Chronic pelvic pain

It any pain remains unchanged in its character and location for 6 months or
more, and incomplete relief by treatment.
#Causes : -
1- gynecological causes : -
Dysmenorrhea , endometriosis , adenomyosis , endometrial polyp , fibroid &
PID.
2- GIT Causes : -
IBD , IBS, & Diverticular disease .
3- urinary tract causes : -UTI , interstitial cystitis , urethral syndrome .
4- Musculoskeletal causes : - Degenerative disease .
5- Psychological causes : - after check all previous causes.

●Dysmenorrhea
Painful menestration . has 2 types : -
1- primary(spasmodic) .
2- Secondary (congestive) .

1.Primary dysmenorrhea : -
• Occur 1-2 years after monarch, according to ovulation .
• after 1-2 years , the ovulatory cycle begin , so started primary dysmenorrhea.
# Characteristics :-
1- Occur in unmarried women .
2- Crampy, suprapubic pain , start few hours before menses, worsening in first
days of menses then the pain is resolved .
3- Improved by childbirth and increased age .
4-No any pathology.
5- Associated with nausea & vomiting .
#Cause :-
- When ovulation occur , the progesterone is secreted , It is precursor of PG from
archadonic acid (PGF2 α) lead to increase contractility and ischemia which cause
pain
-Also cause increase contractility of gastric smooth muscle lead to nausea &
vomiting.
 #Investigation : -
●U/S to exclude other pathological causes.
{ If there is any pelvic pathology considered as secondary dysmenorrhea} .
#Treatment : -
1- NSAIDs : mainly mefanimic acid or ibuprofen to inhibit PG .
2-COC : used when no benefit of NSAIDs or interfere with daily activity.
• suppress ovulation which lead to "no progesterone " so no PG .
2- Secondary dysmenorrhea : -
● Occur in parous women .
● The pain start 1-2 days before menstruation and Continuance through
menstruation .
● There is pathological cause.

# Differential Diagnosis: -
▪ Endometriosis. ▪ adenomyosis.
▪ PID . ▪ Endometrial polyp.
▪ Endocervical polyp .

☆ Endometriosis :
-It is the most common cause of secondary dysmenorrhea.
-It is endometrial tissue (stromal glands) present out side uterine cavity.
●Common sites of endometriosis :
1-uterosacral ligament "most common" .
2- ovary .
3- umbilical .
4- previous scars .
5- Douglas pouch .
6- anterior cul-de- sac .
7- pleural cavity .
8- nasal cavity .
# Characteristics :
1- common during reproductive age 25-35 years.
2- common in nulliparous women.
3- estrogen dependent , so during cycle the estrogen stimulte endometrosis lead
to cyclic bleeding causes fibrosis which may lead to adhesion.
 # Etiology :
Un -known cause , there are theories , that may explain why endometriosis occur
.
A) Sampous theory :
Menstrual regurgitation and implantation ▪ Petrograde menstraul regurgitation
of endometrial tissue and glands lead to back-flow of tissue to the fallopian tubes
and then to peritoneal cavity.
# Causes of sampous theory :
1- Imperforated hymen .
2- Complete stenosis in cervix .
3- Any intervention during menstruation such as : - HSG , D&C , Biopsy , Sexual
activity , Cervical catheterization .
-should done these intervention post menstruation.
B- Colonic epithelium transformation
Describe the differentiation of peritoneal cells being
Mollerian duct back to their primitive origin which then transfer into
endometriod cells
C- genetic immunogical factor
Explain why endometriosis has family tendency
D- vascular lymphatic spread
Explain why endometriosis occur in distance site such as pleural
Nasal cavity
Clinical presentation :Depend on the site
1_ reproductive organs
Secondary dysmenorrhea 1-2 days before nemesis continues through out
menstruation when nemesis stop pain stop
_dyspareunia
_infertility 20-30%
_pelvic mass in lilac fossa if it occur in ovary endometrooma chocolate cyst))

Why endometriosis lead to infertility ??!

Because it effects
1_ ovarian function
_ anovulation
Un ruptured follicles syndrome
_ fibrosis and adhesion
2_ tubal function
Fibrosis effects tubal motility and fimbria not pick up the oocyte
3_ coital function
_dyspareunia ( pain during intercourse ) lead to decrease coital frequency
4_ urinary tract
Cyclic hematuria ,dysuria
5_ GIT
Cyclic rectal bleeding , dyschozia (pain during defecation
6_ lung
Cyclic hemoptysis help pneumis thorax
7_ scar / umbilicus
Cyclic bleeding / pain
8_ nose
Cyclic epistaxis
Examination
Adnexal mass , tenderness >> endometrioma
Fixed retrorectal utters due to cul de sac adhesion
Nodules in retrorectal ligament
Tender Douglas pouch
Investigation
1_ U/S >>to exclude or confirm endometrioma
2_ MRI >> if lesion >5 mm
3_ laparoscopy>> gold standard of diagnosis and tt

Treatment
According to age , wish of the patient, symptoms
1_ medical treatment
For minimize symptoms
1 NSAID
2 COC continues use for 6-9 months
3 progestin
4 danazol
5 GNRH agonist

2 surgical treatment
a _conservative therapy
Laparoscopy with Technique such as diameter laser vaporization
b_ TAH and bilateral salpingooophrectomy
Remove of uterus and ovary because the ovary is source of estrogen

Adenomyosis
Definition : is an endometrium tissue find with in the myometrium .

- Patients with adenomyosis are usually multiparous commonly after 35 years ,

they present with sever secondary dysmenorrhea and menorrhagia on
examination the uterus will be symmetrically enlarged and tender .

INVESTIGATIONS :

- U/S : will not help in diagnosis .

- MRI : is best pre operative investigation if you suspect that patient may have
adenomyosis it will provide excellent images of the myometrium endometrium
and areas of adenomyosis .
- histopathology : is the definitive diagnostic method it is done after
hysterectomy .

TREATMENT : hysterectomy .

Premenstrual syndrome
Is group of cyclic somatic , psychological and emotional symptoms that occur in
the luteal phase of the menstrual cycle and resolve by the time menstruation
ceases so there is free interval of symptoms for 3 to 7 days .

- CLINICAL PICTURE : the clinical nature of symptoms must be cyclic for three
consecutive months and interfere with daily activity .

MANAGEMENT :
- 1st line : life style modification by : stress reduction , alcohol and caffeine
limitation , exercise and increase intake of calcium and magnesium .
- 2nd line : combined oral contraceptive drugs (( COC )) .
- Selective serotonin reuptake inhibitors .

* once the symptoms sustained the dose of COC or SSRI will be increased if all
treatment lines fail we will do hystero salpingo oophorectomy after giving the
patient GnRH agonist drug that will switch off the ovarian function before
removal .

Somatic symptoms Psychological symptoms

* cyclic weight gain. * depression .

* mastalgia * irritability .
* lower abdominal pain * anxiety .
* fatigue .
* headache .