How to Cure Chronic Pelvic Pain
Endometriosis of the vulva is uncommon, and most likely to occur in scars such as episiotomy scars (15) or may occur secondarily to implantation of endometrial tissue after a surgical procedure or trauma (Fig. 7A-C). It has also occurred within the Bartholin's gland (16). There is cyclical symptomatology, including pain and dyspar-eunia. Grossly, the lesions appear as firm nodules that may have a blue cast to them. Histologically, the diagnosis is confirmed by the presence of endometrial glandular epithelium and stroma (Table 7).
Figure 7 Endometriosis. (A) (See color insert) Grossly endometriotic implants on the vulva often have a blue appearance. (B,C) The criterion for definitive diagnosis of endometriosis histologically is the presence of endometrial glandular epithelium and stroma. In (B), actual glands are formed, while endometrial-type epithelium is seen lining a space in (C). Endometriosis, vestibulitis Table 7 Endometriosis Table 7 Endometriosis Endometriosis
The poor outcome with needle suspension procedures leads to efforts to combine the advantages of the needle suspension approach with the strength and durability of sling procedures. Materials used for slings vary but early attempts to use synthetic material were plagued by voiding dysfunction, obstructive uropathy, erosion into the urethra or bladder, vaginal bleeding, dyspareunia, pelvic pain, osteitis pubis, and occasionally osteomyelitis. These rather serious problems occurred with Gore-Tex slings, Vesica slings, and with various materials used for slings where bone anchor fixation of the device was utilized 29, 30, 31 . Other materials used for slings can be dealt with in exactly the same manner as described for autologous fascia. The exception is in those cases where bone anchors have been placed transvaginally into the posterior surface of the symphysis. These can become infected vaginal granulation tissue can develop, together with severe pelvic pain. This may result from...
The primary symptom of Trichomonas vaginitis is severe pruritus, irritation, and, often, vulvar dysuria, accompanied by a grossly and microscopically purulent vaginal discharge. Sometimes, pelvic pain is present. The severity of disease varies widely, with some patients exhibiting fairly mild symptoms and signs. The infected male partner is usually asymptomatic. A physical examination reveals deep redness of the introitus, vagina, and cervix, classically but nonspecifically and unpredictably producing a strawberry cervix.'' This finding is characterized by a red cervix covered with monomorphous, discrete, bright-red, tiny papules. Vaginal secretions are most often described as yellow and frothy. Microscopically, vaginal secretions show small (about the size of white blood cells), rapidly moving, teardrop-shaped, flagellate organisms that quickly lose motility and distinctive shape as they cool. In addition, very large numbers of neutrophils are present and lactobacilli are absent,...
A 19-year-old nulligravida presents to the emergency room with bilateral lower abdominal pelvic pain. The onset was 24 h ago after she had just finished her menstrual period. She is sexually active but using no contraception. Speculum examination reveals mucopurulent cervical discharge. Bimanual pelvic examination shows bilateral adnexal tenderness and cervical motion tenderness. She is afebrile. Her qualitative urinary p-hCG test is negative. Complete blood cell count (CBC) shows a WBC of 14,000. ESR is elevated. Symptoms. Bilateral lower abdominal-pelvic pain may be variable ranging from minimal to severe. Onset may be gradual to sudden, often after menses. Nausea and vomiting may be found if abdominal involvement is present. Differential Diagnosis. Adnexal torsion, ectopic pregnancy, endometriosis, appendicitis, diverticulitis, Crohn disease, and ulcerative colitis. Symptoms. Chronic bilateral lower abdominal-pelvic pain is present, varying from minimal to severe. Other symptoms...
The answer is a. (DeCherney, 8 e, pp 668-669.) The most common cause of postmenopausal vaginal bleeding is atrophic vaginitis (with or without trauma). Endometriosis is the most common cause of infertility patients present with dyspareunia (painful intercourse), abnormal vaginal bleeding, and pelvic pain. Uterine leiomyomas (uterine fibroids) change in size with the menstrual cycle but regress in size during menopause. Often the fibroid is palpable on pelvic examination. Polycystic ovarian syndrome (Stein-Leventhal syndrome) affects younger women (15-30). The etiology of polycystic ovary syndrome is unknown patients present with amenorrhea, obesity, hirsutism, and infertility. All postmenopausal women with vaginal bleeding require a biopsy to rule out endometrial carcinoma.
The answer is c. (Hoskins, 2le, pp 928-930.) Serous carcinoma is the most common epithelial tumor of the ovary. On histologic examination, psammoma bodies can be seen in approximately 30 of these tumors. Bilateral involvement characterizes about one-third of all serous carcinomas. Although mesonephroid carcinomas tend to be associated with pelvic endometriosis, a similar association has not been demonstrated for serous carcinomas.
Imperforate hymen is usually diagnosed on routine examination of the neonate. It may present in the neonate with a lower abdominal swelling due to accumulated secretions or in the teenager with delayed menarche, urinary retention, or pain (Fig. 21). Severe endometriosis due to retrograde menstruation may complicate untreated imperforate hymen. Rarely, there may be associated lower urinary tract or anorectal congenital maldevelopments.
