Long-term Lower Abdominal Pain in Women-KPA

in women chronic pelvic ache (long-term lower abdomen – groin-low back pain) common, patient’s life a significant reduction in the quality of health is the problem. chronic pelvic pain (KPA) health economic burden on the system is too much. chronic pelvic job pain in working women negatively affects its productivity. of patients that’s why it’s important work power losses is occurring. chronic pelvic pain patients their activities restricting and sexual in their lives cause problems is happening. chronic pelvic The causes of pain are very complex. Pain many in the pelvic region number of may originate from the organ. chronic pelvic ache genital organs, urinary organs, pelvic floor muscle in this region structure, from the gastrointestinal organs can originate such as the neuropsychiatric system other may arise from the systems. chronic pelvic patients with pain however more than half at least one partial to the doctor is applying. S weight to your services applicant and chronic pelvic pain diagnosis placed of patients enough evaluated and appropriate TRUE orientation reported in studies that were not performed. Correct diagnosis for pain intensity, spread, pain exacerbation and reducing causes, your pain sexual relationship and with custom relationship, possible pregnancy status before spent surgeries, menstrual cycle, depression symptoms as detailed questions including your findings D assessment And a good inspection is very important. So it is necessary to spend time with the patient. disease Treatment options range from simple drug therapy to surgical treatment. wide place in a range gets. This disease versatile in the treatment approach It is very important.

In this review in women long-term lower abdomen – groin-back pain aka chronic pelvic definition and assessment of pain To provide up-to-date information on treatment and treatment intended.

in women prolonged lower abdomen – groin-back pain It is a very common clinical problem. By KPA American College of Obstetricians and Gynecologists (ACOG):

– Lasting for 6 months or more,

– radiating to the groin and/or the lower-frontal wall of the abdomen and/or the lower back and/or the buttocks

– will create functional and/or sexual limitations

– defined as pain severe enough to require medical treatment.

in women long-term lower abdomen – groin-back pain people It negatively affects mental health, physical activity and quality of life. In addition, it negatively affects the work efficiency of working women. In a study conducted on 5325 American women, 16% of the patients reported CPA, 11% of them restricted their home activities due to KPA, 12% restricted their sexual life, 16% took various drugs, 4% of them reported that they had at least one month’s minimum monthly activity for this reason. It was determined that one day he did not go to work.

in women prolonged lower abdomen – groin-back pain patients can apply to various clinics and seek treatment due to the confusion of the lower abdominal nerves and the close neighborhood of the lower abdominal organs (bladder-uterus-bowel). With these complaints, patients apply to gynecology, algology, gastroenterology, urology, physical therapy and psychiatry clinics.

in women long-term lower abdomen – groin-low back pain-prevalence

Although it is difficult to determine the frequency of CPA due to the variations in its definition, considering the patients aged 15-73 who applied to primary health care services in England, 38 of every 1000 admissions were women. prolonged lower abdomen – groin-back pain n with the person. This frequency is equal to or even higher than the frequency of patients applying to primary health care services due to asthma. As age increases, women long-term lower abdomen – healthy with groin-back pain The frequency of applying to public health institutions is increasing. In many field studies, women prolonged lower abdomen – groin-back pain Its frequency varies according to countries and ranges from 2.1% to 25.4%. In a study conducted in New Zealand, the female population between the ages of 18-50 was screened. prolonged lower abdomen – groin-back pain its frequency has been reported as 25.4%. In a study from the USA examining a similar age range, the frequency was reported as 14%. in women prolonged lower abdomen – groin-back pain It is the cause of 12% of uterine surgeries and 40% of diagnostic laparoscopies performed. These figures are in women prolonged lower abdomen – groin-back pain It reveals that it is a frequent and important problem.

in women prolonged lower abdomen – groin-back pain The causes of ‘ are mixed and not fully elucidated . Many organs are located side by side in this region, and the pain may originate from the reproductive organs, excretory organs, lower abdominal floor musculature, intestines or nervous system.

in women prolonged lower abdomen – groin-back pain The diseases that can cause the disease are detailed below.

