Cyclic Pain Research Articles

PRIMARY UMBILICAL ENDOMETRIOSIS: A RARE CASE REPORT

Umbilical endometriosis is a rarest form of extrapelvic endometriosis, incidence being 0.5% - 1% of all extrapelvic endometriosis. In primary umbilical endometriosis there is no history of any previous abdominal and pelvic invasive procedures. Most patients present with an umbilical nodule which is associated with cyclical pain and bleeding from the lesion during menstrual cycle. It is mainly diagnosed clinically and is conrmed by histopathology. Surgery is the treatment of choice. Pre and post operative hormonal supplementation results in better outcome

Eletroestimulação no controle da dor na dismenorreia primária

ABSTRACT Primary dysmenorrhea is a gynecological disorder characterized by a cyclic pain in the lower back and abdomen, with a high prevalence among young women, which contributes to absenteeism. This study aimed to assess the effects of low and medium frequency electrotherapy in 30 women, aged from 18 to 26 years, who suffer from primary dysmenorrhea. Participants were divided into groups that received the transcutaneous electrical nerve stimulation current (frequency of 100Hz and 100μs pulses), Aussie current (4kHz carrier frequency, modulated at 100Hz, and 4ms bursts), and placebo (electrodes placed with the machine turned off). All treated groups received electrical current at the sensory threshold and its intensity was adjusted every five minutes. The treatment lasted 30 minutes. For the evaluation, pain during the menstrual cycle (via VAS), pain interference in activities of daily living (ADL), and sleep quality (via VAS sleep quality) were collected. After statistical analysis, pain reduced significantly in all groups evaluated, with better outcomes for the currents than for the placebo. Although all groups showed significant difference regarding ADL, the Aussie group was the only one that improved pain in all days evaluated. Sleep quality changed little after treatment, thus, further studies are required to assess this variable.

An Interdisciplinary Approach to Müllerian Outflow Tract Obstruction Associated with Cloacal Malformation and Cloacal Exstrophy.

People with cloacal malformation and 46,XX cloacal exstrophy are at risk of developing Müllerian outflow tract obstruction (OTO). Management of OTO requires expertise of many medical and surgical specialties. The primary presenting symptom associated with OTO is cyclical and later continuous pain and can be initially quelled with hormonal suppression as a temporizing measure to allow for patient maturation. The decision for timing and method of definitive treatment to establish a patent outflow tract that can also be used for penetrative sexual activity and potential fertility is a complicated one and incredibly variable based on patient age alone. To understand the management approach to OTO, we put forth five phases with associated recommendations: (1) caregiver and patient education and evaluation before obstruction; (2) presentation, diagnosis, and symptom temporization; (3) readiness assessment; (4) peri-procedural management; (5) long-term surveillance. This review will emphasize the importance of interdisciplinary team management of the complex shared medical, surgical, and psychological decision making required to successfully guide developing patients with outflow obstruction secondary to cloacal malformations and cloacal exstrophy through adolescence.

Menstrual and reproductive health in female adolescents with developmental disabilities

Youth with intellectual and developmental disabilities (I/DD) are impacted by pubertal changes and the onset of menses disproportionately. Despite the fact that for most youth with I/DD, the progression of puberty, menarche, and irregular cycles due to axis immaturity appear to be consistent with the general population, cyclic behavioral changes and premenstrual symptoms may be more common. Furthermore, for some disabled youth there are endocrine or medication effects that may impact menses disproportionately. Education and access to care is essential for this group to address many aspects of treatment, from prepubertal anticipatory guidance to menstrual management, with special attention required for addressing issues concerning hygiene, cyclic pain, behavior changes, sexuality, potential for abuse, and pregnancy prevention.1-4 This article will provide an overview of the policies and guidance available for management of the menstrual issues encountered in adolescents with intellectual and developmental disabilities and complex medical disorders. Included will be a review of studies that evaluate the different types of methods that are utilized for menstrual management and the different conditions that are encountered.

Axillary ectopic breast tissue in the adolescent.

