Acute Pelvic Pain Flashcards by Sanjana Shaunak

What is the most common cause of pelvic pain in women (pass med)

Primary dysmennorrhea

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What are all the DD for pelvic pain you can think of?

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)
Degeneration of fibroids
Torsion of an ovarian cysts
Hematocolpos
Hematometra / pyometra

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Thinking of pelvic pain as acute vs chronic:

What are some ACUTE causes of pelvic pain? (passmed)

Ectopic pregnancy

UTI

Appendicitis

PID

Ovarian torsion

Misscarriage

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Thinking of pelvic pain as acute vs chronic:

What are some CHRONIC causes of pelvic pain? (passmed)

Endometriosis

IBS

Ovarian cyst

Urogenital prolapse

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What is pelvic inflammatory disease?

infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum.

Usually due to ascending infection from the endocervix.

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What are the causative organisms of PID?

Chlamydia trachomatis

+ the most common cause
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis

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What are the clinical features of PID?

lower abdominal pain
fever
deep dyspareunia
dysuria and menstrual irregularities (Abnormal vaginal bleeding, including post-coital, inter-menstrual, and heavy menstrual bleeding may occur)
vaginal or cervical discharge can be prurulent
cervical excitation on examination

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What is cervical excitation?

Also called cervical motion tenderness or ‘chandelier sign’ (elicits so much pain, woman lifts her arms off bed as if to grab onto ceiling mounted chandelier

Significant clinical sign of excruciating pain when performing a bimanual pelvic examination when cervix comes into contact with clinicians gloved hand.

Suggests inflammatory process in pelvic organs

E.g. PID or ectopic pregnancy

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In what 2 causes of acute pelvic pain may you elicit ‘cervical excitability’ or ‘chandelier sign’?

Classically PID

can also get with ectopic pregnancy

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What examination could you do to differentiate between PID and appendicitis (2 worrying presentations of acute pelvic pain in a woman)

Bimanual examination - elicit cervical excitation and diffuse tenderness in PID

Speculum: prulent mucocervical discharge

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What investigations should you do for PID?

Bedside:
- Pregnancy test to exclude an ectopic pregnancy

Lab:
-Bloods e.g. CRP, WCC, ESR (raised- inflamm), LFTs- Perihepatitis
- Triple swab e.g. high vaginal swab, endocervical
- screen for Chlamydia and Gonorrhoea

Imaging:
- Transvaginal US (confirm when uncertain, tubal wall thickness >5mm, tubo-ovarian abscess)
- Laproscopy (great for diagnosis but invasive to visualise the gynae structures)

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What is the outpatient management of PID?

Removal of the IUD should be considered

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What are some potential complications of PID?

perihepatitis (Fitz-Hugh Curtis Syndrome
- occurs in around 10% of cases
- RUQ pain (confused with cholecystitis)
infertility - risk 10-20% after a single episode due to scarred / obstructed fallopian tubes
chronic pelvic pain
ectopic pregnancy
tubo-ovarian abscess

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What is a typical history for a patient with an ectopic pregnancy?

women with 6-8 weeks amenorrhoea
who presents with lower abdominal pain and later develops vaginal bleeding
Shoulder tip pain and cervical excitation may be seen

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How might a urinary tract infection present as acute pelvic pain?

Dysuria and frequency are common but women may experience suprapubic burning secondary to cystitis

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How might a patient with acute pelvic pain secondary to appendicitis present?
History, examination, clinical signs

History:
- Pain initial in the central abdomen before localising to the right iliac fossa
- Anorexia is common

Examination:
- Tachycardia
- low-grade pyrexia
- tenderness in RIF

Clinical signs:
- Rovsing’s sign: more pain in RIF than LIF when palpating LIF

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How might ovarian torsion present as a cause of acute pelvic pain? History + examination

Hx:
- Usually sudden onset severe, colicky unilateral lower abdominal pain.
- Triggers:
Onset may coincide with exercise.
associated symptoms:
- Nausea and vomiting are common

Examination:
- Unilateral, tender adnexal mass on examination
- localised peritoneal irritation

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How might a patient with acute pelvic pain due to miscarriage present?

Vaginal bleeding and crampy lower abdominal pain following a period of amenorrhoea

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PID: History and exam
What key RF are there for pelvic inflammatory disease?

