Cyclic Pain Research Articles

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.

Herlyn Werner Wunderlich Syndrome with Vagino-umbillical Fistula: A Most Unique Presentation

The Herlyn–Werner–Wunderlich (HWW) syndrome is an uncommon Mullerian duct anomaly composed of a triad of obstructed hemivagina, renal agenesis, uterine didelphys with a prevalence of [Formula: see text] females. Aside from its usual presentation of cyclic hypogastric pain and abdominal mass, there has been no other reported case in literature of the syndrome presenting with a vagino-umbilical fistula. Presented here is a unique case of a 35-year-old woman presenting with purulent, foul-smelling discharge extruding from a fistula on her umbilicus and her vagina associated with a tender hypogastric mass. Three-dimensional transvaginal ultrasonography aided the diagnosis of HWW syndrome with a concomitant vagino-umbilical fistula. Excision of the vaginal septum together with antibiotic coverage resolved her symptoms. The syndrome’s embryopathogenesis, classification, diagnostics, definitive surgical management and other issues during follow up are discussed.

One of the rare reason of abdominal pain: abdominal wall endometriosis.

Endometriosis is defined as the presence of normal endometrial mucosa abnormally implanted in locations other than the uterine cavity. It is most commonly located in the pelvis but it is also rarely observed in the gastrointestinal tract, lung, liver, kidneys, central nervous system and abdominal wall. Abdominal wall endometriosis (AWE) commonly occurs following a caesarean section or pelvic surgery. The patients consult the physician mostly with complaints of cyclic abdominal pain and a palpable mass in the abdomen. The basic methods in diagnosing AWE are anamnesis and physical examination but ultrasound, computerized tomography, and sometimes magnetic resonance imaging of the abdomen are also used. In our study, we retrospectively analyzed 9 patients who underwent surgery at Avcılar State Hospital General Surgery Service between January 2015 and December 2018 with a preliminary diagnosis of AWE and confirmation through pathology results. Median age of the patients was 32 ± 4.66 and median body mass index (BMI) was 24.6 ± 1.15. Every patient except 1 had a history of cesarean section history. One patient was operated because of recurrence. Patients consulted the hospital with complaints of pain during menstruation and abdominal swelling. The start of the complaints was 4.1 years following C-section. Mostly ultrasound was used for imaging. For treatment, they all received en-bloc mass excision and their pathological diagnosis were compliant with endometriosis. Average surgery time was 40 minutes and average endometriosis lesion dimension was 3.4 cm. It was observed that the lesion extended to the anterior abdominal fascia in 6 of the patients, and 2 patients underwent fascia repair with propylene mesh because of the excessive defect size. No postoperative complication occured in any patient and no recurrence is observed. In patients with periodic abdominal pain and swelling on the abdominal wall, AWE could be suspected and early diagnosis can be realized by carefully taking medical history and following physical examination, and appropriate radiological examinations and necessary surgical intervention can be performed. The method of diagnosis and treatment is to remove the lesion through wide excision.

Diaphragmatic endometriosis and thoracic endometriosis syndrome: a review on diagnosis and treatment.

Endometriosis of the diaphragm has been gaining more attention in the practice of gynecologists and thoracic surgeons in recent years. Understanding related symptoms and developing imaging methods have improved their approach. A review of the literature was performed with the aim to report on incidence, diagnosis, treatment and prognosis of diaphragmatic endometriosis. We also cover the issue of the Thoracic Endometriosis Syndrome (TES). Complaints of cyclic chest pain in patients of childbearing age should have as differential diagnosis the presence of thoracic endometriosis. Catamenial pneumothorax is the main manifestation of diaphragmatic endometriosis and Thoracic Endometriosis Syndrome. Other possible manifestations are hemothorax, pulmonary nodules, and diaphragmatic hernia. Despite the possibility of drug treatment, many patients will be submitted to surgical treatment. The minimally invasive approach should be the one of choice. The robotic pathway allows for an easier approach due to its ability to articulate robotic arms, allowing the treatment of lesions in hard-to-reach locations, such as the posterior part of the diaphragm. Multidisciplinary treatment should be used in most cases, as only abdominal approach is not sufficient for the diagnosis and treatment of lesions in the thoracic cavity. The approach of endometriosis of the diaphragm and Thoracic Endometriosis Syndrome should be multidisciplinary, allowing the improvement of quality of life in most 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.

