Gynaecology Thrissur

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Dysfunctional uterine bleeding 

Infertility  

Anovulation   Contraception   Menopause   Chronic pelvic pain 
    

Chronic pelvic pain may be defined as noncyclic abdominal and pelvic pain of at least 6 months duration. 

Aetiology:

Chronic pelvic pain could be due to pelvic,abdominal,musculoskeletal,or urogenital problems.Pelvic causes are commonly due to endometriosis, chronic pelvic inflammatory disease or due to adhesions.(12,34,38) Pelvic venous congestion, a condition where the pelvic veins remain dilated could also give rise to pelvic pain.   The most common gastrointestinal problem associated with pelvic pain is irritable bowel syndrome, which is usually accompanied by altered stool passing.  Abdominal neural trigger points could be another cause of pelvic pain.  These are discrete (usually 1-2cm diameter) hyperpathic foci, the cause of which remains obscure.  It could be due to subcutaneous sensory nerves being trapped in fibrotic or retracted surgical incisions.  They could occur in nonsurgical conditions also.  Urogenital causes of chronic pelvic pain include urinary tract infections, cystitis, or even interstitial cystitis of autoimmune etiology.  In a few cases it becomes difficult to identify any cause for the pain.

 

   

Gynaecologic  causes of Pelvic pain:

 Some of the gynaecologic causes of pelvic pain could be pelvic inflammatory disease, pelvic adhesions, pelvic venous congestion, endometriosis, ectopic pregnancy, fibroids, ovarian cysts, or neoplasms. 

 

Diagnosis:

Pelvic inflammatory disease:  Pelvic inflammatory disease (PID) is a difficult disease to diagnose because it may present with a wide range of nonspecific symptoms ranging from minimal discomfort to septic shock.(16) It may range  from subclinical endometritis to frank salpingitis, pyosalpinx, tubo-ovarian abscess, pelvic peritonitis, and perihepatitis Bilateral lower abdominal pain is the most common presenting symptom. Perihepatitis causes right quadrant upper abdominal pain mimicking acute cholecystitis. Other common symptoms are abnormal vaginal discharge, metrorrhagia, postcoital bleeding, abnormal uterine bleeding (endometritis), dysuria, fever, and nausea or vomiting; The centre for disease control (CDC) have laid down criteria for diagnosis and grading of pelvic inflammatory disease. Diagnosis of pelvic inflammatory disease requires the presence of all 3 major plus one or more minor criteria.  Major Criteria are, Lower abdominal pain with or without rebound adnexal tenderness/mass,Adnexal tenderness and Cervical motion tenderness.  Minor criteria are, Temperature .380 C,White blood count> 10,000/mm3,Pus or bacteria on Gram stain from culdocentesis, Inflammatory pelvic mass or complex by ultrasound or bimanual examination,Elevated sedimentation rate and Cervical Gram stain with intracellular Gram-negative diplococci. However,Peipert et al have in one study found that if one uses the CDC criteria for diagnosis of  PID, >15% of cases will be missed.They have concluded that a clinician should consider empiric treatment of at-risk women with adnexal tenderness if there is no other obvious diagnosis to explain the clinical signs and symptoms(17). Overdiagnosis of PID may be less deleterious than underdiagnosis.It is useful to remember that women who have acute PID present during the first half of the menstrual cycle. Presentation later in the cycle indicates an infection of longer duration and increases the likelihood that a tuboovarian abscess has organized.(19)

Pelvic adhesions:

Not all patients with adhesions have pain and it has been found in one study that the incidence of pelvic adhesions in patients with chronic pelvic pain was not statistically different from the overall patient population. Kresch et al theorized that adhesions could restrict the mobility of the pelvic organs and that those involving the parietal peritoneum or bowel would cause pain(9). It has been proved that peritoneal adhesions contain sensory nerve endings and that they may cause pain when appropriately stimulated(30).Adhesions overlying the ovary may result in pain at ovulation by restricting the proper growth of the follicular cyst and discharge of the oocyte. Adhesions resulting from infection or endometriosis are sources of noxious stimulation which accompanies the adhesions formation process. Adhesions which have formed or are forming in the cul-de-sac create the opportunity for pain with movement of the uterus and hold of the uterus in retroversion which can then result in increased dysmenorrhea, pelvic congestion, and collision dyspareunia.However, when a patient comes with pelvic pain after pelvic inflammatory disease, the clinician should be cautious and rule out all other possible causes of pelvic pain before subjecting the patient to surgery for adhesiolysis.