-Prior infection with chlamydia or gonorrhoea or PID

young age at onset of sexual activity,
unprotected sexual intercourse with multiple sexual partners
IUD use
Diabetes
Immunocompromised e.g. HIV
Endometriosis (especially if endometriotic cyst)
non sexually active women - e-coli haemophillius influenzae wiping back to front cleaning perineum

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Why is it important to have a low threshold of diagnosis for PID? What group is especially at risk?

Often missed as can present as non specific signs e.g. abnormal bleeding, dyspareunia, and vaginal discharge

pts at risk:
- sexually active women between the ages of 15 and 24
- patients attending STI clinics
- where the rates of gonorrhoea or chlamydia are high

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How would you examine a pt with suspected PID?

general:
- include temperature - pyrexial?

Abdo:
- light and deep palpation (looking for bilateral lower abdo tenderness / pain)

Pelvic :
- inspect external genitalia for vaginal discharge - yellow / green?
- speculum examaintion expose cervix (look for mucpurulent or purulent exudate at the endocervix)
- Bi manual examination - cervical excitation or adenexal tenderness

ASK about:
IMB, PCB and dyspareunia

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What are the 3 findings looking for on bimanual pelvic examination of a patient with PID (1 or more minimun criteria)

Cervical motion tenderness
Uterine tenderness
Adnexal tenderness

What other additional criteria (other than minimum criteria) can support diagnosis of PID ?

Oral temperature >38.3°C (>101°F)

Abnormal cervical mucopurulent discharge or cervical friability

Presence of abundant numbers of white blood cells on saline microscopy of vaginal fluid

Elevated erythrocyte sedimentation rate

Elevated C-reactive protein

Laboratory documentation of cervical infection with Chlamydia trachomatis or Neisseria gonorrhoeae.

You have a pt in A&E who you think has PID but you need to rule of ECTOPIC pregnancy b) What investigations would you do?

(can resemble severe PID. PID can exist concurrently with ectopic pregnancy!) Investigations: - Pregnancy test -Result: hCG high in serum and urine (if ECTOPIC) US - empty uterus and mass in fallopian tubes (if ECTOPPIC)

You have a pt in A&E who you think has PID but you need to rule of acute appendicitis b) What investigations would you do?

Abdo US - outer diameter >6mm and aperistaltic / non compressible structure Abdo / pelvic CT - appendix >6mmm / calcified apppendicolith present with periappendiceal inflammation Laproscopy - confirms diagnosis

You have a pt in A&E who you think has PID but you need to rule out ovarian cyst torision b) What investigations would you do?

Pelvic ultrasound confirms diagnosis of ovarian torsion

You have a pt in A&E who you think has PID but you need to rule out endometriosis? What clues in hx endometriosis? What investigations to confirm endometriosis?

signs/ symptoms - Adnexal enlargement - lateral displacement of uterus - cyclic pain that is exacerbated by onset of menses and during the luteal phase; or - dyspareunia. ( Cyclic pain is not a feature of PID) Investigations - Transvaginal US - show ovarian endometrioma / deep pelvic endometriosis e.g. uterosacral ligament involvement -Laproscopy - diagnose by visualising peritoneal implants and biopsy endometrial glands / stroma outside uterine cavity.

What are key features in your history and exam that would point to Ectopic preganncy?

History: Abdo pain - lower or general ammenorhoea 6-8 weeks vaginal bleeding referred shoulder pain urge to defecate (blood pooling in cul-de-sac) Examination: general: orthostatic hypotension / haem instability Abdominal tenderness (acute e.g. guarding warning sign of rupture) adnexal tenderness or mass blood in vaginal vault (in absence of rupture) cervical motion tenderness

A young woman in A&E you are thinking could this be miscarriage or ectopic pregnancy as the cause of acute pelvic pain. 1. What hx /signs / symptoms more likely miscarriage? 2. What investigations / examinations are you doing that would confirm miscarriage?

1. - vaginal bleeding in the first trimester + abdominal discomfort secondary to uterine contractions. - disappearance of pregnancy symptoms e.g. breast tenderness and nausea. 2 - Ultrasound - inter-uterine pregnancy - pelvic examination - dilation of cervix + tissue at cervical oss Low HcG and low progesterone

What counselling should you give a woman after treatment for PID as primary prevention?

Behavioural change is central to the prevention of PID, as potentially modifiable risk factors are associated with PID (e.g., practising safe sex). High-risk patients should be counselled on safer sex behaviours such as the use of condoms, and the risk of infection with STIs.[20] Counselling and testing for HIV infection should be done where appropriate.