Clinico-pathological assessment of surgically removed abdominal wall endometriomas following cesarean section

BackgroundOver the past few decades, the rate of Cesarean Section (CS) delivery has been rising rapidly and the prevalence of CS-associated complications including Abdominal Wall Endometriomas (AWE) increases with each additional operation. The aim of this study was to evaluate the clinical characteristics, histopathological diagnostic role and surgical management of post-CS AWE through a retrospective case review. MethodsWe calculated the incidence of AWE and reviewed all the patients underwent surgical removal of Post-CS AWE during the period of 2012–2018 who were diagnosed, treated and followed up for 2–8 years at our tertiary hospital. ResultsThirty women with AWE were included. The main symptom in 2/3 of cases was cyclic pain and 4 cases (13.3%) had no symptoms. The mean interval between prior CS and appearance of symptoms was 55.2 months and the mean size of the excised mass was 42 mm. Free surgical margin was less than 9 mm in 9 patients (30%) but no recurrence was recorded among all the studied patients. Pre-operative FNAC diagnosis was performed for only 3 patients (10%) which helped in excluding other potential pathologies. The clinical–pathological agreement value for detection of the nature of the abdominal wall mass was 93.4%. ConclusionsPatients with suspected AWE should undergo preoperative cytological biopsy to exclude alternative diagnosis. Wide surgical excision with margin of less than 1 cm could be accepted especially in case of weak abdominal wall. More studies on the post-CS complications; risks, prevention, early detection and proper management should be encouraged.

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.

Skin endometriosis at the caesarean section scar: a case report

Endometriosis is a pathology little referenced in the dermatological literature and is defined as the presence of endometrial tissue outside the uterus. When it is a well-defined mass of endometriosis it is called endometrioma. Cutaneous endometriosis is one of the rare gynecological conditions. Cutaneous endometriosis is a disorder that primarily affects women of reproductive age. The disorder is most commonly associated with cyclical pain during menses, but it can be difficult to diagnose in the absence of these symptoms and requires biopsy testing for a definitive diagnosis. We report on a case of a 39-year-old patient who presented with pain at the cearean section scar. She was ultimately diagnosed with cutaneous endometriosis and underwent surgical excision.

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.

Umbilical Mass with Cyclical Pain: Surgical Management

Umbilical Mass with Cyclical Pain: Surgical Management

Susceptibility-Weighted MRI in the Evaluation of Gynecologic Diseases

Introduction: Owing to the advanced development of MRI science, it causes obvious great changes of many diseases that affect the female genital system and affect their fertility. Hemorrhagic gynecological diseases especially endometriosis affect young females and cause cyclic pain, in addition to infertility. So early detection is essential for proper treatment. Susceptibility-weighted (SWI) as one of the most recent newly created MRI sequences is highly sensitive to detect products of hemorrhage within different gynecologic disorders with 94.7% sensitivity being more meticulous than conventional MRI sequences as T1 and T2. Aim of the Work: A comparison between T1 and T2 as conventional MRI sequences with susceptibility-weighted images (SWI) in many gynecologic disorders by the detection of the presence of internal products of hemorrhage at any stage. Subjects and Methods: 48 consecutive patients from Benha University clinics (age range, 17 - 60 years; mean age, 35.67 years). The patients included in the study were presenting with pelvic pain, irregular menses, Dyspareunia, and swelling. All with suspicious diagnosis of ovarian and extra-ovarian lesions. 38 patients out of the 48 patients were known to contain hemorrhagic disorder; all the patients underwent MRI routine pelvis protocol adding SWI sequence. Results: There was a greatly significant difference between SWI and conventional MRI sequences T1and T2 with sensitivity 94.7%, 57.9% and 33.3% respectively. Conclusion: SWI is a promising tool in the evaluation of hemorrhagic foci within different gynecological disorders. The great ability of detecting hemosiderin foci increases the value of SWI over conventional MRI or US.

Post-Ablation Cavity Evaluation: A Prospective Multicenter Observational Clinical Study to Evaluate Hysteroscopic Access to the Uterine Cavity 4 Years After Water Vapor Endometrial Ablation for the Treatment of Heavy Menstrual Bleeding

(Abstracted from J Minim Invasive Gynecol 2020;27:1273–1280) A minimally invasive treatment for heavy menstrual bleeding (HMB) due to benign causes in women who have completed childbearing is endometrial ablation (EA). Intracavity scarring following EA may result in recurrent heavy bleeding, cyclic pelvic pain with or without bleeding, and postmenopausal bleeding, often manifesting many years after the original treatment.