Ectopic breast tissue (EBT) includes a spectrum of disease that entails other entities based on the presence of glandular tissue, nipple, or areola. The diagnosis in adolescents is infrequent. A retrospective study was performed including girls with axillary EBT (class IV or V of Kajava's Classification) operated in 2006-2020. Imagining studies, clinical and surgical reports, and histopathology were reviewed. Eleven girls from 13 to 16years old were included. Two patients (18.2%) presented bilateral EBT. The most frequent clinical manifestation was 2-5cm mass (100%), associating cyclic pain with menstruation (45%) and fluctuating volume (36%). Bilateral axillary ultrasonography allowed preoperative diagnosis. All of them were treated by open excision, through small incisions located in an axillary y fold. Clinical and aesthetic results were self-assessed as "very good", with normalization of the axillary y hollow and imperceptible scars. No recurrences were observed after one year of follow-up. An immediate postoperative hematoma was reported, which did not require drainage. Histopathology showed mature breast tissue without atypia. Axillary accessory breasts must be included in differential diagnosis of pediatric axillary masses. Bilateral ultrasonography is recommended for the preoperative diagnosis. Excision through minimal incision at this age seems to be safe and effective.

A targeted educational programme improves fundamental knowledge of menstrual pain and endometriosis in young women: The Endometriosis Awareness Promotion Project

Research questionWould a properly designed educational programme offered to young women improve their awareness and fundamental knowledge of menstrual pain and endometriosis? DesignA multinational cross-sectional study using a pen-and-paper questionnaire among women aged 19–24 years was conducted between 2017 and 2019 to assess fundamental knowledge of menstrual pain and endometriosis. Improvement in knowledge was also analysed using a separate questionnaire completed before, and 1–3 months after, a group discussion, lecture on menstrual pain and endometriosis, or both. ResultsAmong three groups of students (college [n = 271], medical [n = 877] and nursing [n = 763]), knowledge of menstrual pain and endometriosis was lowest among college students, modest among nursing students and fair among medical students (P < 0.001 for each). The experience of cyclical pain, even when painkillers were taken, was reported by 15.5%, 4.6% and 3.8% of students, respectively. Most students managed their cyclical pain by enduring it or by taking over-the-counter medication. An informative education programme with group discussions, lectures, or both, was successful in improving knowledge and consequences of menstrual pain and endometriosis. Proper education and dissemination of knowledge to college students failed to motivate them to visit gynaecologists; however, medical and nursing students became highly interested in visiting gynaecologists. ConclusionsAn educational programme can improve awareness and knowledge of endometriosis and dysmenorrhoea among young women. The programme motivated nursing and medical students, but not college students, to seek medical attention for early detection and management of endometriosis.

Effects of oral N-acetyl cysteine on pain and plasma biochemical parameters in fibrocystic breast disorder: A randomized controlled trial

BackgroundFibrocystic change is the most common benign lesion in breasts of a woman in her reproductive age. It is an outcome of estrogen excess due to sex hormone imbalance. Cyclical pain as the most common symptom worsens life quality, compels patient to seek health care support continuously, and imposes large amounts of expense to both patient and health system. Current study aims to evaluate effects of N-acetyl cysteine on decreasing pain and changes in plasma biochemistry. MethodA total of 64 eligible women participated in this double-blinded randomized controlled trial. They were between 18 and 40 years. Participants were randomly allocated into oral N-acetyl cysteine and placebo receivers. Intervention and follow-up lasted for, respectively, a 12-week drugs-on and 12-month drugs-off period. Visual analog scaling was applied to measure severity of pain. Peripheral venous plasma was extracted and compared for inflammatory parameters including high-sensitivity C-reactive protein, total antioxidant capacity, malondialdehyde, total plasma glutathione, lipid profile, and fasting blood sugar. ResultsOral N-acetyl cysteine significantly decreased feeling of cyclical mastalgia (P < .01) after 12 weeks of consumption. In addition to lowering of plasma level of high-sensitivity C-reactive protein (P = .008), total plasma glutathione significantly increased (P = .02) among N-acetyl cysteine receivers. No change in lipid profile and insulin sensitivity was seen. ConclusionN-Acetyl cysteine could mitigate cyclical mastalgia. Inflammation as a considered reason for cyclical mastalgia also was halted by N-acetyl cysteine consumption.

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.

