Treatment for Endometriosis
CAUSES OF PELVIC PAIN Table 11 Cause of pelvic pain Common cause of pelvic pain Endometriosis Endometriosis Adequate time should be given for the initial assessment of women with pelvic pain, especially chronic pain. It has been shown that consultations that allow women to express their own ideas about their pain result in a better practitioner-patient (or therapeutic ) relationship, and therefore improved concordance with investigation and treatment (Selfe et al., 1998). MANAGEMENT OF PELVIC PAIN Ectopic pregnancy Generally there is an acute onset of symptoms. The most significant symptoms include unilateral pelvic pain, amenorrhoea, and vaginal bleeding. The most significant signs are lower abdominal tenderness, extreme tenderness in the lateral fornix on one side, and pain on moving the cervix. Pregnancy test -Positive. Tubal pathology - PID, endometriosis
Endometriosis is caused by metaplasia of endometrial tissue. In only 3 of patients does it occur in the intestine (small intestine, appendix, colon, rectum), most often in the rectosigmoid. Endometriosis is frequently in the subserosa and is rarely submucosal. If localized in the rectum, there may be narrowing of the lumen with normal mucosa or there may be a polypoid tumor. In extremely rare cases, endometriosis may penetrate the bowel wall (intramural) to the mucosa, causing menstruation-related mucosal bleeding. In these cases, a bluish submucosal tumor can be seen shimmering through the mucosa. Diagnosis is usually made, however, by a gynecologist during laparotomy.
Various functional gastrointestinal pain syndromes have been defined, but there is substantial overlap between them. There is also substantial overlap with other functional disorders such as chronic fatigue syndrome, fibromyalgia, and chronic pelvic pain. The classification system for functional gastrointestinal disorders (FGID) therefore remains controversial and is seldom used outside specialist and research settings. Furthermore, the psychological management of these different syndromes is essentially similar.
A clinical suspicion of adhesions is also often entertained by both physicians and patients with chronic abdominal pain even though the literature suggests that such a diagnosis is seldom validated. Adhesions are very common in women, even in the absence of prior surgery and are found in equal proportion in patients complaining of pelvic pain and those with other complaints. Indeed, laparoscopy for chronic pain seldom leads to a specific diagnosis and even less often to a change in management.
Therapeutic Alternatives and Developping Treatments in Refractory Urge Incontinence and Idiopathic Bladder Overactivity
The other treatments available are more invasive and often irreversible surgical procedures. Surgical therapy should only be considered when all conservative methods have failed. Endoscopic approaches have been used in urgency incontinence 162 . Overdistension of the bladder is thought to reduce bladder distension by causing degeneration of unmyelinated C afferent small sensory fibers. This technique requires anaesthesia and have some complications including hematuria, urinary retention and bladder perforation in 5 to 10 146 . Although effective in short term management, this procedure is usually temporary in symptomatic control. Bladder myectomy (autoaugmentation) has beeen proposed as an alternative to enterocystoplasty. Detrusor myectomy involves incising and removing the bladder muscle to allow bladder mucosa to form a pseudodiverticulum. Detrusor myectomy for treatment of refractory urge incontinence due to detrusor overactivity in both sexes has been reported to be successful in...
More than one third of patients go to surgical revision 143 , mostly for repositioning of the lead or the extension. Tempory removal with subsequent reimplantation is normally the result of infection or chronic pelvic pain. Repositioning of the internal pulse generator is performed to relieve pain at the site, or because the battery is dead. Permanent removal is to the result of infection, chronic intractable pain, or because the device has not proved satisfactory. Surgical revision does not appear to affect the overall degree of patient satisfaction 143 , and it seems to decline with time 131 .
Ganglion impar block has been described for the treatment of intractable perineal and pelvic pain where the sympathetic nerve seems to predominate. The ganglion impar is a retroperitoneal structure located at the level Presacral neurectomy has been used for the control of intractable pelvic pain, whether due to malignancy or chronic pelvic pain syndromes. The technique involves the division of the superior hypogastric plexus at the L5 S1 region as described above. The presacral nerves can be divided as an open procedure or via the laparoscope. Laparoscopic presacral neurectomy is probably the technique of choice (Figures 5 and 6). Bowel preparation is indicated preoperatively to decompress the bowel. Under direct vision an incision is made in the peritoneum over the lateral sacral promontory and dissecting forceps are used to dissect out the hypogastric plexus. It may then be ligated, cut or cauterized (Figure 7).
Neuromodulation of the sacral nerves is a therapeutic option for voiding dysfunction in patients who do not respond to the common non-invasive therapies and in whom disturbance in reflex coordination between the bladder, sphincter and pelvic floor is suspected. The rationale for using electrical stimulation techniques for the treatment of such voiding dysfunction is that this stimulation turns the neurological control mechanism back towards a more functional status. The main indications are urge incontinence, OAB syndrome, urinary retention and chronic pelvic pain. Pelvic pain syndrome is the occurrence of persistent or recurrent episodic pelvic pain associated with symptoms suggestive of lower urinary tract, sexual, bowel or gynecological dysfunction, without any infection or other obvious pathology 4 . Chronic pelvic pain is defined as pain of a minimum of 6 months duration that is not related to any identifiable cause or etiology 125 . In patients suffering from chronic pelvic...
