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MRCOG PART 2 SBAs and EMQs

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Essay 262 - Pelvic pain

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		Posted by Ritu J. Wed Feb 13, 2008 05:49 am
A]Most likely causes are endometriosis and chronic pelvic inflammatory disease ,chronic pelvic pain. b]I would be empathic, supportive and take detail history of severity of pain,radiation, associated bowel symptoms,pain during defeacation,any muscular pain,quality of life due to pain.Important history include abnormal excessive foul smelling discharge,any invasive proceedure ,heavy and frequent flow during periods ,urinary symptoms. Iwould sensitively enquire about chidhood sexual abuse.Any progression of symptoms to find about severity of disease. Along with general examination per abdomen palpation for any mass,tenderness.Per speculum look for any purple /blue spots/nodules,type of vaginal dischage,prepare wet mount,take swab for culture..P/V to check for uterine position,fixity,tenderness and nodularity of uterosacrals[best d\\in menstrual phase] c]Severity of pain and its affect on quality of life would need involvement of dedicated pain clinic,psychologial support.multidisplinary input will improve results. Her desire for child bearing would direct future medical/surgial management. Her past obstetric history and need of future contraception would decide cyclical hormonaltherapy. Medical treatment is simple,cheap,effective after 3-6 months,temporary and effective in only 50% cases and can not be given in those willling for pregnancy. With Gnrh analogues cost is signifant factor,also need for addback calcium therapy. Laproscopy is the gold standard for diagnosis and treatment ,even though negative in 30% cases,useful for desiring fertility,but has associated anaesthesia and surgical morbidity,but most important factor is adequate and accurate patient information and her wishes.
		Posted by S M. Wed Feb 13, 2008 06:10 am
The differential diagnosis for a 30 yr old woman with a 12 month history of pelvic pain, dysmenorrhea and dyspareunia is Pelvic Endometriosis, Chronic Pelvic Inflammatory disease, Adhesions from previous abdominal surgeries, Psycho sexual problems and adenomyosis. My clinical assessment would involve a detailed medical and social history and a through examination. To start with, I will enquire about the nature, character, location and symptoms associated with pain (ie intermenstrual bleeding, PV discharge,dyschesia, urgency and frequency of micturition). I will find out if the pain is cyclical or present throughout the month. I will enquire about her periods and find out if they are regular and whether or not they are associated with heavy bleeding. I will ask about the nature of pain during intercourse ie is it superficial or deep. If there is deep dyspareunia, I will find out if that is so in specific positions or always. I will enquire about her smear history and whether she is using any contraception. I will take an obstetric history. I will ask her if she had any sexually transmitted diseases in the past. I will sensitively ask her about social support and whether she is in a stable relationship. I will enquire about the impact of pain on her social, sexual and material quality of life. I will take a family history and enquire specifically about endometriosis. I will do a general examination (Height, weight, BMI, Pulse, BP) and a per abdominal examination to rule out obvious pelvic masses. I will do a speculum examination and take triple swabs (HVS, and endocervical swabs for Chlamydia and gonorrhea). I will do a vaginal examination and feel for cervical excitation, any adenexal masses and size, mobility and texture of the uterus. Intermenstrual bleeding, PV discharge, past history of STD and H/O multiple sexual partners and presence of discharge and cervical excitation will point me towards Chronic PID. H/O deep dyspareunia, cyclical dysmennorhea, dyschesia or PR bleed and on examination a fixed uterus with nodules in uterosacral ligament will point me towards endometriosis. Previous surgeries (esp caesareans)can suggest pain due to adhesions. H/O depression and not geeting on well with partner can suggest psychosocial problems. Subsequent management will depend on severity of condition, effect of pain on the lady?s quality of life, her desire for future fertility, and her intent as to whether she just wants symptomatic relief or a definitive diagnosis of the ailment. Simple investigations like swabs to rule out PID and a scan to see if there is an endometrioma can be done in outpatient department. However, if the patient wants to know the cause of pain we can do a laparoscopy, which is a gold standard for diagnosis of endometriosis , if the lady is medically fit and suitable for a general anaesthetic. If fetility is not an issue and the lady does not want surgery we can give her a trial of Combined Oral contraceptive pills or GnRH agonists if we have a strong feeling that we are dealing with endometriosis. If pain seems to be of a psychosocial nature, appropriate counselling from a specialist would be needed. If swabs suggest PID or if there is strong clinical suspicion of PID, patient must be given antibiotics and also referred to GU clinic for further tests and contact tracing.
		Posted by hoping .. Wed Feb 13, 2008 06:51 am
Most probable causes for her symptoms are endometriosis or pelvic inflammatory disease. Other causes include adenaxal pathology, pelvic venous congestion, irritable bowel syndrome and psychological. Initial clinical asessment should involve detailed history regarding these symptoms- severity and effect on her quality of life. If she has intermenstrual bleeding or abnormal vaginal discharge. Her sexual history, in long term relationship or new partner, number of partners in last year, use of barrier methods of contraception should be enquired sensitively. Her menstrual history and menorhagia and presence of clots should be checked. Dyspareunia should be addressed, if superficial or deep and if it is worse during penetration or during following hours as may suggest pelvic venous congestion. Psychosexual aspects should also be taken into account. Past history of sexual abuse should be enquired sensitively. Any gastrointestinal symptoms and dyschesia should be asked. Her current method of contraception should be checked if any. With informed consent abdominal and vaginal examination should be undertaken Abdominal examination to check for any tenderness or palpable mass. Vaginal examination including bimanual examination to determine site of tenderness, asses mobility of uterus and adnexal masses or tenderness. Uterosacral ligaments should be checked for palpable nodules and tenderness. Urine should be sent for microscopy and culture and NAAT testing for chlamydia. High vaginal and endocervical swabs should be sent for infection screening . Transvaginal ultrasound scan should be done to check for adenaxal pathology and fibroid changes in uterus. Ca 125 is not specific for diagnosing endometriosis. Subsequent mangement would be influenced by probability of causative factor as antibiotics would be appropriate for PID. This patient is likely to have endometriosis and treatment options will depend upon her desire for pregnancy as methods that suppress ovulation shouldnot be used if she wishes to get pregnant . Any contraindications for use of combined pill should be checked as family history of venous thromboembolism. This patient is healthy , her past history and BP and BMI should be checked. If she wishes to get pregnant then laparoscopy would be preffered mangement. If there is high probability of IBS then trial of mebeverine maybe useful prior to laparoscopy. Patients preference is of paramount importance. She should be provided with appropriate information and be able to make informed decision. hER EXPECTATIONS AND EFFECT ON QUALITY OF LIFE ARE IMPORTANT PARAMETERS.
		Posted by S M. Wed Feb 13, 2008 06:51 am
A healthy 30 year old woman is referred to the gynaecology clinic because of a 12 months history of pelvic pain, painful periods and pain during intercourse. Her symptoms have not responded to simple analgesia. (a) List the likely causes of her symptoms [2 marks]. (b) Logically outline your initial clinical assessment [10 marks]. (c ) Evaluate the factors that will influence your subsequent management [8 marks]. a) Endometriosis or adenomyosis are the most likely causes of the pain. Other causes include pelvic infection, pelvic congestion and ovarian cyst. b) A detailed history of the severity of her presenting symptoms and the effect on her quality of life will guide us towards the necessity and type of treatment. I would enquire into the regularity of the cycles and amount of blood flow. Menorrhagia is associated with adenomyosis. Past history of chlamydia would suggest a chronic pelvic inflammatory disease. Previous operations may have led to the development of adhesions. which could cause pelvic pain. A social history of the state of her current relationship and work life is important because any increase in stress may have reduced her ability to cope with pain that she use to manage well. Physical examination will include examination of the abdomen looking for abdominal tenderness and an abominal or pelvic mass. Speculum examination wil allow for vaginal and cervical swabs to be taken for infection screen. It will also allow for examination of any vaginal discharge. Vaginal examination for tenderness of the fornices and cervical excitation which will point towards pelvic infection. A tender pelvis, retroverted fixed uterus and tender nodules in the posterior fornix points towards endometriosis. c) The first factor that will influence the management is the patient\'s wishes. This is important since all competent individuals should make an informed decision on their medical care. The second factor is the need for contraception. Some types of treatment are also contraceptives such as the combined oral contraceptive pill and would be more appropriate if she wanted to use a contraceptive method also. This is also important because some forms of treatment such as danazol should only be used with effective contraception because of it\'s teratogenic effects on a fetus. The third factor is her desire to have children. This may be required in the short term or longterm. Some forms of treatment such a s gonadotrophin hormone releasing hormones inhibit ovarian function and therefore it is unlikely that she would conceive at that time. If she was in severe pain and wanted a child, then a diagnostic laparoscopy and ablation of endometriotic deposits would be more suitable.
