Clinical Diagnosis: pelvic pain lecture + neglected glaucoma content

Non-cyclical, 6 months

***Non-cyclical means that the pain does not come and go in relation to the menstrual cycle

A patient qualifies for a diagnosis of chronic pelvic pain only if the pain is _____-cyclical and lasts for at least _____ months. The pain must be severe enough to cause functional disability to require treatment.

Dyspareunia

***This is commonly associated with chronic pelvic pain

____ is a term that means painful intercourse.

No - about 60% of patients with chronic pelvic pain are not able to find an obvious cause of their pain

Do the majority of patients with chronic pelvic pain have an obvious etiology?

Gastrointestinal (37%)

***In patients with chronic pelvic pain, only 20% of cases are attributed to problems with the reproductive tract. Both urinary and gastrointestinal problems are more common causes.

Of the patients with chronic pelvic pain that have an identifiable cause, which body system is the most common source of the pain: reproductive, urinary, gastrointestinal, or musculoskeletal?

Central sensitization

***This is a process that is implicated in a variety of conditions including fibromyalgia, interstitial cystitis, vulvodynia, irritable bowel syndrome, etc.

_________ is the process in which repetitive painful stimuli, chronic inflammation, and nerve injury cause alterations to the processing of pain in the brain. This leads to increased perception of pain by the patient.

"Wind up"

***If a patient has something that causes them pain, the body will undergo processes that makes the pain even more painful. Even if the painful lesion heals, the high density of sensory neurons in this area will make the patient more sensitive other stimuli.

______ is the process in which the presence of painful lesions in the body causes production of more sensory nerves and blood vessels in the area (neuroangiogenesis). This leads to increased perception of pain by the patient.

Q-tip testing

________ is an examination process in which a q tip is used to press on different places around the vestibule of the vagina (ie 5, 7, 11, 1 o'clock). If this elicits pain in the vulva without any identifiable lesions, the patient can be diagnosed with vulvodynia.

Vulvodynia

_____ is a condition in which a patient has pain in the vulva without an identifiable source for at least 3 months. .

Pelvic floor muscle spasm

***In this condition, insertion into the vagina or palpation of the vulva illicits spasming of the pelvic floor musculature. When these muscles spasm, the nerves that run through the muscle get compressed, which causes exquisite pelvic and vulvar pain.

A patient presents with pelvic and vulvar pain. During the pelvic exam, you notice that the patient develops immediate pain and spasming when 2 fingers are placed in the vagina and the vulva is palpated. This finding is consistent with _____.

Endometriosis

***Very common cause of chronic pelvic pain.

_____ is a condition in which ectopic endometrial tissue implants on other organs outside of the uterus such as the bladder, peritoneum, and rectum.

Laparoscopy which shows ectopic endometrial tissue

How is endometriosis definitively diagnosed?

Endometriosis

***These brown spots are sometimes described as "powder burns". They are ectopic endometrial tissue that has implanted on other structures within the abdomen/pelvis outside of the uterus

A patient has a laparoscopy to determine the cause of her chronic pelvic pain. These small brown spots are noted. This finding is consistent with _____.

Laparoscopic removal of ectopic endometrial tissue

***A hysterectomy/bilateral salpingoophorectomy (BSO) can also be performed (which reduces the chance of recurrent endometriosis), but this will cause infertility

What is the definitive surgical treatment for endometriosis in a patient who wants to preserve their fertility?

Oral contraceptives

What is the 1st line treatment for medical management of endometriosis?

She says that this has a tendency to cause more weight gain than other methods of birth control

Why does Dr. Lynn rarely use progesterone implants such as Nexplanon?

6 months, menopause-like state

***Leuprolide = GnRH agonist. When given daily at a low-dose, it causes downregulation of GnRH receptors on the pituitary, causing decreased production of FSH and LH, and therefore decreased production of estrogen and progesterone (hence mimicking menopause). The decreased estrogen production causes decreased osteoblast activation/osteoclast inhibition leading to reduced bone mineralization. (also can cause hot flashes, insomnia, vaginal dryness)

A 28 yo patient presents with endometriosis and asks about starting Leuprolide to help with their abdominal cramps. This is a medication that can only be used for ____ months because it induces a _____-state, which dramatically increases their risk of developing osteoporosis later in life.

