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Pelvic Pain, PID/STDs, Dsypareunia, Vaginal Discharge

Pelvic Pain, PID/STDs, Dsypareunia, Vaginal Discharge. Dr Barbara Kerkhoff Consultant Obstetrician Gynaecologist Clinical Senior Lecturer. Lecture plan. Chronic/ acute pelvic pain Endometriosis Pelvic inflammatory disease STDs Vaginal discharge Dyspareunia. Pelvic pain. Acute pain

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Pelvic Pain, PID/STDs, Dsypareunia, Vaginal Discharge

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  1. Pelvic Pain, PID/STDs, Dsypareunia, Vaginal Discharge Dr Barbara Kerkhoff Consultant Obstetrician Gynaecologist Clinical Senior Lecturer 2/2/2011

  2. Lecture plan • Chronic/ acute pelvic pain • Endometriosis • Pelvic inflammatory disease • STDs • Vaginal discharge • Dyspareunia 2/2/2011

  3. Pelvic pain Acute pain intense and characterized by the sudden onset, sharp rise, and short course. Chronic pelvic pain Pain of > 6 month in duration with at least 2 weeks duration/ month Localized to the anatomical pelvis Severe enough to cause functional disability or necessitating medical care 2/2/2011

  4. Chronic Pelvic Pain • Prevalence: 38/1,000 in primary care populations (asthma is 37/1,000) • Women > men • Misdiagnosis or lack of diagnosis is common • Accounts for 10% of referrals to gynaecologists • 40% of laparoscopies performed by gynecologists are for chronic pain • Only 50% of patients actually receive a diagnosis, 20% never had any investigations • 34% have had at least one diagnostic procedure 2/2/2011

  5. What Contributes to CPP • Visceral sources • Uterus, fallopian tubes, ovaries • Bladder, GI tract, Peritoneum • Blood vessels • Muscles of pelvic floor and abdominal wall • Bone • Neuropathic sources • Central and peripheral nerves • Sympathetic nerves 2/2/2011

  6. What Contributes to CPP • Psychosocial phenomenon • Secondary gain • Previous therapies/iatrogenic causes • Multiple surgeries • Adhesions, Distorted anatomy, Nerve compression, Nerve injury • Fibromyalgia • Lower back - spinal cord • Medication/treatment history 2/2/2011

  7. Other Risk Factors • Poor posture • Sedentary lifestyle • Muscle trauma • Post delivery • Obesity • Sexual abuse • Local and referred pain • May be a primary disorder or occur secondary to other visceral or somatic pathology 2/2/2011

  8. Common Diseases in CPP • Endometriosis • Adenomyosis • Interstitial cystitis • Myofascial pain syndrome • Irritable bowel syndrome • Adhaesions • Pelvic congestion syndrome • Pudendal neuralgia • Post herpetic neuralgia • Vulvodynia • Vaginismus/ Dyspareunia 2/2/2011

  9. Pelvic pain Non-Gynaecologic Origin • Gastrointestinal – Appendicitis or appendiceal abcess – Inflammatory bowel disease • Urinary Tract – Acute cystitis or pyelonephritis – Ureterallithiasis • Orthopaedic –Lumbo-sacral muscle spasm –Lumbar disc disease 2/2/2011

  10. Pelvic pain - gynaecological • Endometriosis • PID • Mass - e.g fibroid, ovarian mass • Trapped ovary • Adhaesions • Psychological • Chronic UTI • (Constipation / IBS) 2/2/2011

  11. Therapy for CPP • Physical therapy • Psychological evaluation and support, • stress management • Maximizing co-morbid pathology • Depression, low back pain, obesity, diarrhea, constipation • Medications • Hormones (OCP, progesterone, GnRH angonists) • Muscle relaxants and other agents • Adjunctive medications • Analgesics • Disease specific medications • Injection therapy (Trigger Point injections Nerve blocks) • Surgery 2/2/2011

  12. Summary • CPP is a complex pain syndrome • Many contributing factors • Myofascial contributors frequently over looked • Pelvic floor “forgotten” myofascial source • Integrated approach offers best chance at best outcomes • Evaluate pain behaviors • Return to functioning is a more realistic goal than making a patient pain free • Correct predisposing factors 2/2/2011

  13. Acute pelvic pain Causes • Endometriosis • Flare of endometriosis • Adnexal accidents • Ovarian torsion, hemorrhage, rupture • Ovulation (Mittelschmerz) • Ruptured ectopic pregnancy • Endometritis • PID, STDs 2/2/2011

  14. Endometriosis • Definition • The presence of functioning endometrium cells • outside the uterine cavity • 5 - 10% of all women • Aetiology • Retrograde menstruation, • coelomic metaplasia, blood borne, • immunological • Where • Anywhere! • Ovaries and uterosacral ligaments 2/2/2011

  15. Endoscopic image of endometriotic lesions at the peritoneum of the pelvic wall. 2/2/2011

  16. Endometriotic lesions in the Pouch of Douglas and on the right sacrouterine ligament 2/2/2011

  17. Symptoms • Acute and chronic pain, • Dysmenorrhoea, • Dyspareunia, • Dyschezia • Dysuria • Infertility Signs • Tenderness, cervical excitation, endometrioma 2/2/2011

  18. Endometrioma 2/2/2011

  19. 2/2/2011

  20. 2/2/2011

  21. Endometriosis • Diagnosis • Biopsy • Laparoscopy • Treatment • Do nothing / simple analgesia/ anti inflammatories • Hormonal – COCP, Progestogens, Implanon,Depot Provera, IUCD, danazol) • GnRH analogues • Surgical – ablation/excision • Hysterectomy +/- BSO 2/2/2011

  22. Ovarian Cysts • Follicular, Corpus luteum Cyst • Dermoid cysts • Cystadenomas • Endometrioma • PCOS 2/2/2011

  23. Adnexal torsion • Physical findings • –50% nausea, vomiting • –43% ▲WBC • –34% peritoneal signs • –20% fever • Pain often intense initially, then improves with ischemia and loss of nerve transmission • Exam: unilateral tender adnexal mass 2/2/2011

  24. Pelvic Inflammatory Disease • Inflammation of upper genital tract and surrounding structures • Endometritis, salpingitis, • Tuboovarian abcess, • Peritonitis, • Perihepatitis (Fitz-Hugh-Curtis) 2/2/2011

  25. Perihepatitis (Fitz-Hugh-Curtis) 2/2/2011

  26. Pelvic Inflammatory Disease • Causation • Often polymicrobila infection • Chlamydia trachomatis, Neisseria gonorrhoea • Anaerobes and aerobes of normal vaginal flora • NOT NECESSARILY STD • Risk factors • Multiple sexual partners • Lack of condom/contraception use • Drugs alcohol 2/2/2011

  27. Pelvic Inflammatory Disease The most common etiologic agents in PID are: • Neisseria gonorrhoeae, • Chlamydia trachomatis • Anaerobic bacterial species found in the vagina, • particularly Bacteroides spp., • Anaerobic gram-positive cocci, (Peptostreptococci), • E. coli • Mycoplasma hominis 2/2/2011

  28. Pelvic Inflammatory Disease • Symptoms • Lower abdo pain, mild to severe • Vaginal discharge, Dysuria • Prolonged menstrual bleeding • Dysmenorrhoea / dyspareunia • Symptoms may persist despite treatment ?chronic infection or scarring of organs • Signs • Abdo tenderness, cervical excitation • Cervical muco-purulent discharge • ↑temp ↑WBC ↑ESR ↑CRP may be normal if Chronic PID 2/2/2011

  29. Pelvic Inflammatory Disease • Diagnosis • Swab vaginal, endocervical, peritoneal • Ultrasound/ MRI • Laparoscopy/ Laparotomy • May need admission 2/2/2011

  30. Laparoscopic findings – Acute PID Pyosalphinx 2/2/2011

  31. Treatment • Antibiotics • Surgical Long term problems • Chronic pelvic pain • Ectopic (12 - 50%) • Infertility (6 to 10 fold increase) 2/2/2011

