1.03 - Pelvic Pain Flashcards
Give some causes of pelvic pain in women.
- urinary tract infection (UTI)
- dysmenorrhoea
- irritable bowel syndrome (IBS)
- inflammatory bowel disease (IBD)
- ovarian cysts
- endometriosis
- pelvic inflammatory disease (PID)
- ectopic pregnancy
- appendicitis
- Mittelschmerz
- pelvic adhesions
- ovarian torsion
What is pelvic inflammatory disease (PID)?
Inflammation and infection of the organs of the pelvis, caused by infection ascending through the cervix.
What are the affected organs of PID?
a) endometritis
b) salpingitis
c) oophoritis
d) parametritis
e) peritonitis
a) endometrium
b) fallopian tubes
c) ovaries
d) parametrium
e) peritoneal membrane
What are the causes of PID?
Common sexually transmitted pelvic infections:
- Neisseria gonorrhoea (severe)
- Chlamydia trachomatis
Can be caused by non-sexually transmitted infections, such as:
- Gardnerella vaginalis
- Haemophilus influenzae
- Escherichia coli
What are the risk factors for PID?
- no barrier contraception
- multiple sexual partners
- younger age
- existing STIs
- previous PID
- IUD
Presentation of PID.
- pelvic pain
- abnormal vaginal discharge
- abnormal bleeding (intermenstrual / postcoital)
- dyspareunia
- fever
- dysuria
OE of PID.
- pelvic tenderness
- cervical motion tenderness
- inflamed cervix
- purulent discharge
Patient’s may have fever and other signs of sepsis.
How should PID be investigated?
- NAAT (gonorrhoea and chlamydia)
- HIV test
- Syphilis test
- HVS (bacterial vaginosis, candidiasis, trichomoniasis)
Exclusion tests:
- pregnancy test to exclude ectopic pregnancy
- microscope to look for pus cells (absence excludes PID)
Possible complications of PID.
- sepsis
- abscess
- infertility
- chronic pelvic pain
- ectopic pregnancy
- Fitz-Hugh-Curtis syndrome
What is Fitz-Hugh-Curtis syndrome?
Inflammation and infection of the liver capsule, leading to adhesions between the liver and the peritoneum.
Results in right upper quadrant pain, that can be referred to the shoulder tip if there is diaphragmatic irritation.
Laparoscopy can be used to visualise and treat the adhesions by adhesiolysis.
How should PID be managed?
Specific abx regimes:
a) gonorrhoea
b) chlamydia / Mycoplasma genitalium
c) Gardnerella vaginalis
Refer to GUM specialist service for management and contact tracing.
Empirical abx started, before swab results to avoid delay and complications.
a) IM Ceftriaxone (1g)
b) 100mg Doxycyline BD (2/52)
c) 400mg Metronidazole BD (2/52)
Note in severe cases (sepsis or pregnancy), consider hospital referral for IV abx.
What are the functional ovarian cysts?
Benign cysts commonly presenting in premenopausal women, caused by hormonal fluctuations of menopause.
Follicular cysts - developing follicle fails to rupture and release the egg, causing the cyst to remain for a few cycles.
Corpus luteum cysts - when the corpus luteum fails to break down, but instead fills with fluid. They are often seen in early pregnancy.
How can follicular cysts and corpus luteum cysts be differentiated on ultrasound?
Follicular cysts typically have thin walls and are empty.
Corpus luteum cysts fill with fluid.
Name some pathological ovarian cysts.
- cystadenoma
- endometrioma
- dermoid cyst
- sex cord-stromal tumour
Presentation of ovarian cysts.
- incidental USS finding (asymptomatic)
- pelvic pain
- bloating
- fullness in the abdomen
- palpable pelvic mass
Ovarian cysts may present with acute pelvic pain if there is ovarian torsion, haemorrhage or rupture of the cyst.
What features of an ovarian cyst would suggest malignancy?
- abdominal bloating
- reduced appetite
- early satiety
- weight loss
- urinary symptoms
- pain
- ascites
- lymphadenopathy
What are some risk factors for ovarian malignancy?
- age
- postmenopause
- increased number of ovulations
- obesity
- HRT
- smoking
- BRCA1 / BRCA2
*breastfeeding is protective
What factors will reduce the number of ovulations?
- late menarche
- early menopause
- any pregnancies
- use of COCP
What blood tests are required for the following scenarios:
a) premenopausal woman with simple ovarian cyst <5cm
b) postmenopausal woman with simple ovarian cyst >5cm
c) women under 40 with complex ovarian mass
a) no further investigation
b) CA125 (tumour marker for ovarian cancer)
c) tumour markers for germ cell tumour (LDH, a-FP and HCG)
What are the causes of raised CA125?
