Cyclic Abdominal Pain Research Articles

A Narrative Review on the etiopathogenesis of Primary Dysmenorrhea with reference to Kastartava in Ayurveda literature

Objectives: Different dimensions of Primary Dysmenorrhea in Ayurveda literature has been explored and conceptualised it with the available physiological and anatomical understanding. Content: The concept of Primary Dysmenorrhea is better understood upon the basic understanding of Kastartava dating back to the phase of adolescence. 75% of adolescent girls’ experiences problems related to menstruation including delayed, irregular, painful, and heavy menstrual bleeding. Among these, painful menstruation or dysmenorrhea is the most common gynecological problem seen in reproductive age group. “Primary dysmenorrhea, one among its two types, is a cyclical lower abdominal or pelvic pain of sufficient magnitude so as to incapacitate day to day activities without any identifiable or evident pelvic pathology”. Ayurveda classics were reviewed to analyse the various aspects of Kastartava and correlated with research papers in terms of evidence-based physiological and anatomical advancements. Databases like PubMed, Scopus were searched using keywords like Shoola, Kastartava, Udavartini, Vatiki Yonivyapat, Dysmenorrhea, Primary Dysmenorrhea AND Ayurveda, Pain measurement, Quality of life, Inflammatory Markers, Prostaglandin theory. Summary: Various aspects of Shoola and Kastartava in Ayurveda from evidence-based advancements in Primary Dysmenorrhea based on recent researches have been put forward for basic evidence in relation with Pathophysiology of Primary Dysmenorrhea. Outlook: Understanding the pathophysiology of pain in Primary Dysmenorrhea with respect to the clinical presentation of Kastartava will give new insights to manage the clinical condition.

Surgical Management of Mullerian Development Anomalies: 5 Years’ Experience of a Tertiary Care Center

Maldevelopment of the mullerian duct occurs in variety of forms and each anomaly is distinctive. This study was conducted to study clinical profile of patient with mullarian anomalies, different modalities used in diagnosis, and surgery performed to patients with mullerian duct anomalies. This was retrospective study of 23 patients who underwent surgery for different mullerian duct anomalies in last 5 years. There presenting problem, diagnostic modalities used, types of anomalies, other associated anomalies and different surgical management were evaluated. As per American Fertility society 6 patients belong to class I, 12 in class II and 5 in class III. Most of patients with Mayer Rokitansky Kuster Hauser (MRKH) syndrome had primary amenorrhea, patient of vaginal septum usually presents with cyclical abdominal pain, primary subfertility or dyspareunia. Patients with septate uterus had recurrent abortion 2D Ultrasonography (USG), Magnetic Resonance imaging (MRI) and hysteroscopy were modalities used for diagnosis of these defects. Patient of MRKH syndrome and vaginal agnesis were managed with vaginoplasty using amnion graft. Patients with septate uterus were managed with hysteroscopic septal resection. Septum resection was performed in all patients with transverse vaginal septum. Uterine anomalies are different groups of malformations with a broad spectrum of presentations. Management of each anomaly is individualized depending on the symptoms and fertility concerns.

Vaginal atresia in a patient with uterus didelphys

Background: Female reproductive tract abnormalities are generally encountered in 4%-7% of women. Various combinations have been described in the literature. Our case reports a rare female genital tract anomaly of the distal vagina combined with uterus didelphys. Case Presentation: A 15-year-old girl with lower vaginal atresia associated with uterus didelphys presented with cyclical progressively worsening abdominal pain and primary amenorrhea. Pelvic ultrasound (US) and magnetic resonance imaging (MRI) illustrated two separated uterine cavities associated with a distended fluid-filled structure ending in a blind pouch at the lower margin of the vagina. Conclusion: The presence of congenital anomalies of the female urogenital system may be suspected in the case of cyclical abdominal pain in young girls with primary amenorrhea. The use of US as a primary approach is recommended. MRI is preferred to specify the height and extent of vaginal aplasia as long as to guide the choice of the most appropriate surgical technique.

