Acute pelvic pain

Question 1

Causes of acute pelvic pain in women

Answer 1

• Pregnancy: miscarriage, ectopic pregnancy
• Ovary: ovarian cyst rupture or torsion, ovulation
• Other pelvis: PID, pelvic tumour, pelvic vein thrombosis, dysmenorrhoea
• Non-gynaecological

Question 2

Name 3 non-gynae causes of acute pelvic pain

Answer 2

appendicitis, IBS, strangulated hernia

Question 3

Pelvic inflammatory disease
Define
Causes [4]
Chronic PID [2]

Answer 3

Infection of the upper genital tract
Causes:
- Ascending infection from endocervix e.g. STIs
- Uterine instrumentation
- Post-partum
- Descending from other infected organs eg appendicitis

Chronic PID:

• Unresolved or untreated infection causes chronic inflammation, fibrosis and adhesions
• Pyosalpinx, hydrosalpinx

Question 4

PID risk factors [3] and protective factors [3]

Answer 4

RFs:
- <25y/o, previous Hx STIs, new or multiple sexual partners
Protective factors:
- condoms, COCP, Mirena

Question 5

PID acute presentation
Symptoms [6]
Signs [2]

Answer 5

Symptoms:

• Lower abdo pain
• Deep dyspareunia
• Vaginal discharge
• IMB, PCB
• Dysmenorrhea
• Fever

Signs:

• Cervical excitation
• Adnexal tenderness

Question 6

PID chronic presentation
Symptoms [5]
Signs [2]

Answer 6

Symptoms:

• pelvic pain
• menorrhagia
• secondary dysmenorrhea
• discharge
• deep dyspareunia

Signs:

• tubal masses
• retroversion, fixed retroverted uterus

Question 7

PID Ix [4]

Answer 7

Vulvovaginal and endocervical swab - chlamydia, gonorrhea, MC&S
FBC, CRP (if acutely unwell)
TVUSS (tuba-ovarian abscess)
Laparoscopy

Question 8

PID Ix: laparoscopy indications in acute and chronic

Answer 8

o Acute: only if diagnostic doubt (right iliac fossa pain and suspected appendicitis) or abscess drainage rq
o Chronic: to distinguish between endometriosis

Question 9

PID Mx Acute

Answer 9

Contact tracing
Outpatient:
- CEFTRIAXONE 500mg IM stat
- or AZITHROMYCIN one off
- with DOXYCYCLINE 
- and METRONIDAZOLE oral for 14 days
Inpatient: (septic, refractory)
- CEFFTRIAXONE 2g IV OD plus DOXYCYCLINE 100mg IV BD then 14 days DOXYCYLINE and METRONIDAZOLE oral

Question 10

PID Complications [5]

Answer 10

Tuba-Ovarian abscess
Fitz-Hugh-Curtis syndrome
Ectopic pregnancy
Subfertility
Tubal blockage

Question 11

What is Fitz-Hugh-Curtis syndrome

Answer 11

Liver capsule inflammation

with perihepatic lesion

Question 12

Ovarian torsion
Ax
Px [3]

Answer 12

Ax: ovarian cyst disrupts the weight of the ovary causing the ovary to tort
Px:
- venous return to ovary occluded
- eventually becoming oedematous and occluding arterial supply.
- Pain improves after 24h after ovary starts to die

Question 13

Ovarian torsion
Symptoms [3]
Signs [2]
Ix [2]

Answer 13

Symptoms:
- Sudden severe lower unilateral abdo pain
- Radiates to groin
- Nausea, vomiting
Signs:
- Lower abdomen tenderness
- Adnexal tenderness or mass

Ix: pelvic USS, doppler velocimetry

Question 14

Ovarian torsion
What would you see on pelvic USS? [2]
Mx [2]

Answer 14

Edematous ovary with reduced blood flow

Mx:

• Urgent laparoscopy to untwist ovary
• Cyst removal