Non-Cancerous Causes of Chronic Pelvic Pain

A. Gynecological – related to gynecological diseases

1. Endometriosis (chocolate cyst)

2. Adhesions (adhesions)

3. Pelvic Congestion Syndrome (blood accumulation in the lower abdomen)

4. Ovarian remnant Syndrome (remaining ovarian waste after surgery)

5. Ovarian Retention Syndrome (post-operative ovarian compression)

6. Pelvic Inflammatory Disease (uterine and ovarian inflammations)

7. Myomas

8. Adenomyosis (uterus muscle disease)

9. Adnexal Cysts (ovarian cysts)

1 O. Intrauterine Uterus Intra Vehicle (spiral)

11. Symptomatic pelvic Desensus (uterine prolapse)

12. Cervical Stenosis (narrowing of the cervix)

13. Cervical or Endometrial Polyp (womb and cervical tissue pieces)

B. Gastroenetrological (stomach – intestinal system)

one. Irrtable Cup Syndrome

2. inflammation Bowel Syndrome

3. Celiac

4. Constipation

5. Diverticulum

C. Urological

one. interstitial Cystitis (bladder muscle inflammation)

2. Chronic kidney system infections

3. Urolithiasis (kidney excretory stones)

4. Urethral Syndrome ( urinary excretory tube disease )

5. Detrusive Dyssynergia (bladder muscle disease)

D. Musculoskeletal system

1. Degenerative Disc Disease (impaired vertebra)

2. F’ibromyalgia (connective tissue inflammation)

3. Myofascial pain (muscle-joint-beam-induced pain)

4. Levator Ani Syndrome

5. Posture disorder

6. Priformis Muscle Syndrome

7. hernias

8. Osteitis pubis (inflammation of the pelvis)

E. Neurological-Psychiatric

1. Depression

2. Abdominal Migraine

3. Abdominal Epilepsy

4. Somatization

5. iliohypogastric and/or iliinguinal and/or Genitofemoral Neuralgia

6. Pudental Neuralgia

F. Other

1. Familial Mediterranean Fire

2. Porphyria

in women prolonged lower abdomen – groin-back pain Evaluation of:

These patients are frequently evaluated by the clinics and physicians to which they apply.

Since they are not evaluated and directed, they cannot find a permanent solution to their problems. In addition, only 1/3 of the patients apply to the physician. in women prolonged lower abdomen – groin-back pain 60% of the patients are not sent to tertiary health institutions. Taking a good history (the severity of the pain, its spread, the reasons that increase and decrease the pain, the relationship of the pain with sexual life and menstruation, possible pregnancy status, previous operations, menstruation, vacuum delivery, superficial or deep sexual life pain, discharge, sexually transmitted diseases, pain during urination, urinary frequency, frequent urination at night, constipation and diarrhea attacks, sexual abuse, family violence history, depression symptoms, etc.) and a good examination in women prolonged lower abdomen – groin-back pain important for diagnosis.

Complete blood count, urine analysis, urine culture and sedimentation determination, smears and smears for the determination of gonorrhea and chlamydia are appropriate in the first stage. The characteristics of the pain should be carefully questioned during 2-3 menstrual periods by giving a pain diary to the patients who were first evaluated. Although pain is generally classified as mild, moderate and severe, the use of a pain scale (for example, the visual analog pain scale -YAS- or the verbal pain scale-VAS-) gives better results in understanding the severity of pain. These scales are also important for evaluating the change of pain over time or day. Giving the patients a body pain map to mark the places where they feel the pain and marking the location of the pain and the spread areas on this map by the patient will greatly facilitate the work of the physician. Examination with transvaginal ultrasound or abdominal ultrasound is beneficial in this group of patients. Although magnetic resonance examination and computed tomography examination are not routinely used, they can help the diagnosis. Hysteroscopy can play an important role in the diagnosis of CPA causes, which may be gynecological, and is an important part of the treatment of these causes. Laparoscopy is a method used successfully for the diagnosis and treatment of CPA causes such as endometriosis and adhesions that cannot be diagnosed by ultrasound in patients without a cause. However, a point that should not be forgotten here is that adhesions do not always cause KPA. It should be kept in mind that 40% of diagnostic laparoscopies are performed for CPA and 40% of these patients have normal structures. Selective ovarian and internal iliac venography or periuterine venography may be required for the diagnosis of pelvic congestion syndrome. Cystoscopy can be performed for the diagnosis of interstitial cystitis. Zung or Beck depression screening tests can be used to screen for depression in the patient. The Carnett test can provide information about whether the pain is muscular or not. In some cases, patients require sigmoidoscopy and/or colonoscopy.