Painful Nodules and Chronic Abdominal Pain: An Unusual Cause

Question: A 48-year-old woman with a history of locally treated left second toe melanoma and a previous cesarean section (C-section) presented for evaluation of cyclic abdominal pain of several years’ duration. Her discomfort was localized to the right lower quadrant associated with her menstrual period. Physical examination revealed 2 tender small nodules, 1 in the right lower quadrant and 1 in the midline approximately at the level of her prior C-section scar. She did not notice any specific change in the size of these nodules associated with her menstrual period. Computed tomography imaging of the abdomen/pelvis performed at an outside institution demonstrated 2 nodules along the abdominal wall associated with the musculature measuring 2.2 and 1.5 cm in diameter (Figure A and B). Locally, a laparoscopy was normal, revealing no evidence of endometriosis. Given her previous history of melanoma and to also rule out the possibility of desmoid tumor, ultrasound-guided biopsy was performed. A representative histopathology image from fine-needle aspiration is shown in Figure C.

Haematocolpos and Secondary Hematometra Due to Imperforate Hymen: Diagnosis and Treatment

BackgroundImperforate hymen is an uncommon congenital anomaly of the female genital tract and is rarely diagnosed in newborns. An imperforate hymen is a cause of primary amenorrhea. Case DescriptionA 12-year-old girl was admitted to the pediatric outpatient clinic with cyclic abdominal pain for eight days. She had lower abdominal pain with dysuria and constipation for the previous six weeks. There is a bulging mass on the perineal that appears when straining. Fever, nausea, vomitus, abdominal enlargement, and leucorrhea were denied; breast enlargement since 12 years old with no history of menarche. The patient vital signs were normal. On physical examination obtained, lower abdominal pain and tender suprapubic mass were palpable. The pubertal status was normally secondary sexual characteristics. An interlabial mass was found protruding from the introitus vagina and the hymen intact on inspection of the external genitalia. Laboratory and urinalyses revealed normal. Hematometra and hematocolpos were found on abdominal ultrasonography, which led to the diagnosis of imperforate hymen. Therefore, a hymenectomy was performed and evacuated 520 ml of dark red blood. The patient’s condition was good, and she had regular menstruation. ConclusionsImperforate hymen is an easy diagnosis, but sometimes clinicians are oblivious to including this in the differential diagnosis of lower abdominal pain in pubescent girls with primary amenorrhea. Also, a lack of awareness about the importance of external genitalia examination as part of routine physical examination in children and adolescents makes this diagnosis easily missed or delayed.

A case report of an endometriosis cyst at cesarean scar defect and review of literature

BackgroundCesarean scar defect (CSD) presents as a cystic defect that connects the uterine cavity at the site of the previous cesarean section (CS). Endometriosis refers to the discovery of endometrial glands and stroma outside the uterine cavity. Cases of endometriosis cysts at CSD have not been reported.Case presentationIn this article, we will present a patient with an endometriosis cyst at CSD with symptoms of a prolonged menstrual cycle, periods without cyclic abdominal pain, and a history of cesarean delivery. The gynecologic ultrasound showed a CSD and a mixed mass in the right front of the uterus. After about 1 month, the tumor grew from a diameter of 4.75 cm to 8.06 × 6.23 × 3.66 cm. The patient eventually had an operation, which revealed a mass protruding from the incision in the anterior uterine wall, which was attached to the anterior uterine wall by a thin tip with a smooth surface. Intraoperative rapid cytopathology suggested that endometrial glands were seen within the smooth muscle tissue, similar to endometriosis. Subsequently, the patient underwent resection of the endometriotic cyst. Final paraffin pathology showed smooth muscle with visible endometrial glands and old hemorrhage, and a one-year follow-up showed no recurrence of endometriosis cysts at CSD.ConclusionsEndometriosis cysts at CSD are very rare. The clinical symptoms may be less obvious, and the diagnosis relies mainly on the patient’s previous surgical history and imaging. A finding of a pelvic mass in the location of the CSD, with or without symptoms of menstrual changes and intermittent abdominal pain, should be considered an endometriotic cyst at CSD. Surgical treatment is a good choice for this disease. Further studies are needed regarding the etiological mechanism of this case and why the mass enlarged rapidly in one mouth.