		Posted by Sahathevan S. Wed Feb 13, 2008 08:44 am
(a) List the likely causes of her symptoms [2 marks]. Likely causes includes Gynaecological and non gynaecological disorders. Gynecological causes includes Endometriosis, Chronic PID, Adenomyosis and Uterine fibroids.Psycosexual problems also a possible cause. (b) Logically outline your initial clinical assessment [10 marks]. Detailed history should be taken including direct questions regarding the onset timing and quality of the pain, as well as relationship with the menstrual cycle, effects of pain on quality of her life, occupational family and social disruption to this problem. Also History of previous pregnancies, infertility, acute PID, abdominal or pelvic surgeries and STD are valuable informations. History of sexual abuse in childhood and psychosexual problems if suspected, should asked subtly and sensitively.Psycological evaluation may also be benefit in some cases. History of Contraceptions and fertility wishes should be asked. It is important to clarify whether she was treated for chronic pelvic pain previously and the treatment detail should be asked. As COCP is a recommended medical treatment for endometriosis it is important to ask previous and current medical problems to find out any contraindication for COCP. BP and BMI recording is important to assess any contraindication for COCP. Thorough clinical examination should be carried out to rule out palpable masses or examine for significant tenderness. Findings on pelvic examination including uterine and adenxal tenderness, fixed retroverted uterus and, nodularity of of the Pouch of Douglas are suggestive for endometriosis. (c) Evaluate the factors that will influence your subsequent management [8 marks]. Management is directed towards diagnosis and nature of severity of the disease. For instance surgical management of Laparoscopy of excision of endometrioma is required if endometrioma identified on USS. Also woman\'s priorities and wishes and fertility issues also influence on management for example if the patient diagnosed as mild to moderate endometriosis( on laparoscopy)ablation of endometriotic lesion plus adhesiolysis is improve fertility in compared with diagnostic laparoscopy alone . quality of life issues is play a vital role in management options , if the pain cause disruption in women?s social , working and sexual life she may need multidisciplinary management including psychosexual counseling. Cormobidities like systemic diseases and failure of previous treatments also influence on embark on initial management. Patient acceptability and availability of the expertise also influence on management of her chronic pelvic pain.
		Posted by Sarwat F. Wed Feb 13, 2008 11:06 am
Likely causes include gynaecological and nongynaecological causes. Gynaecological causes include chronic pelvic inflammatory disease, endometriosis, ovarian cyst and degenerating fibroids. Nongynaecological causes include disorders related to gastrointestinal tract, urinary tract , presence of adhesions due to previous surgeries, psychological causes including sexual abuse and idiopathic. Disorders related to gastrointestinal system include divertisulosis, inflammatory bowel disease and irritable bowel syndrome. Urinary tract disorders include chronic urinary tract infections and pyelonephritis. Initial clinical assessment includes history examination and certain investigations. In history it is important to ask about location of pain whether it is present in lpelvis only or it radiates towards loin, severity of pain on a scale of 1 to 10. This will help in deciding urgency of treatment. Factors that increase the pain like menstruation, coitus, micturition, posture movement will be asked if there is any relation as pain that is associated with menstruation and coitus can be due to endometriosis as well as pain during bowel movement. Factors that relieve pain like pain due to irritable bowel syndrome is relieved by defaecation. Menstrual history will be asked like duration of menstrual cycle, any history of heavy menstrual flow and her last menstrual period to exclude any missed period or chances of pregnancy. Any symptoms of abnormal vaginal discharge like offensive yellow or green discharge is important to evauate regarding pelvic inflammatory disease. Any intermenstrual bleeding or postcoital bleeding will be asked as irregular bleeding can happen in PID. Any history of STDs and treatment taken for it. She gives history of dysmenorrohea and dysperunia which can be a clue to diagnosis of endometriosis. She will be asked about method of contraception she is using as certain treatment like for endometriosis includes administration of oral contraceptive pills. Past medical history will be asked as any history of migraine headaches can make use of OCPs less likely. Previous surgeries like multiple abdominal surgeries can give rise to pain due to adhesions. Any history of urinary tract infections will be asked and treatment taken for it as inadequate or ineffective treatment may lead to chronic UTIs. Any history of bowel disturbance like diarrohea or constipation will be asked as it can help in diagnosing bowel disorders. History of psychological stress and sexual abuse should be taken with a sympathetic and sensitive approach. Social history will be asked like her occupation and whether she lives with her partner and occupation of partner will be asked. Clinical examination will be done including general physical examination to assess her personality. Extremely anxious patient may indicate for psychological stress or history of sexual abuse. Abdominal examination will be done to assess any abdominal tenderness that may indicate PID or to elicit any pelvic masses like ovarian cysts or endometriomas. Vaginal speculum examination will be done to check for anu unhealthy discharge and high vaginal swabs and endocervical swabs for Chlamydia are taken at the same time. Vaginal examination will be done gently to assess the size and mobility of uterus and any tenderness and any adnexal masses. An ultrasound scan can be done in case of any suspicion of pelvic masses. Factors including subsequent management depend on cause of pain as treatment will be directed towards treating the respective condition. It also depends on parity of patient as if she is keen for fertility then she may not opt for Oral contraceptive pills as treatment for endometriosis. BMI is also important as laparoscopy to diagnose and treat endometriosis can be difficult in patients with high BMI. Availability of multidisciplinary care is also important as in case if no gynaecological cause is found patient will need to be seen by colorectal surgeons, urologist and psychologist. patients attitude towards her symptoms is also important as compliance with outpatients appointments will be influenced by this especially if all investigations turn out to be negative. Detailed explanation of various possibilities should be provided backed up with information leaflets.