In this article, it is aimed to present a rational approach to the causes of CPA and the treatment of this common syndrome that reduces quality of life. There may be various approaches in the treatment of CPA. For chronic pain, the treatment of the underlying cause should be at the forefront.

A. Drug Treatments

1. Analgesics-Neuroleptics-SpasmolyticsOpioids

The first-line drugs used in treatment are nonsteroidal anti-inflammatory drugs (simple pain relievers). An important point to remember here is that long-term use of these drugs can lead to significant side effects such as ulcers. The use of gastric protective treatments in addition to medications may come to the fore. Paracetamol treatment can be used in the presence of contraindications to nonsteroidal anti-inflammatory drugs. The most feared side effect of paracetamol treatment is acute and dose-dependent hepatic necrosis. In addition, chronic use of paracetamol may also have an effect on kidney damage. In patients in whom muscle spasm contributes to pain, the addition of antispasmodic treatments helps the treatment. ———Neuroleptic drugs play a role in the treatment of CPA by preventing overstimulation of nerve cells in the spinal cord.

2. Antidepressants

Tricyclic antidepressants increase pain tolerance, reduce depressive symptoms, and

They help improve the patient’s sleep.

3. Hormones:

– Medroxyprogesterone Acetate (MPA)

MPA and MPA + psychotherapy have been found to reduce pain scores in CPA .

-GnRH agonists (temporary menopause treatment)

GnRH agonist therapy is especially used in patients with advanced endometriosis. In addition, GnRH agonist therapy can reduce pain in pelvic congestion syndrome (blood collection in the lower abdomen), increased IBS during menstruation (inappropriate bowel function) and interstitial cystitis (bladder muscle inflammation). In a study from Turkey, better results were obtained with Gosorelin in CPA due to pelvic congestion compared to MPA. In the treatment of temporary menopause, patients may have hot flashes and emotional symptoms. Moreover, up to 6% of bone resorption may occur at the end of 6 months. Administration of low dose hormone therapy to these patients is important to correct these complaints and to prevent bone loss .

birth control pills

Many pain-inducing causes occur in the menstrual cycle and endometriosis

The effects of many common pain-causing issues such as (chocolate cyst) increase. In women who do not want children, birth control pills completely eliminate menstrual pain. In addition, it can stop the pain and progression of endometriosis in patients with mild to moderate endometriosis. Contrary to popular belief, these drugs do not cause weight gain.

4. Multiple Drug Treatments

The combined use of drug treatments with different mechanisms of action can reduce pain. For example, a combination of NSAIDs and opioids or a combination of opioids and antidepressants may be appropriate. Or, if muscle spasm is part of the pain, spasmolytic therapy can be added to them.

B. Surgical Treatments

1. Opening adhesions

Today, opening of pelvic adhesions is accepted as a standard treatment.

One of the reasons for this is that it is frequently used in patients without complaints.

adhesions are found. In a study, pelvic adhesions were found in 36% of patients with KPA and 15% in the control group. Therefore, it is very difficult to establish a cause-effect relationship between adhesions and pelvic pain. In addition, recurrence of adhesions after surgery is common. In a study , more complications were seen in the group that underwent adhesion removal in addition to diagnostic laparoscopy , compared to the group that underwent only diagnostic laparoscopy , but postoperative pain was found to be the same in both groups . In another study, the opening of mild or moderately severe adhesions was not associated with lower abdominal pain. Only in patients with severely dense, vascularized adhesions including the large intestine, the opening of adhesions reduced pain. Especially in adhesions involving the intestines, surgery should be performed by surgeons experienced in intestinal damage and repair. It has been reported that the use of Interceed TM (TC7 Johnson & Johnson Medical ine. Arlington, TX) after the procedure reduces the recurrence of adhesions.

It is useful to remember the trapped ovary syndrome here. Here, the remaining ovaries after uterine surgery remain stuck in the thick adhesions and cause CPA. In this case, the treatment is surgery.

