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Gynacology > Chronic pelvic pain > Flashcards

Chronic pelvic pain Flashcards

1
Q

Define endometriosis

A

the presence and growth of tissue similar to endometrium outside the uterus

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2
Q

Who is endometriosis more common in?

A

30-45 year, nulliparous women

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3
Q

Why does endometriosis regress after menopause and during pregnancy?

A

It’s thickening is oestrogen-dependent (like the endometrium)

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4
Q

Which ligament does endometriosis commonly occur in?

A

the uterosacral ligaments

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5
Q

What is a chocolate cyst and what condition is it associated it?

A

accumulated altered blood is dark brown and can form a chocolate cyst or endometrioma in the ovaries. Found in endometriosis

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6
Q

Describe the progressive pathology of endometriosis to a frozen pelvis

A

Endometriosis causes inflammation, with progressive fibrosis, adhesions. In it’s most severe form, the entire pelvis is ‘frozen’, the pelvic organs rendered immobile by adhesions.

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7
Q

How does endometriosis spread?

A

Most in the pelvis through retrograde menstruation. More distant foci may result from mechanism, lymphatic or blood-borne spread.

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8
Q

What is retrograde menstruation?

A

Endometrium flows backwards through the fallopian tubes and into the abdomen, instead of leaving the body as a period The tissue then embeds itself on the organs of the pelvis and grows

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9
Q

Why does retrograde menstruation not cause endometriosis in everyone?

A

happens in many women - not all have endometriosis. Thought to be a genetic predisposition. An unpopular theory is that endometriosis is the result of metaplasia of coelomic cells

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10
Q

What pattern of pelvic pain occurs in endometriosis?

A

Cyclical pelvic pain

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11
Q

Describe some common symptoms of endometriosis

A

Dysmenorrhoea, chronic pelvic pain, deep dyspareunia, subfertility, cyclical bowel or bladder symptoms inlcuding pain and or bleeding, dyschezia (pain on defaecation), dysuria

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12
Q

Can you get bowel and bladder symptoms in endometriosis?

A

Yes - often cyclical

Pain and or bleeding, pain on defacation

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13
Q

What symptoms might you get in very severe endometriosis?

A

Haematuria, rectal bleeding, umbilical bleeding

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14
Q

On vaginal examination, what findings might you get in endometriosis?

A

Tenderness, thickening behind the uterus or in the adnexa

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15
Q

In advanced cases of endometriosis, how might the uterus feel?

A

Retroverted and immobile uterus (due to adhesions) and rectovaginal nodule of endometriosis on digital exam, and can be visible on speculum exam posterior to the cervix if full thickness vaginally

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16
Q

Can the pelvis ever feel normal in endometriosis?

A

Yes - in mild endometriosis the pelvis can feel normal

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17
Q

How do you diagnose endometriosis?

A

LAPAROSCOPY Only certain after visualisation and/or biopsy, most often at laparoscopy

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18
Q

What do active endometriosis lesions look like on laparoscopy?

A

red lesions of punctuate marks on the peritoneum

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19
Q

What does less active endometriosis look like on laparoscopy?

A

White scars or brown spots (powder burn) - white areas of scarring with surrounding abnormal blood vessels

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20
Q

When might MRI be used in diagnosis of endometriosis?

A

If adenomysosis is suspected, to visualise peritoneal endometriosis, if there is clinical evidence of deeply infilitrating endometriosis, urteric, bladder and bowel involvement

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21
Q

What grading system is used for endometriosis severity?

A

American fertility society (rev-AFS) grading system

Grade 1-4 (minimal to severe)

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22
Q

Name some differential diagnoses when endometriosis si suspected

A

Other causes of abdo pain, heavy menstrual bleeding
Adenomyosis (when the endometrium breaks through the myometrium)
Chronic PID - will have discharge, fever and malaise
IBS
Uterine fibroids

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23
Q

Does asymptomatic endometriosis require treatment?

A

Not usually - but could consider removing endometriomas in low risk of misdiagnosing ovarian cancer

24
Q

What are the broad treatment options of endometriosis?

A

Analgesia - NSAIDs, paracetamol, opiate
Hormonal treatments - COC 3-6 month trial in those not wanting to concieve
Progesterons for those not wanting to take hormonal contraceptive
HRT in woman taking GnRH
IUS
Surgery

25
Q

How does GnRH and HRT help in endometriosis?

A

Gonadotrophin-releasing hormone analogues + HRT induce temporary menopausal state
Overstimulation of the pituitary = down regulation of its GnRH receptors
Pituitary gonadotrophin and therefore ovarian hormone production are inhibited

26
Q

What are the side effects of GnRH and HRT in endometriosis?

A

Mimic menopause: reversible bone demineralisation limits therapy to 6 month, but can be extended up to 2 years with add-back HRT (prevents bone loss and menopausal SE)

27
Q

What are the surgical options for the treatment of endometriosis?

A

Laparoscopic laser ablation diathermy/ scissors/ adhesiolysis
Hysterectomy and bilateral salpinoophorectomy

28
Q

Discuss laparoscopic laser ablation of endometriotic lesions

A

Can be used to destroy endometriotic lesions
Surgery can improve conception rates therefore preferable to medical treatment in whose with endometriosis-related infertility
More radical includes diseection of adhesions and removal of ovarian endometriomas

29
Q

Discuss hysterectomy treatment of endometriosis

A

Last resort
HRT is required if ovaries are removed and can occasionally cause reactivation if endometriosis returns
HRT containing both oestrogen and progresterone is given to avoid prolonged unopposed oestrogen stimulation, linked with development of malignancy change in ectopic endometrium

30
Q

Why can surgery be difficult in endometriosis?