		Posted by Srivas P. Wed Feb 13, 2008 12:06 pm
a) Causes could be due to Chronic PID, Endometriosis, Pelvic venous congestion, Adenomyosis, Fibroid uterus, adnexal masses, and adhesions following endometriosis, PID or previous surgeries b)I would take her history for vaginal discharge, haematuria, dyschezia, and nature of her pain?whether continuous or cyclical, if associated with postural movement. H/o Migraine as it contra-indicates COC in this young patient. Menstrual H/O for heavy bleeding, post coital bleeding. Sexual history for number of partners, use of contraception-IUCD, condoms, H/O past or present sexual assault. Past history of STD?s, any pelvic/ abdominal surgeries should be taken. I will take obstetric history to understand her fertility/ contraceptive needs. I will ask her about any psychological stress, depression, appetite, sleep and quality of life. I will take B.P, BMI. Pevic examination should look for vaginal discharge, if any endometritic nodules on cervix, vagina, nodularity in POD, fixity of uterus, adnexal masses, tenderness. Vaginal urethral swabs for Chlamydia/ Gonococcus, though negative report does not rule out chronic PID. ESR may be raised in genital TB. TV USG will detect adenomyosis, ovarian endometriomas, rectovaginal endometriosis but is not sensitive for peritoneal endometriosis. MRI-usefulness is similar to TVUSG-detects adenomyosis, deep infiltrating endometriosis, adnexal masses but not peritoneal endometriosis. Both TVUS and MRI are non ?invasive, but MRI is costly. Diagnostic Laproscopy is gold standard and will identify endometriosis, adhesions, chronic PID and adnexal mass and is indicated when pelvic examination is abnormal or she does not respond to empiric treatment as it is associated with complications of laproscopy. Negative result maybe found in 1/3 to ? cases and may make woman more anxious when no cause is found. c)Subsequent management depends of underlying diagnosis, her main complaints, her contraceptive or fertility needs, any contra indications to hormonal treatment, her goals for treatment and results of any previous treatment. If a cause of the chronic pelvic pain is found, treatment is directed to treating it. Broad spectrum antibiotics for chronic PID and she should have GUM referral for contact tracing. If she has endometriosis, her treatment will depends on severity of disease, whether she has associated infertility, if severe pain is affecting her quality of life and the treatments she has received so far. Deep seated recto vaginal endometriosis and ovarian endometriomas are best treated surgically by laproscopic laser ablation of endometriotic lesions. Mild endometriosis associated with infertility can be treated surgically by laser ablations and she can be given stimulated cycles with IUI for best results. Medical treatment is not effective for endometriosis related infertility. However role of surgery in severe endometriosis is unsure. If fertility is not an issue and her complaints are mainly due to pain she can be treated empirically. NSAIDs can control endometriosis related pain. Also it does not cause contraception. Treatment with COCP, progestogens like DMPA, GnRH analogues, Danazol, Gestrinone, and LNG-IUS are all equally effective in controlling endometriosis related pain but the side effect profiles differ. The choice of treatment has to be individualized. If she has extremely painful condition not responding to medical treatment, she should be referred to pelvic pain clinics. Sometimes no cause is found and she may need psychological counseling. Treatment may need to be multidisciplinary if there appears to be non-gynecological reasons for her pain. The information should be provided in written form and her wishes should be always taken in to account. She should be given details of support groups like Pelvic pain Support network.
		Posted by Elizabeth V. Wed Feb 13, 2008 12:20 pm
The likely diagnosis in this scenario can be broken down into Gynaecological and non-Gynaecological. The Gyneacological causes include endomertriosis,adenomyosis ,chronic PID,ovarian pathology,fibroid polyp,IUCD. Non -Gynaecological causes could be gastrointestinal causes such as irritable bowel syndrome,inflammatory bowel disorder,diverticulosis,colon malignancy,urinary tract causes such as interstitial cystitis,urethral syndrome.Psychological causes such as sexual abuse,depresson,pelvic congestion. Clinical assessment would include a detailed history of each of the symptoms.Details of the type and severity of pain and associated symptoms such as bowel or bladder symptoms .A menstrual history is important regarding the last menstrual period ,menstrual cycle ,flow , onset and duration of dysmennorrhoea aswell as contraception .Obstetric history including parity,type of delivery,miscarriage,ectopic pregnancy,complications,infertility are important.A history of treatment for gynaecological conditions such as endomtriosis, PID,pap smear history and a sexual history is relevant including a sensitive history of sexual abuse.Details of medical and surgical history are also important . A general examination including the chest ,abdomen for mass ,tenderness,hernia.Local examination of the perineum for nodules ,discharge.Vaginal examination should include appearance of the cervix,abnormal discharge,size of the uterus,mobility,adnexal masses, nodularity.A per rectal examination if necessary to assess the uterosacral ligaments and the POD . Subsequent management depends on the severity of the symptoms and their effect on her quality of life.Allowing the woman to express her concerns and expectations is important as it helps us to judge her main symptom. The diagnosis is important and a clear and simple explaination including information leaflets and possible management options will help her to decide on the management option. In case of diagnosis of endometriosis, the important issue to be discussed includes plans for pregnancy in the immediate future and also issues of infertility.if this is the main concern then surgical management would be more appropriate such as laparoscopic ablation,adhesiolysis,cystectomy which is associated with symptomatic improvement,as well as increased chances of fertility.Medical management including continuous COCP,Depot progestrone ,GNRH analogue,LNG inta uterine device ,would be suitable for symptom control.Chronic PID would benefit from surgical management ,such as removal pyosalpinx ,adhesiolysis rather than a course of antibiotics. Non gynaecological causes would require referral and input from other specialist such as gastro physician,urologist depending on the likely cause.If Psychological causes are suspected she would benefit from seeing a psychologist.Support groups would also be beneficial.
		Posted by Hala T. Wed Feb 13, 2008 02:32 pm
a) The likely causes of her symptoms are endometriosis ,adenomyosis, chronic pelvic inflammatory disease, uterine fibroids and psychosexual problems. b) A detailed history should be taken including effect of symptoms on her quality of life, occupational family and social disruption of this problem. Her contraception history ,previous sexual transmitted disease ,acute PID ,previous therapies and its results. Any contraindications to COCP use and her fertility wishes should be explored. History of sexual abuse in childhood ,if suspected should be subtly and sensitivity asked. Thorough clinical examination including abdominal examination to rule-out any palpable mass or abdominal tenderness.Finding on pelvic examination including uterine and adenxal tenderness , fixed retroverted uterus are suggestive of endometriosis ,also nodularity of of the Pouch of Douglas. c)Endocervical swabs are typically negative in women with chronic PID and positive test may be incidental. Non-invasive investigations like pelvic ultrasound may be reassuring to the patient and sometimes may reveal patholohy not noted on clinical examination as endometriosis. Markers such as CA-125 may be used to identify women in whom early laparoscopy is beneficial. Laparoscopy is the gold standard but is not a first line investigation. It should be the last resort , as it may cause erroneous diagnosis .If clinical examination is abnormal or thorough examination is not possible then MRI is of value in the diagnosis of deep peritoneal endometriosis ,recto-vaginal septum endometriosis . It also may diagnose adenomyosis, contents of pelvic masses but it is not routinely used, as not widely available and is expensive. Initial treatment is directed towards diagnosis , woman\'s priorities , wishes , future child-bearing and quality of life issues. COCP if no contraindications is effective treatment for endometriosis associated pain and provides contraception. Drugs such as danazol and GnRH agonists are very effective but have significant side effects , that may limit their long-term use , and should only be used after a firm diagnosis of endometriosis has been made. Referral to GUM should be offered if chronic PID , for partner screening , treatment and follow-up. Laparoscopic ablation relieves pain and improves fertility in case of mildly moderate endometriosis ,but adhesiolysis is not associated with significant improvement. Severe endometriosis should be treated in specialist centre with patient reassurance and the value of endometriosis association support group is emphasized with providing written information leaflet to the patient. Myomectomy may be offered for the patient if she was with fibroid uterus . Alternative therapies such as acupuncture may be helpful in some women. Resistant cases may benefit from treatment by the pain clinic. If no underlying cause is found , reassurance may be sufficient . Psycho-sexual counselling , referral to psychosexual medicine specialist , and support groups such as institute of Psychosexual medicine in woman with a history of sexual abuse is appropriate .