  32. Prevention • Risk reduction • Barrier methods, condoms • Avoiding vaginal activity after end of pregnancy or surgical procedures (cx closed) • Education • Early treatment, STD screening • Treatment of partner 2/2/2011

  33. Dyspareunia Pain during intercourse • Primary • Secondary • Superficial • Deep 2/2/2011

  34. Dyspareunia - causes • Vulval – infection, trauma, skin condition • Vaginal – infection, vaginismus, xerosis • Cervical – PID, endometriosis (tumour) • Pelvic – PID, endometriosis • Anatomical • Non- gynae • Psychological 2/2/2011

  35. Management • Take carefully history • Careful examination of pelvis to identify site and source • Remove the source of pain 2/2/2011

  36. Dyspareunia • Vaginismus - spasm of vaginal muscles • Fear and pain of penetration • Gynaecological surgery • Radiation in oncology • After childbirth 2/2/2011

  37. Treatment • Superficial dyspareunia • Vaginal dilators • Local infection • Corrective surgery 2/2/2011

  38. Treatment • Deep dyspareunia • Treat causes • Endometriosis • PID • STDs

  39. Vaginal discharge • Most common gynae complaint in primary care • Take full history – colour, consistency, duration, STD’s, contraception, odour • Examination – systemic and local • Vaginal and endocervical swabs 2/2/2011

  40. Vaginal discharge - causes • Physiological – often cyclical • Bacterial Vaginosis • Trichomas Vaginalis • Candidiasis • Gonorrhoea / Chlamydia • Atrophic vaginitis • Rare causes – malignancy 2/2/2011

  41. Bacterial vaginosis • Prevalence of 12% • May occur and resolve • with menstrual cycle • Not necessarily sexually transmitted • Change in bacterial flora (anaerobs) • Gardnerella vaginalis, Bacteroides spp, Mobiluncus spp, Mycoplasma spp • Resulting rise in vaginal pH 2/2/2011

  42. Bacterial vaginosis • Diagnosis by Amsel criteria • Vaginal ph > 4.5 • Release of fishy smell with KOH • Characteristic discharge • Clue cells on microscopy • Treatment • Metranidazole – oral or topical 2/2/2011

  43. Trichomonas • Flagellated protozoan • STI • Irritation and soreness • of vulva, perineum • Dyspareunia, dysuria • Strawberry cervix • Treat with metronidazole 2/2/2011

  44. Candidasis • Affects 33% of women, many asymptomatic • Colonisation to infection • Risk factors – antibiotics, COCP, pregnancy, immunosuppression • Only treat if symptomatic • Can be difficult to treat • if chronic 2/2/2011

  45. Candidasis • Pruritis, white/yellow • discharge, thick • No odour / yeasty • Hyperaemic vagina • Treatment • Intravaginal imidazoles • and tiazoles • Fluconazole oral 2/2/2011

  46. Chlamydia trachomatis • Common genital & eye disease • most common sexually transmitted infections worldwide • 50 - 70% asymptomatic • Dyspareunia, discharge, dysuria, • PID, mucopurulent cervicitis • Male sterility, female infertility • Azithromycin, Doxycycline, erythromycin 2/2/2011

  47. Vaginal discharge – differential diagnosis 2/2/2011

  48. STDs or STIs • Person may be infected, may potentially infect others, without showing signs of disease (STIs) • Mainly via vaginal intercourse, oral or anal sex • Transmitted via iv drug needle • Childbirth • Breastfeeding 2/2/2011

  49. STIs • Incidence • WHO 1999, 340 million new infection, excluding HIV • Causes • Bacterial • fungal • Viral • Paracites • Protozoal

  50. Sexual transmitted disease • Incidence • WHO 1999 1 million new infection a day • 60% < 25yrs, of those 30% < 20yrs From 60 - > 1000/ 100.000 inhabitants, excluding HIV, 2004 WHO

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