Pelvic venous congestion:

Varicosities in the pelvic veins could cause pelvic pain.  The uterus, the ovaries and the vulva could be affected by this condition.  The patients could present with pain during and after intercourse (lasting up to 24 hours), tender ovaries, backache,dysmenorrhoea,varicosities  on one or both sides  of the vulva and buttocks or even the  whole leg,irritable bladder,abnormal menstrual bleeding or vaginal discharge. The pain is typically described as dull and aching pain that periodically gets worse premenstrually and during periods, when tired, when standing  (It may get worse as the day wears on), during or after intercourse, and during pregnancy.   After flaring up, the pain typically takes anywhere from   several hours to a full day to resolve.  Pelvic congestion syndrome is usually diagnosed after a thorough pelvic exam reveals no inflammation or other   abnormalities. (5) A specific diagnoses is made by examining the pelvic veins by means of Pelvic ultrasound or Laparoscopy. Venography is also useful in diagnosing the condition, but is not used in India to diagnose this condition.

Endometriosis:

Women reporting two or more of dysmenorrhea, pelvic pain or deep dyspareunia symptoms could be having endometriosis.  Local tenderness on pelvic examination could be associated with uterosacral and cul-de-sac implants of endometriosis. For details of this condition, refer to the chapter on endometriosis(Q11,15

 

Evaluation:

 

A: A proper history should be taken, keeping in mind the various causes of pelvic pain.  As mentioned before, the diagnosis of ovarian cyst, ectopic pregnancy or fibroid could be made from history, examination and ultrasonography.  If no obvious cause is found, the following guidelines should be followed.

1)     A gentle palpation of the introitus can diagnose vestibulitis

2)     While palpating the relaxed pelvic muscles posteriorly  any muscular spasm could be noted.

3)     Any nodularity near the uterosacrals suggests endometriosis.

4)                Tenderness on bimanual examination could suggest PID. 

When clinical examintion does not give a correct diagnosis, a diagnostic laparoscopy remains the best procedure

 

Abdominal wall causes of pain:

 

1)Iatrogenic peripheral nerve injuries (entrapment of a cutaneous nerve in the suture or scar of an abdominal incision),

2)Nerve entrapment without prior history of surgery: Usually found along lateral margin of rectus muscle

3)Impalpable interparietal hernias. Small hernias in obese women are usually not easily identifiable.

4)Myofascial pain syndromes

5)Rib tip syndrome:There is pain along the costal margin generated by the hypermobility of the 8th,9th and 10th ribs.

6)Abdominal pain of spinal origin: When normal anatomy of the spine is disturbed in such a way that the roots of the intercostals nerves are irritated, abdominal pain may result.

7)Rectus sheath haematoma arising from spontaneous rupture of epigastric vessels .

To differntiate abdominal pain arising from the viscera and pain arisng from the musculofascial structures, Carnetti’s test may be useful.  The examiner’s hand is placed over the tender spot in the abdomen. The patient is asked to slowly raise her head up with the examining hand still placed over the abdomen. When the abdominal muscle is tensed, the pressure is reapplied and the patient is asked if the pain has altered.   If the cause of the symptom is intra-abdominal, the tense muscles now protect the viscera and the tenderness should be diminished.  If the source of pain is in the abdominal wall, the pain remains the same or is increased. 

 

Treatment of pelvic inflammatory disease:

The center for disease control had given the following guidelines for outpatient therapy of pelvic inflammatory disease.

Regimen A:  Cefoxitin, 2 g intramuscularly, plus probenecid, 1 g orally in a single dose.

 Concurrently;  ceftriaxone, 250 mg intramuscularly or other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime);

 plus doxycycline, 100 mg orally two times a day for 14 days.

 Regimen B: Ofloxacin, 400 mg orally two times a day for 14 days; plus either clindamycin, 450 mg orally four times a day, or metronidazole, 500 mg orally two times a day for 14 days.

 In view of the lack of sensitivity of some currently used laboratory tests for C.trachomatis and N.gonorrhoeae among asymptomatic men, the Study Group endorses the recommendation contained in the CDC Sexually Transmitted Diseases Treatment Guidelines that sex partners should be treated empirically with regimens effective against both of these infections. (34) . Pavoneen.J has, mentioned that in most situations, combination treatment with doxycycline plus metronidazole is an effective treatment for inpatient and outpatient PID (17). In cases where N.gonorrhea is suspected, it is recommended that a single-dose therapy for gonorrhea should be provided (e.g., ciprofloxacin 500mg, or cefixime,1-g oral single dose).

