DYSMENORRHOEA AND

PELVIC PAIN

Dr.Tarig Mahmoud

MD SUDAN

HAIL UNIVERSITY KSA

Dysmenorrhoea is defined as painful

menstruation.

It is experienced by 45–95 per cent of

women of reproductive age.

DYSMENORRHEA

Primary[no underline disease]

Secondary [secondary to pelvic disease]

PRIMARY DYSMENORRHEA

Description: Pain associated with

ovulatory menses that usually start at or

just before the onsets of menses; and

last 1-3 days.

Age group: 17-22 years.

Etiology : due to uterine contraction with

ischemia and prostaglandin production.

Symptoms: Crampy lower abdominal

pain; +/- nausea, emesis, diarrhea or

headache.

normal physical examination.

TREATMENT

Reassurance

NSAIDS

Hormonal Therapy (OCPs, progestagins,

Mirena IUD, Depo-Provera

GnRH analogues

acupuncture

psychothearpy

transcutaneous nerve stimulation

SECONDRY DYSMENORRHEA

Pathophysiology:

depends on the underling secondary

cause

Clinical feature

Develop in older women.

Can occur days before and after the

menses.

Associated with dyspareunia, infertility

and abnormal uterine bleeding.

Causes :

Endometriosis

Pelvic inflammation

Adenomyosis

cervical stenosis and haematometra (rare).

Fibroid

Ovarian congestion

Ovarian cyst

Treatment :

Depend on the causes.

PELVIC PAIN

Can be:

Acute pelvic pain

Chronic pelvic pain

The initial approach to the patient

with pelvic pain should include a

detailed history and physical

examination

The history should include

characterize the pain [location, duration

(constant or intermittent),onset, radiation,

associated symptoms, severity sharp pains,

cramping, dull aching pain.

alleviating and aggravating factors.

system symptoms (eg, urinary,

gastrointestinal, and musculoskeletal) to

exclude non gynecological causes.

Examination

abdominal examination

pelvic examination

Performance of a pelvic examination is the

standard of care for women with lower

abdominal and pelvic symptoms

ACUTE PELVIC PAIN

Pain of sudden onset

Gynecological causes

Non Gynecological causes

GYNECOLOGIC CAUSES OF ACUTE PELVIC PAIN

Adnexal accidents[ torsion, Ruptured,

heamorrage].

Pelvic inflammatory disease.

Ectopic pregnancy, abortion.

NONGYNECOLOGIC CAUSES OF ACUTE

PELVIC PAIN

Appendicitis ,Diverticulitis.

Bowel obstruction.

Adhesions.

Hernia.

Urinary tract infection.

Urolithiasis.

Pelvic thrombophlebitis.

CHRONIC PELVIC PAIN

Definition

Is pelvic pain for more than 6 month and

affect the quality of life.

Difficult to diagnose.

Difficult to treat.

Associated great medical costs.

Incidence

Common complain

Affects 15-20% of women of reproductive age

GYNAECOLOGICAL CAUSES

endometriosis, adhesions .

fibroids, adenomyosis, endometritis.

Pelvic congestion syndrome.

PID/salpingitis, hydrosalpinx.

IUD/infection.

severe prolapse.

NON- GYNAECOLOGICAL CAUSES

Urologic

UTI/urethritis, interstitial cystitis (IC), urine retenion, urethral diverticulum, nephrolithiasis, malignancy.

GIT

constipation, IBS, Crohn’s disease, bowel obstruction, diverticulitis, malignancy.

Musculoskeletal

myalgia of pelvic floor, hernias, neuralgia, low back pain.

Other

psychiatric – depression, ; abdominal cutaneous nerve entrapment in surgical scar.

DIAGNOSIS

Obtaining a

COMPLETE and DETAILED HISTORY

is the most important key to

formulating a diagnosis

HISTORY OF CHRONIC PELVIC PAIN

1.Duration of Pain

2.Nature of the Pain

Sharp, stabbing, throbbing, aching, dull?

3.Specific Location of Pain

Associated with radiation to other areas?

4.Modifying Factors

Things that make worse or better?

5.Timing of the Pain

Intermittent or constant?

Temporal relationship with menses?

Temporal relationship with intercourse?

Predictable or spontaneous onset?

6.Detailed medical and surgical history

Specifically abdominal, pelvic, back surgery

DIAGNOSIS: OBJECTIVE EVALUATIVE TOOLS

Gonorrhea and

Chlamydia

Urinalysis

Urine Culture

Pregnancy Test

CBC with Differential

ESR

PELVIC ULTRASOUND

MRI or CT Scan

Endometrial Biopsy

Laparoscopy

Referral to Specialist

Basic Testing Specialized Testing

MANAGEMENT

A team management

Multidisciplinary team pain clinic [

gynecologist , psychologist expert in

pelvic pain , sexual & marital counseling

, physical therapist with pelvic floor

expertise .

CONCLUSIONS

Chronic Pelvic Pain requires patience,understanding and collaboration from bothpatient and physician

Obtaining a thorough history is key toaccurate diagnosis and effective treatment

Diagnosis is often multifactorial – may affectmore than one pelvic organ

Treatment options often multifactorial –medical, surgical, physical therapy andcognitive.

Thank you