Conundrum of chronic pelvic pain and a pelvic journey of unparalleled grit: The good, the bad, and the ugly

Conundrum of chronic pelvic pain and a pelvic journey of unparalleled grit: The good, the bad, and the ugly

Endometriosis of the Canal of Nuck: A Systematic Review of the Literature

Endometriosis is a common benign gynecological condition defined as the presence of endometrial tissue in tissues outside the uterine cavity. Apart from the common sites of endometriosis, rare sites other have also been reported including the liver, the thoracic cavity, the muscles, nerves, and more rarely in a patent Nuck canal. We aim to evaluate the clinical presentation, diagnostic features, and management of the Nuck endometriosis. A meticulous search of three electronic databases was performed until May 2020 for articles reporting cases of Nuck endometriosis. A total of 36 patients from 20 studies were analyzed. Median age of patients was 36 years with 33 women being of reproductive age. A right-sided lesion was identified in 30 cases (83.3%), while all patients suffer from a groin mass with cyclic pain in a proportion of 22%. All the patients finally underwent surgery for investigation of the lesion and fixation of the defect. Five cases of malignancy were detected at final pathology. All of them were alive with a median reported overall survival of 37 months. Nuck endometriosis should be included in the differential diagnosis of female patients with groin swelling. An evaluation by a gynecologist is important when endometriosis is suspected.

Cesarean scar endometriosis - a case report

Scar site endometriosis is a rare event. It mostly occurs after obstetrics and gynaecological related surgeries. Classical presentation is cyclical pain and swelling at or near scar in relation to menstrual cycle. A case of scar site endometriosis in a 25-year-old female is presented. Patient developed characteristic clinical features 3 years after cesarean section. Clinical diagnosis was supported by ultrasonography. A wide excision with clear margins was curative. High index of clinical suspicion and wide excision remain the keys to successful management.

A Study of Management of Fistula in Ano at a Tertiary Health Care Centre

A Fistula is an abnormal communication between any two epithelial-lined surfaces. Fistula in Ano is an abnormal communication between the anal canal and the perineal skin. Fistula in ano denotes the chronic phase of anorectal sepsis and is characterized by chronic purulent drainage or cyclical pain associated with abscess reaccumulation followed by intermittent spontaneous decompression.

Topical Capsaicin for Treating Cannabinoid Hyperemesis Syndrome

Introduction Cannabinoid hyperemesis syndrome (CHS), associated with chronic cannabis use, presents with cyclic abdominal pain, nausea, and vomiting. With increasing use of marijuana, the incidence of CHS is expected to increase. Most patients with CHS make frequent visits to the emergency room and are usually refractory to conventional treatment. We, therefore, present a case of CHS successfully treated with topical capsaicin application. Case Presentation. A 41-year-old female with a recent excess use of cannabis presented to the emergency department for evaluation of recurrent excruciating epigastric pain accompanied by severe nausea and vomiting. She had similar, milder symptoms a year ago and underwent endoscopic evaluation which was negative except for mild reflux esophagitis for which she was started on a proton pump inhibitor. On this presentation, basic laboratory workup, EKG, and CT scan of abdomen and pelvis were unremarkable. A detailed abdominal exam was only positive for mild epigastric tenderness. She was instructed to continue pantoprazole and pain medication and outpatient repeat esophagogastroduodenoscopy. The patient returned the next day with extreme retching, nausea, and vomiting and was admitted for further evaluation. Intravenous fluids, antiemetics, and morphine were started for pain control with no symptomatic improvement. A diagnosis of cannabis hyperemesis syndrome was made based on history of chronic marijuana use and otherwise negative workup. A trial of topical capsaicin, over the epigastric region, was tried that provided dramatic relief within 24 hours. Repeat endoscopic evaluation had no evidence of ulcers, celiac disease, or esophagitis. She was discharged on topical capsaicin and counselled on marijuana abstinence, with no return of symptoms. Conclusion Based on the dramatic resolution of symptoms with topical capsaicin, our case supports this promising intervention and provides an alternate approach to antiemetics and narcotics routinely used in patients with cannabis hyperemesis syndrome.

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.

ASSESSMENT OF BREAST CANCER INCIDENCE IN PATIENTS WITH MASTALGIA AND ROUTINE SCREENING

About 70% of the women experiences breast pain once in their life time1. Mastalgia is described as tension, discomfort, and ache in breast1. The prevalence of cancer in patients manifesting with breast pain is reported to be 0.3-2% 2. As breast cancer awareness increases, the concern that breast pain may indicate malignancy contributes to the tendency of breast pain to be the most common breast symptom and leads to a woman consulting a breast surgeon3. Breast pain is categorized broadly in to two types; cyclical and non-cyclical breast pain. Cyclical mastalgia is a unilateral or bilateral pattern of pain or tenderness, frequently associated with swelling that reduces with the menstrual cycle. Noncyclic mastalgia tends to be unilateral and is more local than cyclical breast pain. The location of the pain can usually be localized. Typically, most women who had non cyclic mastalgia are in the fourth or fifth decade of life at the time of diagnosis.

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.