骨盆腔疼痛

1. 骨盆腔疼痛

2. 急性骨盆腔疼痛 • 慢性骨盆腔疼痛 • 診斷

3. 急性骨盆腔疼痛-常見原因 • 早期懷孕併發症,像ectopic pregnancy & miscarriage • PID • Appendicitis • Ovarian cyst ”accident” or Mittelschmerz

4. 急性骨盆腔疼痛-其它原因 • OHSS • Hematomatra or hematocolpos • Necrosis of uterine fibroid • 其他非婦產科的原因,像腸道或泌尿道疾病

5. 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)

6. 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

7. Mittelschmerz • From german mittel=middle and schmerz=pain • Middle cycle pain occuring at the time of ovulation • More common ly in teenagers and older women

8. 慢性骨盆腔疼痛-定義 • 疼痛的時候超過六個月 • 慢性骨盆腔疼痛是影響生殖年齡女性最常見的婦科問題

9. 常見原因 • Endometriosis • Chronic pelvic inflammatory disease • Pelvic adhesion • Bowel related pain • Urological causes • Musculoskeletal pain • Neuropathic pain • Psychological factors

10. 骨盆腔沾粘 • 引起疼痛的原因還不清楚 • In uncontrolled studies,adhesionlysis relief pain • In a randomized controlled trial,adhesionlysis 只徵對嚴重緻密血管豐富牽連到腸子的沾粘有幫助,對一般的簡單骨盆腔沾粘沒用 • Ovarian remnant syndrome-卵巢周圍有緻密的纖維沾黏所引起的疼痛,藉由抑制或移除卵巢可緩解疼痛

11. 骨盆腔充血 • Pelvic vein dilatationcyclical dragging pelvic pain • Occure in premenstrual phase of cycle and worsen in standing or walking • 發生的位置與強度變異性大,和深度的性交疼痛有關 • Dilated vein 有時可由laparoscopy or ultrasound看到

12. 骨盆腔充血-治療 • MPA(medroxyprogesterone acetate) 30-50 mg daily for 3 months-side effect:weight gain,amenorrhea,bloating • GnRH analogue-inhibit ovarian function • Severe cases-TAH +BSOcurative

13. 腸道有關的疼痛 • Irritable bowel syndrome-是最常見引起腸道有關的慢性骨盆腔疼痛,影響10-20%的一般族群,常可影響生殖年齡的女性-它是功能性的疾病,由疼痛的病史及腸胃道的症狀診斷,可用高纖食物及anti-spasmodic drugs • constipation-也是常見腸子脹及慢性骨盆腔疼痛的原因 • Inflammatory bowel disease-pain and bloody diarrhea

14. 泌尿道的原因(I) • Interstitial cystitis -不明原因的發炎情況,它可引起疼痛及泌尿道的症狀,像frequency,urgency,nocturia;當膀胱脹滿,疼痛會增加,當解尿後,疼痛會緩解 -可用膀胱鏡診斷(submucosal edema and petechiae) -dyspareunia (+)

15. 泌尿道的原因(II) • Chronic urethral syndrome-symptoms of irritation,postvoiding fullness,incontinence • Other conditions:urethral diverticulae,urinary calculi,bladder neoplasm,or radiation cystitis

16. 肌肉骨骼疼痛 • Sacroiliac dysfunction-疼痛發生在關結本身或有關的肌肉經巒,疼痛在移動時會惡化 • Abnormal posture-chronic muscle tension and strain on joints and ligaments • Tension myalgia of the pelvic floor itself

17. 神經引起的疼痛 • 疼痛源自受傷的神經而不是受傷的組織 • 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

18. 精神上的原因 • 促進因子:精神上,身體上及社會的原因 • 這些因子的平衡將隨著病人間與個別疾病的不同時間而有變化 • 它會惡化睡覺品質與造成憂鬱沮喪 • 精神上的問題較常是結果而不是原因 • 它常常在身體檢查或腹腔鏡檢查上沒問題但一半以上的病人都有情緒困擾問題 • 有慢性骨盆腔疼痛的病人在過去有較高的性暴力的發生率

19. 診斷(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?

20. 診斷(II) • Physical examination -move or crouched up in bed? -check vital sign -abdominal examination:location of pain,rebounding tenderness or guarding,any mass or hernia -pelvic examination:vaginal 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

21. 診斷(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 age;”gold standard” for diagnosis of endometriosis,ectopic pregnnacy and PID