		Posted by Reiaz M. Wed Feb 13, 2008 04:02 pm
a)Likely causes of her symptoms include: Endometriosis, chronic pelvic inflammatory diseases, ovarian cyst, uterine fibroids, irritable bowel syndrome, interstitial cystitis, intra abdominal adhesions. b) The first aspect in the clinical assesment of this patient is taking the history. Adequate time must be allocated and the patient should be allowed to express her concerns and what she thinks may be the cause of the pain. Since her symmptoms may have more than one cause a detailed history is mandatory. It is important to determine the effect that the pain has on her quality of life. The history is aimed at differentiating between gynecological and non gynecological causes. Aspects of the history that would support a gynecological cause include menorrhagia, history of infertility, abnormal vaginal discharge and a history of sexually transmitted infections. A history of prior surgery may suggest either adhesions or nerve entrapment. Gastrointestinal symptoms must be elicited. A diagnosis of irritable bowel syndrome can be made on history alone. The presence of abnormal bowel movements, change in the appearance of stool and pain that is relieved by defecation is suggestice of irritable bowel syndrome. Urinary urgercy and frequency are likely indicators of interstitial cystitis. A history of sexual abuse may indicate a psychological component to the pain. Examination is aimed at determining which patients need further investigation for gynecological disease. An abdominal examination may reveal a pelvic mass and indicate the location of the pain. Bilateral pain is suggestive of PID whereas unilateral pain may suggest an ovarian cyst. Endometriosis may be suspected in cases of a fixed retroverted uterus with nodularity in the Pouch of Douglas. Endometritic deposits may be visualised. The majority of examination will reveal no obvious abnormality. c) The patienst wishes are an important aspect in her management. The patients history will help determne further care. Referral to another specialist eg gastroenterologist, urologist or psychologist may be indicated. If the history and examination suggest a gynecological origin then a transvaginal ultrasouns scan is done. Screening for sexually transmitted infections is also valuable. If the patient is desirous of pregnancy then referral to a reproductive specialist may be indicated. If she is not desirous of pregnancy a trial with a GnRH agonist can be used. Diagnostic laparoscopy is indicated if there is no improvement in her pain. It must be emphasised that no pathology wmay be detected. If the pain is thought to be musculoskeletal, referral to a physiotherapist may help. Amitriptyline or gabapentin is indicated for neuropathic pain. Referral to a pain clinic involving a multidisciplinary approach is helpful. She should be provided with information on chronic pelvic pain and support groups.
		Posted by Anna A. Thu Feb 14, 2008 04:02 am
(a) List the likely causes of her symptoms [2 marks] The likely gynecological causes of her symptoms include pelvic inflammatory diseases (PID), endometriosis, pelvic venous congestion and adenomyosis or fibroid. Non gynecological causes include bowel irritable syndrome (IBS), adhesion and underlying psychological illness. (b) Logically outline your initial clinical assessment [10 marks]. Chronic pelvic pain is associated with underlying cause of gynecological, non gynecological problem and psychiatric illness. It is important to know the nature of her pain especially if it is related to menses and sexual intercourse or certain identified aggravating factor to her pain. The effect of the pelvic pain on her quality of life should be assessed especially her sexual relation to her partner. Associated symptoms include history of intractable per-vaginal discharge or intermenstrual bleeding (may suggestive of pelvic inflammatory diseases) should be obtained. Sexual history should be asked especially the presence of multiple sexual partners. High risk behavior like alcoholic and drugs abuser should be noted. History of sexually abused (during childhood or current condition) should be asked carefully. Bowel or urinary symptoms might suggestive of bowel or cystitis pathology. Previous gynecological problem or any surgery is important factors. The need of contraception or the desire to conceive should be established. Physical examination should stress for the presence of abdominal masses or tenderness. Presence of intractable vaginal discharge or cervical excitation should be noted. Fixity or Retro-verted uterus and presence of nodularity on the uterosacral ligament would suggestive of endometriosis. Tenderness or masses on the adnexal site should be assessed. (c)Evaluate the factors that will influence your subsequent management (8 marks) The underlying pathology of the chronic pelvic pain will have an impact on the subsequent management. Endometriosis can be treated surgically or medically, patient who wish to conceive the main management should be stress on assisted reproductive technique (ART) as hormonal treatment to control her pain will cause a delay for her to conceive. If the patient main concern is only pelvic pain and she requires contraception, therefore the hormonal treatment in a form of combined contraceptive pills is justified. Severe pelvic pain which affect her quality of life should be seen urgently and appropriate treatment should be given promptly. Surgery is justified if there is presence of endometrioma, as this condition respond poorly with medical treatment. Psychiatric referral should be arranged if there is a predominant psychiatric symptom and normal physical examination. Presence of bowel symptom or urinary symptoms would suggestive of IBS or cystitis, therefore referral to surgeon or gastroenterology is justified. History of intractable per-vaginal discharge and chronic pelvic pain may suggestive of PID, a course of broad spectrum antibiotic should be given.
		Posted by Shankaralingaia N. Thu Feb 14, 2008 06:10 am
a)Chronic pelvic pain could be due to gynaecological, bowel related or idiopathic. Gynaecological causes are endometriosis,adenomyosis,pelvic inflammatory disease(PID) and pelvic congestion. Bowel related pain could be due to Irritable bowel syndrome,ulcerative colitis and crohns disease. Adhesions due to previous surgeries,endometriosis or PID may also contribute. b)History taking and understanding women\'s anxities to evaluate the cause of pain is important. I would ask about the nature and severity of the pain whether affecting the quality and any aggravating or relieving factors like pain is relieved after opening her bowel. I would take a detailed menstrual history in terms of whether it is heavy with clots,regular and associated dyemenorrhoea. Ask about the family,number of children,what type of delivery she had if she has had caesarean section to rule out adhesions.I would like to know if she has completed her family and what type of contraception she is using if any.History of termination of pregnancy and dilatation and curettage can cause PID. Vaginal discharge or previous chlamydia infection and treatment is important as it can cause pelvic inflammatory disease. Ask for any abdominal distension,change in bowel habits,constipation and chronic inflammatory conditions like ulcerative colitis and crohns disease. Previous surgeries may cause adhesions and hence pain. Assess socio economic status of the women,any history of sexual abuse as a child,history of depression as pain can be psychological. I would assess general health condition of the women,do a vaginal examination take endocervical and High vaginal swabs to investigate for sexually transmitted infections.Also assess any mass felt in the fornices,tenderness in the posterior fornix or any palpable nodule on the uterosacral ligament and if uterus is mobile or fixed. Document the finding in the notes. c)Severity of the pain,depression,unable to work due to pain has influence on the quality of life and may need attention straight away and could be referred to pain clinic. Previous surgeries may make laparoscopic surgeries risky with associated complications and further surgeries can lead to more adhesions. Fertility issues in terms of whether she has completed her family,if she wants to have more children or infertility problems may influence the treatment options used.For example surgical management of endometriosis is the main treatment in case of infertility management. Other factors to consider is the Body Mass Index,general health condition to assess fitness for surgery if needed.
		Posted by Idris O. Thu Feb 14, 2008 08:45 am
a) The following diagnosis should be considered. 1.Endometriosis, 2. Chronic PID. 3. Pelvic venous congestion. 4.Functional bowel disorders eg irritable bowel syndrome, adhesions. 5. Non gynaecological causes eg interstitial cystitis, musculoketal, neurological, and psychological causes.. b)Cyclical menstrual pain is more likely to be gynaecological but other causes need to be excluded. The pattern of pain and its association with bladder, bowel, or psychological symptoms and effect of movement and posture on the pain. Symptons usually adequate to make a diagnosis of irritable bowel syndrome. Menstrual history to include menorrhagia and regularity of the period. Her obstetric history of parity and number of children. Previous sexual abuse in childhood.Previous STI’s and treatment. Previous pelvic surgery. Severity of the symptoms and the effect on her quality of life. Abdominal examination is necessary to rule out palpable pathology. A distended and tender caecum and sigmoid is sometimes found in irritable bowel syndrome. Pelvic examination may show fixed retroversion, nodularity in the pouch of Douglas, cervical excitation and enlarged adnexae which may suggest endometriosis in the pouch of Douglas and ovary. Urine microscopy showing haematuria may suggest interstitial cystitis. Endocervical swabs for chlamydia and gonorrhoea and Erythrocyte sedimentation rate may be useful in acute on chronic infection. Transvaginal ultrasound may diagnose ovarian endometrioma, adenomyosis or hydrosalpinx suggestive of chronic PID. Barium studies and colonoscopy may be useful in Irritable bowel Syndrome. Conscoius pain mapping may be useful in delineating the site of pain and its relationship to pathology. C) The factors influencing subsequent management include previous treatment and the outcome. The desire of the patient for fertility. The wishes of the patient for contraception. Non response to medical treatment may necessitate further investigations. If the pain is non gynaecological in nature may warrant referral to the appropriate specialists which may be gastroenterologist, urologist or a GUM physician. The absence of pathology may suggest referral to psychologist, psychosexual counselor or pain clinic. The facilities and expertise available for treatment will also influence subsequent management. The desire of the patient for treatment.
