my patient has pelvic pain · pelvic floor prolapse . 36 yr with pain and dysfunctional bleeding...
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My Patient Has Pelvic Pain
David A. Kenny DO
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CHRONIC PELVIC PAIN
Definition Of apparent pelvic origin Present most of the time for at least six months Severe enough to cause functional disability Requiring surgical or medical treatment
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ACUTE/CHRONIC PAIN Most women at some point experience pelvic pain Common presenting complaint Accounts for up to 40% of all gynecological office visits
Accounts for 20 to 30 % of all adult laparoscopies in the US 15% of women miss an average of 14.8 hrs of work/month Accounting for $880 million in healthcare costs and 2 billion in indirect costs
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Causes of chronic pelvic pain
Urologic abnormalities Gastrointestinal tract Musculoskeletal Gynecologic diseases
Common pathologies Under diagnosed
Endometriosis/adenomyosis/pelvic congestion/pelvic floor prolapse
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Ultrasound First line modality
Majority of indications Inexpensive/Fast Limitations
Body type Tech dependent
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Pelvic
Ultrasound Clinically useful information without the biologic effects of radiation
Important in Obstetrics and pediatrics Real-time evaluation
Rapidly moving parts heart Multiplanar Capabilities
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MRI Excellent spatial resolution Definitive diagnostic tool for many different pathologies May require pre certification or initial ultrasound exam
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Other modalities CT less common for Gyn eneteric causes mimicking pelvic Urologic abnomalities Xray Nuclear medicine
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Acute Pelvic Pain Ruptured Ovarian Cyst Ovarian Torsion Ectopic pregnancy PID/TOA Non-gynecological causes
Enteric causes Musculoskeletal
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ACR Appropriateness criteria http://www.acr.org/Quality-Safety/Appropriateness-Criteria http://www.acr.org/Quality-Safety/Appropriateness-
Criteria
• Evidence based guidelines
• Most appropriate decision: enhancing quality
• Developed by expert panels in 1994
• ACR Select.
• licensed software product used to be incorporated into
EHR and computerized order entry.
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18 yr old female vaginal bleeding
and pain
Positive BHCG
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36 yr Dyfunctional Bleeding
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65 yr post
menopausal bleeding
Ultrasound TA/TV appropriate first line diagnostic tool If the endometrial stripe measures less than 5mm no further imaging is neccessary If >5mm sonohysterography is recomended
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37 yr old TV irregular
endometrial
appearance/thickening
Excessive bleeding
Sonohysterogram showing a polypoid
mass biopsy revealing endometrial
cancer
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When is MRI appropriate in diagnostic workup of vaginal
bleeding?
Differentiation of heterogeneous fibroid disease vs. adenomyosis Suspected endometriosis
May not be associated with dysfunctional bleeding Pre/Post Treatment for fibroid embolectomy (adenomyosis as well) Known cancer
Staging - local extent of disease Pelvic floor prolapse
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36 yr with pain and dysfunctional bleeding Heterogeneous appearance of the uterine corpus- fibroids? Adenomyosis?
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Adenomyosis Under diagnosed common cause of pelvic
pain
Two forms diffuse and focal
Ectopic endometrial tissue embedded within the myometrial muscle
Causes
Uterine enlargement
Menorrhagia and dysmenorrhea
Can be seen with fibroids & endometriosis
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Fibroid disease Common cause of pain Can cause dysfunctional uterine bleeding Can cause problems with fertility
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MRI of Leiomyomas Pre/post UAE Fine anatomic detail Accurate size and composition Post contrast imaging showing lack of enhancement
✤ TSE sagital T2
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26 yr cyclic
Pelvic Pain
Homogeneous Hypoechoic mass in adenexa
hemorrhagic cyst vs Endometrioma/mass
Persisted on a follow up exam
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Characteristic appearance of an
endometrioma on MRI
T2 shading
In many circumstances the
ultrasound exam does not reveal
evidence of endometriosis
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Endometriosis Ectopic endometrial tissue outside the endometrial cavity Can occur almost anywhere Early diagnosis can limit significant morbidity
infertility/pain/risk of ectopic pregnancy
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20 yr Pelvic Pain
Neg BHCG Elevated WBC/fever Suspected infection ACR recommends
1. Ultrasound 2. CT or MRI
Tubo ovarian Abscess
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50 yr vague abdominal
discomfort
Complex cystic mass
What Next?
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Right ovarian cystic mass with nodular enhancing
components
T2 and subtracted T1 weighted sequences
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mucinous carcinoma
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Summary
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✤ACR appropriateness criteria
✤Ultrasound TA/TV - First line imaging study under most circumstances
✤Sonohysterography - follow up for endometrial pathology
✤MRI - Great for:
✤endometriosis/adenomyosis
✤Pre/post embolization
✤Evaluation of ovarian/endometrial masses
✤Pelvic floor prolapse
✤Problem solving tool
✤CT rarely used for the indication of pelvic pain
Summary