physical and pelvic exam are normal.

* How is dysmenorrhea diagnosed? How is it distinguished from other types of pelvic pain?
* What is the pathophysiology of dysmenorrhea?
* What are reasonable approaches to treatment?

Dysmenorrhea
* Dysmenorrhea – severe, painful cramping sensation in the lower abdomen often accompanied by other symptoms – sweating, tachycardia, headaches, n/v, diarrhea, tremulousness, all occurring just before or during menses
- Primary: no obvious pathologic condition, onset < 20 years old - Secondary: associated with pelvic conditions or pathology Primary Dysmenorrhea * Pathogenesis: elevated PG F2α in secretory endometrium (increased uterine contractility) * Treatment: NSAIDs – PG synthetase inhibitors – 1st line treatment of choice * Other treatment options: OCPs, other analgesics Secondary Dysmenorrhea * Etiologies - Cervical Stenosis - Endometriosis and Adenomyosis - Pelvic Infection - Adhesions - Pelvic Congestion - Stress and Tension * Cervical Stenosis - Severe narrowing of cervical canal may impede menstrual outflow – congenital or iatrogenic - can cause an increase in intrauterine pressure during menses - can lead to endometriosis * Cervical Stenosis - Hx – scant menstrual flow, severe cramping throughout menses - Dx – inability to pass a thin probe through the internal os OR HSG demonstrates thin cx canal - Tx – cervical dilation via D&C or laminaria placement * Pelvic Congestion - Due to engorgement of pelvic vasculature - Hx – burning or throbbing pain, worse at night and after standing - Dx – Laparoscopic visualization of engorgement/varicosities of broad ligament and pelvic sidewall veins Evaluation of Pelvic Pain * Detailed history, targeted physical exam, labs (UA, UCx, CBC, HCG, tumor markers), diagnostic imaging studies (US, MRI, CT) as appropriate * Consider age of patient * “OLDCAAR”: onset, location, duration, context, associated sx, aggravating/relieving factors * Temporal characteristics: cyclic (e.g. dysmenorrhea), intermittent (e.g. dyspareunia), non-cyclic * Risk factors * GYN and Non-GYN causes DDx Pelvic Pain - GYN * GYN - Uterus - fibroids, adenomyosis, endometritis - Fallopian tubes - PID/salpingitis, hydrosalpinx, ectopic - Ovaries - cysts – functional, pathological, TOA, torsion; mittleschmerz - Other - endometriosis, adhesions, IUD/infection, severe prolapse DDx Pelvic Pain – Non-GYN * Urologic - UTI/urethritis, interstitial cystitis (IC), OAB, urethral diverticulum, nephrolithiasis, malignancy * GI - constipation, IBS, IBD (Crohn’s, UC), bowel obstruction, diverticulitis, malignancy, appendicitis * Musculoskeletal - trigger points, fibromyalgia, hernias, neuralgia, low back pain * Other - psychiatric – depression, somatization; abdominal cutaneous nerve entrapment in surgical scar; celiac disease Case 1 * At the age of 30, the patient presents with a 2 year history of infertility. Her menses are still regular but she has 2-3 days of spotting before her menses are due. She also complains of pain with intercourse and pelvic pain. In reviewing the patient’s history, the gynecologist notes that over the past year the patient was repeatedly treated by her internist with antibiotics for recurrent microscopic hematuria. * What is the most likely diagnosis? * What are the main theories regarding the pathogenesis in this case? * How would you evaluate and treat this patient? Endometriosis - Symptoms * Variable and unpredictable - asymptomatic - dysmenorrhea - CPP - deep dyspareunia - sacral backache w/ menses - dysuria +/- hematuria (bladder involvement) - dyschezia/hematochezia (bowel involvement) Endometriosis – Physical Exam * Uterosacral nodularity * Adnexal mass (endometrioma) * Normal exam Endometriosis - Incidence * 7-10% of general population * 20-50% of infertile women * 70-85% in women w/ CPP * No racial predisposition * +Familial association with almost 10x increased risk of endometriosis if affected 1st degree relative Endometriosis - Pathogenesis * Retrograde menstruation (Sampson) * Hematogenous or lymphatic spread (Halban) * Coelomic metaplasia (Meyer/Novack) * Iatrogenic dissemination * Immunologic defects (Dmowski) * Genetic predisposition Endometriosis - Pathogenesis * Retrograde menstruation (Sampson’s theory) - Monkey experiments – sutured cervix closed to create outflow obstruction caused development of endometriosis - Clinical observation of retrograde menstrual flow during laparoscopy in humans - Increased risk of endometriosis in women with cervical/vaginal atresia, other outflow obstruction - Increased risk with early menarche, longer and heavier flow - Decreased risk with decreased estrogen levels e.g. exercise-induced menstrual disorders, decreased body fat, + tobacco use Endometriosis - Pathogenesis * Hematogenous or lymphatic spread - Endometriosis found in remote sites – lung, nose, spinal cord, pelvic lymph nodes. Endometriosis - Pathogenesis * Coelomic metaplasia - Mullerian ducts are derived from coelomic epithelium during fetal development - Hypothesize that coelomic epithelium retains ability for multipotential development - Endometriosis seen in prepubertal girls, women w/ congenital absence of the uterus, and RARELY in men Endometriosis - Pathogenesis * Iatrogenic dissemination - Endometriosis has been found in cesarean section scar * Immunologic defects * Genetic predisposition - polygenic, multi-factorial Endometriosis - Diagnosis * Laparoscopy with biopsy proven histologic diagnosis – standard for dx of endometriosis * Empiric medical treatment with improvement in symptoms * CA 125 – NOT considered to be of clinical utility * Imaging – US, MRI, CT – only useful in the presence of pelvic or adnexal masses (endometriomas) * Laparoscopy with biopsy proven histologic diagnosis – standard for dx of endometriosis - Extent of visible lesions do not correlate with severity of sx, but depth of infiltration of lesions seems to correlate best with pain severity - classic powder-burn lesions, endometriomas - lesions can be red, clear or white – more commonly seen in adolescents * Endometrial epithelium * Endometrial glands * Endometrial stroma * Hemosiderin-laden macrophages 2 or more of the following histologic features are criteria for Dx: * Imaging – US, MRI, CT – only useful in the presence of pelvic or adnexal masses (endometriomas) - on US, endometriomas appear as cysts that contain low-level homogeneous internal echoes consistent with old blood (ddx includes hemorrhagic cysts) Endometriosis - Treatment * Medications - Progestins - OCPs – continuous vs. cyclic – if no relief in 3 months, consider tx with Depo Provera or GnRH agonist - NSAIDs - GnRH agonists – most expensive - Danazol – appears to be as effective as GnRH agonist for pain relief but with increased side-effects * GnRH agonists – create a state of relative estrogen deficiency – vasomotor side effects and potential decrease in bone density - 12-month course of GnRH agonist therapy associated with 6% decrease in bone density - No data regarding extended treatment with GnRH agonists beyond 1 year * Add-back therapy is advocated for women undergoing long-term therapy (i.e. > 6 months)
* Some evidence to suggest that immediate add-back therapy may result in even less bone loss
- Add-back regimens: progestins alone, progestins + bisphosphonates, low-dose progestins + estrogens, pulsatile PTH

