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Obstetrics & Gynaecology > Abdominal and pelvic pain > Flashcards

Abdominal and pelvic pain Flashcards

1
Q

Define:
Acute pelvic pain
Chronic pelvic pain

What are the causes of mild acute pelvic pain?

A

Acute pelvic pain <3 months
Chronic pelvic pain <6 months, not associated with pregnancy, menstruation or sex

Menstruation

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2
Q

What are the causes of acute pelvic pain?

A

Obstetric: Ruptured ectopic pregnancy, Incomplete or septic miscarriage

Gynae: Endometriosis, Acute PID, Ovarian cyst rupture/torsion, Ovarian malignancy

Other: Renal caliculi/infection
Appendicitis

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3
Q

What are the causes of chronic pain?

A

Gynae: Endometriosis, Adenomyosis, Chronic PID, Adhesions, pelvic organ prolapse

Other: Diverticular disease, IBS, peritonitis UTI, interstitial cystitis, nerve entrapment

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4
Q

What is in the assessment of pelvic pain?

A
  1. History
  2. Infection screen- Urine MC & S, endocervical swab, high vaginal swab
  3. Transvaginal ultrasound/MRI
  4. Diagnostic laproscopy
  5. CA-125
  6. Urine bHCG
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5
Q

What are the red flags in the a pelvic pain history which prompt further investigations? (CLUE would indicate malignancy)

A

Bowel: bleeding per rectum, new onset bowel symptoms >50
Weight loss, suicidal ideation
Gynae: post-coital bleeding, irregular vaginal bleeding in >40, new onset pain in >50, palpable mass

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6
Q

In endometriosis what are the common and rare places endometrial tissue can grow?

What are aetiological theories?

A

Common:
Ovaries, uterosacral ligament
Rectosigmoid colon, pouch of douglas
Bladder, distal ureter

Rare: umbilicus, C section scar, pleura, pericardium, CNS

Aetiology

  • retrograde menstruation
  • Foci/distant lesions via embolisation Hablans theory and Meyers theory Malignancy
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7
Q

What is epidemiology, and risk factors for endometriosis?

CLUE endometriosis is oestrogen dependent condition

A

Most common in reproductive ages, rare under 20’s
Regresses during menopause, and pregnancy
Common in nulliparrous women

Risk factors:

  • Early menarche late puberty
  • Outflow obstruction to bleeding eg fallopain tube or uterine abnormalitiies
  • 1st degree relative
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8
Q

What are protective factors for endometriosis?

A

multiparity and OCP

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9
Q

Clinical features of endometriosis?

A 
Chronic cyclical pain 
Deep dyspauerenia 
Dyscherizia 
Subfertility 
Sudden acute pain- rupture of endometrioma

Cylical haematuria, rectal bleeding, bleeding from umbilicus: Severe disease
Asymptomatic

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10
Q

What are the findings of endometriosis on bimanual pelvic examination?

A

Retroverted immobile uterus
Thickness and tenderness behind uterus or adnexa
Retrovaginal nodule may be felt digitally on speculum or vaginal exam

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11
Q

Investigations for endometriosis

A

Acute: FBC, urine MC+S, endocervical swab

1.Transvaginal ultrasound- exclude endometrioma
Transvaginal MRI- if peritoneal endometriosis or adenomyosis suspected

  1. Diagnostic laparoscopy- gold standard!!! You can explore the pelvic cavity I guess and adhesions
  2. CA 125- exclude ovarian malignancy
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12
Q

What are the lesions which are found on diagnostic laparoscopy in endometriosis
Active
Less active
Severe

A

Active- red punctuate marks on peritoneum
Less active- white brown scars
Severe- adhesions/ endometrioma

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13
Q

Medical management of Endometriosis, and how long is it given for?

A

Abolish cyclity:
COCP
GnRH analogues with HRT add back therapy

Glandular atrophy- medroxyprogesterone acetate (oral), depot, Mirena IUS, Danazol (not used much cos androgenic SEs)

Given for 6 months

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14
Q

Surgical management of endometriosis?

A
  • Laproscopy- adhesiolysis, cystectomy (improve fertility)
  • Hysterectomy with salpingooopherectomy
  • pelvic clearance
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15
Q

What are the complications of endometriosis?

A

Endometrioma
Inflammation- fibrosis-adhesions- frozen pelvis
Subfertility
Increased risk of breast and ovarian cancer
Increased risk of IBD
Increased risk of autoimmune and atopic disorders

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16
Q

What is adenomyosis?

A

Presence of myometrium within endometrium

adenomyotic nodules cause proliferation and hyperplasia of myometrium cause slow growing adenomyoma tumour

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17
Q

Epidemiology and associations of adenomyosis?

A

Begins in 40’s and more common in multiparrous women

Associated with fibroids, endometriosis

18
Q

Clinical features of adenomyosis?

A

Cyclical pelvic pain
Secondary subfertility (present in 40’s)
Menorrhogia, more frequent periods, spotting, staining
———- Above differentiates between endometriosis and adenomyosis

19
Q

Investigations adenomysosis?

A

Transvaginal MRI, and transvaginal venous ultrasonography

20
Q

Management of adenomyosis?

