Transcript Ovarian Tumours

Chronic Pelvic Pain
Max Brinsmead MB BS PhD
May 2015
Definition and Incidence
Intermittent or constant pain in the lower
abdomen or pelvis for >6 months
– With or without menstruation
– Can be coital or postcoital
– Not associated with pregnancy
Is as common as low back pain or headache
Approach
Patient needs to feel that she is being taken
seriously
Give her time to tell her story
A single diagnosis at initial presentation is often
impossible
The cause of the patient’s dis-ease is often
multifactorial...
So attempt to list all these possible factors
And aim for an explanation or process of
management for the patient
The Short List
Endometriosis
– External (peritoneal)
– Adenomyosis (intra uterine)
Pelvic Congestion/Ovulation sensitivity
Chronic PID
Irritable Bowel Syndrome/Interstital
Cysitis
Musculoskeletal
– Includes the pelvic floor muscles
Post inflammatory or Postsurgical
– Adhesions
– Nerve entrapment
Psychological and Social Factors
Depression
• May be secondary to the pain
• Check sleeping patterns
• Libido and sexual activity
Sexual and physical abuse
• Complex
• May be problems of self esteem
Other family/inter relationship issues
Drug use and abuse
• Smoking
• Other drugs
History
If there is a strong cyclical component to the pain
it is likely to be of reproductive tract origin
Nature of the pain may be useful
• Localised, sharp or stabbing suggests neuropathic cause
How much does it interfere with daily life, work,
sleep and sexual function?
Careful bowel and bladder history
Relationship to posture and activity
Unlocking psychosexual history or dysfunction
can be difficult
More History
Sexual and contraceptive history
Past surgical and gynaecological history
Reproductive history
Family History
• Endometriosis
• Hysterectomy
• Cancer
Examination
Examine the abdomen, PV +/- PR and also
lower back and sacro-iliac joints
Look for tenderness, enlargement,
distortion or tethering
Prolapse
Any trigger points?
• Including those in the pelvic floor
Investigations
Screen sexually active for STD
Ultrasound useful for assessing enlarged uterus
and adnexal mass
– But has a limited role otherwise
MRI little better except in the detection of deep
rectovaginal endometriosis
Diagnostic Laparoscopy
– Risks and benefits should be discussed
– Should not be a reason for gynaecological absolution
– Much controversy about the Dx of endometriosis
CA125 – for bloating, early satiety and those >50
Management
If not clearly gynaecological in origin then it should
be MULTIDISCIPLINARy
If the pain is cyclical then trial hormonal Rx for 3m
before laparoscopy
• COC, Progestins, Danazol or Mirena
Trial antispasmodics for suspected IBS + diet
modification
• Mebeverine plus bulking agents
Multidisciplinary approach to pain management
• Regular NSAID, Compound analgesics, Amytriptaline/Gabapentin,
Counselling, Hypnotherapy , Self-help groups etc
Any Questions or Comments?
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