Endometriosis – Treatment Considerations in Adolescents
* GnRH treatment is NOT recommended for patients < 18 years because the effects of these medications on bone formation and long-term bone density have not been adequately studied * Depo provera used for longer than 2 years has been shown to decrease bone density in adolescents – FDA warning against long-term use * If no improvement in symptoms after 3 months of empiric treatment with NSAIDs and OCPs, diagnostic laparoscopy should be offered Endometriosis - Treatment * Surgery - Laparoscopic laser vaporization vs. cauterization vs. excision - Ovarian cystectomy for endometrioma - Hysterectomy +/- BSO * Medications vs. Surgery - Lack of data to support surgery vs. medical treatment for tx of pain symptoms due to endometriosis - Starting with empiric medical therapy is appropriate - Offer GnRH agonist therapy if initial medical treatment with OCPs and NSAIDs not helping - Cost of comparing empiric medical management with definitive surgical diagnosis is difficult to assess, but 3 months of empiric treatment is less than a laparoscopic procedure .... Pelvic Pain – Dysmenorrhea and Endometriosis.ppt

Read more...

Urinary Tract Infections

Urinary Tract Infections
By:Lourdes Lozano Vargas

Urinary Tract Infections
* Leading cause of morbidity and health care expenditures in persons of all ages.
* An estimated 50 % of women report having had a UTI at some point in their lives.
* 8.3 million office visits and more than 1 million hospitalizations, for an overall annual cost > $1 billion.

Acute Uncomplicated Cystitis
* Sexually active young women.
* Causes: anatomy and certain behavioral factors, including delays in micturition, sexual activity, and the use of diaphragms and spermicides tract.
* Aggressive diagnostic work-ups are unwarranted in young women presenting with an uncomplicated episode of cystitis.

Acute Uncomplicated Cystitis
* The microbiology is limited to a few pathogens.
* 70%- 85% are caused by Escherichia coli
* 5-20%are caused by coagulase-negative Staphylococcus saprophyticus
* 5-12% are caused by other Enterobacteriaceae such as Klebsiella and Proteus.

Acute Uncomplicated Cystitis
* Clinical Features: dysuria, frequency, urgency, suprapubic pain, hematuria.
o Fever >38C, flank pain, costovertebral angle tenderness, and nausea or vomiting suggest upper tract infection.

Acute Uncomplicated Cystitis
* Diagnosis: direct history and PE
* PE: Temperature, abdominal exam, assessment of CVA tenderness, pelvic exam.
o H/o STD’s, new sexual partner, partner with urethral symptoms, gradual onset.

Acute Uncomplicated Cystitis
* Guidelines for tx of acute cystitis recommend empiric antibiotic tx.
* Unnecessary antibiotic use??
* Clinical criteria for Dx:

Dysuria, presence of > trace urine leukocytes, and presence of nitrites or...
Dysuria and frequency in the absence of vaginal discharge.
Acute Uncomplicated Cystitis
* UA: Evaluation of midstream urine for pyuria.
o White blood cell casts in the urine are Dx of upper tract infection.
* Urine Culture: Not necessary
o Warranted in: Suspected complicated infection, persistent symptoms following tx, symptoms recur < 1 mo after tx. Acute Uncomplicated Cystitis * Urine dipsticks: o Leukocyte esterase (pyuria), sensitivity 75-90%, specificity 95% o Nitrite (Enterobacteriacea), sensitivity 35-85%, specificity 95%, false positive with phenazopyridine, beets. o Microscopic evaluation for pyuria or a culture is indicated in pt with negative leukocyte esterase that have urinary symptoms. Acute Uncomplicated Cystitis * Susceptibility: o E.coli o S.saprophyticus Acute Uncomplicated Cystitis * Treatment: o Short course vs. prolonged tx + Short course preferred except with beta-lactam agents o TMP-SMX (160/800mg BID x 3) first-line tx if: no allergy to the drug, no antibiotics in the past 3 mo, no recent hospitalization. o Nitrofurantoin (100mg BID x 5 days) o Analgesia: Phenazopyridine 200mg TIDx2 Acute Urethral Syndrome * Acute symptomatic women with dysuria and frequency with a midstream culture containing < 10(5) CFU/mL. * > 10(2) CFU/mL in women with acute symptomatic pyuria = UTI
* Tx as an uncomplicated UTI
* Mycoplasma genitalium, Ureaplasma urealyticum

Acute Complicated Cystitis
* UTI when/with structural, functional or metabolic abnormalities (polycystic, solitary, transplant kidney;DM, CRF, indwelling cath, neurogenic bladder) or elderly, male, child, pregnant or h/o recurrent UTI)
* E.coli accounts for fewer than one third of complicated cases.
* Clinically, the spectrum of complicated UTIs may range from cystitis to urosepsis with septic shock.

Acute Complicated Cystitis
* Urine culture and susceptibility are necessary.
* These infections are usually associated with high-count bacteriuria (> 10(5) CFU/mL).
* MO: Proteus, Klebsiella, Pseudomonas, Serratia, and Providencia, enterococci, staphylococci and fungi AND E.coli

Acute Complicated Cystitis
* Empiric therapy for these patients should include an agent with a broad spectrum of activity against the expected uropathogens: fluoroquinolone, ceftazidime, cefepime, aztreonam, imipenem-cilastatin. (Obtain Ucx prior to Tx)
* Tx x 7-14 days
* Follow-up urine culture should be performed within 14 days after treatment???

