Acute Pelvic Pain

Question 1

Definition of Acute pelvic pain

Answer 1

Less than 3 months

If episodic then best described as recurrent or cyclic

Question 2

Causes of Acute Pelvic pain

Answer 2

Ectopic pregnancy or Miscarriage
Cyst related events  (torsion, haemorrhage, rupture)
Fibroid degeneration
Endometriosis or Dysmenorrhoea
Mittelschmerz
Neoplasms or non-gynae causes

Question 3

Non-gynae causes of acute pelvic pain

Answer 3

UTI, pyelonephritis or stone
Appendicitis, IBS or diverticulitis
Trauma (bowel or bladder perforation)
Sexual abuse

Question 4

History in causes of acute pelvic pain

Answer 4

SOCRATES the pain
Sexual Hx–> partners, contraception, STIs
Menstrual and Gynae Hx –> endometriosis, PCOS, ovarian cysts, surgery
Obstetric Hx –> Could you be pregnant?

Question 5

Ectopic Pregnancy – Presentation

Answer 5

Iliac fossa pain –> severe if ruptured. may develop gradually
PV bleeding
Will be ‘pregnant’ (missed periods, Hx of UPSI, BHCG high)

Question 6

Ectopic Pregnancy – Examination

Answer 6

Abdomen –> may be distended or peritonitic, Will be tender and guarding
PV bleeding may be significant or not

Question 7

Ectopic Pregnancy – Investigations

Answer 7

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

Question 8

Ectopic Pregnancy – Treatment

Answer 8

Surgical removal, emergency if ruptured
Can be laparoscopic or open
If significant blood loss may need a blood transfusion

Question 9

PID

Answer 9

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

Question 10

Examination of acute PID

Answer 10

Generally unwell–> CRP and WCC raised
abdomen generally tender but not peritonitic or guarded
No masses–> USS to check

Question 11

Endometrioma

Answer 11

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

Question 12

Treatment of Endometrioma

Answer 12

Opiate analgesia
Emergency Drainage and excision (open or laparoscopic)
Follow up for endometriosis

Question 13

Ovarian cysts

Answer 13

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

Question 14

Ovarian cysts - torsion

Answer 14

Cause sudden onset unilateral pain

treatment is surgical, may change depending on type of cyst

Question 15

Miscarriage

Answer 15

See Miscarriage deck

Question 16

Fibroid Degeneration

Answer 16

Causes acute pain from ischemia or torsion

Treatment is the same for problematic fibroids

Question 17

Primary Dysmenorrhoea

Answer 17

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.

Question 18

Secondary Dysmenorrhoea

Answer 18

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.

Question 19

Adenomyosis

Answer 19

Ectopic endometrial tissue within muscle, either in the uterus or elsewhere
Causes cyclic pain and sometimes bleeding

Question 20

Functional Ovarian cysts

Answer 20

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)

Question 21

Dermoid Cysts

Answer 21

Benign mature cystic teratomas or Dermoid cysts
Solid tumours can also occur
Usually unilateral
Have teeth and shit

Question 22

Haemotometra

Answer 22

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

Question 23

Causes of pregnancy related acute pelvic pain

Answer 23

Ectopics

In the 2nd or 3rd trimester there is a risk of placental abruption

Question 24

Neurology of pelvic pain

Answer 24

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)

Question 25

Differentials of Sharp, severe, sudden onset and continuous pelvic pain

Answer 25

Ruptured follicle or CL cyst
Usually unilateral
More generalised if there is significant intra-abdominal bleeding

Question 26

Ovarian Torsion - presentation

Answer 26

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

Question 27

Differentials of gradual, worsening, crampy and fluctuating pelvic pain

Answer 27

Uterine or GI generally

Central but may radiate to back or thighs

Question 28

Differentials of gradual onset constant pain

Answer 28

Typical of inflammation such as PID
usually bilateral
Follicular phase of cycle

Question 29

Distinguishing PID from Appendicitis

Answer 29

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

Question 30

Haemorrhagic or corpus luteum cysts

Answer 30

Common in women of reproductive age with a natural cycle

anticoagulation, adhesions or endometriosis increase risk

Question 31

Ovarian cyst torsion - risk

Answer 31

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

Question 32

WRA

Answer 32

women of reproductive age

Question 33

Treatment of Ovarian cyst torsion

Answer 33

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

Question 34

Findings on examination for pelvic pain

Answer 34

Vulval pain or masses (genital herpes or bartholin’s cyst

Question 35

Use of bimanual in cases of pelvic pain

Answer 35

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

Question 36

If there are visible genital ulcers

Answer 36

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

Question 37

If there is a bartholin’s abscess

Answer 37

Book a OnG review - probs get it removed in surgery

Question 38

If swab returns TV

Answer 38

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

Question 39

Suspected PID

Answer 39

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

Question 40

Management of Primary Dysmenorrhoea

Answer 40

NSAIDs (mefenamic acid or ibuprofen) are effective in 80% of women - inhibit prostaglandin production.
COC is second line treatment.