Acute Pelvic Pain Flashcards
Definition of Acute pelvic pain
Less than 3 months
If episodic then best described as recurrent or cyclic
Causes of Acute Pelvic pain
Ectopic pregnancy or Miscarriage Cyst related events (torsion, haemorrhage, rupture) Fibroid degeneration Endometriosis or Dysmenorrhoea Mittelschmerz Neoplasms or non-gynae causes
Non-gynae causes of acute pelvic pain
UTI, pyelonephritis or stone
Appendicitis, IBS or diverticulitis
Trauma (bowel or bladder perforation)
Sexual abuse
History in causes of acute pelvic pain
SOCRATES the pain
Sexual Hx–> partners, contraception, STIs
Menstrual and Gynae Hx –> endometriosis, PCOS, ovarian cysts, surgery
Obstetric Hx –> Could you be pregnant?
Ectopic Pregnancy – Presentation
Iliac fossa pain –> severe if ruptured. may develop gradually
PV bleeding
Will be ‘pregnant’ (missed periods, Hx of UPSI, BHCG high)
Ectopic Pregnancy – Examination
Abdomen –> may be distended or peritonitic, Will be tender and guarding
PV bleeding may be significant or not
Ectopic Pregnancy – Investigations
Urine –> pregnancy test (positive), may also be contaminated with blood
Blood tests–> CRP/WCC may be raised, BHCG will be high
USS–> mass in adnexa which is seperate from the uterus, may also be free fluid in the POD
Ectopic Pregnancy – Treatment
Surgical removal, emergency if ruptured
Can be laparoscopic or open
If significant blood loss may need a blood transfusion
PID
Ascending STI–> at risk if cervical barrier is broken
Will have bilateral lower abdo pain with fever and nausea
Will have discharge, may be blood stained or offensive
Examination of acute PID
Generally unwell–> CRP and WCC raised
abdomen generally tender but not peritonitic or guarded
No masses–> USS to check
Endometrioma
Known as a chocolate cyst
Endometriosis on the ovary leads to cyst growth and eventual rupture
Causes sudden severe pain with peritonism and distension of abdomen
Treatment of Endometrioma
Opiate analgesia
Emergency Drainage and excision (open or laparoscopic)
Follow up for endometriosis
Ovarian cysts
A follicular cyst of >2cm
Can be malignant, endometrioid or teratomas (dermoid cysts)
Can Rupture or tort, leading to bleeding, infarction or necrosis
May cause pain simply due to size
Ovarian cysts - torsion
Cause sudden onset unilateral pain
treatment is surgical, may change depending on type of cyst
Miscarriage
See Miscarriage deck
Fibroid Degeneration
Causes acute pain from ischemia or torsion
Treatment is the same for problematic fibroids
Primary Dysmenorrhoea
Pain from menstruation
Physiological 45% of women decreasing with age. Presents 1-2yrs after menarch starting a few hrs before the periods. May have suprapubic pain radiating to the back or thigh.
Secondary Dysmenorrhoea
Due to a pathological process and starts many yrs after menarche. Adenomyosis, endometriosis, PID, IUD or fibroids. Pain starts 3-4days before the period starts. Should be referred to gynaecology for investigation.
Adenomyosis
Ectopic endometrial tissue within muscle, either in the uterus or elsewhere
Causes cyclic pain and sometimes bleeding
Functional Ovarian cysts
24% of all cysts–> can grow to 6cm and often spontaneously resolve
Can be follicular, where a single follicle enlarges and fills with fluid–> more common in women receiving infertility treatment
Corpus luteum cysts are when the CL fills with fluid or blood (haemorrhagic cysts)
Dermoid Cysts
Benign mature cystic teratomas or Dermoid cysts
Solid tumours can also occur
Usually unilateral
Have teeth and shit
Haemotometra
A collection of blood in the uterus due to non-communicating post-surgical or congential abnormalities
Should be considered when there is amenorrhoea after an intervention
Causes of pregnancy related acute pelvic pain
Ectopics
In the 2nd or 3rd trimester there is a risk of placental abruption
Neurology of pelvic pain
Lower pelvic gynaecological structures share visceral innervation with the hindgut structures, so it can be hard to distinguish them based on pain
Ischemia and injury to viscera will be accompanied by autonomic reflex response (nasuea, vomiting and sweating)
Differentials of Sharp, severe, sudden onset and continuous pelvic pain
Ruptured follicle or CL cyst
Usually unilateral
More generalised if there is significant intra-abdominal bleeding
Ovarian Torsion - presentation
Causes severe but fluctuating unilateral pain
may radiate to loin or thigh
Will have nausea and vomiting
If this leads to ischemia or rupture it will cease fluctuations
Differentials of gradual, worsening, crampy and fluctuating pelvic pain
Uterine or GI generally
Central but may radiate to back or thighs
Differentials of gradual onset constant pain
Typical of inflammation such as PID
usually bilateral
Follicular phase of cycle
Distinguishing PID from Appendicitis
Likely PID if–> (1) No migration of pain (2) bilateral tenderness (3) No nausea or vomiting (least powerful)
Unimportant factors–> diarrhoea, fever, rebound tenderness, WCC or CRP, pyuria
Haemorrhagic or corpus luteum cysts
Common in women of reproductive age with a natural cycle
anticoagulation, adhesions or endometriosis increase risk
Ovarian cyst torsion - risk
only 2.7% of emergency gynae admissions
mostly in WRA
70-80% present with nausea and vomiting,
PCO and dermoid cysts increase risk, as does increased size
Rare if there is adhesions or endometriosis
WRA
women of reproductive age
Treatment of Ovarian cyst torsion
Conservative management if <48hrs of symptoms as good chance of detorting
Over 48hrs chance of good outcome is much lower
If confirmed torsion corrective surgery ASAP
Findings on examination for pelvic pain
Vulval pain or masses (genital herpes or bartholin’s cyst
Use of bimanual in cases of pelvic pain
positive predictive value of 65-90% compared to laparoscopy.
vaginal pus has a strong negative predictive value but poor positive predictive value
Always do a bimanual on symptomatic patients
If there are visible genital ulcers
swab for HSV and DGM for syphilis - if HSV suspected start aciclovir 200mg 5x/day for 5 days
Review in two weeks and offer a health advisor review
If there is a bartholin’s abscess
Book a OnG review - probs get it removed in surgery
If swab returns TV
2g metronidazole stat – need to test cure
Assess the patient fully, does this patient need any more care
advise about personal hygiene and partner notification
Suspected PID
As PID is a clinical diagnosis dont wait for results before treating - 400mg cefixime/250mg ceftriaxone stat + 100mg bd doxycycline for 2wks + 400mg bd metronidazole 2wks
follow up in 2wks
Management of Primary Dysmenorrhoea
NSAIDs (mefenamic acid or ibuprofen) are effective in 80% of women - inhibit prostaglandin production.
COC is second line treatment.
