Cyclical Lower Abdominal Pain Research Articles

Cryptomenorrhea due to Agenesis of Upper Part of Vagina Treated by Vaginoplasty with Amnion Graft and Cervicovaginal Anastomosis: a Case Report

Cryptomenorrhea due to vaginal agenesis is a rare developmental anomaly of Mullerian duct. It may be complicated by retrograde menstruation, endometriosis and acute or chronic pelvic infection. We report a case of a 12-year-old girl who presented with a history of severe cyclical lower abdominal pain for 2 months. Her clinical examination revealed well developed secondary sexual characteristics, slightly bulged lower abdomen with a palpable tender mass and a short blind vagina. Ultrasound imaging showed hematometra, hematocervix and vaginal agenesis. She was treated by vaginoplasty with amnion graft and cervicovaginal anastomosis with serial vaginal dilatation using plastic vaginal mold. The patient was symptom free with regular menstruation on follow up visit at 1, 3 and 9 months. The Uterus was normal in size with empty cavity and well-defined endometrial lining on ultrasound. Bangabandhu Sheikh Mujib Med. Coll. J. 2024;3(1):49-51

Holistic treatment of endometriosis

The pain phenomena caused by endometriosis are manifold. In addition to nociceptive pain there is also anociplastic reaction with central sensitization. Atypical symptoms, such as acyclic lower abdominal pain, radiating pain, nonspecific bladder and intestinal complaints or even depression increasingly occur in addition to the classical cyclic complaints, such as severe dysmenorrhea, cyclic lower abdominal pain, dyspareunia, dysuria and dyschezia. Due to the diffuse range of symptoms, affected patients often consult not just gynecologists but also specialists from other disciplines (internal medicine, gastroenterology, orthopedics, pain therapy, psychology etc.). The complexity of endometriosis is presented. The resulting approaches to multimodal interdisciplinary holistic treatment are described. Interdisciplinary concepts should be involved in the optimal treatment of endometriosis patients along with hormonal and surgical treatment, mostly under the supervision of agynecologist and pain management, dietary changes, psychological support and physiotherapeutic management should also be included. This article provides an overview of possible treatment strategies for chronic symptomatic endometriosis. Based on multimodal treatment strategies and regarding the complex pathophysiological alterations of this disease, the complex complaints that significantly impair the quality of life of endometriosis patients can be greatly improved.

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.

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.

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.
 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.
 Conclusion: Vaginoplasty with total hysterectomy is an alternative management method in failed uterovaginal anastomosis.

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 & 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.

Partial Mullerian Agenesis with Renal and Skeletal Anomalies: An Observational Study of MURCS Association

Background: Müllerian agenesis is a disorder of genital development characterized by absence of the vagina, an absent or hypoplastic uterus, and normal or hypoplastic fallopian tubes. Typically, the ovaries are entirely normal, although one or both also may be undescended, hypoplastic, or associated with an inguinal hernia. Affected patients often also have urologic anomalies (15-40) % (unilateral renal agenesis, ectopic or horseshoe kidney, and duplication of the collecting systems) and skeletal malformations (5-10) %, (e.g., hemiverterbrae and scoliosis, or the Klippel-Feil syndrome). The cause is unknown, although some cases are associated with chromosomal translocations or occur in familial aggregates, suggesting a genetic basis. Logically, müllerian agenesis might be attributed to an activating mutation in the gene encoding AMH or its receptor, causing excess AMH activity, but none have been identified. Aim: The aim of this study was to analyze and present rare cases of partial mullerian agenesis combined with renal and/or skeletal malformations, their causes, clinical features, diagnosis and treatment along with review of literatures. Methods: A retrospective observational study was conducted in the department of Bangabandhu Sheikh Mujib Medical University. All four cases presented with similar type of presentation and were diagnosed as partial Mullerian aplasia (cervico-vaginal agenesis) with other associated anomalies (renal, skeletal or cardiac anomalies) ie: MURCS association. Results: We analysed four cases of mullerian agenesis with renal and/or skeletal abnormalities presented with primary amenorrhoea with cyclical lower abdominal pain. Subsequently these patients were ascertained to have cervicovaginal agenesis with renal and skeletal abnormalities by physical examination and relevant investigations. Two (50%) patients had renal anomalies in the form of renal agenesis and one small malrotated kidney while 100% patients had skeletal abnormalities. One (25%) patient had congenital cardiac anomaly, one (25%) patient had history of cleft lip and cleft palate and one (25%) patient had history of imperforated anus at birth. Evaluation included clinical examination, whole abdominal ultrasound, skeletal survey and karyotyping along with some supportive investigations. Conclusion: The management is varied but multidisciplinary approach, psychological and social supports are the key points of managing such cases.

