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 cystitis | IBS irritable bowel syndrome | Pelvic floor dysfunction | pudendal nerve entrapment | Endometriosis | |
| Pain | Pain worsens as bladder fills and improves after voiding | Rome 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 symptoms | Urgency Hesitancy Frequency dyspaurenia | Pseudo-weakness of the involved muscles and reduced range of motion | Genital numbness, urinary/faecal incontinence | dyspareuniadysuria, haematuria, urinary frequency (if bladder involvement) | |
| Signs | Tenderness at bladder base | Normal examination | Levator 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 pain | tender retroverted uterus, tender nodules and masses in pelvis, implants in uterosacral ligaments |
| Investigations | 24 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) |
| Treatment | See below | Dietary 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 |