A

Severity of adhesions, anatomic distortion - risk of damaging bowel, bladder, blood vessels and ureters

31
Q

Why can surgical options sometimes be preferable to medical in endometriosis?

A

Symptomatic improvement in 70% - longer term than medical therapy, medical treatment in 80-90% of patients, however symptoms come back when treatment is stopped

32
Q

In how many women does endometriosis regress or not progress?

A

> 50%

33
Q

Is fertility affected in endometrosis?

A

Yes - 25% of cases are found incidentally on laparoscopy for infertility

34
Q

What is the prognosis like in endometrisos?

A

In 5 years after surgery/ medicine 20-25% of women will have a recurrence

35
Q

Who is more likely to get PID?

A

Younger, poorer, sexually active (no condoms), nulliparous women

36
Q

What is the pathology of PID?

A

Ascending infection from the vagina/ cervix causing an infection in the upper female genital tract

37
Q

Which contraceptives are protective of PID?

A

COP and Mirena IUS are partly protective

38
Q

How can treatments contribute to PiD?

A

Uterine instrumentation can spread previously asymptomatic STIs
Complications of childbirth and miscarriage

39
Q

What pathogens commonly cause PID?

A

Frequently polymicrobial

Chlamydia in up to 60%, gonnorrhea

40
Q

Discuss fits-hugh-curtis syndrome in PID?

A

Periheptatis in 10% and causes RUQ pain due to adhesions, early visible at laparoscopy, between the liver and anterior abdominal wall

41
Q

Describe some symptoms of PID

A
  • Commonly asymptomatoc
  • Bilateral lower abdomen pain and deep dyspareunia
  • abnormal bleeding or discharge
  • can feel feverish and malaise in acute infective phase
  • Late presentation: fertility problems or menstrual problems
42
Q

Describe some examination findings of PID

A 
In severe cases - tachycardia, high fever, signs of lower abdominal peritonism and bilateral adnexal tenderness and cervical excitation (pain on moving the cervix)
A mass (pelvic abscess) may be palpable vaginally
43
Q

think of some differential diagnosis for PID (aka causes of bilateral abdo pain)

A
  • appendicitis (unilateral pain)
  • ovarian cyst accidents (unilateral pain)
  • ectopic pregnancy (+ve PT, unilateral pain)
44
Q

Discuss how you would investigate a patient for PID

A
  • pregnancy test (to exclude ectopic pregnancy)
  • endocervical swaps to culture for chalamdyia and gonococcus (and their antibiotic sensitivity)
  • blood cultures if fever is present
  • bloods - WBC and CRP may be raised in acute infection
  • Pelvic USS - may exclude an abscess or ovarian cyst
  • Gold Standard: Laparoscopy with fimbiral biopsy and culture = not commonly done because invasive
45
Q

Discuss management for PID

A

Mild disease can be managed in community, severe infection and fever needs hospital admission and IV therapy
Analgesics
Antibiotics
Possible referal to GUM and partner notification

46
Q

Describe the antibiotic treatment for PID

A

Ceftriaxone 500mg IM

followed by doxycycline 100 mg orally twice daily and metronidazole 400 mg twice daily for 14 days

47
Q

What’s the alternative antibiotic regime for PID

A

An alternative regime is oral ofloxacin 400 mg twice daily and oral metronidazole 400 mg twice daily for 14 days

48
Q

In febrile PID patients, Iv therapy is recommended, what is this antibiotic regime?

A

Initial treatment is with doxycycline, single-dose IV ceftriaxone and IV metronidazole, then change to oral doxycycline and metronidazole to complete 14 days of treatment.

49
Q

Describe some of the complications of PID

A
  • formation of an abscess
  • tubal obstruction, subfertility
  • chronic infection and pelvic pain
  • ectopic pregnancy 6 x more common after PID
  • tubal damage (12% after 1 episode of PID)
50
Q

Describe the pathology of chronic pelvic inflammatory disease

A

Chronic PID describes a persisting infection due to inadequate treatment of acute PID
There are normally dense pelvic adhesions, fallopian tubes are obstructed and dilated with fluid (hydrosalpinx) or pus (pyosalpinx)

51
Q

Describe the symptoms of chronic PID

A
  • chronic pelvic pain
  • dysmenorrhoea
  • deep dyspareunia
  • heavy and irregular menstruation
  • chronic vaginal discharge
  • subfertility
52
Q

What might you find on examination in someone with chronic PID

A
  • abdo and adnexal tenderness and a fixed retroverted uterus
53
Q

Does transvaginal ultrasound have a place in chronic PID?

A

Yes - transvaginal USS may show fluid collections within the fallopian tubes or surrounding adhesions

54
Q

What is the best diagnostic tool for chronic PID?

A

Laparoscopy

55
Q

Will a culture grow from chronic PID?

A

Culture is often negative

56
Q

What is the treatment of chronic PID?

A
  • analgesics
  • antibiotics if there is evidence of active infection
  • severe cases: cutting of adhesions (adhesioloysis) or removal of affected tubes may be required

Gynacology (6 decks)

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