Elagolix

***can only be used for 6 months in a woman of reproductive age because it induces a menopause-like state.

_____ is a new medication of endometriosis that acts as a GnRH antagonist.

Diagnosis of exclusion.

Vulvodynia is a diagnosis of ____, meaning that other causes of vulvar pain such as yeast infections, bacterial vaginosis, lichens, ulcers, cancer, and contact dermatitis need to be ruled before a diagnosis can be made.

Gabapentin, amitryptiline

***These are medications that are used to nerve pain in other conditions such as fibromyalgia and neuropathy. Other medications like duloxetine and pregabalin (Lyrica) are used primarily to address the central sensitization that occurs with chronic pain.

_____ and ____ are two medications used to treat vulvodynia that function by reducing nerve pain.

Duloxetine

***This helps to reduce the brain's perception of pain (this is used similarly in conditions like fibromyalgia).

______ is a SNRI that is used in the treatment of vulvodynia to reduce the degree of central sensitization that may be contributing to the pain.

Congenital neuroproliferation vulvodynia

***The classic presentation for this is a patient who has never been able to use a tampon or have sex because it is so painful

Patients with vulvodynia may have congenital ______, which is when there are way more sensory nerve endings in the vulva, which causes increase sensation of pain.

Pelvic floor muscle spasm

***I don't know if this is the actual cause, but the posterior vestibule is the only region of the vulva that is within the S4 dermatome (the rest us either S2 or S3). The muscles that make up the pelvic floor (coccygeus + levator ani) are primarily innervated by S4 VPR, so it makes sense that this would be area of the vestibule that would be most likely to illicit a pelvic floor muscle spasm

A patient presents with vulvar pain. On a q-tip test, there is tenderness only in the posterior vestibule. This is a classic presentation of ______.

Myofascial pelvic pain syndrome (MPPS)

_______ syndrome is a condition in which a patient has tight, tender pelvic floor muscles that might have palpable nodules and trigger points.

Urethra, vagina, anus

What three structures pass through the pelvic floor musculature?

Pelvic floor muscle spasm

_____ is defined as persistent or recurrent difficulties to allow vaginal entry of any object despite a person's expressed with to do so.

Pelvic floor physical therapy

***Yoga can be used to if the patient does not have access to pelvic floor physical therapy

What is the first line therapy for pelvic floor muscle spasm?

Intravaginal diazepam (Valium)

***diazepam functions as a muscle relaxant to help reduce the spasming

***Intravaginal botox can also be used, but it's super expensive and never covered by insurance (it's literally $1000 per treatment)

A patient with pelvic floor muscle spasm continues to have symptoms despite undergoing pelvic floor physical therapy. What medication would you try next?

Bowel and bladder incontinence

***Giving botox near the external anal and urethral sphincters will cause patient to lose control of when they pee and poop

You are administering intravaginal botox to a patient with pelvic floor muscle spasm, but you are bad at it and accidentally inject it close to the urethra and anus. What is the most likely complication of this?

Interstitial cystitis (aka painful bladder syndrome)

***Interstitial cysitis is like the fibromyalgia/vulvodynia/IBS of the bladder. It is thought to be a disorder of central pain processing that causes the patient to experience chronic symptoms of a lower urinary tract. infection (dysuria, frequent urination, urinating at very low volumes because it hurts to distend the bladder)

A patient presents with several months of pelvic pain and frequent, painful, low-volume urination. They have undergone a thorough evaluation and have ruled out UTI, nephrolithiasis and STIs. This presentation is consistent with ______.

Low volumes

***In this condition, it is painful for patients to fill their bladder, so they will urinate frequently at low volumes to prevent bladder distention

Will a patient with interstitial cystitis produce high volumes of urine or low volumes of urine when they void?

Urine culture

***Interstitial cystitis is a diagnosis of exclusion. In order to be sure that a patient's pelvic pain, dysuria and frequent urination are not from a UTI, a urine culture must be performed.

A patient presents with symptoms concerning for interstitial cystitis. What test must be performed to rule out a UTI before this diagnosis can be made?

Hydrodistention

_______ is a procedure used to treat interstitial nephritis that involves distending the bladder with water while under anesthesia.

Amitriptyline

***Interstitial cystitis is a disorder of central pain processing that causes patients to experience UTI symptoms. These disorders of central pain processing (fibromyalgia, vulvodynia, IBS) can all be treated with amitryptyline

_____ is a tricyclic anti-depressant that can be used to treat the pain associated with interstitial cystitis.

Irritable bowel syndrome

***Diagnosis of exclusion

_____ is a condition characterized by chronic abdominal pain and altered bowel habits that does not have an identifiable cause.

Collision dyspareunia

______ is a condition in which a patient develops pelvic/vaginal pain during intercourse whenever something hits the cervix.

No

***Just like they aren't used to treat fibromyalgia or irritable bowel syndrome

Are opioids used to treat chronic pelvic pain?

10000.

***She was put on this earth to be a gynecologist.

On a scale of 1 to 10, how fabulous is Dr. Becky Lynn?

Aqueous humor

***(Aqueous = Anterior), vitreous humor fills the posterior segment

_____ humor fills the anterior segment of the eye

Posterior segment

***The eye is divided into two segments: anterior and posterior. The anterior segment is filled with aqueous humor while the posterior segment is filled with vitreous humor. The anterior segment is subdivided into the anterior and posterior chambers. Because both chambers are within the anterior segment, they are filled with aqueous humor

Which of these is filled with vitreous humor: anterior chamber, anterior segment, posterior chamber or posterior segment?

Ciliary body

***Ciliary muscle is the muscle responsible for accommodation. The muscle is covered by an epithelium (ciliary epithelium) that produces aqueous humor.

The epithelium of the ______ is responsible for synthesizing aqueous humor.

Beta 2 receptors

***Aqueous humor is needed for optimal vision/focusing of light --> you need good vision for fight/flight response (hence why it is sympathetic stimulation, not parasympathetic stimulation)

The production of aqueous humor is stimulated by the stimulation of _____ receptors on the ciliary body.

Pupil, trabecular meshwork, canal of Schlemm

***Here is the whole pathway:

Ciliary epithelium --> posterior chamber --> pupil --> anterior chamber --> trabecular meshwork --> canal of Schlemm --> other veins

Aqueous humor is produced by the ciliary epithelium and released into the posterior chamber of the eye. It then travels to the anterior chamber via the _____. It drains out of the anterior chamber via the _____, which then drains to the _____.

Tanometry

A patient's intraocular pressure is measured by performing _____.

Aqueous humor

A patient's intraocular pressure determined by the amount of _____ in the eye.

M3 receptors

***This makes sense because in a fight or flight response, you want more aqueous humor in your eye to have optimal vision. Decreased stimulation of muscarinic receptors would decrease drainage, which would increase the amount of aqueous humor in the eye.

Under normal circumstances, the amount of aqueous humor that drains out of the anterior chamber is controlled by stimulation of ______ receptors in the ciliary body.

Glaucoma

_____ is a condition in which a patient has high intraocular pressure.

Optic nerve (cause optic neuropathy)

If a patient has glaucoma, you are concerned that the elevated intraocular pressures could cause damage to the ____.

Cornea, iris

***Notice that the trabecular meshwork is located in the corner of the angle

The "angle" referred to in open/closed angle glaucoma refers to the angle between the _____ and the _____.

Open angle glaucoma

***This is also the less scary one

Which is more common: open vs closed angle glaucoma?

Open angle glaucoma

***Acute closed angle glaucoma is a medical emergency

Which would you rather have: open angle glaucoma or closed angle glaucoma?

Right side - notice that the angle between the cornea and iris is small, which prevents drainage of aqueous humor from the trabecular meshwork

Which side of this diagram is consistent with closed angle glaucoma?

Acute closed angle glaucoma

***The sudden onset pain + vision changes + worsening of sxs with pupillary dilation (entering dark room) is consistent with closed angle glaucoma.

***Pupillary dilation causes the iris to thicken, which then further closes the angle and blocks drainage

A patient presents with an abrupt onset of blurry vision with halos as well as eye redness and pain. He says that his eye feels "rock hard." The pain is worse when going into a dark room. What type of glaucoma are you most concerned about?

Pupillary dilation (ie entering a dark room)

***Dilation causes the muscle of the iris to bunch up near the trabecular meshwork, further constricting the angle and blocking the trabecular meshwork

If a patient has closed angle glaucoma, would you expect their symptoms to get worse with pupillary dilation or constriction

No - scopolamine is a muscarinic antagonist that causes pupillary dilation. In patients with closed angle glaucoma, the pupillary dilation will further close the angle and worsen their symptoms

***Muscarinic agonists like pilocarpine are helpful because they contract the ciliary muscle to open to trabecular meshwork, which increases drainage and reduces IOP

You suspect that a patient has acute closed angle glaucoma. Will scopolamine help their symptoms?

