1: Pelvic Pain, Dyspareunia, Endometriosis Flashcards
What are 6 acute gynaecological causes of pelvic pain
- Ectopic
- Miscarriage
- Ovarian torsion
- Fibroid torsion or red degeneration
How will ectopic pregnancy present clinically
- 6-8W amenorrhoea
- Unilateral iliac fossa pain
- Bleeding
How will miscarriage present clinically
- Amenorrhoea
- Crampy abdominal pain
- PV bleeding
How will PID present clinically
- Pelvic pain
- Discharge
- Dysuria
- Pyrexia
How will PID present on examination
Cervical excitation
How will ovarian cyst torsion present clinically
Sudden-onset unilateral abdominal pain
How will torsion/ruptured ovarian cyst present OE
Unilateral tender adenoxa
how does torsion of a fibroids present
Acute pelvic pain
what is mittelschmerz
Mid-cycle pain
how long does mittelschmerz last
48-72h
what are the two urinary causes of pelvic pain
UTI
Renal calculi
how will UTI present
frequency
urgency
haematuria
how will renal calculi present
loin to groin pain
haematuria
fever
N+V
what are 3 GI causes of pelvic pain
IBD
Appendicitis
Diverticulitis
how will appendicitis present
- T10 then radiates to RIF
- N+V
how will IBD present
- Abdominal pain
- Bloating
- Change in bowel habit
how will diverticulitis present as a cause of abdominal pain
- Severe abdominal pain in left quadrant
- N+V
- Change in bowel habit
define chronic pelvic pain
persistent or intermittent pelvic pain lasting >6-months
what are 5 categories of causes of chronic pelvic pain
- Gynaecological
- Urological
- GI
- Neuropathic
- MSK
what are 7 gynaecological causes of pelvic pain
Endometriosis Adenomyosis Adhesions Ovarian cysts Urogenital prolapse Fibroids Chronic PID
what are 4 features of endometriosis
- Dysmenorrhoea
- Dyspareunia
- Pelvic pain = 1 day before period
- Subfertility
in endometriosis when is the pain
One day before period onset
how will adenomyosis present clinically
Dysmenorrhoea
Menorrhagia
what are the examination features in adenomyosis
Symmetrical enlarged tender uterus
‘Boggy uterus’
what is a feature of adhesions as a cause of pelvic pain
Previous surgery
how will ovarian cysts present
Dull unilateral ache
how can torsion or rupture of an ovarian cysts present
Sudden-onset pelvic pain
what may large ovarian cysts cause
Compress on bladder to cause frequency and urgency
in which patients is urogenital prolapse more common
Older patients
how does urogenital prolapse present clinically
Dragging sensation
how do fibroids present
Crampy abdominal pain
Menorrhagia
how will chronic PID present
Deep dyspareunia
Change in discharge
what are the GI causes of chronic pain
IBD
Hernia
how will IBS present
Bloating
Abdominal pain
Change in bowel habit
how will hernia present
Dragging sensation
what are urological causes of chronic pain
Urethral syndrome
what are MSK causes of abdominal pain
Fibromyalgia
in which population is fibromyalgia more common
Females
how does fibromyalgia present
Chronic pain at several sites
what are two neurological causes of chronic pelvic pain
Entrapped nerve
what is a risk factor for nerve entrapment
Previous surgery
what is the psychological association of pelvic pain
women with pelvic pain have increase history of abuse and depression
in RCOG guidelines on chronic pain what is first method to investigate
History
- Ask about symptoms
- Ensure to exclude red flags
what can be excluded solely based on history
IBS
what are 8 red flags of chronic pelvic pain
- New-onset Bowel symptoms >50
- PR Bleeding
- Post-menopausal bleeding
- Post-coital bleeding
- Irregular PV bleeding
- Pelvic mass
- Suicidal Ideation
- Excessive weight loss
what other ‘bedside’ measures are used in work-up of chronic pelvic pain
STI Check
Exam
Symptom diary - complete for at least two cycles to check for any patterns to pain
what imaging is used to for pelvic pain
TVUS
MRI
why is MRI ordered
Endometriosis
Adenomyosis
what is seen on adenomyosis
Thickening of myometrial-endometrial junction
what is gold-standard investigation in examination of chronic pelvic pain
Diagnostic laparoscopy
what is diagnostic laparoscopy reserved for
