3- Pelvic pain (acute) Flashcards
pelvic pain is a
Common complaint in primary care
- As frequent as migraine and lower back pain
- Significantly affects woman’s quality of life
- Multifactorial
cause of pelvic pain broad
- Bowel
- Bladder
- Uterus
- Ovaries
- Bones
- Muscles
Aetiology of acute and chronic pelvic pain
Pelvic pain can be acute or chronic. The presentation of pelvic pain varies significantly. A detailed history and examination are usually able to identify the cause. There are a large number of possible causes, including:
- Urinary tract infection
- Dysmenorrhoea (painful periods)
- Irritable bowel syndrome (IBS)
- Ovarian cysts
- Endometriosis
- Pelvic inflammatory disease (infection)
- Ectopic pregnancy
- Appendicitis
- Mittelschmerz (cyclical pain during ovulation)
- Pelvic adhesions
- Ovarian torsion
- Inflammatory bowel disease (IBD)
history taking for pelvic pain
- SOCRATES
- Use of protection
- Use of contraception
- Associated symptoms
o Psychological
o Bladder
o Bowel
o Movement and posture - Rule out red flags
- Pain diary for 2-3 months
- Effect on QoL
- Symptoms based diagnostic criteria
examinations for pelvic pain
- Abdominal and pelvic
- Focal tenderness
- Trigger points- abdominal wall and/or pelvic floor
- Enlargement, distortion or tethering, or prolapse.
- Sacroiliac joints or the symphysis pubis may
investigation for pelvic pain
- STI screening
- Transvaginal sonography
- MRI
- Laparoscopy
management of pelvic pain
- Treat the cause
- Cyclical pain should be treated using hormonal treatment for a period of 3-6 months before having a diagnostic laparoscopy
- IBs- antispasmodic and life-style changes
- Optimise pain relied
- Referral to chronic pelvic pain team
examples of acute pelvic pain
- Ectopic pregnancy
- PID
- Torsion or rupture of ovarian cysts
- Lower genital tract infections such as candidiasis
- Fibroid degeneration
- Hematocolpos
- UTI
ectopic pregnancy background
When a pregnancy is implanted outside the uterus e.g. fallopian tubes , cornual region, ovary, cervix or abdomen
*Always ask someone about the possibility of pregnancy and do a pregnancy test
*
RF for ectopic pregnancy
- Previous ectopic pregnancy
- Previous pelvic inflammatory disease
- Previous surgery to the fallopian tubes
- Intrauterine devices (coils)
- Older age
- Smoking
presentation of ectopic pregnancy
- 6-8 weeks gestation
- Missed period
- Lower abdominal pain in the right or left iliac fossa
- Vaginal bleeding
- Lower abdominal or pelvic tenderness
- Cervical motion tenderness (pain when moving the cervix during a bimanual examination
- Shoulder tip pain- peritonitis
- Dizziness or syncope – blood loss
investigation for ectopic pregnancy
- Pregnancy test
- Transvaginal US scan
- HCG levels
transvaginal US scan in ectopic pregnancy
o A gestational sac containing yolk sac or fetal pole may be seen in fallopian tube
o A mass representing tubal ectopic pregnancy moves separately to the ovary
o Empty uterus
o Fluid in uterus- may be mistaken as a gestational sac
HCG in pregnancy of unknown location (PUL)
Measure HCG in 48 hours
1) A rise of more than 63% after 48 hours is likely to indicate an intrauterine pregnancy. A repeat ultrasound scan is required after 1 – 2 weeks to confirm an intrauterine pregnancy. A pregnancy should be visible on an ultrasound scan once the hCG level is above 1500 IU / l.
2) A rise of less than 63% after 48 hours may indicate an ectopic pregnancy. When this happens the patient needs close monitoring and review.
3) A fall of more than 50% is likely to indicate a miscarriage. A urine pregnancy test should be performed after 2 weeks to confirm the miscarriage is complete.
PUL
- Pregnancy of unknown location
Management of ectopic pregnancy
All ectopic must be terminated
There are three options for terminating an ectopic pregnancy:
* Expectant management (awaiting natural termination)
* Medical management (methotrexate)
* Surgical management (salpingectomy or salpingotomy)
PID background
Ascending infection from the endocervix of organs in the pelvic- usually polymicrobial
- High mortality rate
- Can cause infertility
- Can cause appendicitis, diverticulitis and pyelonephritis
- Can cause abscess
PID RF
- 15-24
- Unprotected sex- chlamydia or gonorrhoea
o Non STI: gardenerella vaginalis, haemophilius influenzae, E.coli) - Earlier age of first intercourse
- Multiple sexual partners
- Diabetes
- Immunocompromised
- Co-existing endometriosis
- Previous PID
presentation of PID
- Asymptomatic
- Lower abdominal pain
- Pyrexia
- Vaginal discharge yellow or green
- Dyspareunia
- Post coital bleeding
- Dysuria
PID: on exam
- Cervical excitation
- Pelvic tenderness
- Inflamed cervix
- Purulent discharge
- Septic signs
investigation for PID
- Pregnancy test
- Bloods (FBC, CRP, WCC)
- MSU
- STI tests
- Looking for Pus cells using microscope
- US pelvis/ abdomen
- X-ray
- Diagnostic laparoscopy
STI tests for PID investigaton
- Low vaginal swab: NAAT swabs for gon and chlamydia
- High vaginal swab for bacterial vaginosis, candidiasis and trichomoniasis
- Blood tests: HIV test and syphilis test
inpatient management of PID
- IV ceftriaxone, doxycycline, metronidazole
- Surgical treatment-Laparoscopy/Laparotomy for drainage
o Laparoscopy- key hole
o Laparotomy- larger hole - Counselling-Risk of ectopic, Subfertility
- Partner notification and treatment
- Follow up
SEPSIS 6 IF SEPTIC
outpatient management of PID
o Even if triple swabs are negative, it does not exclude PID
o IM ceftriaxone 500 mg single dose
o Oral doxycycline 100mg twice daily
o Metronidazole 400mg twice daily for 14 days
complications of PID
- Sepsis
- Abscess
- Infertility
- Chronic pelvic pain
- Ectopic pregnancy
- Fitz-Hugh-Curtis syndrome
ovarian torsion on US
Scoring system for identifying ovarian torsion:
