《骨盆腔疼痛》ppt课件

1、骨盆腔疼痛 急性骨盆腔疼痛 慢性骨盆腔疼痛 診斷急性骨盆腔疼痛-常見缘由 早期懷孕併發症,像ectopic pregnancy & miscarriage PID Appendicitis Ovarian cyst accident or Mittelschmerz急性骨盆腔疼痛-其它缘由 OHSS Hematomatra or hematocolpos Necrosis of uterine fibroid 其他非婦產科的缘由,像腸道或泌尿道疾病Ovarian cyst accident Dermoid cysts,teratomas,or simple cysts are more

2、 common cause of torsion Result of torsion(leading to occlusion of blood supply and necrosis) Presenting symptom of ovarian neoplasm,more common associated with functional ovarian cysts in younger Acute chemical peritonitis if they contain irritant material(as endometriotic or dermoid cysts)Ovarian

3、cyst accident Pain pattern of torsion: -sudden onset of coliky pelvic pain -located to one or other of iliac fossa -more constant after several hours or disappear -initially apyrexial,later on necrosis can cause pyrexia Mittelschmerz From german mittel=middle and schmerz=pain Middle cycle pain occur

4、ing at the time of ovulation More common ly in teenagers and older women慢性骨盆腔疼痛-定義 疼痛的時候超過六個月 慢性骨盆腔疼痛是影響生殖年齡女性最常見的婦科問題常見缘由 Endometriosis Chronic pelvic inflammatory disease Pelvic adhesion Bowel related pain Urological causes Musculoskeletal pain Neuropathic pain Psychological factors骨盆腔沾粘 引起疼痛的缘由還不

5、清楚 In uncontrolled studies,adhesionlysis relief pain In a randomized controlled trial,adhesionlysis 只徵對嚴重緻密血管豐富牽連到腸子的沾粘有幫助,對普通的簡單骨盆腔沾粘沒用 Ovarian remnant syndrome-卵巢周圍有緻密的纖維沾黏所引起的疼痛,藉由抑制或移除卵巢可緩解疼痛骨盆腔充血 Pelvic vein dilatationcyclical dragging pelvic pain Occure in premenstrual phase of cycle and worse

6、n in standing or walking 發生的位置與強度變異性大,和深度的性交疼痛有關 Dilated vein 有時可由laparoscopy or ultrasound看到骨盆腔充血-治療 MPA(medroxyprogesterone acetate) 30-50 mg daily for 3 months-side effect:weight gain,amenorrhea,bloating GnRH analogue-inhibit ovarian function Severe cases-TAH +BSOcurative 腸道有關的疼痛 Irritable bowel

7、syndrome-是最常見引起腸道有關的慢性骨盆腔疼痛,影響10-20%的普通族群,常可影響生殖年齡的女性-它是功能性的疾病,由疼痛的病史及腸胃道的症狀診斷,可用高纖食物及anti-spasmodic drugs constipation-也是常見腸子脹及慢性骨盆腔疼痛的缘由 Inflammatory bowel disease-pain and bloody diarrhea 泌尿道的缘由(I) Interstitial cystitis -不明缘由的發炎情況,它可引起疼痛及泌尿道的症狀,像frequency,urgency,nocturia;當膀胱脹滿,疼痛會添加,當解尿後,疼痛會緩解 -

8、可用膀胱鏡診斷(submucosal edema and petechiae) -dyspareunia (+)泌尿道的缘由(II) Chronic urethral syndrome-symptoms of irritation,postvoiding fullness,incontinence Other conditions:urethral diverticulae,urinary calculi,bladder neoplasm,or radiation cystitis肌肉骨骼疼痛 Sacroiliac dysfunction-疼痛發生在關結本身或有關的肌肉經巒,疼痛在移動時會惡化

9、 Abnormal posture-chronic muscle tension and strain on joints and ligaments Tension myalgia of the pelvic floor itself神經引起的疼痛 疼痛源自受傷的神經而不是受傷的組織 Nerve entrapment in scar tissue or fascia Sharp,stabbing in nature,or constant dull ache Diagnosis-confirmed by injecting local anaesthetic at the site of m

10、aximal tenderness Prescaral neurectomy for patents with endometriosis with mixed results精神上的缘由 促進因子:精神上,身體上及社會的缘由 這些因子的平衡將隨著病人間與個別疾病的不同時間而有變化 它會惡化睡覺品質與呵斥憂鬱沮喪 精神上的問題較常是結果而不是缘由 它经常在身體檢查或腹腔鏡檢查上沒問題但一半以上的病人都有情緒困擾問題 有慢性骨盆腔疼痛的病人在過去有較高的性暴力的發生率診斷(I) History -location of pain,mode of onset,constant or coliky

11、in nature,radiaion,and relation to the menstrual cycle -LMP? -used contraception? -vaginal discharge or bleeding -bowel or urinary symptoms?診斷(II) Physical examination -move or crouched up in bed? -check vital sign -abdominal examination:location of pain,rebounding tenderness or guarding,any mass or

12、 hernia -pelvic examination:vaginal discharge or pelvic mass or assess the pelvic tenderness -cervical lifting painblood in the peritoneal cavity(ectopic pregnancy) or inflammation in the peritoneal (PID) -OHSSPV was not done (risk of rupture of ovarian cysts),but suspected ectopic pregnancy immediate laparotomy 診斷(III) Investigations -triple swabs(high vagina,cervix,endocervix)r/o STD as chlamydia or gonorrhea -sent midstream uriner/o UTI -check CBC/CRP -check urine or serum HCGr/o ectopic pregnnacy -pel