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 cysts background
- Premenopausal- benign
- Postmenopausal- more likely malignant
- People with ‘string of pearls’ appearance cannot be diagnosed with PCOS without other symptoms
types of ovarian cysts
- Functional
o Follicular cysts- Harmful and disappear after a few menstrual cycles
Thin walls
No internal structures
o Corpus luteum cysts
Seen in early pregnancy - Serous cystadenoma- benign epithelial cell tumours
- Mucinous cystadenoma- benign epithelial cell tumours which can become huge
- Endometrioma
- Dermoid cyst- teratomas
o Germ cell- benign - Sex cord stromal tumours
o Can be benign or malignant
presentation of ovarian cyst
- Pelvic pain
- Bloating
- Fullness in abdomen
- Palpable mass
- Acute pain if:
o Ovarian torsion
o Haemorrhage
o Rupture
investigations for ovarian cysts
- full hisotry to assess risk of malignancy
- US (no need with simple ovarian <5cm)
- Blood tests
- risk of malignancy index
blood tests for ovarian cysts
- CA125 tumour marker for ovarian cancer (RMI)
Also: endometriosis, fibroids, adenomyosis, pelvic infection, liver disease, pregnancy - Women <40 years with complex ovarian mass require tumour markers for germ cell tumours
LDH
A-FP
HCG
risk of malignancy index (RMI)
Risk of malignancy index (RMI)- estimates the risk of ovarian mass being malignant : 1) menopausal status, US findings, CA125
management of simple ovarian cysts in premenopausal women
o <5cm- should resolve in 3 weeks
o 5cm-7cm – routine referral to gynaecology and yearly US
o >6cm – MRI scan and surgical eval
management of Possible ovarian cancer (complex cyst and raised CA125)
2 week wait referral to gynaecological oncology specialist
management of dermoid cysts
further invest and consideration of surgery
management of cysts in postmenopausal women
o 2 week wait if raised CA125
o Simple cysts with normal CA125- monitor every 4-6 months
management of peristing or enlarging cyst
o Surgical intervention (with laparoscopy)- ovarian cystectomy +- oophorectomy
Complications of ovarian cysts
- Torsion
- Haemorrhage
- rupture
ovarian cysts are also known as
Adnexal cysts- fluid containing mass in the pelvis.
Ovarian torsion
- Ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply (the adnexa).
ovarian torsion cause
due to an ovarian mass larger than 5cm, such as a cyst or a tumour. It is more likely to occur with benign tumours. It is also more likely to occur during pregnancy.
o Can also happen with normal ovaries in younger girls before menarche (the first period), when girls have longer infundibulopelvic ligaments that can twist more easily.
prognosis of ovarian torsion
Twisting of the adnexa and blood supply to the ovary leads to ischaemia. If the torsion persists, necrosis will occur, and the function of that ovary will be lost. Therefore, ovarian torsion is an emergency, where a delay in treatment can have significant consequences.
presentation of ovarian torsion
Symptoms
o Sudden, serve unilateral abdominal pain
o Constant
o Fluctuating
o Radiating to loin
o Nausea
o Vomiting
Signs
o Pyrexia
o Tachycardia
o Rebound tenderness and guarding
o Vaginal examination: Cervical excitation, adnexal tenderness and adnexal mass
investigations for ovarian torsion
- Bloods
o FBC
o CRP
o Tumour markers - US pelvis (transvaginal ideal)
o Whirlpool sign, free fluid in pelvis and oedema of ovary - Doppler study- lack of blood flow
- Definitive diagnosis- laparoscopic surgery
management of ovarian torsion
- Admit
- IV fluids
- Pain relief
- Surgery - laparoscopy
o Detorsion
o Remove affected ovary (oophorectomy)
ovarian torsion on US
Scoring system for identifying ovarian torsion:
fibroid degeneration: red degeneration
Red degeneration refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply.
- Red degeneration is more likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy.
causes of red degeneration
- Red degeneration may occur as the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic.
- It may also occur due to kinking in the blood vessels as the uterus changes shape and expands during pregnancy.
presentation of red degernation
Red degeneration presents with severe abdominal pain, low-grade fever, tachycardia and often vomiting.
management of fibroid degernation
is supportive, with rest, fluids, abx and analgesia.
- Emergency surgery if pedunculated fibroid torsion
Haematocolops/ haematometra
Hematocolpos- Menstrual blood pools in the vagina due to blockage of menstrual flow
Haematometra- uterus fills with blood
cause of Haematocolops/ haematometra
combination of menstruation and imperforate hymen
presentation of Haematocolops/ haematometra
- At puberty
- Primary amenorrhoea
- Pelvic pain
- Recurrent pelvic pain with pelvic mass
- Constipation and urine output changes
management of Haematocolops/ haematometra
- Depends on cause
- Imperforate hymen
o Minor surgery involving incision into the hymen membrane
UTI
The urinary tract includes the urethra, bladder, ureters and kidneys. Urinary tract infections are infections anywhere along this pathway.
- Acute pyelonephritis- kidney
- Cystitis- bladder
causes of UTI (bac)
- E.coli
- Klebsiella pneumoniae
- Staphylococcus saprophyticus
presentation of UTI
- Fever
- Lethargy
- Abdominal suprapubic pain
- Vomiting
- Dysuria
- Urinary frequency
- Incontinence
investigation for UTI
- MSU and dipstick
- `` If nitrites or leukocytes are present, the urine should be sent to the microbiology lab. If neither are present the patient is unlikely to have a UTI.
- Sensitivity testing
management fot UTI
- 3 days of antibiotics for a simple lower urinary tract infection in women
- 5-10 days of antibiotics for women that are immunosuppressed, have abnormal anatomy or impaired kidney function
- 7 days of antibiotics for men, pregnant women or catheter related UTIs
UTI and catheter
It is worth noting that NICE recommend changing the catheter when someone is diagnosed with a catheter related urinary tract infection.
antibiotics for UTI
An appropriate initial antibiotic in the community would be:
* Trimethoprim
* Nitrofurantoin
Alternatives:
* Pivmecillinam
* Amoxicillin
* Cefalexin
management of UTI during pregnancy
- 7 days of antibiotics (even with asymptomatic bacteruria)
- Urine for culture and sensitivities
- First line: nitrofurantoin
- Second line: cefalexin or amoxicillin
nitrofuranotin vs trimethoprim in pregnancy
- Nitrofurantoin is generally avoided in the third trimester as it is linked with haemolytic anaemia in the newborn.
- Trimethoprim is generally considered safe in pregnancy but avoided in the first trimester or if they are on another medication that affects folic acid (such as anti-epileptics) due to the anti-folate effects.
