GYNECOLOGY

Dysmenorrhea

  • primary/idiopathic
  • secondary (acquired)
    • endometriosis
    • adenomyosis (ectopic endometrial tissue within the musculature of the uterus)
    • uterine polyps
    • uterine anomalies (e.g. non-communicating uterine horn)
    • leiomyoma
    • intrauterine synechiae
    • ovarian cysts
    • cervical stenosis
    • imperforate hymen, transverse vaginal septum
    • PID
    • IUD (copper)
    • foreign body
 BPS/ interstitial cystitisIBS irritable bowel syndromePelvic floor dysfunctionpudendal nerve entrapmentEndometriosis
PainPain worsens as bladder fills and improves after voidingRome criteria:
-Continuous/recurrent abdominal pain, relieved with defaecation/ associated with change in frequency/consistency of stool+/- disturbed defecation

(2 or more of: altered stool frequency/ consistency/ passage of stools (straining/ urgency/tenesmus)/ passage of mucus

Usually with bloating

Exclude red flag symptoms: (significant weight loss, nocturnal symptoms, bloody diarrhoea, family history of colon cancer,
new onset of symptoms in patients >50 years)

More commonly suffers from concomitant chronic fatigue syndrome, fibromyalgia, depression, anxiety
Well-localised, aching and deep in nature,focal point tenderness

Associated with
– obesity
– Menopause.
– pregnancy
– childbirth
– inherited collagen deficiency
Pain is positional (worsened by sitting, relieved by standing, absent when recumbent)

More common in competitive cyclists, after pregnancy, trauma, surgery due to scarring
Perimenstrual lower abdominal pain
Associated symptomsUrgency
Hesitancy
Frequency
dyspaurenia
Pseudo-weakness of the involved muscles and reduced range of motionGenital numbness, urinary/faecal incontinencedyspareuniadysuria, haematuria, urinary frequency (if bladder involvement)
SignsTenderness at bladder baseNormal examinationLevator muscle spasm, myofascial pain elicited by pelvic floor muscle palpation (PMP) and the forced flexion, abduction and external rotation test (fFAER)Palpation of the ischial spine may produce paintender retroverted uterus, tender nodules and masses in pelvis,
implants in uterosacral ligaments
Investigations24 hr voiding diary,Urinalysis,urine cytologyTo establish

diagnosis:
Cystoscopy with hydrodistention of bladderIntravesical anaesthetic challenge
Diagnosis of exclusion
investigations to rule out organic causes e.g.
– lactose intolerance (Hydrogen breath test)
– coeliac disease (coeliac serology),
– small bowel bacterial overgrowth –
– colorectal cancer (colonoscopy + biopsy for patients over 50 years or <50 with red flags)
EMG: to measure motor latency along the pudendal nerve
(a greater than normal conduction delay indicates nerve entrapment)

MR neurography: asymmetrical swelling and hyperintensity in the
affected pudendal neurovascular bundle
Laparoscopy +biopsy for visualisation of lesions + histological
confirmation 

(false +: endosalpingiosis, malignancies, carbon
deposits from previous ablations)
TreatmentSee belowDietary modification (high-fibre diet, increase fluid intake)
Psychotherapy (CBT, stress management)
Antispasmodics
Tricyclics or SSRI
Physiotherapy e.g. Pelvic floor exercise, muscle relaxants,
electrical stimulation to increase muscle tone, biofeedback
Behavioral modification, physical therapy (stretching exercises),
analgesics, medication for neuropathic pain (gabapentin, amitriptyline),
pudendal nerve block, surgical decompression, pulsed radiofrequency
Medications:
Analgesics: NSAID, HRT (COCP), progestins
Danazol, GnRH

Surgery: laparoscopy + ablation of endometriosis or hysterectomy
with bilateral salpingo-oorphorectmy

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