11. Pelvic Pain Flashcards
approach to pt with pelvic pain
- Hx
- PE
- DDx
- Directed testing
- Treatment plan
what is important to note when taking hx of a premenopausal W with pelvic pain
menstrual history and menstrual profile
what is menstrual profile
- menarche
- cycle length and variability
- flow
- dysmenorrhea
- cramping/pain/radiation
- changes in bowel or bladder
PE of pt with pelvic pain
- General appearance
- Head to toe: skin, back, spine, abdomen, pelvic, bladder and bowel eval
Glands and stroma, invading into the walls of the uterus.
adenomyosis
DDx of cyclic pelvic pain
- Endometriosis *** => ectopic glands and stroma
- Mittelschmerz => pain with ovulation
- Dysmenorrhea
DDx of non-cyclic pelvic pain
- Interstitial cystitis
- Diverticulitis
- Hernia
MEnstrual related causes of pelvic pain
- Endometriosis
- Adenomyosis
- Mittelschmerz
- Post-ablation syndrome = menstrual fluid behind scar in uterus
- Leiomyoma
- Catamenial
A cloning phenomena, where proliferation of cells can enlarge the uterus, the adnexa, or the supporting ligaments of the uterus. These may be intramural, pedunculated, subserosal, ligamentous, cervical, or intracavitary.
leiomyoma
ectopic glands in stroma in other places of body
catamenial
theories of endometriosis
- Coelomic metaplasia = metaplasia of cells from ovarian and peritoneal surfaces
- retrograde menstruation +> retrograde flow of endometrial cells through tubes and onto pelvic surfaces
ovarian related causes of pelvic pain
- Ovarian cysts
- painful with rupture, bleeding or leaking of fluid
- OVarian torsion
- rotation on suspensory l; precipitated by cyst or mass that is >5cm
- OVarian remnant = ovarian tissue regenerates/grows in response to gonadotropins, forming a cyst or mass.
MC reason for cyclic pelvic pain
ovarian cysts
how do OCS affect risk of ovarian cysts, ovarian and uterine cancer
decrease
bilateral removal of ovaries causes what?
ovarian remnants most often on __ side
increased estradoil
L
fallopian tube causes of pelvic pain
- Obstruction of flow or infection (hematosalpinx = blood; pyosalpinx = pus; hydrosalpinx = fluid) are the MC.
- Pain with distension of lumen
- PID Salpingitis
- peritonitis + abscess or spsis
- pain, fever, high WBC/EST
- Ectopic PG
- pain w distension/rupture
when can a IUP be detected on
- transvaginal sonography
- transabdominal US
- transvaginal sonography: >1200 mIU/mL hCG
- transabdominal US: >2000 mIU/mL hCG
*
Uterus causes of pelvic pain
- endometritis
- IUD
- Threatened/septic abortions, post-term pain
- = pain when round ligament is stretched early in PG
what is endometritis and what can cause
- infection of uterine cavity
- ascending infection with strep, myoplasma, ureaplasma, haemophilus, anaerobes
cervicitis is most likely due to ___
STI
vascular causes of pelvic pain
-
1. pelvic congestion: dilated veins in pelvis (broad ligament, paratubal/ovarian supporting structures, paravaginal/vulvar)
- pain and congestion after activity, standing, sex or period
noncyclic causes of pelvic pain due to bladder
- UTI,
- urinary retention
- bladder prolapse
Pain = centra land related to bladder patterns
A defect in the protective layer of the bladder => causing frequency, burning pain, decreased bladder compliance, UTI-like symptoms, and flares of increased symptoms
interstitial colitis
what can be seen in intersitial colitis and is pathognomonic
Hunners uclers = red area with prominant radial vessels but nOT A TRUE ULCER
UReter causes of bladder pain
- Stone
- => pain is anterior/flank pain d/t renal colic
- Fibrosis, injury, endometriosis => ureteral obstruction or stenosis
- lower abdomnal painm flank, lower back
bowel related causes of pelvic pain; which are cyclic vs non
- IBD (Crohns or UC) = non-cyclic
- IBS = cyclic due to shared nerve pathways in presence of endometriouss
- Diverticulitis, Chronic constipation, intolerance
- pain, bloating and bowel discomfort
- Appendiciits = mid-abdomina => RLQ pain
- fever, anorexia, bloating and pain
- perforation = sepsis and shock
dx appendicitis
mc-buneys point: 1/3 of distance from ASIS to BB
MC hernia in women
indirect inguinal
nerological caues of bladder pain
- Varicella Zoster (shingles) or Nerve entrapment (ilioingiinal/genitogemorial)
- => lower ABD pain that radiates to groin/anteiror thigh and worse when extend back
- Pelvic floor neuralgia/pudendal neuralgia
- Pain in deep pelvis/ paravaginal/vaginal tissue: cant poop or pee and occurs when lifting or strain
- Dysuria
- Dysmenorrhea
- Dyscheziais
- Dyspareunia
- Dyssnergiais
- Dysuria = painful urination
- Dysmenorrhea = painful period
- Dyscheziais = painful bowel movement = constiaption
- Dyspareunia = painful sex
- Dyssnergiais = disturb of musclar/neuromuscular coordinatio
difference in acute and chronic pelvic pain
acute = sudden onset of lower adbominal pain less than 3 months
chronic = lower abdominal pain that lasts 4 months or longer and is NOT related/seperate from organ system or menses