		Posted by Maud V. Thu Feb 14, 2008 01:19 pm
A healthy 30 year old woman is referred to the gynaecology clinic because of a 12 months history of pelvic pain, painful periods and pain during intercourse. Her symptoms have not responded to simple analgesia. (a) List the likely causes of her symptoms [2 marks]. (b) Logically outline your initial clinical assessment [10 marks]. (c ) Evaluate the factors that will influence your subsequent management [8 marks]. a) Likely causes are endometriosis, adenomyosis or pelvic inflammatory disease (PID). She could also have pelvic adhesions from previous surgery or irritable bowel disease (IBS). b) A pain history, incuding location, radiation and timing of onset or relief related to her menses, opening her bowels and activity should be taken. She must be asked how the symptoms are effecting her life and her functioning. A menstrual history, including cycle lenght and regularity and any intermenstrual or post coital bleeding must be taken. Type of contraception and any past or present fertility problems must be enquired after. Vaginal discharge, rectal bleeding and haematuria must enquired after as well. A past history of sexually transmitted infections or surgery could suggest adhesions as the cause, while a family history of endometriosis increase the woman\'s risk of having this condition herself. On examination, the abdomen must be palpated for masses and tenderness. On speculum examination, cervical swabs can be taken to exclude infections like Chlamydia and gonorrhoe. A bimanual examintation may reveal a fixed uterus and/or cervical excitation. Occasionally endometriotic nodules may be felt in the posterior fornix. A rectal examination should only be undertaken if there is a history of rectal bleeding. c) A strong history of bowel symptoms, including pain relieved by defecation and constipation, warrants advice on diet and lifestyle and a course of fybogel or mebeverine, with follow up to see whether the symptoms have improved. The gold standard for diagnosing whether there are pelvic adhesions or endometriosis, is laparoscopy. This does have risks and the patient may be keen to avoid surgery. if there is a history of subfertility, surgery should be advised, as ablation and resection of endometriotic deposits improves both fertility and pain symptoms. A transvaginal ultrasound scan may reveal an endometrioma, which is best removed laparoscopically. If there are no fertility issues, a trial of ovulation suppressing medication can be undertaken. Relief of symptoms suggests endometriosis. Symptoms do often return after medication is discontinued. Options are the COCP, which is even more effective if tricycled, or progesterone only medication, either orally or as the IUS. Danazole is also effective, but not advised as first line treatment, because of the side effects of hirsutism. GnRH analogues are effective, but there is a risk of loss of bone mineralisation when used for more nthan 6 months and HRT should be given if it is used that long. If swabs taken show infection, this should be treated with antibiotics. The woman should be explained the various options and information leaflets given so she can make an informed choice. How the symptoms affect her functioning will make the biggest impact on deciding how to manage her.
		Posted by Dr seema jain J. Thu Feb 14, 2008 08:13 pm
a)The likely causes of her symptoms would include endometriosis,chronic pelvic inflammatory disease,adenomyosis,pelvic venous congestion,irritable bowel syndrome,inflammatory bowel disease and adhesions.It is important to keep in mind that there may not be a single cause leading to these symptoms and quite often it may be multifactorial in origin. b)A woman coming with these symptoms of 12 months duration is likely to have visited other doctors and it is important to give her enough time and attention and be dealt with sensitively so that she feels that she has been heard and believed.The aim of clinical assessment would be to identify contributory factors rather than aiming to find a singlr causal factor.Intensity of pain and whether it is affecting the quality of her life is important.Type of pain whether continuous or colicky,exact location,radiation to any area .and its association with posture should be noted.Any bowel or bladder complaints like change in frequency of stool,change in form or appearance of stool and relief from pain following defaecation ,frequency of micturition should be noted.Sexual history to know whether she is sexuallu active,number of partners,any recent change in partner,duspareunia affecting the sex life and history of any sexually transmitted disease should be inquired into.Use of contraception and the mode of contraception should be asked.History of infertility and or any previous pregnancies is important.Factors like depression,anxiety,child abuse and adult abuse should be inquired into in a sensitive manner.Clinical examination should be done to rule out tenderness(abdominal/pelvic) and any mass.Uterine size,mobility .any nodules in the PODand forniceal tenderness should be checked.Screening for Chlamydia and gonorrhoea should be offered. c)The most important factors would be whether she wants to reach a diagnosis , wants only relief from her symptoms,associated infertility or other nongynecological com[ponents of pain.Diagnosis can be aided by a transvaginal scan to screen for and assess adnexal masses and adenomyosis..MRI can be helpful in diagnosis of adenomyosis and any other rare pelvic pathology.Diagnostic laparoscopy can be offered as a second line of treatment with proper counseling that in 30-50% cases no cause may be found.If pain is the only issue then compound analgesics like co-dydramol may be tried.A 3-6 months trial of oral contraceptives or Gn RH analogues or LNG-IUS can be given.Antispasmodics can be tried in women with IBS.If she is interested in fertility and has been trying since last 6 months and if there is a high suspicion of moderate or severe endometriosis ,therapeutic laparoscopy to burn the Endometriotic deposits, followed by ovulation indiction after pretreatment suppression by Gnrh analogues can be offered.If there is any association of nongynecological component of pain prompt referral to a gastroenterologist,genitourinary physician,physiotherapist,urologist or a counselor should be done.Amitryptiline or gabapentin can be offered if there is any neuropathic component.If Chlamydia or gonorrhoea screening is positive,appropriate antibiotics can be given.