Endometrial ablation plus levonorgestrel releasing intrauterine system versus endometrial ablation alone in women with heavy menstrual bleeding: study protocol of a multicentre randomised controlled trial; MIRA2 trial

BackgroundIt is estimated that between 12 to 25% of women who undergo an endometrial ablation for heavy menstrual bleeding (HMB) are dissatisfied after two years because of recurrent menstrual bleeding and/or cyclical pelvic pain, with around 15% of these women ultimately having a hysterectomy. The insertion of a levonorgestrel-releasing intrauterine system (LNG-IUS) immediately after endometrial ablation may inactivate residual untreated endometrium and/or inhibit the regeneration of endometrial tissue. Furthermore, the LNG-IUS may prevent agglutination of the uterine walls preventing intrauterine adhesion formation associated with endometrial ablation. In these ways, insertion of an LNG-IUS immediately after endometrial ablation might prevent subsequent hysterectomies because of persisting uterine bleeding and cyclical pelvic pain or pain that arises de novo. Hence, we evaluate if the combination of endometrial ablation and an LNG-IUS is superior to endometrial ablation alone in terms of reducing subsequent rates of hysterectomy at two years following the initial ablative procedure.Methods/designWe perform a multicentre randomised controlled trial in 35 hospitals in the Netherlands. Women with heavy menstrual bleeding, who opt for treatment with endometrial ablation and without contraindication for an LNG-IUS are eligible. After informed consent, participants are randomly allocated to either endometrial ablation plus LNG-IUS or endometrial ablation alone. The primary outcome is the hysterectomy rate at 24 months following endometrial ablation. Secondary outcomes include women’s satisfaction, reinterventions, complications, side effects, menstrual bleeding patterns, quality of life, societal costs.DiscussionThe results of this study will help clinicians inform women with HMB who opt for treatment with endometrial ablation about whether concomitant use of the LNG-IUS is beneficial for reducing the need for hysterectomy due to ongoing bleeding and/or pain symptoms.Trial registration Dutch Trial registration: NL7817. Registered 20 June 2019, https://www.trialregister.nl/trial/7817.

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.

Hematocolpos on late-onset hymenal imperforation: A case report

Abstract We report the case of a patient with hematocolpos on hymenal imperforation, revealed following cyclic pelvic pain with primary amenorrhea associated with pelvic heaviness for one year. MRI showed significant distension of the vagina forming a pseudo mass, well limited, in T1 high signal, in moderate T2 high signal, with the presence of declining deposits in hyposignal related to hemosiderin. A hymenotomy was performed under general anaesthesia, the postoperative course was favourable. This case illustrates the particularity of suspecting a hematocolpos in the presence of a pelvic mass in a young girl with amenorrhea.

Transverse vaginal septum evaluation

Female genital malformations mostly affect women`s reproductive health. Vaginal septa are rare conditions that occur secondary to defectuous fusion or canalization of the Mullerian ducts. There are longitudinal and transverse septa. Transverse septa can be found in the upper, middle or lower vagina and the main symptom is primary amenorrhea in the presence of cyclic pelvic pain. Imaging discoveries can reveal urological, anorectal and uterine abnormalities that accompany the vaginal abnormalities.

Laparoscopic Management of Innumerable Diaphragmatic Fenestrations

A 50-year-old woman known to have severe endometriosis was referred with cyclic pelvic pain, right shoulder pain, and recurring bilateral pleural effusions necessitating near-monthly thoracentesis of up to one liter of fluid. Gonadotrophin-releasing hormone agonism produced incomplete success. Diaphragmatic endometriosis is a condition affecting 1.5% of patients with endometriosis [1]. The mechanism postulated combines Sampson's theory of retrograde menstruation with clockwise transport of endometrial cells into the right subdiaphragmatic space via peritoneal fluid [1].