Single dose Azithromycin has been shown to be effective in the treatment of chlamydial cervicitis, but its role in the treatment of PID remains controversial (19).Patients should demonstrate clinical improvement (ie, defervescence and decreased pain) within 72 hours of the initiation of treatment. Outpatients who do not improve within 72 hours require hospitalization, and inpatients who do not improve within 3 to 5 days require further diagnostic evaluation and/or surgical intervention.

 

Tubo-ovarian abscess:

 (10)Patients suspected of having a tubo-ovarian abscess should be hospitalized and given broad-spectrum antimicrobial drugs that include adequate coverage for gram-negative anaerobes. Failure of response to medical therapy is suggested by lack of improvement within 72 hours or increase in the size of the mass. Eighty-five percent of abscesses with a diameter of 4 to 6 cm respond to antibiotics alone, but only 40% of those 10 cm or larger respond. Surgical intervention for a tubo-ovarian abscesses that does not respond to antimicrobial therapy can be carried out laparoscopically, percutaneously, transvaginally, or by laparotomy. Patients with a suspected leaking or ruptured abscess should undergo immediate laparotomy after rapid stabilization and institution of broad-spectrum antibiotics.Hysterectomy with bilateral salpingo-oophorectomy as the sole treatment for tubo-ovarian abscess is now outmoded. , unilateraladnexectomy with continued medical management is an accepted surgical treatment of unilateral TOA. Some advocate simple drainage of abscess collections with aggressive medical therapy as the best way to maximize ovarian conservation for future reproduction. Laparoscopic and pelviscopic drainage of abscess collections and of pyosalpinxes is increasingly used. Ultrasound-guided transvaginal aspiration of abscesses may also be effective .After cure of acute PID complicated by TOA, there is justification for fertility surgery and for treatment with procedures aimed at optimizing either natural or in vitro fertilization techniques.

The center for disease control recommends the following regimen for the inpatient therapy of pelvic inflammatory disease:

A.Uncomplicated acute  salpingitis -Cefotetan 2 g IV q 12 hr orCefoxitin 2 g IV q 6  hr plus Doxycycline 100 mgIV or PO q 12 hr  

B.Complicated salpingitis-   (tuboovarian abscess or inflammatory complex Clindamycin 900 mg  IV q 8 hr  plus Gentamicin loading  dose of 2 mg/kg IV or IM followed by a  maintenance dose of 1.5 mg/kg q 8 hr . Notification, evaluation, and treatment of symptomatic and asymptomatic sexual partners is an integral part of PID therapy to prevent reinfection. Assessment of male partners should take into account the reservoir of asymptomatic males who harbor gonorrhea and chlamydia, regardless of the organisms isolated from their female partners with PID. At a minimum, all sexual partners should be assessed for the presence of these organisms. Some authorities advocate presumptive therapy for all sexual partners of women with newly diagnosed PID.

 

      Genital Tuberculosis:

A: Genital tract tuberculosis is an extremely indolent infection. Disease may not become

manifest for more than 10 years after the initial seeding of the genital tract. Presenting symptoms may be unusual vaginal bleeding patterns, including altered menses, amenorrhea, and postmenopausal bleeding. Approximately 25% to 35% of women with

pelvic tuberculosis have vague, chronic lower abdominal or pelvic pain. The chief symptom of young women with genital tract tuberculosis is infertility. Occasionally, women with the disease have tuberculous peritonitis and ascites, although these more commonly are secondary to direct hematogenous seeding of the peritoneum.

 

Treatment options for a patient with chronic pelvic pain:

The patient with chronic pelvic pain should be evaluated thoroughly regarding the cause of pelvic pain whether the cause is abdominal or pelvic.  If the pelvic examination shows any abnormality, it should be treated accordingly.  A course of NSAID’s is usually given as first line of treatment.  Next, a course of tricyclic antidepressants may be given.  They are thought to act by the blockage of the uptake of serotonin and norepinephrine in the central nervous system.   If medical treatment  is not effective, surgical modalities may have to be thought of. A laparoscopy may aid in further diagnosis and any surgical therapies like adhesiolysis, fulgration of endometriotic implants, etc.    If the pelvic examination is normal, any neuropathies should be identified and treated with injections. 