		Posted by Shatha A. Fri Feb 15, 2008 02:04 am
a) most likely causes are : endometriosis, pelvic inflammatory disease Adhesions due to previous pelvic operations, GIT & genitourinary related pain , Neuromuscular pain and Psychosexual . b) history including detailed pain history and its relation to menstruation, bowel, urinary or sexual symptoms. Detailed menstrual history (Hx) including duration ,frequency and amount of bleeding and relation of pain to time of menstruation. Hx of associated vaginal discharge& if her symptoms dated to new relationship, also type of contraception used as IUCD may predispose to PID . Surgical Hx especially pelvic operations including previous CS deliveries, also Hx of previous PID especially partially treated PID. Examination will include assessment of general conditions , abdominal examination to exclude abdominal or pelvic mass, pelvic examination will include inspection of the perineum and vulva for presence of secretion , scare tissues for previous badly healed episiotomy .Speculum examination to inspect the vagina for presence of secretion , mass or brownish spots that may suspect endometriosis ,also swabs for gonorrohea and Chlamydia can be taken in addition to HVS .Bimanual pelvic examination to assess the size ,position& mobility of the uterus and to exclude or confirm presence of adnexal mass c) Subsequent management depend on the severity of symptoms and its effect on the quality of life , also depend on the patient?s wishes regarding future pregnancy or contraception use. And also depend on previous received treatment . Trans vaginal Ultrasound is non invasive method which can give idea about presence of pelvic mass or ovarian cyst ( endometriomas) or presence of pelvic collection . Detection of infection like Chlamydia or gonorrhea may confirm diagnosis of PID .laparoscopy is the gold standard investigation that used to diagnose endometriosis or chronic pelvic pain also its used for therapeutic treatment of mild to moderate endometriosis . In this case the most likely diagnosis is endometriosis. Patient information leaflets should be provided . If the woman wants pain symptoms suggestive of endometriosis to be treated with out diffenitive diagnosis a therapeutic trial of hormonal treatment can be started which include adequate analgesia , progestational agents or combined contraceptive pills ,GnRH agonist can be used but its expensive and may cause hypoestrogenic state unless it used with add- back therapy to protect against bone loss, medical treatment can be used for 6 months but recurrence of pain is common after cessation of treatment. The use of levonorgestreal IUS may be effective in relief pain symptoms especially if the woman want also effective contraception. Surgical treatment will include ablation of endometriotic lesions laproscopically, also used to do cystectomy in ovarian endomeriomas . laparoscopic uterine nerve ablation dose not reduce endometiosis related pain relive. If her main issue is infertility laparoscopic ablation with adhesolysis may improve mild to moderate endometriosis. But its role to improve moderate to severe disease is uncertain . Assisted reproduction in form of IUI in mild endometriosis or IVF may be beneficial in case of compromised tubes or in presence of male subfertility
		Posted by Farina A. Fri Feb 15, 2008 02:11 am
1. Endometriosis, 2. Chronic PID, 3. Adenomysosis, 4. Irritable bowel syndrome, 5. Interstitial cystitis, 6. Pelvic congestion syndrome. Initial clinical assessment requires ample time with the patient in a sympathetic manner. Additional history of regularity of menses intermenstrual bleeding and menerrhagia is important as it may suggest the diagnosis of adenomyosis. Her smear history, vaginal discharge, any previous vaginal swabs taken, high risk sexual behavior, use of barrier or intrauterine contraception is important to note as it may suggest pelvic adhesions due to PID. Type character severity and periodicity of pain is essential to know as a dull aching type of pain is more common in endometriosis, chronic PID and pelvic adhesions. Previous abdomino pelvic surgery leads to pelvic adhesion and ovarian entrapment. Bowel and bladder symptom like painful defication,diahroea, constipation, bleeding PR, burning micturation and frequency are important to ask, as irritable bowel syndrome and intesrstital cystitis may present with chronic pelvic pain, dysparunea and dysmenhorrea. Psychosexual and social history is also important in this regard as sexual abuse, depression and anxiety may present with these symptoms. The extent to which these symptoms are affecting her quality of life e.g. absence from work and inability to perform routine work at home is important to note as it will give an idea about the severity of the problem. Superficial dysmennorrhea is more common with local vulval or vaginal causes while deep dysmenorrheal is more likely with PID and endometriosis. On examination any palpable mass per abdomen suggests an etiology like a palpable ovaian endometrioma. Vaginal examination may reveal a tender pelvis with uterine fixity, retroversion or a palpable mass in the adnexia. These findings cannot differentiate between endometriosis and pelvic adhesion due to chronic PID or a tubovarian mass. Presence of nodularity in the pouch of Douglas is highly suggestive of endometriosis. The clinical findings will influence the subsequent management like uniformly enlarge tender uterus with menorrhagia and free adnexia is usually a finding in adenomyosis. A scan preferably transvaginal can be beneficial. A normal sized uterus with tender fixed pelvis and nodularities in pouch of Douglas is suggestive of endometriosis. Larger endometriomas can be diagnosed by ultrasound however diagnostic laparoscopy is the gold standard to diagnose smaller endometrial deposits. History of high risk sexual behavior, STI and vaginitis along with normal sized uterus and a fixed pelvis can lead to a diagnosis of chronic PID, again diagnostic laparoscopy is the gold standard for establishing a diagnosis, vaginal swabs may or may not help. A change in bowel habits, diahrroea, constipation, passage of mucus and blood suggests a referral to gastroenterologist. Once a diagnosis is established, specific treatment like antibiotics for PID and OCP, progestational agents, GNRH analogues and danazol for endometriosis can be prescribed. It is important to know about the fertility wishes of the pt as OCP may be inappropriate for them and laproscopic adhesioolysis is required in case of blocked tubes. It is important to note that diagnostic laparoscopy may not reveal any pathology and the patient should be counseled beforehand.
		Posted by M M A. Sat Feb 16, 2008 04:55 am
a)The most likely causes are endometriosis, adenomyosis, chronic pelvic inflammatory disease, uterine myoma, adhesions, adnexal pathology or ovarian cyst. Also it can be multifactorial due to physical, psychological and social causes. For some women the cause remain unknown. b)We should elicit woman\'s own idea about her symptoms and build a good doctor ?patient relationship, this will improve concordant investigations and treatment. Adequate time is allowed for the initial assessment. We take history about pattern of pain, whether constant persistent or cyclical, cyclical pain goes more with gynaecological disorder, we ask also about severity and if it affects her quality of life and her sleeping pattern. We ask about any provocative factors for her pain or symptoms, association with posture changes, this may reflect musculoskeletal causes. History of infertility or subfertility can be a clue for endometriosis and chronic PID, also history of ectopic pregnancy. Symptoms like vaginal discharge, postcoital bleeding or fever can support the diagnosis of PID. We ask also about cycle regularity and amount of blood loss particularly if there is suspicion of ovarian pathology. We inquire about previous contraception use like combined oral contraception specifically before 12 months as these pill may mask the picture of her disease. Psychosexual and social history also elicited including history of violence. Bowel and urinary symptoms should be excluded also like bleeding per rectum, dichasia or dysuria. We do general examination for her including BMI assessment, significant weight loss can be due to malignancies or genital TB, however, these causes rarely the cause of her symptoms. Abdominal examination is done to reveal if there is any abdominal mass also to assess site of maximum tenderness. We undertake pelvic examination to elicit cervical excitation and adnexal tenderness or masses also take cervical swab for Chlamydia and gonorrhea screening. We advice her to make a pain diary to record time of pain, severity, aggravating factor and its relation to menstrual cycle, this can help reaching the diagnosis. c)Subsequent steps will be according to the possible finding reached via initial assessment. Arrangement for TVS is done if there is Suspicion of endometriosis, lieomyoma or ovarian pathology to help reaching the diagnosis. It can detect also presence of tubo-ovarian abscess or pelvic collection. Features of PID will require screening for Chlamydia and GC, however, negative test doesn\'t exclude the diagnosis of PID and antibiotic should prescribed if there is high index of suspicion. If the pain occurs regularly at specific time of the cycle, we can offer her suppression of ovarian activity for 3-6 months, this can help reaching the diagnosis also she will get improvement if she has heavy period. Her wishes of intending pregnancy or seeking contraception will affect the management. Suspicion of adhesions whether due to endometriosis, pelvic infection or previous operation or the diagnosis still not reached , diagnostic laparoscopy is arranged, it can visualize pelvic cavity and detect endometriosis, although some times ,no abnormality can be detected but if adhesion present we can do adhesiolysis if consent has been taken from the patient. Cystectomy of ovarian cyst or endometrioma can be done also. Swab from both fallopian tubes and from pouch of Douglas for bacteriological examination. If there is no response to pain killers, we do referral for pain management Team or pelvic pain clinic. Presence of feature of bowel, urinary or musculoskeletal disorder, we refer to the relevant clinician. Presence of psychosexual element should consider referral to psychosexual counselor.
		Posted by Dr.Anies S. Sat Feb 16, 2008 06:56 pm
a) Likely causes of these symptoms are endometriosis,adenomyosis,pelvic inflammatory disease,adhesions,adnexal masses ,irritable bowel syndrome,cystitis,musculoskelital pain,nerve entrapement ,social and psychological cause. b)Adequate time should be allowed for initial assesment of this woman with chronic pelvic pain.She needs to feel that she has been listened to and believed. Intial assessment will include detailed history and examination.History includes pattern of pain ,that is location,duration,nature of pain,radiation,aggravating and relieving factors and associated bowel and bladder symptoms.Effect of movement and posture on pain is also ellicited. Past history of any pelvic inflammatory disease,abdominal /pelvic surgeries and infertility is noted. General examination consists of pulse,temperature.Abdominal examination performed to look for tenderness and any masses. Pelvic examination performed making note of any vaginal discharge,cervical excitation,any retroverted fixed tender uterus,adnexal masses and nodularity in adnexa or in postertior fornix.Vaginal and cervical swabs are obtained if there is asuspicion of PID. c)A partnership must be developed between clinician and patient to plan a management programme.A proper counselling of the patient that most of the time it is multifactorial is essential. .Management depends on various factors.Obesity and previous surgeries may pose a problem for laparoscopy which is indicated to look for peritoneal endometriosis and for treatment of adhesiolysis. mangement depends on physical cause of pain and its severity affecting her quality of life and desire for contraception or fertility,as ovarian suppression in endometriosis with hormones for six months reduces pain.Antispasmodics for IBS gives relief and antibiotics for PID. The other factors are social and psychological,social causes like stress due to strained relationships,separation,financial issues play a important role.Psychological issues like depression and sleep disorders when treated improve the outcome. Any past history of sexual abuse should be addressed sensitvely. If pain is due to non-gynaecological causes referral to relevant healthcare professional like gastroenterologist,urologist,genito-urinary medicine physician in case of PID for further management and contact tracing,psychologist,psychosexaual counseller should be considered. Patient\'s informed choice in management is essential.