Management of endometriosis pain : Stage-based treatment strategies and clinical experience

Endometriosis is associated with various types of intense pain. In addition to nociceptive pain, there is also anociplastic reaction with central sensitization. Atypical symptoms such as acyclic lower abdominal pain, radiating pain, non-specific bladder and intestinal complaints or even depression are frequent as are classic cyclical complaints such as severe dysmenorrhea, cyclical lower abdominal pain, dyspareunia, dysuria and dyschezia. In cases of adiverse range of symptoms, patients often consult not just gynecologists but specialists from other disciplines (e.g., internal medicine, gastroenterology, orthopedics, pain therapy, psychology). Overview about the pathophysiology and complexity of the disease and the resulting treatment options. Amultimodal interdisciplinary concept might be able to take into consideration all aspects of the complex disease. Interdisciplinary concepts should be involved in the treatment of endometriosis patients along with hormonal and surgical therapy, which are generally under the supervision of agynecologist. Pain management, dietary changes, psychological support, as well as physiotherapy should be included. The present article is intended to provide an overview of possible treatment strategies for chronic, symptomatic endometriosis. The use of multimodal treatment strategies regarding the complex pathophysiological aspects of this disease might be helpful in significantly improving the quality of life of endometriosis patients.

English

A 22-year-old woman, single, came to Radiodiagnosis Department of North Bengal Medical College and Hospital for ultrasonography examination of whole abdomen for evaluation of amenorrhoea and vague cyclical lower abdominal pain. She had been treated outside the hospital for several years for above symptoms without any fruitful outcome. There was no history of any surgical management to this patient. Careful clinical examination of pelvis revealed an imperforate hymen. No other clinical signs were found except mild lower abdomen tenderness. Routine ultrasound was done with curvilinear probe with frequency of 5 MHz in GE LOGIQ P 9 model ultrasound sonography (USG) Machine. Cervical agenesis was suspected based on sonographic findings, non-visualization of the cervix with a uterus like structure (measuring approx. 30 x 36 x 30 mm.) in right adnexal region. Mild collection seen in pouch of Douglas. Both ovaries and bilateral adnexa were normal. Vagina showed no abnormal collection. Other abdominal organs like liver, gallbladder (GB), common bile duct (CBD), portal vein (PV), pancreas, spleen, both kidneys, and bladder appeared normal. Transvaginal examination as well as transvaginal sonography could not be performed as imperforate hymen. Therefore, the patient underwent magnetic resonance imaging (MRI) examination of whole abdomen which confirmed the ultrasonographic findings and the case diagnosed as congenital atresia of uterine cervix with imperforate hymen.

A Rare Case of Imperforate Hymen Presenting with Perineal Pain

Introduction: Imperforate hymen is a rare local fusion anomaly of the female reproductive tract and diagnosis can be easily missed. Cyclic lower abdominal pain and amenorrhea are common symptoms in cases left untreated after menarche. Perineal pain may be an unusual presenting symptom of imperforate hymen. In order to avert complications related to delayed treatment, hymenotomy is considered effective management. Case Report: We herein describe a case of a 13-year-old adolescent girl with an imperforate hymen presenting with lower abdominal and perineal pain. The girl underwent and hymenotomy and postoperative period was uneventful. Perineal and pelvic pain relieved instantly after surgical treatment and during follow up her menstrual cycles were regular.

Herlyn-Werner-Wunderlich Syndrome Presenting with Abdominal Pain: A Case Report

Herlyn-Werner-Wunderlich (HWW) syndrome is a rare congenital anomaly characterized by triad of uterus didelphys, obstructed hemi vagina, and ipsilateral renal agenesis. The most common presentation is abdominal pain, dysmenorrhea, and abdominal mass secondary to hemi-hematometrocolpos. We report an emergency presentation of this syndrome during the pandemic of COVID-19 in Qatif Central Hospital, Saudi Arabia, April 2020. An 11-year-old Saudi girl presented to the emergency room with three months history of cyclical lower abdominal pain. The pain was progressive, continuous and not relieved by analgesics. Abdominal examination revealed a tender abdominal mass mainly in the left iliac fossa, Ultrasound evaluation showed two uterine bodies. The left uterus was distended with complex fluid. Pelvic MRI findings consistent with Herlyn-Werner-Wunderlich (HWW) syndrome were found with uterine didelphys and left sided hematometra resulting from obstructed hemi-vagina and ipsilateral agenesis of the left kidney. Resection of the vaginal septum and drainage of hematometra was done. The patient recovered with normal cyclical menstruation. Cyclical or continuous lower abdominal pain with or without amenorrhea is the usual presentation of HWW syndrome during adolescence. Diagnosis is made by ultrasonography and MRI. Early diagnosis and accurate management can provide pain relief, prevent future complications, and preserve fertility.