Bacterial folliculitis, 86 Bacterial infections, 77-93 Bacterial vaginosis, 3, 84 diagnosis, 84, 92 risk factors, 84 therapy, 84, 92 Bartholin's adenocarcinomas, 160 Bartholin's duct cyst, 135-136 Bartholin's glands. See Vestibular glands Basal cell carcinoma, 166 Basal layer hyperpigmentation, 114 Basaloid lesions, 158 Behcet's syndrome, 53-54 Behcet's disease, 7 Benign nevi. See Melanocytic nevi Benign tumor-like lesions endometriosis, 139-140 (ELND), 124 Endometriosis, 139-141 Epidermophyton floccosum, 97 Epithelial lesions Figure 6.7 Endometriosis. (A) Grossly endometriotic implants on the vulva often have a blue appearance. (See p. 141)
Leiomyoma may also cause pelvic pain, either through a mass effect, or by the spontaneous necrosis of the tumor. Acute onset pelvic pain may occur when a myoma either outgrows its blood supply, producing a necrotic central core, or when a pedunculated fibroid undergoes torsion on its stalk and becomes ischemic. Pelvic discomfort, pressure, or pain may also result from compression of adjacent organs by an enlarging fibroid uterus. Urinary frequency and constipation may result from compression of bladder or bowel, respectively.
Ascending spread of C. trachomatis from the endocervical canal to the endometrium, fallopian tubes, and peritoneal cavity is the most serious complication of both asymptomatic and symptomatic chlamydial infection in women. The organism is capable of inducing a plasma cell endometritis, acute and chronic salpingitis, and full-blown peritonitis with associated perihepatitis (Fitz-Hugh-Curtis syndrome) and periappendicitis. Infected pregnant women are at risk of developing late post-partum endometritis. Resolution of these upper genital tract infections may result in chronic pelvic pain, tubal infertility, or ectopic pregnancy. However, a body of evidence has accumulated that the majority of cases of chlamydial salpingitis are symptom-free and that these cases of so-called silent PID may contribute significantly to tubal infertility.28
Sacral nerve stimulation may work in a similar fashion, but also affects the nervous system through direct stimulation of unmyelinated C-fiber sacral nerve afferents, which have a much higher threshold of stimulation than the myelinated A-delta fibers. It is certain that these nerves play an important role in abnormal bladder activity and in syndromes with pelvic pain (10). Because SNS devices are implanted, they can continue to modulate abnormal reflex activity even if the patient is incapable of conscious behavioral change, or if the changes in the CNS are otherwise permanent.
Indications for IVF include severe tubal dysfunction, endometriosis, an-tisperm antibodies, oligospermia, and infertility of unexplained origin.16 Assisted fertilization is indicated if the probability of conception by IVF exceeds the likelihood of successful conception using conventional means.
Sexual abuse during childhood, especially incest, is linked to potentially devastating consequences in women that may not be recognized until middle age. These women may present with comorbidities of substance abuse, eating disorders, depression and other psychiatric conditions, as well as somatic symptoms, particularly chronic pelvic pain and gynecological complaints.39 The lifetime prevalence of PTSD is greater in women (12.5 ) than in men (6.2 ).38
Retrospectively, symptoms have been reported by 78 of patients with early tumor diagnosis, including abdominal pelvic pain (35 ), bloating (32 ), and vaginal bleeding (19 ).26 Clinicians providing primary care to women will recognize that abdominal and pelvic complaints are common. Diagnostic investigations in the setting of the above symptoms may be more properly considered case-finding than screening, and the yield of an ovarian cancer diagnosis may be low compared with other diagnoses. The finding of a symptomatic or asymptomatic pelvic mass on routine examination always bears further investigation, but confounding factors that may make detection of masses difficult include obesity and coexisting uterine fibroids. In general, ovaries should not be readily palpable in the menopausal woman, and any ovarian enlargement should be considered suspicious until proven otherwise.
Diseases such as endometriosis, pelvic inflammatory disease, ovarian cysts and tumors, uterine fibroid, and cancer can be diagnosed through the use of pelviscopy. The pelviscope can also be used to identify the causes of infertility and pelvic masses.
The pleura due to the infection or tumor. The incidence of parapneumonic pleural effusion is dependent upon the organism 10 of pneumonias caused by pneumococci can cause parapneumonic effusion. Fifty percent of pneumonias caused by staphylococci can cause effusion. Exudates have increased protein, increased LDH, and increased ratios. Bilateral effusions are usually transudates. Unilateral effusions are most often exudates left-sided effusions occur due to rupture of the esophagus, dissecting aneurysm, or traumatic injury to the aorta. Pancreatitis also typically leads to left-sided effusion. Pleural thickening and enhancement on CT usually indicates an exudate. Pleural fluid with an inhomogeneous appearance suggests a hemo-thorax its causes include trauma, malignancy, embolism, and, rarely, pleural endometriosis. Imaging is helpful, but thoracentesis is the mainstay in the diagnosis because the composition of the fluid suggests its etiology. Chylo-thorax refers to effusion containing...