		Posted by Gulfreen J. Sat Feb 16, 2008 07:43 pm
A)List the likely causes of her symptoms. The causes could be multifactorial, gynaecological or non-gynaecological. Gynaecological causes include endometriosis, adenomyosis, Chronic pelvic inflammatory disease (PID), pelvic venous congestion syndrome, post-surgery or infection adhesions, Fibroid uterus, intrauterine polyp or intrauterine contraceptive device (IUCD). Non-gynaecological causes could be related to gastrointestinal tract (GIT) such as irritable bowel syndrome (IBS), inflammatory bowel disease, diverticular disease or constipation. Urinary tract problems such as Interstitial cystitis, chronic urethral syndrome or calculi may contribute to her problem. Musculoskeletal disorders such as after back injury may cause pain. Finally, psychosocial problems such as past or present sexual abuse or depression may have alter her perception of pain and be responsible for her symptoms. b) Logically outline your initial clinical assessment. Comprehensive history would be taken to elicit the pattern, severity and impact of symptoms on quality of life. Any associated symptoms, aggravating and relieving factors would be determined. Her perception and ideas of her problem and pain would be explored and she would be counseled by giving explanation of her condition supplemented by written information. A relationship of patient-doctor trust and confidence would be established. Complete examination of the patient to elicit any mass, areas of tenderness or guarding in the abdomen would be done. Pelvic examination to detect adenexal masses and tenderness giving attention to rectovaginal pouch would be done. Screening for pelvic infections by endocervical and urethral swabs for Chlamydia and gonnorrhaea would be done and high vaginal swab would be taken at the time of examination. Pelvic ultrasonography (USS) would be done to detect adenexal masses or uterine pathology, pelvic endometriosis may not be visualized. It is non-invasive and sometimes a negative USS itself is reassuring for the patient that there is nothing wrong with her. Urine analysis, full blood count and ESR may point to infection. Diagnostic laparoscopy would be performed with consent to proceed only if there is suspicion of pelvic pathology. It is an invasive procedure associated with risk of bowel, bladder and blood vessel damage and requires general anaesthesia and may not visualize endometriosis in all cases. However a negative laparoscopy may reassure the patient. Patient would be told that Laparoscopic conscious pain mapping is an option if no cause is determined. c) Evaluate the factors that will influence your subsequent management. The management would depend upon the cause of her symptoms determined so far, impact of her problem on quality of life, patient?s wishes, her fertility desires and her ideas and perception of her problem. A multidisciplinary approach involving a pain specialist, physiotherapist, psychiatrist, gastroenterologist, urologist or genitor-urinary (GUM) specialist would employed as required. She would be given written information and would be involved in decision making. If a gynaecological cause is determined it is recommended that a 3 months trial of medical hormonal treatment to suppress ovulation should be given before resorting to surgical treatment. If endometriosis is diagnosed medical treatment for 3-6 months would be done with Gonadotrophin releasing hormone (GnRH) analogues, combined oral contraceptive pill (COC), medroxyprogesterone acetate (MPA), gestrinone or danazol. These are equally effective but vary in side effect profile and choice would depend upon her tolerance of the drug used. Surgical treatment for ovarian endometrioma as laparoscopic cystectomy or removal of endometriotic deposits from pelvic by laparoscopic excision, electro-coagulation or laser may result in relieve of her symptoms. Adhesiolysis for adhesions due surgery, infection or endometriosis may not be effective in all cases. Adenomyosis may respond to GnRH analogues or MPA but definitive treatment is hysterectomy, which would not be recommended for her. Pelvic congestion may also respond to hormonal treatment or psychotherapy. Antisposmodics and diet therapy is effective for IBS and may reduce her symptoms. Interstitial cystitis would be diagnosed on cystoscopy and intravesical injection of dimethyl sulfoxide may be tried. Dilatation of urethra may treat chronic urethral syndrome. Laparoscopic uterosacral nerve ablation or presacral neurectomy may be may reduce her pain refractory to other treatments, but she must be explained that even this may not completely relieve her symptoms. Antidepressants and psychotherapy would be recommended if a psychological cause is responsible for altered perception of pain without giving her a feeling that it is all in her head.
		Posted by S D. Sat Feb 16, 2008 09:12 pm
a) Likely causes include : Endometriosis Fibroid uterus Adenomyosis Irritable bowel syndrome Chronic PID b) I would enquire about the nature and site of pain, any radiation of pain and its relation to menstruation. Duration of menstrual cycle, any IMB / PCB, any dyspareunia (whether superficial / deep) is also asked. History of chronic vaginal discharge, urinary and bowel problems, current contraception and previous obstetric history is also important. I would also ask about any medical disorders such as inflammatory bowel disease which might con tribute to the pain. Any previous surgeries which might cause adhesions. I would also enquire sensitively about any relationship problems and sexual abuse and assure her of confidentiality. I would then perform an abdominal examination for any pelvic masses and tenderness. Speculum examination to take HVS, endocervical swabs for chlamydia and gonorrhea. Bimanual examination for the size of uterus, mobility and tenderness and also adnexal masses and tenderness. c) The main factors are the woman\'s desire for future fertility, the predominant symptom affecting her quality of life, the results of investigations and the woman\'s preferences. If the woman wants a definitive diagnosis, then laparoscopy should be performed if there is a strong suspicion of endometriosis/adhesions and diathermy or adhesiolysis should be performed accordingly. If ultrasound and clinical examination is normal, then tranexamic acid and mefenamic acid can be used if she wants to have children. Otherwise she can be given the option of OCP, Mirena IUS / GnRH analogues which are equally effective in relieving the pain. If swabs suggest STI, then she should be referred to GUM clinic for treatment and contact tracing. If sexual abuse is suspected, then appropriate counselling and psychological support should be provided.
		Posted by Azza S. Sat Feb 16, 2008 10:04 pm
a) Gynaecological causes include chronic pelvic inflammatory disease [PID], endometriosis, adenomiosis, and an endometrial polyp or a fibroid polyp, . Gastro-intestinal causes include irritable bowel syndrome, inflammatory bowel disease , diverticuler disease and colo-rectal cancer. Urogenic causes as interstitial cystitis ,and chronic urethral syndrome. Musculoskeletal causes. Psycho- sexual causes. b) A detailed history about nature of pain, relation to cycle, defecation, urination or movement. The effect of pain on her working, social and sexual live. Menstrual history regularity and the amount of loss. Contraception history. Obstetric history and her future plan. A previous history of sexually transmitted disease, PID or pelvic or abdominal surgery. Sexual history, any history of sexual abuse. Urinary or bowel symptoms. Her views about her pain should be noticed. Medical history may be relevant e.g. depression. Examination of abdomen for mass, scars. A pelvic examination for cervical excitation, adnexeal tenderness or mass. The size of the uterus, position and mobility. The presence of nodules or endometriotic deposits. Swabs should be collected for Chlamydia, gonorrhea and bacterial vaginosis. Serum CA125 may be raised but it is not specific. Ultrasound may be requested in case if a mass is felt but it is poor in detecting fibrosis or endometriosis. MRI may be of help with regard to endometriosis and adhesions. Laparoscopy is gold standard and a positive pathology may be found in up to 83% of cases. c) A negative laparoscopy may be reassuring for many women and they may control their pain with simple analgesics. The most common finding at laparoscopy is adhesions and adhesionlysis is found to be infective compared to a diagnostic laparoscopy. Second common finding is endometriosis, which can be treated medically or surgically. In case of history of sexual assault a referral to a psychosexual counselor is needed. A referral to pelvic pain clinic for better control of pain may be needed.