PREVENTION OF DISMENORRHEA

Dismenorrhea is a medical condition characterized by severe uterine pain during menstruation that manifests as cyclical lower abdominal pain. Dismenorrhea is classified into primary dismenorrhea in the absence of pathology and secondary dismenorrhea in the event of an identifiable pathological condition. About 40-70% of women of childbearing age suffer from dismenorrhea accompanied by associated psychological, physical, behavioral, and social distress. This is the main cause of the decline in the quality of life of adolescents. The pathophysiological process due to increased myometrium activity caused by excessive production of prostaglandins that cause ischemia. Risk factors are very important in enforcing the diagnosis of dismenorrhea and also in distinguishing between primary and secondary dismenorrhea. Mainstay treatment is generally supportive by relieving symptoms in primary dismenorrhea and surgical treatment may be recommended for secondary dismenorrhea. Therefore, patients with primary dismenorrhea may only require simple non pharmacological and analgesic therapies, whereas patients with secondary menorrhea require treatment for major problems.

PREVENTION OF DISMENORRHEA

Dismenorrhea is a medical condition characterized by severe uterine pain during menstruation that manifests as cyclical lower abdominal pain. Dismenorrhea is classified into primary dismenorrhea in the absence of pathology and secondary dismenorrhea in the event of an identifiable pathological condition. About 40-70% of women of childbearing age suffer from dismenorrhea accompanied by associated psychological, physical, behavioral, and social distress. This is the main cause of the decline in the quality of life of adolescents. The pathophysiological process due to increased myometrium activity caused by excessive production of prostaglandins that cause ischemia. Risk factors are very important in enforcing the diagnosis of dismenorrhea and also in distinguishing between primary and secondary dismenorrhea. Mainstay treatment is generally supportive by relieving symptoms in primary dismenorrhea and surgical treatment may be recommended for secondary dismenorrhea. Therefore, patients with primary dismenorrhea may only require simple non pharmacological and analgesic therapies, whereas patients with secondary menorrhea require treatment for major problems.

Diagnosis and Surgical Treatment of Uterine Isthmus Atresia: A Case Report and Review of the Literature

Uterine isthmus atresia is a rare Müllerian duct anomaly occasionally diagnosed in adolescents with primary amenorrhea and cyclic abdominal pain. A case is presented of a 14-year-old female with monthly cyclic lower abdominal pain of a 2-year duration. Magnetic resonance imaging and 3-dimensional ultrasound showed separation of a 10-mm fibrotic tissue between the cervical canal and the endometrial cavity. In an attempt to preserve reproductive ability, an end-to-end anastomosis was laparoscopically performed between the cervical canal and uterine cavity. A platinol stent (WallFlex Biliary RX; Boston Scientific, Boston, MA) was placed by hysteroscopy to avoid stenosis after surgery. Laparoscopic end-to-end anastomosis is proposed to treat congenital uterine isthmus atresia.

Imperforate hymen: a rare cause of tenesmus

Imperforate hymen is an uncommon obstructive anomaly of the female reproductive tract for which early diagnosis is easy to miss. Untreated cases after menarche may cause cyclic lower abdominal pain and amenorrhea. Hymenotomy is considered proper management in order to avoid complications associated with late treatment. We report a case of an imperforate hymen in a 13-year-old adolescent girl presenting with tenesmus and acute lower abdominal pain. The patient was treated with hymenotomy and postoperative period was uneventful. Tenesmus and lower abdominal pain resolved immediately after surgery and during follow up the girl reported normal menstrual cycles. According to our case, tenesmus may be an atypical clinical presentation of imperforate hymen. Therefore, imperforate hymen should not be eliminated from differential diagnosis when it comes to adolescent females with abdominal pelvic pain and gastrointestinal symptoms and gynecological examination should be performed.

