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Essentials - Gynecology > 11. Pelvic pain > Flashcards

11. Pelvic pain Flashcards

1
Q

Describe: Acute pelvic pain (1)

A

lasting < 6 mo

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2
Q

Describe: Chronic pelvic pain (1)

A
  • 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)
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3
Q

Name ACUTE GYNE DDx of pelvic pain (9)

A
  • 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
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4
Q

Name CHRONIC/RECURRENT GYNE DDx of pelvic pain (10)

A
  • Endometriosis
  • Chronic PID
  • Adenomyosis
  • Leiomyomata
  • Dysmenorrhea
  • Pelvic adhesions
  • Vulvar vestibulitis
  • Vulvodynia
  • Residual ovarian syndrome
  • Chronic pelvic infection (TB)
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5
Q

Name ACUTE GI DDx of pelvic pain (4)

A
  • Acute appendicitis
  • Diverticulitis
  • Irritable bowel
  • IBD
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6
Q

Name CHRONIC GI DDx of pelvic pain (6)

A
  • Irritable bowel
  • IBD
  • Diverticulitis
  • Constipation
  • Hernia
  • Neoplastic lesions
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7
Q

Name ACUTE UROLOGIC DDx of pelvic pain (2)

A
  • UTI
  • Renal calculi
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8
Q

Name CHRONIC/RECURRENT UROLOGIC DDx of pelvic pain (4)

A
  • Chronic UTIs
  • Interstitial cystitis
  • Urethral disorders
  • Bladder neoplasm
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9
Q

Name ACUTE MSK DDx of pelvic pain (3)

A
  • Levator ani syndrome
  • Disc disease
  • Hernia
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10
Q

Name CHRONIC/RECURRENT MSK DDx of pelvic pain (4)

A
  • Fibromyalgia
  • Nerve entrapment syndromes
  • Mechanical low back pain
  • Disc disease
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11
Q

Name SYSTEMIC DDx of pelvic pain (4)

A
  • Sleep disturbance
  • Mental health issues
    • Depression, somatization
    • Abuse (sexual, physical, and/or psychological)
    • Domestic violence
    • Substance abuse
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12
Q

Mental Health Issues and CPP (2)

A
  • Approximately25%ofpatients with CPP have a PMHx of sexual/ physical abuse.
  • DepressionoftencoexistswithCPP (25%–50%). It is a predictor of:
    • Pain severity
    • Response to Rx
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13
Q

Describe HX: Pelvic pain (7)

A
  1. Pain history, prev treatments tried, pain diary if chronic
  2. Associated Sx: fever, abnormal bleeding, vaginal discharge, dysuria, urinary frequency/urgency
  3. Associated events: urination, defecation, menstrual period, intercourse
  4. OB/GYN Hx: menstrual, contraception, STIs, prev. ectopic pregnancy, fertility
  5. Past medical/surgical Hx: GI, GU, MSK
  6. Mental Health Hx: depression
  7. Psychosocial stressors: physical/sexual abuse, domestic violence, substance abuse
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14
Q

Describe physical exam: Pelvic pain (6)

A
  1. Vital signs
  2. Abdominal exam: tenderness, scars, hernias, trigger points
  3. Pelvic exam: vaginal discharge, cervical erythema, cervical motion tenderness, adnexal mass/tenderness, nodularity
  4. Digital Rectal Exam
  5. MSK exam: scoliosis, sacroiliac tenderness, trigger points, pelvic asymmetry, straight leg raise (SLR)
  6. Completion of pain diary
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15
Q

Name DDX possible in this situation (7)

A
  • 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
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16
Q

Name investigations for pelvic pain if B-HCG negative (6)

A
  1. ± CBC, electrolytes
  2. ± Urinalysis and C&S
  3. ± Pap smear, G&C swabs
  4. ± Pelvic U/S
  5. ± Diagnostic laparoscopy
  6. ± Psychosocial assessment

*Depends on information gathered from Hx and physical exam

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17
Q

Name GYNECOLOGIC DDX for pelvic pain if B-HCG negative (12)

