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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
how do endometriotic lesions affect fertility
affect ovaries and endometrium leading to poor oocyte quality and implantation failure
26
epidemiology of endometriosis
``` 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
pathogenesis of endometriosis
possibilities: - retrograde menstruation - hematogenous or lymphatic spread - coelomic metaplasia - immunological factors play a role
28
important symptoms supporting diagnosis of endometriosis
infertility | premenstrual spotting
29
why is it hard to diagnose endometriosis?
pelvic exam could be inconclusive | only definite diagnosis is my laparoscopic excision of the lesions and histology
30
what characteristics of lesions correlates best with severity of endometriosis
NOT extent of visible lesions | depth of infiltration
31
meds for endometriosis
``` progestins OCPs NSAIDs GnRH agonists (most expensive) danazol ```
32
how do GnRH agonists work for endometriosis
create a state of relative E deficiency - vasomotor side effects and potential decrease in bone density - no data beyond 1 year
33
danazol for endometriosis
as effective as GnRH agonist, but with increased side effects reduces estrogen production
34
surgical treatment for endometriosis
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
uterine fibroids
benign tumors that develop from muscle tissue of the uterus | hyperproliferation
36
epidemiology of fibroids
most common in women 30-40, but can occur at any age | more common in AA women
37
symptoms of fibroids
``` changes in menstruation -longer, more frequent, or heavy periods menstrual pain (cramps) vaginal bleeding at times other than menstruation anemia ```
38
pain caused by uterine fibroids
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
physical exam findings with uterine fibroids
enlarged uterus and abdomen miscarriages infertility
40
acute pain from fibroids
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
diagnosis of fibroids
pelvis US | pelvic bimanual
42
treatment of fibroids
hysterectomy myomectomy uterine artery embolization OCs, NSAIDs, GnRH agonists prior to surgery
43
effects of fibroid treatment on fertility
hysterectomy advances age of menopause | all other also affect fertility
44
etiology of fibroids
``` unknown may be: steroid hormones (E2/P4) obesity, parity, race mutations/translocations -HMG2A, MED12, GHD, TSC2 TGFB, ECM dysregulation ```
45
causes of PID
``` STIs -neisseria gonorrhea -chlamydia trachomatis -mycoplasma genitalium douching can increase risk ```
46
symptoms and sequelae of PID
can be asymptomatic | can predispose to infertility, ectopic pregnancy, or cause chronic pain
47
minimum clinical criteria for PID
``` cervical motion tenderness OR uterine tenderness OR adnexal tenderness ```
48
additional clinical criteria to enhance/support a diagnosis of PID
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
most specific criteria for PID
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
treatment of PID
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
unique symptoms of interstitital cystitis
chronic bladder pain urinary urgency/frequency pelvic tenderness
52
unique symptoms of IBS
altered bowel function women > men diarrhea and constipation
53
unique symptoms of IBD
fatigue weight loss fever diarrhea with crampy abdominal pain
54
unique symptoms of fibromyalgia
widespread pain fatigue memory problems sleep dysfunction
55
RED FLAG SYMPTOMS of CPP
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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