 

Surgical intervnentions for the treatment of chronic pelvic pain:

A: The possible surgical interventions for the treatment of chronic pelvic pain are:(34)

1) Resection or vaporization of vulvar/vestibular tissue for HPV induced or chronic vulvodynia/vestibulitis;

2) cervical dilation for cervix stenosis;

3) hysteroscopic resection for intracavitary or submucous myomas or  intracavitary polyps;

4) myomectomy or myolysis for symptomatic intramural, subserosal or pedunculated myomas;

5) adhesiolysis for peritubular and periovarian adhesions, and enterolysis  for bowel adhesions, adhesiolysis for all thick adhesions in areas of pain as well as thin adhesions affecting critical structures such as ovaries and tubes;

6) salpingectomy or   neosalpingostomy for symptomatic hydrosalpinx;

7) ovarian treatment for symptomatic ovarian  pain;

8) uterosacral nerve vaporization for dysmenorrhea;

9) presacral neurectomy for disabling central pain primarily of uterine but also of bladder origin;

10) resection of endometriosis from all surfaces including removal from bladder and bowel as well as from the rectovaginal septal space. Complete resection of all disease in a debulking operation is essential;

11) appendectomy for symptoms of chronic appendicitis, and chronic right lower quadrant pain;

12) uterine suspension for symptoms of collision dyspareunia, pelvic congestion, severe dysmenorrhea, cul-de-sac         endometriosis;

13) repair of all hernia defects whether inguinal, femoral, spigelian, ventral or  incisional;

14) hysterectomy if relief has not been achieved by organ preserving surgery such as resection of all endometriosis and presacral neurectomy, or the central pain continues to be  disabling. Before such a radical step is taken, MRI of the uterus to confirm presence of adenomyosis may be helpful;

15) trigger point injection therapy for myofascial pain and dysfunction in pelvic and abdominal muscles.

    

 Role for laparoscopy in the evaluation and treatment of chronic pelvic pain:

 Laparoscopy serves three important diagnostic functions: diagnostic confirmation, histological documentation, and patient reassurance.  Laparoscopy should be done only after thorough medical and psychologicl evaluation and failure of all medical therapies.  This will reduce the number of negative laparascopies.  However, it has been shown that in patients where medical treatment has failed, laparoscopy does have a positive effect in curing the disease in some patients,by reassuring the patient that she is not suffering from any serious ailment.   Laparoscopy could be done under local anaesthesia with the patient conciously pointing out the areas where she gets pain while the surgeon  probes the various parts of the pelvis. By this technique of laparosocpic pain mapping, it was found that thin filmy adhesions cause more pain than thick adhesions.  Although the role of laparoscopic adhesiolysis has been questioned by a few workers as they found a lot of patients with extensive pelvic adhesionswho did not have pain, various studies have shown that laparoscopic adhesiolysis in patients with chronic pelvic pain effects a cure in 64-84% of patients.(34) Laparoscopic release of intestinal adhesions, ovarian adhesions, fulgration of endometriotic implants, etc could result in curing many cases of chronic pelvic pain.(13)

Uterine nerve ablation:

In patients with central uterine pain and dysmenorrhoea, uterine nerves in the uterosacral ligaments are ablated laparoscopically. This is called laparoscopic uterine nerve ablation or LUNA.  In some of these patients, there are endometriotic implants in the uterosacral ligaments. In these patients, LUNA has to be combined with resection of endometriotic implants. Resection and treatment of the uterosacral nerves may be more effective if accompanied by treatment of the connective fiber tissues bridging the posterior aspect of the cervix and lower isthmic region where the nerve fibers coalesce. This creates an arch of ablated nerve tissue from left uterosacral ligament across the posterior cervical attachment and progressing down along the right uterosacral ligament  The LUNA, in skilled hands, is a safe procedure. In less experienced hands it can result in perforation of uterine vessels and injury to the ureter. It is not as efficacious as presacral neurectomy for central pain.

 

Pelvic venous congestion:

 Pelvic venous congestion is a poorly understood disorder and a myriad of treatment modalities have been suggested but the final answer is yet to be found.  Laparoscopy remains the main mode of diagnosing the disorder. The following treatment modalities have been tried for the disorder.

1)Medroxy progesterone acetate (MPA) 30mg/day for 6 months. The pain is found to recur after stopping treatment. (27)

2)Suprefact 3.6mg monthly for 6 months has been found superior to MPA but is a very costly treatment. (27)

3)D a f l o n 5 0 0 mg  t w ice  a  d a y   f o r  4   m o n t h s  h a s   b e e n  s h o w n   t o   b e   e f f e c t i v e(32)

4)NSAID’s provide temporary relief.

5)Ovarian artery embolization has been tried but long term results are awaited.