Robot-Assisted Excision of Abdominal Wall Endometrioma Utilizing Intra-Operative Ultrasound and Transabdominal Needle Placement

Study Objective Demonstrate technique for robot-assisted laparoscopic excision of abdominal wall endometriosis with intra-operative ultrasound-guided needle placement. Design Description and demonstration of surgical technique. Setting Tertiary care, academic center. Patients or Participants Patient with previous history of 2 cesarean sections and right lower quadrant cyclic abdominal wall pain. Interventions Intra-operative ultrasound-guided needle placement to map location of the lesion. Minimally invasive resection of the lesion with the advancement of needles to confirm clear margins. Measurements and Main Results Complete resection via a minimally invasive approach. Conclusion Minimally invasive resection of abdominal wall endometriosis using intra-operative ultrasound guided needle placement to guide surgical dissection accomplishes clear surgical margins as well as successful treatment. Demonstrate technique for robot-assisted laparoscopic excision of abdominal wall endometriosis with intra-operative ultrasound-guided needle placement. Description and demonstration of surgical technique. Tertiary care, academic center. Patient with previous history of 2 cesarean sections and right lower quadrant cyclic abdominal wall pain. Intra-operative ultrasound-guided needle placement to map location of the lesion. Minimally invasive resection of the lesion with the advancement of needles to confirm clear margins. Complete resection via a minimally invasive approach. Minimally invasive resection of abdominal wall endometriosis using intra-operative ultrasound guided needle placement to guide surgical dissection accomplishes clear surgical margins as well as successful treatment.

A case of Uterine didelphis with cervical atresia: A Case Report

Congenital uterine malformations are deviations from normal anatomy resulting due to defective fusion of Mullerian ducts or the paramesonephric ducts in the developing embryo. The prevalence of female genital tract anomalies is 4%-7% in general population and up to 8%-10% in women who have recurrent pregnancy loss.(1) The type and degree of anatomical distortion has associated health implications that may include, cyclical abdominal pain, reproductive failure, obstructed menses and inability to engage in sexual intercourse.(2) Uterus didelphys (double uterus) is a developmental abnormality that results from the failure of fusion of the Mullerian ducts leading to separate uterine cavities and 2 cervices 1. It is a rare anomaly accounting for 5% of all uterine anomalies. (3) Cervical agenesis is a rare Mullerian anomaly with an incidence of 1 in 80,000 females. (4) It represents 3% of all uterine anomalies. It is rarely associated with a functioning uterus (4.8%). Cervical agenesis is often associated with vaginal atresia (less than 50%). It is important to classify these anomalies for easy diagnosis and plan appropriate preoperative treatment.