Usually after women have tried treatment - as otherwise it reinforces women’s beliefs about pain being debilitating
what is diagnostic laparoscopy looking for
Peritoneal endometriosis
what tumour marker may be looked for in chronic pelvic pain
CA125
when may CA-125 be looked for
if frequent symptoms (more than 12-times a year)
what is the ultimate management of chronic pelvic pain
treat underlying cause
what is used short-term from chronic pelvic pain
analgesia - NSAIDs
what do RCOG recommend about treatment for chronic pelvic pain
individuals should trial hormonal treatment of at least 6m prior to diagnostic laparoscopy
what hormonal treatments do RCOG recommend
- COCP
- GnRH analogue
how long can GnRH analogues be given
- 6m alone
- 2y with HRT
if GnRH is effective at controlling pain what does this indicate
That a hysterectomy and bilateral saplingo-oopherectomy will likely be effective in controlling pain
if GnRH is ineffective at controlling pain what does this indicate
hysterectomy will not relieve persons pain
what does RCOG state should be offered to those with IBS
antispasmodics
define dyspareunia
pain during sex
what is the problem with dyspareunia
leads to a viscous cycle where women anticipates pain causing her to tense and dry
what are the two types of dyspareunia
superficial dyspareunia
deep dyspareunia
what is superficial dyspareunia
pain on entry
what are 5 causes of superficial dyspareunia
- Tears/trauma
- Vaginitis
- Atrophic vaginitis
- Vaginismus
- Inadequate lubrication - psychosocial problems
in what population does atrophic vaginitis occur
Post-menopausal women
what is deep dyspareunia
Abdominal or pelvic pain
what are 7 causes of deep dyspareunia
- IBD
- IBS
- Adenomyosis
- Endometriosis
- PID
- IUD/IUS malposition
- Vaginitis
- Cystitis
Define endometriosis
presence of endometrial tissue outside endometrial cavity
Define adenomyosis
presence of endometrial tissue in myometrium
what age is the peak incidence of endometriosis
20-40years
what are 6 RF of endometriosis
- FH
- Early menarche
- Short cycle
- Long duration bleeding
- Menorrhagia
- Defect in Fallopian tube
how does endometriosis present clinically
- Dysmenorrhoea. Pain starts one day before menses
- Deep dyspareunia
- Dyschezia (pain on defecation)
- Dysuria
- Sub-fertility
explain pain in endometriosis
pain happens one day before menses
if endometrial tissue is at a distant site what can it cause
haemothorax (lung)
what is a classical sign of endometriosis O/E
fixed retroverted uterus
why are symptoms cycle-dependent
as endometrial tissue responds to oestrogen
what can endometriosis lead to and why
repeated inflammation with menstrual cycles can lead to scarring and adhesions
what is gold-standard diagnostic test for endometriosis
diagnostic laparoscopy
explain timing of laparoscopy in endometriosis
diagnostic laparoscopy should not be performed in 6-months of hormonal treatment as this causes false negative
what are 3 features of endometriosis on laparoscopy
chocolate cysts
adhesions
peritoneal deposites
what are chocolate cysts
deep brown-colour cysts in ovary
what other investigation is ordered in endometriosis
pelvic US
what may be seen on pelvic US in endometriosis
kissing ovaries
what are kissing ovaries
endometriosis have adhered together
what is first-line for pain in endometriosis
analgesia - escalate up WHO analgesia ladder as required
what can reduce symptoms in endometriosis
hormonal treatments to suppress ovulation
what may be used to suppress ovulation in endometriosis
- COCP
- IUS
- Low-dose progesterone
what is second-line hormonal treatment in endometriosis
GnRH analogue (Gosrelin)
what is the maximum duration GnRH analogue should be used for and what should it be used for
6-months
Use with HRT (Tibolone)
when is surgery for endometriosis indicated
If symptoms are not managed by medical treatment and impacting women life
what surgery is indicated for endometriosis
endometrial ablation
what is ultimate treatment for endometriosis
hysterectomy and bilateral salpingoopherectomy