Medical and surgical

A

Menorrhagia and pain: Mirena IUS, COCP

MedicalA: hysterectomy give trial of GnRH analogues to see if will be successful

21
Q

What are ovarian cysts (clue include size) and what are the diff types of cysts?

A

Fluid filled sacs larger than 3cm
Simple benign cysts (resolve within 3 months)
Endometrioma
Dermoid cysts

22
Q

What are the complications associated with risks and which types of ovarian cysts are associated with each?

A
  1. Haemorrhage
  2. Torsion- infarction of tube or ovary (dermoid more likely)
  3. Rupture (more dermoid and endometrioma)
23
Q

What are risk factors for ovarian cysts?

A 
Obesity 
Early mencarche  
Infertility 
tamoxifen therapy (causes cysts to persist) 
Family history- dermoid cysts
24
Q

Clinical features of ovarian cysts (acute chronic)

A

Acute:

  • fever, pain or intermitten pain: torsion rupture
  • peritonitis and shock
  • hypovalaemia- if haemorrhage
  • if ascites then malignancy

Chronic

  • abdo distention
  • pressure effects, frequency, varicose veins and leg oedema
  • Dyspaeurinia
  • dull ache in lower abdo or back
25
Q

Investigations of ovarian cyst?

A

All pelvic pain tests first

  1. Transvaginal ultrasound or MRI to visualise cyst
    - some may need diagnostic laparscopy to confirm
  2. Fine needle aspiration and cytology
  3. CA-125
26
Q

Why would you not order CA-125 test if on ultraosund simple benign cysts and women is pre-menopausal?

A

Because of false positive rate

27
Q

Management of ovarian cysts (clue is according to size of cysts)

A

if 5-7cm then yearly ultrasound
if >10cm then laproscopic cystectomy
if malignany then laparatomy

28
Q

What is epidemiology of PID and risk factor?

A

Most common in 20-29 year olds

RF: lower socioeconomic classes, frequent sexual partners, sexually active nulliparrous women, sex without barrier contraception

29
Q

What is aetiology of PID (not bacteria) and which structures most likely to be affected?

A

Ascending infection from cervix, vagina
Descending infection from appendicitis rarely
Or introduction via uterine instrumentation, complications of childbirth or miscarriage

Structures- most likely to cause endometritis, bilateral salpingitis and parametritis (ovaries not affected as much)

30
Q

What is Fitz- Hugh curtis syndrome (clue occurs in PID?)

A

Inflammation of the liver capsule but not parenchyma results in adhesion formation between the liver and anterior abdominal wall
Have RUQ pain

31
Q

What bacteria are responsible for causing PID?

A
  • 80% STI: chlamydia (asymptomatic if symptomatic then due to secondary bacterial infection) and gonorrhoea
  • Mycoplasma genitalium, flora (anaeorobic and aerobic) and aerobic streptococci
  • Bacterial vaginosis organisms- gardenella vaginallis
32
Q

What are the clinical features of PID?

A
  • Asymptomatic (may present later with subfertility menstrual problems)
  • Bilateral pelvic pain
  • Dyspaeurenia
  • Abnormal vaginal bleeding- menorrhagia, post-coital, intermenstrual
  • purulent vaginal discharge
  • Nausea and vomiting
  • Urinary symptoms
33
Q

What are the examination findings of PID?

A 
Tachycardia 
Fever >38degrees
Bilateral adnexal tenderness, and abdominal tenderness 
Cervical motion tenderness- !!!!!!!!!!
Palpable vaginal mass 
Discharge on speculum
34
Q

Which sign helps differentiates PID from appendicitis?

A

Cervical motion tenderness

35
Q

What investigations are indicate in PID?

A

All the ones for pelvic pain (pregnancy, infection screen)

  • FBC, (raised WCC and ESR and CRP)
  • pelvic ultrasound to exclude abscess
  • Gold standard: Laparoscopy with endometrial fimbrial biopsy
36
Q

In PID, what features suggest that patient should be hospitilised and receive IV antiobiotics?

A

If systemically unwell (fever >38), pregnancy, pelvic peritonitis or signs of tubo-ovarian abscess (eg pt will have rigors)

37
Q

What is the outpatient management of PID?

A

IM Ceftriaxone - once

Oral doxycycline and oral metranadizole 14 days

38
Q

Inpatient management of PID?

A

IV Ceftriaxone, doxycline and metranadizole all single dose

  • continue IV for 24 hours after improvement
  • switch to oral doxycycline and metronadizole for 14 days
39
Q

What are the complications of PID? (Acute and long term)

A

Acute: pelvic abscess, psyosalpinx
Chronic:
- Adhesions (subfertility, ectopic pregnancy)
- chronic pelvic pain

40
Q

In chronic PID what is present in the pelvic cavity?

A

dense pelvic adhesions

Fallopian tubes may be obstructed with psyosalpinx or hydrosalpinx

41
Q

On examination what will be signs of chronic PID?

Investigations

A
  • Bilateral adnexal and abdo tenderness
  • Fixed retroverted uterus (due to adhesions)

IX: TVS will show fluid surrounding fallopian tubes
Laparscopy with fimbrial/endometrial biopsy culture tends to be negative

42
Q

What is surgical management of chronic PID?

A

May require adhesiolysis, or salpingectomy

Obstetrics & Gynaecology (16 decks)

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