To date, effectiveness has been assessed by objective and subjective measures. In evaluating the effectiveness of sacral nerve stimulation, results are frequently discussed according to urge incontinence chronic urinary retention, and chronic pelvic pain. Although frequent, chronic pelvic pain syndrome probably receives little attention from clinicians. It is a diagnostic and therapeutic challenge and is often related to psychological and psychosomatic disorders. Theoretically, neurogenic inflammation is responsible for neurogenic pain, as in a complex regional pain syndrome 13 . Trauma may also induce pain (fracture, nerve damage). Compared to dorsal column or peripheral nerve stimulations, some authors propose sacral nerve stimulation for the treatment of chronic pelvic pain syndrome. To date, few results have been reported for this technique but it is feasible. Aboseif et al. 1 analyzed a group of 41 patients with chronic pelvic pain associated with other voiding symptoms...
CA125 levels tend to be lower than in the general population, and lower cut-off points may be more appropriate (Alagoz et al 1994, Bon et al 1996). Approximately 83 of patients with epithelial ovarian cancer will have CA125 levels greater than 35 U ml (Bast et al 1983, Canney et al 1984). Unfortunately only 50 of patients with stage I disease have elevated levels, while raised levels are found in over 90 of patients with more advanced disease (Jacobs and Bast 1989). The incidence of CA125 elevation is lower in mucinous, clear cell and borderline tumours (Vergote et al 1987, Jacobs and Bast 1989, Tamakoshi et al 1996). Elevation of serum CA125 levels may also be associated with other malignancies (pancreas, breast, colon, lung) and with benign and physiological states, including pregnancy, endometriosis and menstruation (Jacobs and Bast 1989) (Figure 1). Many of these nonmalignant conditions are not found in postmenopausal women, thereby improving the diagnostic accuracy of an elevated...
Evista is contraindicated in premenopausal women, women of childbearing age, in pregnancy, and in children, although there is a current clinical trial evaluating the effect of Evista on endometriosis in women who are aged 18 to 45. Evista should never be given during pregnancy, and only used with caution in the perimenopausal period because of the possibility of unanticipated pregnancy as its safety in pregnancy is
These women commonly have only 1 week a month that is symptom-free. It is unclear whether these four patterns represent distinct subtypes of PMS or whether they correspond to other conditions. These four patterns of symptoms must be differentiated from underlying illnesses that either are precipitated during the premenstrual phase or demonstrate a cyclic waxing and waning of intensity related to menstruation. They must also be differentiated from other problems associated with menses, including pelvic pain with menstruation (dysmenorrhea), infrequent menses (oligo-menorrhea), absent menses (amenorrhea), frequent menses (metrorrhagia), and excessive bleeding with menses (menorrhagia).
As has been indicated earlier, Pelvic Inflammatory Disease may be either acute or chronic. PID is a common cause of morbidity, and accounts for 1 in 60 consultations by women under the age of 45 (Simms et al., 2000). It has been reported that a delay of a few days in receiving appropriate treatment can increase the risk of sequelae, which include infertility, ectopic pregnancy and chronic pelvic pain (Hillis et al., 1993). The exact origin of chronic pelvic pain is difficult to ascertain. It may be due to recurrence of infection or adhesions and scarring in the pelvic cavity caused
Male-like hair growth and masculinization of women and the ambiguity of genders has fascinated mankind for millennia, frequently appearing in mythology and the arts. The earliest reports of androgen excess, beginning 400 years bc, focused on the appearance of male-like hair growth and features in women, often accompanied by menstrual cessation. The first etiologies identified as a cause of androgenization in the female were adrenal disorders, primarily adrenocortical neoplasms, but also eventually adrenal hyperplasia. The first report of a patient with nonclassic adrenal hyperplasia (NCAH) was made in 1957. The Achard-Thiers syndrome, which was originally reported in 1921 and was felt to primarily affect postmenopausal women, included the development of diabetes mellitus, hirsutism, and menstrual irregularity or amenorrhea in conjunction with adrenocortical disease. Androgen production by the ovary was not recognized until the early 1900s, with the first case of a patient with glucose...
Ureteral injury occurs in 1-2 of all major gynecologic procedures. Pelvic irradiation, large pelvic tumors, endometriosis and the radicality of the procedures all increase the risk of damage. Ureteral obstruction can also occur as a result of any of the above processes, necessitating reimplantation. The underlying principles to be adhered to in repairing any ureteral injury are
Diverticulosis Angiodysplasia Cancer Polyps Inflammatory bowel disease Radiation proctocolitis Infectious colitis Ischemic colitis Anorectal disease Hemorrhoids Anal fissures Rectal ulcers Fistula in ano Rare Causes Portal hypertensive colopathy Small bowel varices Colonic and rectal varices Endometriosis
Fortunately, leakage at the pouch-anus anastomosis is rare, especially when the anastomosis is protected by a diverting ileostomy. Most surgical series report this as less than 10 , though some higher rates are reported. Anastomotic leakage typically causes pelvic pain and abscess. Pouch dysfunction is exemplified by painful, incomplete evacuation, and excessive frequency. Demonstration of a leak with a retrograde barium contrast study (pouchogram) is usually diagnostic. Occasionally, a pouch-vaginal or pouch-perineal fistula may develop in association with anastomotic leakage this should always raise the question of unrecognized Crohn's
This condition is observed in patients who present with prolonged use of IUDs, usually for longer than two years. Pelvic actinomycosis may also occur from extension of intestinal infection, commonly from indolent ileocecal disease (2). Manifestations of infection may range from a chronic vaginal discharge to pelvic inflammatory disease with tubo-ovarian abscesses or pseudomalignant masses (see chapter 24). Patients generally present with abnormal vaginal bleeding or discharge, abdominal or pelvic pain, menorrhagia, fever, and weight loss.
Acute prostatitis as visualized sonographically. Acute prostatitis is common after urethral or bladder infection (usually by Escherichia coli or Proteus organisms). Another cause is prostate hematogenous contamination, especially by Staphylococcus. Signs and symptoms of acute prostatitis, in addition to fever, chills, and more generally the signs and symptoms of tissue invasion by infection described above, are accompanied by dysuria, pelvic pain, and septic urine. Acute prostatitis is an indication for direct ultrasound (US) examination of the prostate by endorectal probe. In this case of acute prostatitis in a young male, US examination disclosed a prostatic abscess (1) complicating acute prostatitis in the right lobe (2). Acute prostatitis is an indication for thorough radiologic imaging of the whole urinary tract, giving special attention to the urethra. Urethral stricture may favor prostate infection (see Fig. 7-20).
Appendectomy is frequently performed incidentally in association with other pelvic surgical procedures, or whenever pathological changes are identified as in patients with infection, endometriosis or benign or malignant tumor. In certain ovarian cancers, such as mucinous cystadenocarcinoma, the appendix may be removed as part of the staging procedure. 2. After the anatomy of the pelvis is evaluated and any associated procedures (such as treatment of pelvic adhesions or endometriosis, or peritoneal biopsy) are performed, hysterectomy and salpingo-oophorectomy proceed as follows. If oophorectomy is planned, first the infundibulopelvic ligament blood supply is severed using bipolar electrodesiccation or a stapling device. The direction of the ureter
Pelvic pain Pelvic pain is a common presentation in women. Pelvic Inflammatory Disease, ectopic pregnancy, endometriosis, ovarian pathology, uterine cervical cancer and other gynaecological conditions need to be excluded. Often there is no obvious cause found, and often the pain can be a variant of the irritable bowel syndrome (Hopcroft & Forte, 2003).
IBD of the pouch (pouchitis) is a syndrome defined by clinical, endoscopic and histologic criteria that occurs in UC-IPAA patients (Mahadevan and Sandborn, 2003), and seldom, if ever, affects familial adenomatous polyposis-IPAA patients. Patients complain of fecal frequency, and the motions are commonly loose and watery and may contain mucous and blood. Urgency and leakage, especially at night, are common. In addition, depending on the severity of pouch inflammation, the presence of associated fistulas, CD or concurrent pouch outlet obstruction, pelvic pain may be present. Systemic symptoms of malaise, low-grade fever or weight loss are often present in the more severe cases of pouch inflammation. Physical examination in patients with pouch inflammation is often normal. However, individuals with marked inflammation of the pouch from any cause may have the general features of patients with IBD, with low-grade fever, weight loss, and pallor. CD is suggested by signs of small bowel...
The presence of microcystic, sclerocystic, or cystic degeneration of the ovaries was recognized as early as the mid-19th century, although this pathology was primarily associated with pelvic pain, dysmenorrhea, and menorrhagia. Initially, treatment consisted of castration, although this was soon followed by the more conservative bilateral cuneiform or wedge resection. Recognition that this ovarian pathology could also be associated with amenorrhea, infertility, and hirsutism was not made until the report by Stein and Leventhal in 1935. The ovarian wedge procedure was used extensively to treat these women, although recognition that it could result in significant adhesion formation followed by the introduction of clomiphene citrate and then menotropins and laparoscopic electrocau-tery led to the demise of this surgical procedure for the treatment of polycystic ovary-associated amenorrhea and infertility. Our understanding of the steroidogenic, gonadotropic, heritable, and metabolic...
Mary is an air stewardess, working on a domestic route, having had considerable previous experience on international routes. She has just arrived at her flight for the morning. She had been called in suddenly, although not expecting to be rostered on, because three other people had telephoned to say that they were sick. She is feeling very under par. The previous weekend, her boyfriend of some three years said that he thought that they should have a time apart for two or three months because 'things didn't seem to be going very well'. And in the middle of the night, her period had started, waking her with a series of very painful cramps. She had been suffering from endometriosis for some time and it seemed to be getting worse.
51 Tips for Dealing with Endometriosis
Do you have Endometriosis? Do you think you do, but aren’t sure? Are you having a hard time learning to cope? 51 Tips for Dealing with Endometriosis can help.