6)Hysterectomy with bilateral oophorectomy is the last resort, but patients should be warned that pain might persist in a small subset of patients even after surgery.

 

Trigger point injections:

A: Trigger point inections involve injection of local anaesthetics into specific sites.  It is useful in patients with chronic pelvic pain of myofascial origin. This can be diagnosed when there is tenderness or twitch of the muscle on palpating a particular area .Sometimes a thickened band like structure can be felt in the muscle.  In cases of deep dyspareunia, trigger points should be sought in the levator ani, obturator internus, piriformis and iliacus-psoas muscle groups. For pelvic pain expressing itself in the right and left lower quadrants, trigger points are sought in the rectus abdominus, external and internal obliques, iliacus, psoas, and quadratus lumbaricus. For central low pelvic pain, trigger points are sought in the rectus abdominus and pyramidalis. (1)Once an area of abdominal wall pain tenderness has been identified, its position is localized as accurately as possible with a single fingertip.  The tender spot is injected with a mixture of 1ml 1% lignocaine and 25 mg hydrocortisone acetate using a 21 guage needle.  To start with, a small bleb is raised in the skin overlying the tender spot.  The needle is then inserted, and its point is moved around the tissues until the patient complains of pain similar to the original symptom.  The injection is made into that point and into the immediately surrounding area.  80% of correctly diagnosed patients are completely or partially relieved of their pain by this treatment.  56% of patients with parietal pain treated with local injections of 5% aqueous phenol are pain-free or improved at follow-up 3.5 years after treatment.  In one study, treatment of abdominal wall trigger points was performed by placing a 22-guage, 1.5 in. needle through the trigger point and slowly penetrating the fat pad until the needle tip reproduced the same sharp pain.  The abdominal wall trigger points were found in fatty tissues above the fascia or along the margins of the abdominal wall scar tissue.  Injection of 3 to 5 ml of 0.25% bupivacaine stimulated sharp and times severe pain followed by relief.  Additional trigger points of the vulva, vagina and cervix and paracervical tissues were injected.  Using these techniques a total of 89% of patients with abdominal-pelvic pain syndrome reported relief or improvement in pain such that no further therapy was required.  The efficacy of injecting the parietes to relieve chronic abdominal symptoms has been well documented. 

Trigger point injections act by the following mechanisms:

1)                Mechanical disruption of the abnormal contractile elements, which may result in the relief of muscle tautness and hyperirritability

2)     Fluid injections, which may dilute nerve-sensitized substances that may be present

3)     Muscle fiber damage, which may release intracellular potassium, causing a depolarization block of nerve fibers

4)                Feedback mechanisms between the central nervous system and the trigger point, which may be interrupted and

5)     Focal necrosis caused by the anesthetic agent, which could contribute to the destruction of the trigger point. 

Primary dysmenorrhoea:

A: Primary dysmenorrhoea is defined as cramping pain in the lower abdomen occurring just before or during menstruation, in the absence of other diseases such as endometriosis. . Systemic symptoms of nausea, vomiting, diarrhea, fatigue, fever, headache or lightheadedness are fairly common. Pain usually develops within hours of the start of menstruation and peaks as the flow becomes heaviest during the first day or two of the cycle. Secondary causes of dysmenorrhoea, like Adenomyosis, Endometriosis,  Pelvic inflammatory disease, Inflammation and scarring (adhesions), Cervical stenosis and polyps, Functional ovarian cysts, Fibroids (intracavitary or intramural), Benign or malignant tumors of ovary, bowel or bladder, or other site, Intrauterine contraceptive devices or Inflammatory bowel disease must be ruled out. 

NSAID’s like Ibubprofen, Naproxene, Mefenamic acid and Rofecoxib could be effective in providing pain relief.  If pain relief is not obtained, OC-pills could be tried.

Lack of response to NSAID’s and OC-pills calls for further investigations like laparoscopy to rule out causes of secondary dysmenorrhoea like endometriosis.

 In cases of partial congenital cervical stenosis, cervical dilatation should be tried.  The other treatment options available are,

Omega-3-fatty acid supplements,

Transdermal Nitroglycerine, 0.1-0.2 mg given per hour during first few days of the menstrual cycle,

Thiamine {vitamin B6) 100mg given each day for 90 days, and giving magnesium supplements. 

Transcutaneous electric nerve stimulation (TENS) is another modality that is being tried out.

Acupunture and Laparoscopic presacral neurectomy have also been found useful. (3)

 

  Urethral syndrome: