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RDS Test 3 > B8.057 Prework: Pelvic Pain > Flashcards

B8.057 Prework: Pelvic Pain Flashcards

1
Q

6 major sources of the origin of chronic pelvic pain (CPP)

A
  1. gynecological
  2. psychological
  3. myofascial
  4. MSK
  5. urological
  6. GI
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2
Q

gyn diseases causing CPP

A 
endometriosis
adhesions (chronic PID)
leiomyoma
pelvic congestion syndrome
adenomyosis
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3
Q

GI diseases causing CPP

A 
IBS
diverticulitis
diverticulosis
chronic appendicitis
Meckel's diverticulum
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4
Q

GU diseases causing CPP

A

interstitial cystitis
abnormal bladder function (bladder dyssynergia)
chronic urethritis

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5
Q

myofascial diseases causing CPP

A

fasciitis
nerve entrapment syndrome
trigger points
hernias (inguinal, femoral, spigelian, umbilical, incisional)

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6
Q

skeletal diseases causing CPP

A

scoliosis
L1-L2 disk disorders
spondylolithesis
osteitis pubis

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7
Q

psych disorders causing CPP

A

somatization
psychosexual dysfunction
depression

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8
Q

detailed history needed for workup of CPP

A

characteristics of pain
med/surg history
complete gyn history (menarche, pregnancy, delivery complications, dysparenia, sexual assault, trauma)
detailed ROS w focus on repro, GI, MSK, uro, and neuropsych
consider age carefully

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9
Q

targeted physical for CPP

A

abdominal, pelvic, bimanual

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10
Q

pelvic exam for CPP

A

visual inspection for redness, discharge, lesions, fissures, excoriations, and other abnormalities
moistened cotton swab can be used to evaluate the vulva and vestibule for localized tenderness

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11
Q

manual pelvic exam for CPP

A

begin with a single digit; note tenderness or spasm
palpate levator ani muscles directly for tone and tenderness
evaluate pelvic floor
bimanual exam assessing uterine size and tenderness, nodularity, or a fixed, immobile uterus

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12
Q

carnett test

A

place finger on painful abdominal site to determine whether pain increases when rectus abdominis muscles are contracted (when legs or head are raised)
myofascial pain can increase while visceral may decrease

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13
Q

what is dysmenorrhea

A

severe, painful cramping sensation in the lower abdomen, often accompanied by other symptoms - all occurring just before or during menses

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14
Q

symptoms associated with dysmenorrhea

A 
sweating
tachycardia
headaches
nausea/vomiting
diarrhea
tremulousness
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15
Q

primary dysmenorrhea

A

no obvious pathological condition

onset < 20 years old

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16
Q

pathogenesis of dysmenorrhea

A

elevated PGF2a produced by secretory endometrium (increased uterine contractility)

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17
Q

treatment of dysmenorrhea

A

NSAIDS (prostaglandin synthase inhibitors) are first line

others: OCPs, other analgesics

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18
Q

etiologies of secondary dysmenorrhea

A 
cervical stenosis
endometriosis and adenomyosis
uterine fibroids
pelvic infection
adhesions
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19
Q

symptoms of secondary dysmenorrhea

A

aching pain in the abdomen
feeling of pressure in the abdomen
pain in hips, lower back, and inner thighs
painful cramping, reproductive dysfunction/infertility

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20
Q

cervical stenosis

A

severe narrowing of cervical canal may impede menstrual outflow

  • can cause and increase in intrauterine pressure during menses
  • can lead to endometriosis
  • can cause hematometra
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21
Q

symptoms of cervical stenosis

A

scant menstrual flow

severe cramping throughout menses

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22
Q

diagnosis of cervical stenosis

A

inability to pass a thin probe through cervical os or hypersalpingogram demonstrates thin cervical canal

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23
Q

treatment of cervical stenosis

A

cervical dilation via d&c or laminaria placement

24
Q

symptoms of endometriosis

A

can be variable and unpredictable

  • some asymptomatic
  • dysmenorrhea
  • CPP
  • deep dyspareunia
  • sacral backache w menses
  • dysuria +/- hematuria (bladder involvement)
  • dysuria +/- hematochezia
25
Q

how do endometriotic lesions affect fertility

A

affect ovaries and endometrium leading to poor oocyte quality and implantation failure

26
Q

epidemiology of endometriosis

A 
7-10% of general pop
20-50% of infertile women
70-85% of women with CPP
no racial predisposition
familial association with almost 10x increased risk of endometriosis if affected 1st degree relative
27
Q

pathogenesis of endometriosis

A

possibilities:

  • retrograde menstruation
  • hematogenous or lymphatic spread
  • coelomic metaplasia
  • immunological factors play a role
28
Q

important symptoms supporting diagnosis of endometriosis

A

infertility

premenstrual spotting

29
Q

why is it hard to diagnose endometriosis?