A 38-year-old female presents with intermittent pelvic pain. Physical examination reveals a 3-cm mass in the area of her right ovary. Histologic sections from this ovarian mass reveal a papillary tumor with multiple, scattered small, round, laminated calcifications. These structures are most likely the result of
The answers are 143-b, 144-d. (Holmes, 3 e, pp 1081.) Chlamydia trachomatis is the most frequently reported bacterial sexually transmitted disease (STD) in the United States. Infections of the cervix may present as a friable cervix, but are most often without signs or symptoms. Pelvic inflammatory disease (PID) caused by chlamydia often presents with milder symptoms than when it is caused by gonorrhea. Prompt treatment reduces the occurrence of long-term sequelae such as infertility, ectopic pregnancy, and chronic pelvic pain. The risk of infertility appears to be higher for chlamydial infections compared to any other STD. Screening women is important to reduce the risk of PID and its sequelae.
Primary TB is transmitted by infected airborne particles and usually results in mild pneumonic illness that frequently is unnoticed. Following initial infection, a latent phase ensues. By the time genital disease arises, the primary infection site has healed. Rarely, primary infection by sexual transmission or contact may occur. The fallopian tubes are infected in almost 100 of genital tract cases. This is followed by the endometrium in approximately 50 of cases, the ovaries in about 20 of cases, the cervix in 5 of cases, and the vulva and vagina in less than 1 of cases (27). Clinically, patients with genital disease present with infertility, pelvic pain, or abnormal uterine bleeding. Menstrual irregularities occur secondary to direct effects on the endometrium as well as an antagonistic effect on gonadotrophic function. Generally, both fallopian tubes are severely affected. In the endometrium, significant scarring disease may mimic Asherman's syndrome. On the vulva, TB manifests as a...
A 27-year-oid woman comes to the emergency department because of severe abdominal and pelvic pain for the past 12 hours. She says she has two sexual partners that she has been with for years. She is not sure if they are involved with any other women. Her last menstrual period was 4 days ago, and it was normal. She denies any rectal pain or change in bowel habits. Physical examination shows cervical motion tenderness, bilateral lower abdominal tenderness, and right-upper quadrant tenderness. Which of the following is the most likely diagnosis A. Endometriosis 2. A 32-year-old woman comes to the physician with her husband because she just can't seem to get pregnant. They have been unsuccessfully trying to conceive for the past 14 months, having unprotected sexual intercourse during her fertile days. Her menstrual periods arrive at regular 28-day intervals, but they are accompanied by severe abdominal cramps. She says that often experiences rectal pain during defecation and pelvic pain...
After a thorough assessment of a patient's presenting symptoms, the history should then focus on related areas. There are several aspects of a patient's history that may be intimately related to voiding function. Sexual and bowel dysfunction are often associated with voiding dysfunction. Therefore the review of symptoms should focus on these areas including defecation (constipation, diarrhea, fecal incontinence, changes in bowel movements), sexual function, dysparunia, and pelvic pain. As neurological problems are frequently associated with voiding dysfunction, a thorough neurological history is critical, including known neurologic disease as well as symptoms that could be related to occult neurological disease (back pain, radiculopathy, extremity numbness, tingling, or weakness, headaches, changes in eyesight, and so on). In addition to a focused history regarding LUTS and voiding dysfunction, a thorough urological history is important. This includes a history of hematuria, urinary...
Interstitial cystitis is a type of cystitis in which the tissues below the mucosa are inflamed. Symptoms include pelvic pain with discomfort before and after urination. This disease can be diagnosed only with the use of a cystoscope (a kind of endoscope).
A prospective, population-based study (the Iowa Women's Health Study) did not find an increased risk of ovarian cancer in women with endometriosis,17 but endometrioid and clear-cell ovarian carcinomas may originate in endometriosis,18 probably caused by somatic mutations in the PTEN tumor-suppressor gene.19
Culdoscopy is an endoscopic procedure in which the physician is able to visualize the cul-de-sac of Douglas using an endoscope called a culdoscope. The culdoscope is passed through a small surgical incision made into the posterior vagina. This procedure permits the physician to examine the uterus, ovaries, fallopian tubes, pelvic ligaments, rectum, and sigmoid colon. The pelviscopy, which provides better visualization with fewer risks, has replaced the culdoscopy as the procedure of choice when examining reproductive organs. Culdoscopy continues to be used with women who are extremely obese, especially for tubal ligation. It is useful in assessing ectopic pregnancy, fertility abnormalities, and pelvic pain.
51 Tips for Dealing with Endometriosis
Do you have Endometriosis? Do you think you do, but aren’t sure? Are you having a hard time learning to cope? 51 Tips for Dealing with Endometriosis can help.