Successful pregnancies in an adolescent with Herlyn-Werner-Wunderlich (HWW) syndrome: a case report and literature review

BackgroundMüllerian anomaly is a congenital defect in the development of the female reproductive system that varies according to the stage of developmental failure resulting in agenesis, hypoplasia, or fusion defect in one or both Mullerian ducts; in such patients, it is expected to have higher pregnancy and delivery complications.Case presentationThis case presentation of a 14-year-old adolescent girl with uterine didelphys, obstructed right hemi-vagina, and ipsilateral renal agenesis (Herlyn-Werner-Wunderlich syndrome, HWW) that was corrected surgically, then got married at the age of 16 with successful two consecutive term uncomplicated pregnancies of favorable maternal and fetal outcomes without a history of any miscarriage or recurrent collections.ConclusionsHerlyn-Werner-Wunderlich syndrome is a rare case and represents a challenge to diagnose and treat especially in pediatrics and adolescents. Early recognition and treatment will help to improve outcome and reduce possible complications resulting from obstruction with retrograde menstruation and its consequences. Successful early management of our patient improved her quality of life by relieving her cyclical obstructive pain, preserve fertility, and normal sexual life.

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.

026 Treatment of vaginal and uterine septa

Non-obstructing vaginal septa may be asymptomatic. However, both women with non-obstructing as well as (microperforate) obstructing vaginal septa may report tampon related problems. Furthermore, vaginal septa can cause apareunia or dyspareunia, and trauma may occur during intercourse. Obstructing septa cause hemato(metro)colpos, presenting as amenorrhea with cyclic pelvic pain, or progressive dysmenorrhea. Delay in the diagnosis is related to severe complications. Finally, vaginal septa can cause labor dystocia, and laceration of the septum may occur during delivery. The presence of a septate uterus is often asymptomatic. Nevertheless, it may lead to incorrect T-shaped IUD placement, and is related to subfertility and adverse pregnancy outcomes [ [1] Pfeifer, SM (Ed.). Congenital Müllerian anomalies.1st ed. New York, NY, USA: Springer International Publishing Switzerland; 2016, corrected publication 2018. Google Scholar ]. Vaginal septa need to be treated when symptomatic, in case of obstruction, and may be treated to avoid labor or delivery complications. In case of obstruction, endometrial suppression can delay surgical treatment when necessary [ [2] Dietrich J.E. Millar D.M. Quint E.H. Obstructive reproductive tract anomalies. J Pediatr Adolesc Gynecol. 2014 Dec; 27: 396-402 Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar ]. Uterine septa may be treated in order to place a T-shaped IUD. In the only, recent RCT, uterine septum resection was found not improve live birth rates compared with expectant management. The authors therefore recommend against routine septum resection. Still, after counselling, an informed decision can be made [ [3] Rikken J.F.W. Kowalik C.R. Emanuel M.H. Bongers M.Y. Spinder T. Jansen F.W. et al. Septum resection versus expectant management in women with a septate uterus: an international multicentre open-label randomized controlled trial. Hum Reprod. 2021 Apr 20; 36: 1260-1267 Crossref PubMed Scopus (18) Google Scholar ].

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.

Primary Umbilical endometriosis - case series and review of clinical presentation, diagnosis and management.

IntroductionUmbilical endometriosis is the most common cutaneous form and is seen mostly secondary to surgical scar and rarely occurs as primary umbilical endometriosis. The objective of this retrospective case series evaluation is to report the presentation, diagnosis, and management of patients with primary umbilical endometriosis.Presentation of casesWe present a retrospective, observational and descriptive review of cases presenting with primary umbilical endometriosis among Indian women managed in two private tertiary care centres between 2018 and 2020. Patients were assessed at the gynaecological outpatient department. We analysed age, parity, presenting symptoms and duration, associated symptoms, imaging, size of the lesion, associated pelvic endometriosis or any pelvic pathology, management, and histopathological diagnosis for confirmation in all four patients.DiscussionThe patients were aged between 25 and 31 years with an average of 28 years with no previous history of any abdominal surgeries. The mean duration of the symptoms presented in these cases was 25.5 months, with a range from 18 to 48 months. The diagnosis was made by clinical examination supported by imaging followed by complete surgical excision and confirmation on histopathology.ConclusionPrimary umbilical endometriosis is a rare disease with a limited number of cases reported in the literature and should be included in the differential diagnosis if women present with umbilical lesions with cyclical pain. Diagnosis is clinical but can be aided by high resolution imaging such as Ultrasound (US) and Magnetic Resonance Imaging (MRI). Complete surgical excision is the treatment of choice.

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