What monitoring / follow up should be done for pt with PID

Repeat testing of all women who have been diagnosed with chlamydia or gonorrhoea is recommended 3 months after treatment, regardless of whether their sexual partners were treated. If not possible, test when they next seek medical care <12 months after treatment. All women diagnosed with PID should be tested for gonorrhoea, chlamydia, HIV, and syphilis

A woman has acute pelvic pain. You have ruled out ectopic pregnancy and miscarriage. What are differentials for acute pelvic pain in non-pregnant women? | Added from BB slides xx

* **torsion of ovarian cyst** * **degeneration of fibroid** * **PID flare up ** * **haematocolpos **(where there is ablood filled dilated vagina from menstrual bleed in the setting of an anatomical obstruction, e.g. imperforate hymen) * **Haematometra** (retention/collection of blood in uterus due to imperforate hymen or transverse vaginal septum) * **Pyometra** ( accumulation of pus in the uterine cavity resulting from interference with its natural drainage. It is an uncommon condition that occurs mainly in postmenopausal women and is rare in the premenopausal age group) * **Endometriosis**

Ddx for acute pelvic pain in medical and surgical specialities (outside O&G)

What is the INpatient treatment for PID?

Miss Malik lecture : What are causes of acute pelvic pain in pregnant vs non-pregnant women?

Non pregnant: Torsion of ovarian cyst Degeneration of fibroids Flare of PID Hematocolpos Heatometra / Pyometra Endometriosis Pregnant: Torsion of ovarian cyst degeneration of fibroids flare up of PID

Which ovarian cysts are more likely to tort?

Dermoid cysts heavy, once tort cannot go back to original position

outline what you know of a scoring system for women with adnexal torsion?

What are the clinical features of adnexal torsion (includes ovarian cyst torsion) : 1. symptoms 2. Signs - General - Abdominal - vaginal

What are some DDx for ovarian cysts torsion ? Think of discriminatory factors in Hx and clinical features

What is the diagnosis and treatment of ovarian cysts torsion?

Diagnosis 1. USG pelvis (clinical diagnosis if imaging not available - do not delay surgery for further imaging) 2. Tumour markers (don't delay surgery but if suspicious mass - explore results in follow up) 3. Raised CRP and WCC Treatment: 1. Admit 2. IV fluids (pts often dehydrated) 3. Pain relief - opiates a lot of pain 4. Surgery either laparotomy or laproscopy

What is fibroid degeneration?

What findings to aid diagnosis of fibroid degeneration?

Palpable mass raised inflammatory markers

What is management of fibroid degeneration?

Pregnant - conservative management: - Pain relief (opiates) - Hydration - Antibiotic Emergency surgery: - indicated if: pedunculated fibroid that has torted to remove it Hysterectomy: - if suspicious the fibroid is a sarcoma - following investigations, MRI imaging and tumour markers

What is a triple swab ? What is included in it / tested for?

Outside a sexual health clinic three swabs - 'triple swab' used to screen for infection in symptomatic women note: HVS = high vaginal swab ECS - endocervical swab stuarts = charcoal swab

What investigations would you do for suspected tubo-ovarian absecess

Bedside: Pregnancy testing Lab: FBC, CRP, WCC MSU Triple swabs Imaging: USG- pelvis / abdomen X rya Diagnostic laparoscopy

What is the management of tubo-ovarian abscess

For tubo-ovarian abscess compare the benefits of laparoscopy and laparotomy

Is it safe to perform laparoscopy when a woman is pregnant?

yes

When is a laparoscopy indicated for a pregnant woman?

Appendicitis Cholecystitis torsion of ovarian cysts

What are the main risks for a pregnant woman undergoing a laparoscopy?

General anaesthetic acute inflammatory condition itself - Fetal loss 1.5% in appendicitis and 4% in cholecystitis

Who gets haematocolpos?

Younger patients less than 16 yrs old

What are the features of haematocolpos?

Cyclical pain but NO bleeding

What would you see on examination of a pt with haematocolpos and why?

Bluish membrane at introitus becuase: hymen is intact and blood bulges behind it Pt may be in acute urinary retention - often how picked up once blood released retention improves

What is the management of haematocolpos?

Admit for immediate incision and drainage by cruciate incision

What do you see on USS in ovarian torsion?

Whirlpool sign