Laparoscopic Resection of Large Abdominal Wall Endometriosis

<h3>Study Objective</h3> To demonstrate surgical techniques for resection of large fascial and rectus muscle endometriosis implants. <h3>Design</h3> N/A. <h3>Setting</h3> The patient underwent surgery at a tertiary care center. She was placed in dorsal lithotomy position in steep Trendelenburg. Insufflation was carried out to 15 mmHg. A primary 10mm subxiphoid port was used for the camera and three additional 5mm assist ports were placed. <h3>Patients or Participants</h3> The patient is a 44-yo G1P1 with a history of a cesarean delivery, laparoscopic excision of endometriosis, and subsequent hysterectomy who presented with cyclic abdominal wall pain consistent with abdominal wall endometriosis diagnosed on MRI. <h3>Interventions</h3> Laparoscopic excision of abdominal endometriosis lesion with placement of polypropylene mesh. <h3>Measurements and Main Results</h3> Large sub-fascial abdominal wall endometriosis lesion was completely excised and resultant fascial defect successful closed with synthetic mesh. Patient was discharged same day, recovered without issue, and notes complete resolution of pre-operative symptoms. <h3>Conclusion</h3> Abdominal wall endometriosis involving the fascia or underlying structures can be safely and effectively resected using the laparoscopic techniques outlined in this video. This minimally invasive approach allows excellent operative exposure and a quicker recovery. In cases with large fascial defects, synthetic mesh should be utilized, and several techniques can be employed to reduce the incidence of post-op adhesions.

Distal vaginal agenesis and differential diagnosis of other causes of hematocolpos.

Distal vaginal agenesis is an obstructive congenital malformation of the female reproductive tract. The distal part of the vagina is replaced by fibrous tissue and the outflow of the menstrual blood and secretion of the cervical glands is disabled. This congenital anomaly most often manifests during expected menarche by primary amenorrhea and cyclic lower abdominal pain caused by cryptomenorrhea with gradually increasing hematocolpos and hematometra. The dia-gnosis is based on gynecological examination and the suspected anomaly is confirmed by ultrasound examination and magnetic resonance imaging. Therapy of distal vaginal agenesis is exclusively surgical. A pull-through vaginoplasty is the method of choice for distal vaginal agenesis not exceeding 3cm. With a greater extent of agenesis and the risk of postoperative vaginal stenosis, replacement of the missing part of the vagina with other tissues or modified balloon vaginoplasty can be used. The aim of the treatment is to enable the evacuation of the menstrual blood, ensure quality sexual intercourse and the possibility of reproduction.

Hematometra in pubertal girls

Haematometra in pubertal girls is a late presentation of congenital genital malformations. A diagnosis of the anomaly is preferably made before menarche. This will avoid the psychosocial trauma and other complications at puberty. We draw attention to the two cases we managed, reviewed the literature, discussed the specific pitfalls in our setting and arouse clinical awareness to the problem. two cases of haematometra in pubertal girls are discussed and the literature is reviewed. The first case is a 12-year-old girl who presented with cyclic lower abdominal pain, abdominal mass and no menarche. Following investigations, a diagnosis of cervicovaginal atresia was made. She eventually had hysterectomy done by request. She is awaiting vaginoplasty. The second patient is a 14-year-old girl who presented with primary amenorrhoea, cyclic lower abdominal cramps and abdominal mass. A diagnosis of imperforate hymen was made. The hymen was excised and the vulva (introitus) re-epithelialized. Both patients have been followed up for 4 years and have been symptom free. Our literature review shows that haematometra presenting in pubertal girls is rare and the causes are commonly congenital. It is either due to malformation of the Mullerian duct system, the urogenital system, or the external genitalia. Associated malformation of the urinary system is significant. Haematometra can pose challenges in management especially in a low resource setting. Early diagnosis and multidisciplinary approach are mandatory to proffer adequate treatment and avert psychological, sexual and reproductive health complications.

Paediatric cannabinoid hyperemesis.

The prevalence of adolescent cannabinoid hyperemesis syndrome (CHS) continues to grow, as clinicians increasingly recognize the presenting features of cyclical nausea, emesis, abdominal pain and relief of symptoms with hot showers, in the setting of chronic cannabinoid use. Our understanding of the contributory mechanisms continues to grow, but high-quality evidence of effective treatment in adolescents remains lacking. Current best evidence in the treatment of acute paediatric CHS suggests intravenous rehydration and electrolyte correction, followed by 0.05 mg/kg haloperidol with or without a benzodiazepine. The only long-term treatment remains complete cessation of cannabinoid use. This article reviews our growing knowledge of adolescent CHS and provides practical guidance for diagnosis, treatment and understanding the underlying mechanisms of the condition.