A
  1. PID (acute/chronic)
  2. Endometriosis
  3. Ovarian cyst rupture/ hemorrhage
  4. Uterine fibroids (degenerating, infected, toned)
  5. Torsion—ovary, fibroid
  6. Mittelschmerz
  7. Primary dysmenorrhea
  8. Vulvar vestibulitis
  9. Endosalpingitis
  10. Adenomyosis
  11. Intraperitoneal adhesions
  12. Residual ovarian
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18
Q

Name GI/GU DDX for pelvic pain if B-HCG negative (8)

A
  • Appendicities
  • Inflammatory bowel disease (IBD)
  • Irritable bowel syndrome
  • Diverticulitis
  • UTI
  • Interstitial cystitis
  • Renal calculi
  • Neoplasia
19
Q

Name SYSTEMIC DDX for pelvic pain if B-HCG negative (4)

A
  • Depression
  • Abuse
  • Fibromyalgia
  • Substance abuse
20
Q

Name MSK DDX for pelvic pain if B-HCG negative (3)

A
  • Levator ani syndrome
  • Sacroilliac dysfunction
  • Degenerative joint disease
21
Q

Describe: Approach to the Dx of pelvic pain. (Figure)

22
Q

Name roles of laparoscopy in Chronic pelvic pain (4)

A
  • Confirmation of DX
  • Surgical intervention
  • Rx
  • Patient reassurance
23
Q

Name indications of laparoscopy in Chronic pelvic pain (2)

A
  • Persistent CPP with no discernable cause after appropriate investigations
  • CPP refractory to pharmacologic Rx
24
Q

Name general managements of Chronic pelvic pain (4)

A
  • Pharmacotherapy
  • Physical Therapy
  • Psychotherapy
  • If poor response to above: Surgery
25
Describe pharmacotherapy of chronic pelvic pain (9)
Goal: Stop and/or ↓ Sx 1. **Analgesics**: * First line - NSAIDs (ibuprofen, ASA, naproxen) * Second line - opioids (avoid long-term use) 2. **Combined OCPs** 3. **GnRH agonists** (i.e., leuprolide/Lupron) ± add back Estrogen 4. **Progestins** (i.e., MPA suspension/Depo Provera/Visanne) 5. **Adjuncts** * ± SSRIs (fluoxetine, paroxetine, or sertraline) * ± Neuro modulators (gabapentin, amitriptyline or nortriptyline) * ± Trigger point injections * ± Peripheral nerve blocks
26
Describe physical therapy of chronic pelvic pain (6)
Goal: ↓ Sx 1. Hot/cold compress 2. Body positioning 3. Massage 4. Exercise 5. Nerve stimulation ± a cupuncture 6. Pelvic floor exercises
27
Describe Psychotherapy of chronic pelvic pain (4)
Goal: ∆ Pattern of negative thinking 1. CBT 2. Relaxation Rx 3. Stress management techniques 4. Biofeedback techniques
28
Describe surgery of chronic pelvic pain (3)
* 1. Laparoscopic laser ablation * 2. Laparoscopic adhesiolysis * 3. Presacral neurectomy (superior hypogastric plexus excision)
29
Name: Common Locations of ectopic pregnancy (5)
1. Ampullary: 70% 2. Isthmic: 12% 3. Fimbrial: 11% 4. Ovarian: 3% 5. Others:interstitial/cornual—2%,Abdo—1%,cervical—\<1%
30
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.
31
Describe approach to ectopic pregnancy ()
32
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
33
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
34
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
35
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
36
Describe monitoring of Methotrexate in management of ectopic pregnancy (1)
serial (weekly) b-hCG levels until undetectable
37
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
38
Describe: Dyspareunia (1)
Recurrent/persistent genital pain caused by sexual activity
39
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
40
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)
41
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
42
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)
43
Name PSYCHOLOGIC causes of dyspareunia (2)
* Hx of sexual abuse * Prev. painful intercourse
44
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

Essentials - Gynecology (14 decks)

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