A

pelvic exam could be inconclusive

only definite diagnosis is my laparoscopic excision of the lesions and histology

30
Q

what characteristics of lesions correlates best with severity of endometriosis

A

NOT extent of visible lesions

depth of infiltration

31
Q

meds for endometriosis

A 
progestins
OCPs
NSAIDs
GnRH agonists (most expensive)
danazol
32
Q

how do GnRH agonists work for endometriosis

A

create a state of relative E deficiency

  • vasomotor side effects and potential decrease in bone density
  • no data beyond 1 year
33
Q

danazol for endometriosis

A

as effective as GnRH agonist, but with increased side effects
reduces estrogen production

34
Q

surgical treatment for endometriosis

A

laparoscopic removal of lesions is effective and improves fertility
-high rate of recurrence
hysterectomy is curative surgical method
-consider reproductive age, desire to have children

35
Q

uterine fibroids

A

benign tumors that develop from muscle tissue of the uterus

hyperproliferation

36
Q

epidemiology of fibroids

A

most common in women 30-40, but can occur at any age

more common in AA women

37
Q

symptoms of fibroids

A 
changes in menstruation
-longer, more frequent, or heavy periods
menstrual pain (cramps)
vaginal bleeding at times other than menstruation
anemia
38
Q

pain caused by uterine fibroids

A

in abdomen and lower back
-often dull, heavy, and aching
-may be sharp
during sex, pressure
difficulty urinating or frequent urination
constipation, rectal pain, difficult bowel movements
abdominal cramps

39
Q

physical exam findings with uterine fibroids

A

enlarged uterus and abdomen
miscarriages
infertility

40
Q

acute pain from fibroids

A

fibroids that are attached to the uterus by a stem may twist and can cause pain, nausea and fever
fibroids that grow rapidly or start to break down may also cause pain

41
Q

diagnosis of fibroids

A

pelvis US

pelvic bimanual

42
Q

treatment of fibroids

A

hysterectomy
myomectomy
uterine artery embolization
OCs, NSAIDs, GnRH agonists prior to surgery

43
Q

effects of fibroid treatment on fertility

A

hysterectomy advances age of menopause

all other also affect fertility

44
Q

etiology of fibroids

A 
unknown
may be:
steroid hormones (E2/P4)
obesity, parity, race
mutations/translocations
-HMG2A, MED12, GHD, TSC2
TGFB, ECM dysregulation
45
Q

causes of PID

A 
STIs
-neisseria gonorrhea
-chlamydia trachomatis
-mycoplasma genitalium
douching can increase risk
46
Q

symptoms and sequelae of PID

A

can be asymptomatic

can predispose to infertility, ectopic pregnancy, or cause chronic pain

47
Q

minimum clinical criteria for PID

A 
cervical motion tenderness
OR
uterine tenderness
OR
adnexal tenderness
48
Q

additional clinical criteria to enhance/support a diagnosis of PID

A

oral temp >101 F
abnormal cervical mucopurulent discharge or cervical friability
presence of abundant numbers of WBC on microscopy of vaginal fluid
elevated ESR
elevated CRP
lab documentation of cervical infection with chlamydia or gonorrhea by NAAT

49
Q

most specific criteria for PID

A

endometrial biopsy with histo evidence of endometritis
transvaginal sonography or MRI showing thickened, fluid filled tubes with or without pelvic fluid or tubo ovarian complex
laparoscopic findings consistent with PID

50
Q

treatment of PID

A

cefotetan 2 g IV every 12 hr + doxycycline 100 mg orally or IV every 12 hr
OR
cefoxitin 2 g IV every 6 hr+ doxycycline 100 mg orally or IV every 12 hr
OR
clindamycin 900 mg IV every 8 hr + gentamicin loading dose IV or IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) every 8 hours

51
Q

unique symptoms of interstitital cystitis

A

chronic bladder pain
urinary urgency/frequency
pelvic tenderness

52
Q

unique symptoms of IBS

A

altered bowel function
women > men
diarrhea and constipation

53
Q

unique symptoms of IBD

A

fatigue
weight loss
fever
diarrhea with crampy abdominal pain

54
Q

unique symptoms of fibromyalgia

A

widespread pain
fatigue
memory problems
sleep dysfunction

55
Q

RED FLAG SYMPTOMS of CPP

A

postcoital bleeding > cervical cancer
postmenopausal bleeding > endometrial cancer
postmenopausal onset of pain > malignancy
unexplained weight loss > malignancy, systemic illness
adnexal mass > ovarian neoplasm
gross or microscopic hematuria > severe interstitial cystitis, urinary system malignancy
mass on US > malignancy

RDS Test 3 (15 decks)

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