Bilateral Pudendal Thigh Flap In The Creation of A Neovagina and Restoration of Utero-Neovaginal Continuity – A Case Report

The pudendal thigh flap is a sensate flap based on the posterior labial artery, which has shown great versatility in the reconstruction of genital anomalies as well as genital oncologic reconstruction. This report showcases the creation of a neovagina with the restoration of uterovaginal continuity in a 12-year-old girl who had vaginal atresia. She presented with concealed menstruation and cyclical abdominal pain and had a creation of a neovagina with utero-vaginal continuity using a bilateral pudendal thigh fascio-cutaneous flap. Post-operatively, she attained normal menstrual flow and a sensate neovagina with a satisfactory vaginal canal depth. Partial wound dehiscence of the flap donor site was managed with dressing and healing by secondary intention. Even in new centres, the pudendal thigh flap remains a versatile flap for managing vaginal atresia.

Endometriotic cyst and fibrocystic disease of the breast treated with individualised homoeopathy – A case report

Introduction: Endometriosis is one of the benign gynaecological disorders in childbearing women, characterised by the presence of functioning endometrial tissue outside the uterine mucosa. Fibrocystic disease of the breast is the most common and benign lesion among women of reproductive age group seeking medical advice for breast problems during a lifetime. It is characterised by hyperproliferation of connective tissue or fibrosis, which is followed by facultative epithelial proliferation in the breast tissues. Case Summary: A case of a left endometriotic ovarian cyst with multiple cystic lesions in the right breast in a 36-year-old patient successfully treated with individualised homoeopathic medicine is reported. She had severe cyclic lower abdominal pain for more than 7 years, and conventional analgesics and even surgical procedures could not afford relief. Homoeopathic treatment was started with Silicea based on the totality of symptoms and repertorisation and later switched to Conium maculatum as an anti-miasmatic remedy, which showed disappearance of the left endometriotic cyst and reduction in the size of cystic lesion in the right breast with general improvement. The Modified Naranjo Criteria were used to assess causal attribution to the prescribed medicine in this case. Assessment of pain was done using a visual analogue scale. This evidence-based case reported according to the HOM-CASE guidelines suggested that individualised homoeopathic medicines can be used as a useful, safe and non-invasive mode of treatment for ovarian endometriotic cyst, associated with fibrocystic disease of the breast.

Mission Possible, Hymen Imperforate from Imperfect to Become Perfect: A Case Report

Imperforated hymen is a rare presentation in peripubertal girls. Imperforate hymen is the most common obstructive congenital abnormality of the female genital tract. Despite being the most common malformation in the female genital system, imperforate hymen is uncommon. It often emerges at puberty; however, prenatal, infant and adolescent cases have been reported. This study aims to report a case of 12 years girl present with cyclical abdominal pain, backache, and primary amenorrhoea with a huge mass per abdomen. This study implemented a qualitative method with a case report approach. The results of the study show imperforate hymen patients need to be treated by surgical hymenotomy.

085 Obstructed hemivagina and ipsilateral renal anomaly syndrome presenting from prenatal to postmenopausal period: A review

Objective(s): The obstructed hemivagina and ipsilateral renal anomaly syndrome, known by the acronym OHVIRA, [1] is a rare, but specific Müllerian duct anomaly. Typically, patients present shortly after menarche with cyclic abdominal or pelvic pain. Atypical presentations have been described. To our knowledge, the incidence is unknown. A comprehensive literature review was carried out with the aim to provide an overview of different clinical presentations of the OHVIRA syndrome.