Single port laparoscopy combined with vaginal cervicovaginal reconstruction in a patient with congenital atresia of the cervix

To introduce an innovation that combines single port laparoscopic and Wharton-Sheares-George cervicovaginal reconstruction using a small intestinal submucosa (SIS) graft in a patient with congenital cervical atresia, absence of vagina, and incomplete uterine septum (U2aC4V4). Video article introducing a new surgical technique. University hospital. A 15-year-old patient with congenital cervical atresia, absence of vagina, and incomplete uterine septum had primary amenorrhea and cyclic lower abdominal pain. The magnetic resonance imaging did not show hematometra and the endometrium was 6 mm when she had lower abdominal pain. A neovagina (depth, 7 cm; width, 2.5 cm) was created using the Wharton-Sheares-George neovaginoplasty. By single laparoscopy, the bladder was separated from the anterior surface of the uterus. With the mold in the neovagina created by the assistant, the apex of neovagina was opened. Then the lower uterine segment was exposed and incised. A T-shaped intrauterine device was connected to an 8-cm-long catheter scissored from a 14-F Foley catheter and was inserted into the uterus to prevent cervical or vaginal stenosis. The upper end of the graft was applied onto the lower uterine segment with delayed absorbable sutures. The lower end was sutured to the high vaginal or vestibular mucosa. The feasibility and effect of combination single port laparoscopic with vaginal cervicovaginal reconstruction in the congenital atresia of cervix. The operation was successful. The operating time was 90 minutes. Hospitalization was 3 days. There were no intraoperative and postoperative complications. The patient had resumption of menses at three cycles postoperatively, and she had no dysmenorrhea. No cervical or vaginal stenosis occurred because of the Foley catheter. Single port laparoscopic combined with vaginal cervicovaginal reconstruction provided a minimally invasive, safe, and effective surgical option for the young patient with congenital atresia of cervix. It was successful and without complications or cervical or vaginal stenosis.

Cryptomenorrhea Secondary to Past Childhood Pelvic Trauma in Young Adolescent Girls: Case Series

Primary amenorrhea secondary to childhood pelvic trauma is very rare. We report two cases of adolescent girls with cryptomenorrhoea. Case 1 presented at 14 years of age with primary amenorrhea and cyclical lower abdominal pain for 1 year. She was run over by a tractor when she was three years old. Ultrasonography pelvis showed hematometra. Examination under anesthesia with diagnostic laparoscopy proceed laparotomy revealed uterine avulsion at level of isthmus. The second case presented at 13 years of age with urinary retention. Catheterization was not possible due to malpositioning of urethra so suprapubic catheterization was performed by urologists. Ultrasonography pelvis revealed hematocolpos. Detailed history revealed run over injury by a vehicle when she was two years old. Examination under anesthesia showed obstruction due to adhesions high up in vagina which were divided.

Abdominal-wall Endometriosis Occurring at the Wound Site after a Caesarian Section

A 47-year-old woman underwent caesarian section at the age of 23 and 33. Subsequently, she underwent another operation for an umbilical hernia and abdominal-wall tumor of umbilicus when she was 39 years old. Abdominal-wall endometriosis of umbilicus was diagnosed based on the results of pathological examination. There was no post-operative recurrence. At the age of 44 years, two abdominal-wall tumors with cyclical lower abdominal pain were observed in the lower abdominal region. She presented with pain at our hospital and had a palpable abdominal-wall tumor along the caesarian section scar. Tumors were another legions at the age of 39 years. Contrast-enhanced computed tomography revealed that the two tumors had invaded the rectus abdominis muscle. Both tumors were 35 mm in size. Magnetic resonance imaging revealed blood component into tumors. We suspected abdominal-wall endometriosis based on these findings. Core-needle biopsy was not performed due to the risk of re-implantation and dissemination. Surgical excision was used to remove the tumors along with some surrounding tissues. Pathological analysis revealed that the tumors consisted of endometriosis with glands and endometrial stroma. Approximately 79％ of abdominal-wall endometriosis occurs in the operative scar after a caesarian section. As there are no treatment guidelines, wide excision with normal tissue surrounding the tumor is recommended.

Ultrasound features of neonate and paediatric female pelvis: Developmental change, physiologic and pathologic condition

The evaluation of the infant and pediatric pelvis requires the knowledge of the developmental changes occurring in the various stages of pediatric life. To be familiar with imaging findings of uterus and ovary diseases is helpful for diagnosis and preoperative evaluation. The uterus and ovaries undergo remarkable changes in size and appearance over the course of a lifetime. Ultrasonography (US) is the primary modality for the evaluation of the pediatric gynecologic organs. Variable physiologic and pathologic condition may arise from ovary including physiologic and functioning follicles, corpora lutea, hemorrhagic cysts, endometriomas, polycystic ovaries and ovarian tumors. For hydrometrocolpos, most cases present in adolescent period presenting with amenorrhea and cyclic lower abdominal pain. Hernia of uterus and ovary commonly occurs in infant. Herein, we present ultrasound imaging findings of morphologic change and various diseases involving female pelvis organ in infant and pediatric patients. It is helpful to be familiar with the spectrum of ultrasound image findings of the normal and abnormal female reproductive tract in infant and pediatric patients to avoid misinterpretation.