Timolol

Acetazolamide

Mannitol

Pilocarpine

***This is referred to as the "kitchen sink" approach to temporarily lower the IOP while waiting for surgery

Timolol = beta blocker (reduce Aq. hum production)

Acetazolamide = carbonic anhydrase inhibitor (reduces production)

Mannitol = osmotic diuretic, draws fluid out of eye

Pilocarpine = muscarinic agonist that dilates the canal of schlemm to improve drainage

A patient presents to the ED on a Saturday with acute closed angle glaucoma. Since ophthalmologists don't work on weekends, what medications can you give them to "TAMP" down the pressure in their eye while awaiting for surgery?

Surgery

***Medications are just used to temporarily reduce the IOP to reduce optic nerve damage while waiting for surgery

What is the definitive treatment for acute closed angle glaucoma?

Chronic closed angle glaucoma

***Has much slower onset of symptoms than acute closed angle glaucoma

___________ glaucoma occurs when a portion of the angle is blocked and develops scarring, which causes the angle to progressively narrow over time.

Acute closed angle glaucoma

Which tends to produce a higher IOP: acute closed angle glaucoma or chronic closed angle glaucoma

Peripheral vision loss

***Acute closed angle glaucoma will usually present with eye pain/redness before significant vision loss happens

What is the first symptom to appear in open angle glaucoma?

Steroid

***Mechanism unclear - somehow decreases drainage

Chronic ______ use (medication) can increase a patient's risk of develop open angle glaucoma.

Disc cupping, indicates glaucoma

Usually the optic cup (extra bright area in the middle of the optic nerve) takes up less than 1/2 the diameter of the optic disc. In glaucoma, the optic cup takes up a larger portion of optic disc (increased cup/disc ratio), which is referred to as "disc cupping"

On the left is a normal optic nerve while the right is abnormal. What is this finding called and what does it indicate?

open angle glaucoma

***Notice the disc cupping (cup/disc ratio is much greater than 1:2 --> glaucoma)

An 83 yo patient presents with progressive peripheral vision loss. This is what you see on fundoscopic exam. He most likely has _____ glaucoma

Beta 2 antagonists

Alpha 2 agonists

***Alpha 2 agonists indirectly block ciliary epithelium production of aqueous humor. They do this by preventing release of norepinephrine from the presynaptic neuron, which decreases the sympathetic effects on the eye

Beta 2 _____ and alpha 2 _____ can be used to treat glaucoma.

Prostaglandin analogues (all end in -prost)

***M3 agonists cause dilation of the trabecular meshwork indirectly by causing contraction of the ciliary muscle

What class of medication for glaucoma functions by directly causing vasodilation of the canal of Schlemm?

M3 agonists

***contract ciliary muscle to open the trabecular meshwork ---> increase drainage

Carbachol and pilocarpine are two examples of ______ that can be used to treat chronic glaucoma.

Alpha 2 agonists

***Rhymes with clonidine. Causes decreased sympathetic activity --> less stimulation of beta 2 receptors --> decreased aqueous humor production

Apraclonidine and brimonidine are two examples of _____ that can be used to treat chronic glaucoma.

Beta blockers (-olol suffix)

***Decrease aqueous humor production

Timolol, betaxalol, and cartelol are all examples of ____ that can be used to treat chronic glaucoma

Prostaglandin analogues (-prost suffix)

***vasodilate the canal of Schlemm to increase drainage

***Main side effect is darkening of the iris

Latanoprost, bimatoprost, talfuprost, and travoprost are all examples of _____ that can be used to treat chronic glaucoma.

Prostaglandin analogues (latanoprost, bimatoprost, etc)

What class of medication for glaucoma can cause darkening of the iris?

Carbonic anhydrase inhibitor

***decreases synthesis of aqueous humor

Acetazolamide is a ______ that used to be used a lot to treat glaucoma.

No - epinephrine has mixed alpha 1, alpha 2, and beta 2 agonism. The alpha 1 effects cause pupillary dilation, which further closes the angle.

Are epinephrine eye drops able to be used in closed angle glaucoma?