Mixed Müllerian and gonadal dysgenesis: A case report

Background: Globally, the incidence of cervical agenesis is estimated at 0.01% and constitutes 3% of all Müllerian anomalies.&#x0D; Case presentation: A 17-year-old nulliparous presented to the gynecology clinic with a transverse vaginal septum and cyclic lower abdominal pain after two failed vaginal surgical procedures to restore genital tract patency. The examination under anesthesia revealed a 3cm short vagina, and a decision was made for vaginoplasty. Magnetic resonance imaging of the pelvis revealed a bulky uterus. Intraoperatively, locating the cervix through the neo-vagina was difficult, and laparotomy was opted for. The left adnexa and cervix were absent, with an atrophic right ovary and a hydrosalpinx on the fallopian tube. Creating a uterovaginal anastomosis was difficult as the uterus was high in the pelvis. Postoperatively, the patient was counseled, and hysterectomy and right oophorectomy were done four months later.&#x0D; Conclusion: Vaginoplasty with total hysterectomy is an alternative management method in failed uterovaginal anastomosis.

Acute Urinary Retention – It Is Not about the Bladder

Chronic cyclical abdominal pain in an adolescent female is indeed a rare occasion. Nevertheless, concomitant presence of acute urinary retention in the background history delayed menarche will give clues towards possibility of imperforate hymen (IH). Nevertheless, adequate physical examination, especially abdominal and gynaecological assessment in the adolescent female is indeed important in making the conclusion. We shared a case of a 12-year-old girl who came to us with recurrent lower abdominal pain for three months associated with inability to pass urine on the day of presentation. Perineum inspection showed bulging hymen with inability to catheterize the urethral opening. Bedside ultrasound was performed and revealed a fluid filled lesion in her vagina showing features of hematocolpos. A diagnosis of imperforate hymen was made clinically, and she was referred urgently to the gynaecology team for surgical intervention. Hymenotomy was done and she was saved from further morbidity. This case highlights the importance of identifying gynaecological causes in a female patient with acute urinary retention especially if the patient had prior episodes of recurrent cyclical symptoms that may be highly associated with imperforate hymen. &#x0D; Keywords: Hematocolpos, Bladder, Acute Urinary Retention

A Rare Case of Massive Hematocolpos Due to Imperforate Hymen

Imperforate hymen is a very rare anomaly of female reproductive system due to failure of complete canalization of endoderm of urogenital sinus thus obstructing the vaginal opening1, The condition is often diagnosed late due to its low incidence, nonspecific presentation &amp; insufficient physical examination. The teenage girls with imperforate hymen generally present with cyclical lower abdominal pain without the menstruation being established, urinary retention or constipation and sometimes as lower abdominal mass.Diagnosis is clinical and confirmed by ultrasound. It is treated surgically. Keywords: Primary amenorrhea, imperforate hymen, haematocolpos

Hymenal atresia - a rare congenital anomaly with the risk of late diagnosis.

Comprehensive analysis of causes, clinical signs, dia-gnostic process, differential dia-gnosis and therapy of hymenal atresia. Literature search using the Web of Science, Google Scholar and PubMed databases with keywords and analysis of articles published in high impact and reviewed journals. Hymenal atresia is a congenital malformation of a womans genitals, which is manifested by complete obstruction of the vaginal introitus by a closed hymen. It should be dia-gnosed in the neonatal period, but clinically it usually manifests itself only during puberty as a result of menstrual blood retention (cryptomenorrhea) with the cyclic abdominal pain at monthly intervals. The therapy is based on optimally timed surgical creation of communication in the hymen (hymenotomy, hymenectomy) enabling free evacuation of menstrual contents. The aim of this simple treatment method is immediate subjective relief from pain and a permanent solution to this congenital anomaly. Knowledge of all types of congenital malformations of the female genitalia is a basic condition for an early and effective dia-gnostic process in adolescent girls with abdominal pain. The girl who has not yet menstruated and has cyclic lower abdominal pain and a tumor behind the pubic symphysis should be examined by a specialist in pediatric and adolescent gynecology who will confirm hymenal atresia according to a bluish and closed hymen, and suggest prompt and effective therapy.