Recurrent Cystitis
* Up to 27% of young women with acute cystitis develop recurrent UTIs.
* The causative organism should be identified by urine culture.
* Relapse: infection with the same organism (multiple relapses = complicated UTIs).
* Recurrence: infection with different organisms.

Recurrent Cystitis
* >3 UTI recurrences documented by urine Cx within one year can be managed using one of three preventive strategies:
* Acute self-treatment with a three-day course of standard therapy.
* Postcoital prophylaxis with one-half of a TMP-SMX double-strength tablet (80/400 mg).
* Continuous daily prophylaxis TMP-SMX one-half tablet per day (40/200 mg); nitrofurantoin 50 to 100 mg per day; norfloxacin 200 mg per day.

Uncomplicated Pyelonephritis
* Suspect if:
o Cystitis-like illness and accompanying flank pain
o Severe illness with fever, chills, nausea, vomiting, abdominal pain
o Gram-negative bacteremia.

Uncomplicated Pyelonephritis
* DX: Clinical, confirm with:
o UA: pyuria and/or WBC casts
o UCx with > 10 (5) CFU/mL (80%)
* Tx: 14 days total
o Oral: TMP/SMX, fluoroquinolones
o IV: 3rd gen cephalosporin, aztreonam, quinolones, aminoglycoside

Uncomplicated Pyelonephritis
* Pt with symptoms after 3 days of appropriate antimicrobial tx should be evaluated by renal US or CT for obstruction or abscess.

UTI in Men

* At risk: Older men with prostatic disease, UT instrumentation, anal sex, or partner colonized with uropathogens.
* UCx: 10 (3) CFU/mL sensitivity and specificity 97%.
* Additional studies?
o Not necessary in young healthy men who have a single episode.

UTI in Men
* Tx:
o Uncomplicated cystitis:
+ TMP/SMX or fluoroquinolones x 7 days
o Complicated cystitis:
+ Fluoroquinolones x 7-14 days
o Bacterial prostatitis:
+ Fluoroquinolone x 6-12 weeks

Catheter-Associated UTI
* Risk of bacteriuria is ~ 5%/day (long term catheter bacteriuria is inevitable).
* 40% of nosocomial infections
* Most common source of gram-negative bacteremia.
* Dx: Ucx 10 (2) CFU/mL
o MO: E.coli, Proteus, Enterococcus, Pseudomona, Enterobacter, Serratia, Candida

Catheter-Associated UTI
* Mild to mod: oral quinolones10-14days
* Severe infection: IV/oral 14-21days
* Asymptomatic bacteriuria in pt with an indwelling Foley should not be Tx unless they are immunosuppressed, have risk of bacterial endocarditis or pt who are about to undergo urinary tract instrumentation.

Asymptomatic Bacteriuria
* UCx: > 10(5)CFU/mL with no symptoms
* Three groups of pt with asymptomatic bacteruria have been shown to benefit from tx:
o Pregnant
o Renal transplant
o Pt who are about to undergo urinary tract procedures.

Pregnant patients

* Asymptomatic bacteriuria: two consecutive voided urine specimens with isolation of the same bacterial strain >10(5) or a single cath urine specimen.
o Nitrofurantoin 100mg BID x 5-7 days
o Amoxi/Clav 500mg BID or 250 TID x 7days
o Fosfomycin 3g PO x 1

Interstitial Cystitis
* Frequency, urgency, urge incontinence with periurethral and suprapubic pain on bladder filling that is improved by voiding. Terminal hematuria may be present.
* Etiology. Unclear (autoimmune, altered glycosaminoglycal layer, allergic)

Interstitial Cystitis
* TX
o Refer to urology for cystoscopy.
o Dietary modifications
o Behavioral modifications
o Rx:
+ Pyridium
+ Pentosan polysulfate 100mg TID x 6mo to 2 years.
+ Amitriptyline 10-75mg QHS

Interstitial Cystitis
* Intravesical therapies
o Dimethyl Sulfoxide instillations q1-2 wks
o BCG instilled q1wk x 6-8 wks
o Hyaluronic acid instilled q1wk x 4-6wk.

References

Urinary Tract Infections.ppt

Read more...