2. Surgery for pain-inducing nerves

Pelvic Denervation Procedures (Presacral Neurectomy and Laparoscopic Uterosacral Nerve Ablation (LUNA) )

The sensory nerves of the lower abdominal organs arise from certain points (from the superior hypogastric plexus or presacral nerve).

Although the main neural pathways that transmit pelvic pain are known, the relationship between pain, fibers carrying pain and the area where pain is felt is mixed. The distribution of nerve fibers is mixed and there are correlations between them. In addition, the sensory nerves of the peritoneum gain importance in cases such as endometriosis.

in women in long-term lower abdomen – groin-back pain Basically, 2 types of neurosurgery methods are used:

These are Presacral neurectomy and LUNA surgeries. In both, the aim is to deactivate the sensory nerves that carry pain impulses from the lower abdomen.

3. Uterine surgery (Hysterectomy)

10-18% of hysterectomies in the USA are due to CPA. In our country, this rate is not known exactly. In women before the operation prolonged lower abdomen – groin-back pain The cause must be thoroughly investigated. Hysterectomy may be recommended in cases of uterine fibroids, uterine prolapse, pelvic congestion, adenomyosis and similar cases, and in patients who have completed their family, for pelvic pain for which no other cause of pelvic pain can be found. Before hysterectomy, the patient should be informed about the treatment options. Before the operation, the risk-benefit analysis should be well planned. It should be known that pain may continue in 40% of patients after hysterectomy performed for inappropriate reasons. The decision to remove the ovaries together (oophorectomy) is made individually according to the patient’s condition.

D. Nerve Blocks

In cases of muscle-joint pain, the presence of the trigger point and the injection of long-acting local anesthetic to these points can reduce the pain. These points should be revealed before the procedure with a good physical examination. Botulunim toxin (BoNT) injections may also be involved in these points. Nerve blocks can be diagnostic as well as therapeutic.

E. Alternative Therapies

1. Botulunim Toxin (BoNT)

In cases of pelvic pain due to pelvic floor muscle spasm and refractory idiopathic detrusor hyperactivity (drug-resistant contraction of the bladder muscle), pelvic floor pressure and bladder muscle tension decrease and lower abdominal pain symptoms are relieved after BoNT injection. BoNT treatment is also used for external genitalia pain (vulvodynia, provoked vestibuludin, levator ani muscle spasm and puborectalis syndrome). It should always be kept in mind that there may be urinary and fecal incontinence, toxin reactions, secondary treatment failure due to antibody production after BoNT injection as side effects. 2. Hormone Spiral ( Levonorgestrel Intrauterine System – LNG IUS )

LNG IUS especially in patients with endometriosis and adenomyosis

reduces the frequency of pelvic pain. It has been determined that the hormonal spiral reduces the uterine blood flow. These findings may be responsible for the mechanism of the reduction of pelvic pain in patients with LNG IUS.

3. Physiotherapy

a. Exercise therapy

in women prolonged lower abdomen – groin-back pain Exercise is effective in treatment. In addition to its analgesic effect, exercise also improves the patient’s psychological state.

4. Acupuncture

As a complementary medicine approach, acupuncture finds its place in the treatment of CPA patients over time. in women long-term lower abdomen – groin-back pain acupuncture treatment has been reported to be effective.

5. Psychotherapy

in women prolonged lower abdomen – groin-back pain Psychiatric evaluation of patients is important. Approximately 30-54% of patients with CPA have depression; this rate is quite high when compared to 5-17% in the normal population. Problems such as sexual abuse, personality disorder, difficulty in maintaining relationships, conflicts in the family and lack of family support, and problems in marital relations may be found in patients whose cause cannot be found in CPA.

E. Multidisciplinary Approach

There is data on the effectiveness of the multidisciplinary approach . This team may consist of gynecologist, algologist, psychiatrist, psychologist, psychotherapist, physical therapist, physiotherapist, gastroenterologist and pain clinic nurse.

CONCLUSION: In women prolonged lower abdomen – groin-back pain It is a serious and common symptom. Its causes are not fully elucidated and the diagnosis and treatment process is complex. The main goal in the approach to these patients should be permanent and as soon as possible cessation of pain. A multifaceted and detailed approach to these patients is required.

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