		Posted by K P. Sun Feb 17, 2008 03:30 pm
Causes include gynaecological and non gynaecological. Given the history, gyanecological causes such as endometriosis, adenomyosis, pelvic inflammatory disease and pelvic masses are more likely. However non gynaecological causes such as irritable bowel syndrome, interstitial cystitis, musculoskeletal and psychological causes should be considered. I would obtain a history and examine the patient. I ask about the nature of the pain, exacerbating and relieving factors and whether it is related to her periods or occurs at other times. I would also ask if she can identify any trigger factors for her pain. I would obtain a mentrual history - regularity of her cycle, length of the cycle. I would also ask if she has heavy periods. I would ask if she has intermentrual bleeding or post coital bleeding which could suggest a history of PID. I would obtain a detailed sexual history - whether she has a regular partner, the number of partners she has had in the last 6 months, whether she uses condoms regularly and whether or not she has had any sexually transmitted infections in the past. With regards to painful intercourse, I would ask her if it is superficial or deep and whether it is positional. I would also elicit if she has had any pregnancies and the outcome of these. Relevant past medical history include previous abdominal surgery which could suggest adhesions. I would ellicit if she has any urinary symptoms (frequency, dysuria, urgency, haematuria) and bowel symptoms such as dyschezia and PR bleeding as these could suggest non gyane pathology but also endometriosis involving bowel or bladder. Her wishes with regards to future pregnancy and fertility is also important as it would dictate management.I would do an abdominal examination,looking for scars or large pelvic masses palpable abdominally and evidence of pain. I would perform and vaginal and speculum examination with consent and a chaperone, looking for evidence of vulval or vaginal lesions which can cause superficial dysparaeunia. I would look for evidence of vaginismus, offensive discharge, evidence of STI (warty lesions, herpetic lesions) , size of uterus, wheter there are adnexal masses, a fixed retroverted uterus and uterosacral nodules could suggest endometriosis. I would also ascertain if she is tender or vaginal examination.Initial investigations, would be urinalysis and MSU, high vaginal and endocervical swabs and a transvaginal ultrasound scan. My subsequent management would depend on the history and examination. The patient\'s wishes is important and she needs relevant information to make an informed decision. I would explain that heavy periods, with pelvic pain and dysparaeunia without evidence of a pelvic mass is suggestive of endometriosis. There are medical and surgical options for treatment of endometriosis. Medical options such as the COCP if she has no contraindications are effective in reducing pain related to endometriosis. Progestogens taken from day 5 - 26 are also effective in reducing pain related to endometriosis. However luteal phase progesterone is not effective. She can also have the MIRENA coil inserted as this can reduce pelvic pain. GnRH analogues are also an option, to reduce pain. I would explain that these methods are only suitable if she is not considering a preganancy. I would also explain the side effects of these methods which indluce breast tenderness, mood swings and acne for progesterone only methods, irregular bleeding with the MIRENA and menopausal symptoms with the GnRH analogues. If she is considering a pregancy or there is evidence of pelvic pathology I would explain the benefits of a laparoscopy. This would enable us to remove cysts (if present) and is the gold standard in investigating endometriosis. Mild lesions can be removed at the initial day case procedurehowever if she has significant endometriosis, she may require adhesiolysis and removal of endometriosis which would require inpatient stay. I would warn her of the risk of laporoscopy which are bleeding, perforation of bowel, bladder and blood vessels and infection. I would also warn her that there is a chance of not finding anything on laporoscopy. If there is evidence of sexually transmitted infections from the swabs, I would treat her for this. Vaginismus can be treated with vaginal dilators and physiotherapy. If there are evidence of bowel symptoms I would refer her to a dietician and gastroenterologists. Similarly if there is urinary pathology she may warrant a review from the urologist.Psychological factors will also be borne in mind and if present counselling, and support groups would be useful. I would provide her with written information of all these.
		Posted by rachael L. Thu Feb 21, 2008 07:55 am
(a) Likely causes of her symptoms are: Endometriosis Adenomyosis Chronic pelvic inflammatory disease Dense vascular pelvic adhesions Sexual abuse in the past or ongoing Irritable bowel syndrome Interstitial cystitis (b) Clinical assessment will include the history and examination. In the history enquiries should be made about whether her cycles are regular and if she has observed a cyclical pattern to the pain episodes. I will find out about whether her period pain starts prior to or with the onset of her period. In addition, I would like to know whether the dypareunia persists after sexual intercourse. I would also ask if there is associated menorrhagia, intermenstrual bleeding or abnormal vaginal discharge. Any history of previous diagnosis of acute pelvic inflammatory disease should be noted. It should be noted whether she has had cervical smear tests and whether these are up to date. Enquiries regarding her method of contraception should be elicited. Associated gastrointestinal symptoms such as bloating, change in frequency and consistency of stool should be noted. Urinary frequency or urgency should also be documented. Her past obstetric history should be noted especially if she has had previous caesarean sections. A past history of abdominal or pelvic surgery should be documented. Drug history should include what analgesia and how regularly this has been required or taken. Sensitive enquiry should be made about past or ongoing sexual abuse. A note should be made about how her symptoms are affecting her relationship with her partner, family life, socially and her work. Examination would include noting whether she is in obvious pain. On abdominal examination surgical scars, presence of mass arising from the pelvis and any abdominal tenderness and site of tenderness should be noted. Speculum examination should be performed looking for presence of vaginal discharge and any cervical polyps or spots of endometriosis. Bimanual examination should be performed and note taken of presence of cervical excitation tenderness; the size, mobility of the uterus and whether it is tender; adnexal tenderness or masses and whether unilateral or bilateral and the presence of nodules or tenderness over the uterosacral ligaments. (c) The factors that need to be taken into consideration include provision of adequate analgesia, from the initial assessment what are the most likely causes of her pain and whether further investigation is required or a trial of therapy is appropriate and also whether she has further reproductive ambitions and if so whether she would like to conceive soon. The patient should be fully informed of her options and her wishes taken into account. If she has not optimised use of simple analgesia then she should be advised on how to do so. Investigation and appropriate treatment of underlying cause should be initiated. If this fails to provide satrisfactory relief the referral to the pain team can be considered. Amitryptilline and gabapentin are treatments that can be considered at this level. If endometriosis is suspected then an ultrasound scan can be arranged to rule out presence of endometrioma. If this is ruled out and the patient has no immediate desire to conceive then a therapeutic trial to cause suppression of ovarian cycles may be appropriate. She may be offered the COCP, progestagens or GnRH agonists Invasive investigations can be avoided if this is successful. . The disadvantage is that if unsuccessful then diagnosis is delayed. If this fails then a laparoscopy can be offered. This is a sensitive test for detecting peritoneal disease and adhesions, provides an opportunity for treatment of endometriosis and adhesiolysis. However it is an invasive test with risk of significant complications. If the patient would like to conceive or suspected endometrioma then ovarian suppression is not appropriate or effective and laparoscopy should offered for treatment and a dye test for tubal patency can be performed. If chronic pelvic inflammatory disease or pelvic adhesions are suspected then laparoscopy and adhesiolysis of dense vascular adhesions may be effective for treating symptoms. Further courses of antibiotics for chronic pelvic inflammatory disease are not effective. If IBS is suspected then a tiral of antispasmodics such as mebeverine will provide effective treatment. Referral to the gastroentelogist can be considered. If there is suspicion of interstitial cystitis then cystoscopy can be arranged.