???????,?ectopic pregnancy

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• ??

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???????-????

• ???????,?ectopic pregnancy miscarriage
• PID
• Appendicitis
• Ovarian cyst accident or Mittelschmerz

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• OHSS
• Hematomatra or hematocolpos
• Necrosis of uterine fibroid
• ?????????,?????????

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Ovarian cyst accident

• Dermoid cysts,teratomas,or simple cysts are more
  common cause of torsion
• Result of torsion(leading to occlusion of blood
  supply and necrosis)
• Presenting symptom of ovarian neoplasm,more
  common associated with functional ovarian cysts
  in younger
• Acute chemical peritonitis if they contain
  irritant material(as endometriotic or dermoid
  cysts)

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Ovarian cyst accident

• Pain pattern of torsion
• -sudden onset of coliky pelvic pain
• -located to one or other of iliac fossa
• -more constant after several hours or
  disappear
• -initially apyrexial,later on necrosis can
  cause pyrexia

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Mittelschmerz

• From German mittelmiddle and schmerzpain
• Middle cycle pain occuring at the time of
  ovulation
• More common ly in teenagers and older women

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???????-??

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• Endometriosis
• Chronic pelvic inflammatory disease
• Pelvic adhesion
• Bowel related pain
• Urological causes
• Musculoskeletal pain
• Neuropathic pain
• Psychological factors

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Treatment of Pain in Endometriosis

• Acute Pain
• NSAIDS
• Hormonal
• Oral Contraceptive
• Systemic analgesia, opioids
• Other techniques (TENS, Acupuncture)

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Pain Ladder

• Moderate pain
• combination with minor opioids
• Co-proxamol (propoxifine), Co-dydramol (codeine)
• Minor opioids alone - eg Pethidine, Tramadol
• Severe pain
• Opioids Morphine etc

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Endometriosis and Inflammatory Pain Use of NSAIDS

• Cyclo-oxygenase pathway blocked
• 2 forms
• COX1 COX2
• COX1 always present
• COX2 only induced by inflammation
• Also have central role, where both COX1 COX2
  are found as neuro-transmitters

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NSAIDS

• COX 2 antagonists preferable where there is
  high-risk of peptic ulceration / bleeding
• Still not 100 guarantee

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Treatment of Pain in Endometriosis

• Chronic / Intractable Pain
• Multiple modality pain clinic - holistic approach
• Drugs
• Nerve blocks
• TENS, Acupuncture
• Physio, occupational Ther., Psychology

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Neuropathic Pain in Endometriosis

• Not responsive to opioids
• Two main classes of drugs used
• Tricyclic antidepressants (esp Amitriptyline)
• Anti-epileptics
• Carbamazepine
• Sodium valproate
• Clonazepam
• Gabapentin (Pregaballin)

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• In uncontrolled studies,adhesionlysis relief pain
• In a randomized controlled trial,adhesionlysis
  ??????????????????????,?????????????
• Ovarian remnant syndrome-??????????????????,??????
  ????????

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?????

• Pelvic vein dilatation?cyclical dragging pelvic
  pain
• Occurred in premenstrual phase of cycle and
  worsen in standing or walking
• ????????????,??????????
• Dilated vein ????laparoscopy or ultrasound??

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?????-??

• MPA(medroxyprogesterone acetate) 30-50 mg daily
  for 3 months-side effectweight
  gain,amenorrhea,bloating
• GnRH analogue-inhibit ovarian function
• Severe cases-TAH BSO?curative

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???????

• Irritable bowel syndrome-??????????????????,??10-2
  0?????,???????????-????????,???????????????,?????
  ??anti-spasmodic drugs
• constipation-??????????????????
• Inflammatory bowel disease-pain and bloody
  diarrhea

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??????(I)

• Interstitial cystitis
• -?????????,?????????????,?frequency,urgency,noc
  turia?????,?????,????,?????
• -???????(submucosal edema and petechiae)
• -dyspareunia ()

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??????(II)

• Chronic urethral syndrome-symptoms of
  irritation,postvoiding fullness,incontinence
• Other conditionsurethral diverticulae,urinary
  calculi,bladder neoplasm,or radiation cystitis

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• Sacroiliac dysfunction-?????????????????,?????????
  
• Abnormal posture-chronic muscle tension and
  strain on joints and ligaments
• Tension myalgia of the pelvic floor itself

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???????

• ?????????????????
• Nerve entrapment in scar tissue or fascia
• Sharp,stabbing in nature,or constant dull ache
• Diagnosis-confirmed by injecting local
  anaesthetic at the site of maximal tenderness
• Prescaral neurectomy for patents with
  endometriosis with mixed results

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??(I)

• History
• -location of pain,mode of onset,constant or
  coliky in nature,radiaion,and relation to the
  menstrual cycle
• -LMP?
• -used contraception?
• -vaginal discharge or bleeding
• -bowel or urinary symptoms?

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??(II)

• Physical examination
• -move or crouched up in bed?
• -check vital sign
• -abdominal examinationlocation of
  pain,rebounding tenderness or guarding,any mass
  or hernia
• -pelvic examinationvaginal discharge or
  pelvic mass or assess the pelvic tenderness
• -cervical lifting pain?blood in the peritoneal
  cavity(ectopic pregnancy) or inflammation in the
  peritoneal (PID)
• -OHSS?PV was not done (risk of rupture of
  ovarian cysts),but suspected ectopic pregnancy
  ?immediate laparotomy

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??(III)

• Investigations
• -triple swabs(high vagina,cervix,endocervix)?r/
  o STD as chlamydia or gonorrhea
• -sent midstream urine?r/o UTI
• -check CBC/CRP
• -check urine or serum HCG?r/o ectopic pregnnacy
• -pelvic ultrasound?r/o pelvic pathology
• -laparoscopy-important place in management of
  chronic pelvic pain in women of reproductive
  agegold standard for diagnosis of
  endometriosis,ectopic pregnnacy and PID

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• A 23-year-old woman complains of heavy, painful
  menstrual periods every 2 weeks. On further
  questioning, you find that every other episode of
  bleeding is actually very brief, consisting of
  only 2 days of spotting. At these times, the pain
  is also only an occasional twinge. During the
  heavy bleeding, the pain is crampy, nearly
  constant, located centrally in the pelvis and
  lasts 3 days. A BBT curve is biphasic, compatible
  with normal ovulatory cycles 28 days in length.
  Her physical examination in normal. In addition
  to dysmenorrhea, which of the following is the
  most likely diagnosis?
• (A) anovulatory bleeding
• (B) progressive endometriosis
• (C) chronic constipation
• (D) mittelschmerz
• (E) Halbans disease

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