Acute Pelvic Pain

Question 1

Ectopic pregnancy

Answer 1

• Mal implantation of fertilized ovum
• 95-97% in fallopian tube
• High risk: previous ectopic preg, IUD failure, tubal surgery, sterilization
• Symptoms: abdominal pain, amenorrhea, abnormal vaginal bleeding w sharp pain. Sometimes subtle/absent s&s
• Rupture: sharp/stabbing pain, radiates to neck and shoulder, shock
• Signs: cervical motion tenderness (67%), palpable adnexal mass (25-50%).
  DIAGNOSTICS:
• Transvaginal U/S: sac should be visible by 4-5 weeks pregnancy, if not suspect ectopic
• B hCG hormone decreasing
• Absence of intrauterine pregnancy, with positive preg test and increased hcg hormone- indicates
  TX:
• Immediate referral- surgery
• Give Rhogan if pt is Rh-

Question 2

PID

Answer 2

• Microorganisms from vag and endocervix spreads to endometrium, fallopian tubes, ovaries, or adnexa
• High risks: STI (GC/CT) exposure, BV, invasive medical procedures, smoking
• Symptoms: lower abdominal pain, dyspareunia, onset precipitated by menses, abnormal bleeding, mucopurulent discharge, fever, back pain.
• Signs: MINIMAL CRITERIA: Cervical motion tenderness, uterine tenderness or adnexal tenderness and may palpate mass. Additional criteria: 38.3, abundant WBCs, abnormal vaginal/cervical dc
  DIAGNOSTICS:
• Clinical findings!
• ESR and CRP increased
• GC/CT +
• Endometrial biopsy most specific
• Sonogram or MRI: thickened fluid filled tubes
  Tx:
• Treat infection: Cetriaxone, Azithro (GC/CT), Flagyl (BV)
• Treat partners
• Inpatient if: pregnancy, no response to PO therapy, severe illness

Question 3

Ovarian tumor/cysts

Answer 3

• Rare in premenarchal girls— malignant
• Genetic predisposition
• Functional cysts: asymptomatic, resolve on its own, light bleeding, cyclical. Smaller than 10cm
  
  • Follicular: failure of ovarian follicle ro rupture in
    follicular phase
    - Luteal: forms when the corpus luteum become cystic
    or hemorrhagic and fails to degenerate after 14 days
• Unilateral R pain
• Palpable mass: 3-8cm
• Pain is related to ruptured, torsion, or hemorrhage
  Tx:
• Expectant
• OCP to suppress new cysts
• If larger than 10cm refer: laparoscopy with severe pain and hemorrhage

Question 4

Ovarian/tubal torsion

Answer 4

• Rare children
• Twisting of ovary in the adnexa
• Higher risk with pregnancy
• Unilateral pelvic stabbing pain/ sudden radiates to back
• Nausea, vomiting
  Dx:
• Pelvic U/S
  Tx:
• Emergency- Inpatient

Question 5

Myoma

Answer 5

• 30-50 year old, black
• Pain with menses, abnormal heavy bleeding
• Firm, non tender nodules
• Non-malignant
  Tx: hysterectomy

Question 6

Dysmenorrhea

Answer 6

• Pain with menses (day 1-3)
• Late teens/young women
• Radiates to rectum, thighs
• Dizziness
  TX:
• OC, NSAIDs

Question 7

Mitter Schmerz

Answer 7

• Midcycle pain with ovulation

Question 8

Endometriosis

Answer 8

• Most common chronic pelvic pain in adolescents
• Happens prior to menses
• Short cycles of long duration
• Symptoms: dyspareunia that continues after pain, abnormal vaginal bleeding, pelvic mass feels like a rosary, uterus is fixed and retroverted
• Endometrial tissue outside of uterus- adhesions
• Infertility
• Estrogen enhances pain!
  TX:
• Profestin, DMPA, NSAIDs, IUD, non-estrogen contraceptives.
  -Pseudomenopause, surgery