Sensitive for ovarian malignancy, but not specific:
- endometriosis
- fibroids
- adenomyosis
- pelvic infection
- liver disease
- pregnancy
When should a woman be urgently referred for suspected ovarian cancer?
- ascites
- pelvic / abdominal mass
- aged >50yrs with IBS sx
- USS suggests ovarian cancer
Simple ovarian cysts in premenopausal women can be managed based upon their size:
a) less than 5cm
b) 5cm to 7cm
c) more than 7cm
a) no follow-up scan required; resolves within 3 cycles
b) routine referral to gynaecology and yearly ultrasound monitoring
c) consider MRI scan or surgical evaluation
How should ovarian cysts in postmenopausal women be managed?
a) raised CA125
b) cysts under 5cm
a) two-week wait
b) monitor with ultrasound every 4-6 months
What are the complications of ovarian cysts?
- torsion
- haemorrhage into the cyst
- rupture
What is Meig’s syndrome?
The triad of:
- ovarian fibroma
- pleural effusion
- ascites
Removal of the tumour results in complete resolution of the effusion and ascites.
What is the risk of malignancy index?
A risk stratification toll in patients with suspected ovarian cancer.
RMI = U x M x CA125
What is ovarian torsion?
Ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply.
What are the risk factors for ovarian torsion?
- benign tumours
- pregnancy
Presentation of ovarian torsion.
- sudden onset severe unilateral pelvic pain
- constant, progressive pain
- nausea and vomiting
OE localised tenderness and ?palpable mass.
How should ovarian torsion be investigated?
- transvaginal ultrasound
- Doppler ultrasound
Definitive diagnosis is via laparoscopic surgery.
Management of ovarian torsion.
Explorative laparoscopic surgery to diagnose and:
- detorsion
- oophorectomy
Complications of ovarian torsion.
Infection > abscess > sepsis
Rupture > peritonitis > adhesions
Can result in loss of function in that ovary, but the other ovary can usually compensate so fertility is not typically affected.
What is dysmenorrhoea?
a) primary
b) secondary?
Painful periods - the most common gynaecological symptom.
a) menstrual pain occurring with no underlying pelvic pathology.
b) menstrual pain that occurs with associated pelvic pathology.
What is the physiology behind dysmenorrhoea?
In the absence of fertilisation, the corpus luteum regresses, and there is a decline in oestrogen and progesterone production.
The endometrial cells are sensitive to progesterone withdrawal, and respond with prostaglandin release. The effects of which:
- spiral artery vasospasm leading to ischaemic necrosis and shedding of the superficial layer of the endometrium
- increased myometrial contractions
Primary dysmenorrhoea is thought to occur secondary to excessive release of prostaglandins by endometrial cells.
Risk factors for primary dysmenorrhoea.
- early menarche
- long menstrual phase
- heavy periods
- smoking
- nuliparity
Presentation of dysmenorrhoea.
- lower abdominal / pelvic pain
- radiates to lower back or anterior thigh
- crampy in nature
- lasts 48-72 hours around the menstrual period
Associated symptoms:
- malaise
- nausea
- vomiting
- diarrhoea
- dizziness
Examination findings in primary dysmenorrhoea.
Abdominal and pelvic examinations are usually unremarkable.
Uterine tenderness may be present.
Differential diagnoses for dysmenorrhoea.
Primary dysmenorrhoea is a diagnosis of exclusion. Therefore, other diagnoses to consider at the main causes of secondary dysmenorrhoea:
- endometriosis
- adenomyosis
- pelvic inflammatory disease
- adhesions
Non-gynaecological differentials include IBD and IBS.
How can primary dysmenorrhoea be managed?
- smoking cessation
- NSAIDs +/- paracetamol
- COCP / IUS
- local application of heat
What is adenomyosis?
Invasion of endometrial tissue inside the myometrium.
Presentation of adenomyosis.
- dysmenorrhoea
- menorrhagia
- dyspareunia
It may also present with infertility or pregnancy-related complications.
Examination findings of adenomyosis.
- enlarged / tender uterus
How can adenomyosis be investigated?
First line: transvaginal ultrasound
Gold standard: histological examination of the uterus after hysterectomy*.
Management of adenomyosis.
Symptomatic relief: Tranexamic acid and Mefenamic acid
Management when contraception is wanted or acceptable:
- IUS
- COCP
- cyclical POP
Specialist intervention may include:
- GnRH analogues (induce menopause like status)
- endometrial ablation
- uterine artery embolisation
- hysterectomy
What are some complications of adenomyosis?
- infertility
- miscarriage
- preterm birth
- postpartum haemorrhage
