11. Pelvic pain Flashcards
Describe: Acute pelvic pain (1)
lasting < 6 mo
Describe: Chronic pelvic pain (1)
- Chronic pelvic pain (CPP) is one of the most common problems in gynecology. It is characterized by:
- Pain located below the umbilicus and in the pelvis • Pelvic pain lasting > 6 mo
- Pain severe enough to interfere with quality of life or daily functioning and may require medical and/or surgical intervention(s)
Name ACUTE GYNE DDx of pelvic pain (9)
- Pregnancy-related:
- EP
- Aborting pregnancy
- Labor / PTL
- Abruptio placenta
- Molar pregnancy
- Nonpregnancy related:
- PID ± adhesions
- Ovarian mass/cyst complications (torsion, hemorrhage, rupture)
- Degenerating broids
- Ovulation pain
Name CHRONIC/RECURRENT GYNE DDx of pelvic pain (10)
- Endometriosis
- Chronic PID
- Adenomyosis
- Leiomyomata
- Dysmenorrhea
- Pelvic adhesions
- Vulvar vestibulitis
- Vulvodynia
- Residual ovarian syndrome
- Chronic pelvic infection (TB)
Name ACUTE GI DDx of pelvic pain (4)
- Acute appendicitis
- Diverticulitis
- Irritable bowel
- IBD
Name CHRONIC GI DDx of pelvic pain (6)
- Irritable bowel
- IBD
- Diverticulitis
- Constipation
- Hernia
- Neoplastic lesions
Name ACUTE UROLOGIC DDx of pelvic pain (2)
- UTI
- Renal calculi
Name CHRONIC/RECURRENT UROLOGIC DDx of pelvic pain (4)
- Chronic UTIs
- Interstitial cystitis
- Urethral disorders
- Bladder neoplasm
Name ACUTE MSK DDx of pelvic pain (3)
- Levator ani syndrome
- Disc disease
- Hernia
Name CHRONIC/RECURRENT MSK DDx of pelvic pain (4)
- Fibromyalgia
- Nerve entrapment syndromes
- Mechanical low back pain
- Disc disease
Name SYSTEMIC DDx of pelvic pain (4)
- Sleep disturbance
- Mental health issues
- Depression, somatization
- Abuse (sexual, physical, and/or psychological)
- Domestic violence
- Substance abuse
Mental Health Issues and CPP (2)
- Approximately25%ofpatients with CPP have a PMHx of sexual/ physical abuse.
- DepressionoftencoexistswithCPP (25%–50%). It is a predictor of:
- Pain severity
- Response to Rx
Describe HX: Pelvic pain (7)
- Pain history, prev treatments tried, pain diary if chronic
- Associated Sx: fever, abnormal bleeding, vaginal discharge, dysuria, urinary frequency/urgency
- Associated events: urination, defecation, menstrual period, intercourse
- OB/GYN Hx: menstrual, contraception, STIs, prev. ectopic pregnancy, fertility
- Past medical/surgical Hx: GI, GU, MSK
- Mental Health Hx: depression
- Psychosocial stressors: physical/sexual abuse, domestic violence, substance abuse
Describe physical exam: Pelvic pain (6)
- Vital signs
- Abdominal exam: tenderness, scars, hernias, trigger points
- Pelvic exam: vaginal discharge, cervical erythema, cervical motion tenderness, adnexal mass/tenderness, nodularity
- Digital Rectal Exam
- MSK exam: scoliosis, sacroiliac tenderness, trigger points, pelvic asymmetry, straight leg raise (SLR)
- Completion of pain diary
Name DDX possible in this situation (7)
- No
- R/O Ectopic
- Non cystic adnexal mass
- Fluid in cul de sac
- Yes
- Corpus luteal hemorrage
- Torsion— ovary, fibroid
- Placenta abruptio
- Abortion: Spontaneous, Incomplete, Threatened
Name investigations for pelvic pain if B-HCG negative (6)
- ± CBC, electrolytes
- ± Urinalysis and C&S
- ± Pap smear, G&C swabs
- ± Pelvic U/S
- ± Diagnostic laparoscopy
- ± Psychosocial assessment
*Depends on information gathered from Hx and physical exam
Name GYNECOLOGIC DDX for pelvic pain if B-HCG negative (12)
- PID (acute/chronic)
- Endometriosis
- Ovarian cyst rupture/ hemorrhage
- Uterine fibroids (degenerating, infected, toned)
- Torsion—ovary, fibroid
- Mittelschmerz
- Primary dysmenorrhea
- Vulvar vestibulitis
- Endosalpingitis
- Adenomyosis
- Intraperitoneal adhesions
- Residual ovarian
Name GI/GU DDX for pelvic pain if B-HCG negative (8)
- Appendicities
- Inflammatory bowel disease (IBD)
- Irritable bowel syndrome
- Diverticulitis
- UTI
- Interstitial cystitis
- Renal calculi
- Neoplasia
Name SYSTEMIC DDX for pelvic pain if B-HCG negative (4)
- Depression
- Abuse
- Fibromyalgia
- Substance abuse
Name MSK DDX for pelvic pain if B-HCG negative (3)
- Levator ani syndrome
- Sacroilliac dysfunction
- Degenerative joint disease
Describe: Approach to the Dx of pelvic pain. (Figure)
Name roles of laparoscopy in Chronic pelvic pain (4)
- Confirmation of DX
- Surgical intervention
- Rx
- Patient reassurance
Name indications of laparoscopy in Chronic pelvic pain (2)
- Persistent CPP with no discernable cause after appropriate investigations
- CPP refractory to pharmacologic Rx
Name general managements of Chronic pelvic pain (4)
- Pharmacotherapy
- Physical Therapy
- Psychotherapy
- If poor response to above: Surgery
Describe pharmacotherapy of chronic pelvic pain (9)
Goal: Stop and/or ↓ Sx
-
Analgesics:
- First line - NSAIDs (ibuprofen, ASA, naproxen)
- Second line - opioids (avoid long-term use)
- Combined OCPs
- GnRH agonists (i.e., leuprolide/Lupron) ± add back Estrogen
- Progestins (i.e., MPA suspension/Depo Provera/Visanne)
-
Adjuncts
- ± SSRIs (fluoxetine, paroxetine, or sertraline)
- ± Neuro modulators (gabapentin, amitriptyline or nortriptyline)
- ± Trigger point injections
- ± Peripheral nerve blocks
Describe physical therapy of chronic pelvic pain (6)
Goal: ↓ Sx
- Hot/cold compress
- Body positioning
- Massage
- Exercise
- Nerve stimulation ± a cupuncture
- Pelvic floor exercises
Describe Psychotherapy of chronic pelvic pain (4)
Goal: ∆ Pattern of negative thinking
- CBT
- Relaxation Rx
- Stress management techniques
- Biofeedback techniques
Describe surgery of chronic pelvic pain (3)
- Laparoscopic laser ablation
- Laparoscopic adhesiolysis
- Presacral neurectomy (superior hypogastric plexus excision)
Name: Common Locations of ectopic pregnancy (5)
- Ampullary: 70%
- Isthmic: 12%
- Fimbrial: 11%
- Ovarian: 3%
- Others:interstitial/cornual—2%,Abdo—1%,cervical—<1%
Name Ectopic pregnancy Risk factors (8)
- Previous EP
- Current IUD
- Hx of PID
- Prev. tubal surgery
- In utero DES exposure
- Infertility
- Current smoking
- Uterine structure: broids, adhesions, abnormal shape, etc.
Describe approach to ectopic pregnancy ()
Describe management for ectopic pregnancy (2)
- Methotrexate (MTX)
- Folic acid antagonist that inhibits DNA synthesis and cell reproduction
- 86%–94%successrateforRxofEP
- Laparoscopic surgery or laparotomy
- Methods: linear salpingostomy vs. salpingectomy
Name criteria of Methotrexate in management of ectopic pregnancy (8)
- Hemodynamically stable
- No active bleeding or signs of hemoperitoneum
- < 3.5 cm unruptured mass
- No fetal heart activity
- b-hCG < 5,000
- Patient desires future fertility
- Patient is compliant and able to return for F/U care
- No CI to MTX
Name CI of Methotrexate in management of ectopic pregnancy (5)
- Breast-feeding
- Chronic liver disease (alcoholism, fatty liver, etc.)
- Known sensitivity to MTX
- Blood dyscrasias (i.e., thrombocytopenia, significant anemia)
- Hepatic, renal, or hematologic dysfunction
Describe dosing of Methotrexate in management of ectopic pregnancy (1)
single IM dose (50 mg/m2 body surface area) (88.1% success rate); may require a second IM dose
Describe monitoring of Methotrexate in management of ectopic pregnancy (1)
serial (weekly) b-hCG levels until undetectable
Name indications of surgery for laparoscopic surgery or laparotomy in management of ectopic pregnancy (2)
- Failed or contraindication to MTX Rx
- Previous EP in same fallopian tube
Describe: Dyspareunia (1)
Recurrent/persistent genital pain caused by sexual activity
Define primary/secondary/superficial/deep Dyspareunia
- Primary = constant pain since initiation of sexual activity
- Secondary = occurs after a period of pain-free sexual activity
- Superficial = pain occurs in/around vaginal entrance
- Deep = paint at vaginal apex during intercourse
Name VULVAR causes of dyspareunia (6)
- Imperforate hymen
- Chronic vulvitis (yeast, chemicals)
- Vulvar vestibulitis
- Vulvar skin conditions (lichen sclerosis, psoriasis, eczema, etc.)
- Vulvar atrophy
- Vulvar scarring (i.e., prev. episiotomy)
Name VAGINAL causes of dyspareunia (5)
- Inadequate lubrication (due to medications, arousal disorder, insufficient foreplay etc.)
- Atrophic vaginitis
- Vaginitis (e.g., chronic yeast)
- Vaginal stenosis
- Vaginismus
Name PELVIC causes of dyspareunia (8)
- Endometriosis
- Ovaries in cul de sac
- Fibroids
- Pelvic varicosities
- Peritoneal adhesions
- Chronic PID
- Bowel (chronic constipation, IBD, diverticulitis)
- Bladder (interstitial cystitis, urethritis)
Name PSYCHOLOGIC causes of dyspareunia (2)
- Hx of sexual abuse
- Prev. painful intercourse
Name: Indications for Speciality Referral in CPP (2)
- Persistent pain despite a 3 to 6 mo trial of NSAIDs or OCPs
- Lack of Dx despite appropriate diagnostic investigations
