Chronic Pelvic Pain Flashcards
What is endometriosis?
Presence and growth of tissue similar to the endometrium outside the uterus.
In whom is endometriosis most common?
1-2% of women – most common between 30-45. Nulliparous women.
What is the aetiology of endometriosis?
- Oestrogen-dependent; regresses after menopause and during pregnancy.
- Probably due to retrograde menstruation mechanical, lymphatic, blood-borne spread of the tissue –> implants in different sites.
Causes inflammation progressive fibrosis and adhesions
Sites of endometriosis?
- Peritoneum, Pouch of Douglas, Ovary/tubes, utero-sacral ligaments, Bladder
- Myometrium (adenomyosis)
- More distant foci – i.e. lungs
What is most severe form of endometriosis?
Frozen pelvis - entire pelvis rendered immobile by adhesions
History in endometriosis?
- Chronic cyclical pelvic pain.
- Dysmenorrhea before point of menstruation
- Deep dyspareunia
- Subfertility
- Pain on passing stool during menses (dyschezia)
- Menstrual problems (occasionally)
- Bladder/bowel symptoms
Examination in endometriosis?
PV
- Tenderness and/or thickening behind uterus or in adnexa.
- Uterus fixed, retroverted and immobile (due to adhesions)
- Mild –> may be normal
Investigations in endometriosis?
Diagnosis only made with laparoscopy +/- biopsy.
TV USS
• Exclude ovarian endometrioma and may suggest presence of adenomyosis.
Medical management of endometriosis?
Analgesia
o NSAIDs
Hormonal Treatments (to mimic pregnancy/menopause/) o COP – not suitable for older women or smokers. Back to back pills. o Progestogens (Provera/IUD) – endometrial and ovarian suppression o GnRH analogues – downregulates FSH/LH and oestrogen production – menopause reversible bone demineralisation so only for 6 months.
Surgical management of endometriosis?
- Laparoscopic ablation of endometriotic spots e.g. diathermy
- Laparoscopic resection of active lesions/scar tissue/adhesions
- Laparoscopic cystectomy/oophorectomy
Hysterectomy = last resort, only when family is complete. Not when young as will need HRT.
Definition of PID?
inflammation of the upper urogenital tract
Causes of PID?
- Neisseria gonorrhoeae
- Chlamydia trachomatis
- Bacterial vaginosis associated organisms
- Other organisms (streptococci, staphylococci, E coli)
- Mycoplasma genitalium
- Mycobacterium tuberculosis
BUT always treat as STI initially
Complications of PID?
• Ectopic pregnancy
• Tubal factor infertility
• Chronic dyspareunia and pelvic pain
• Fitz-Hugh-Curtis syndrome (perihepatitis)
o In women <30y, RUQ pain is highly suggestive of perihepatitis rather than cholecystitis
History in PID?
Recent onset…
o Lower abdominal pain – typically bilateral
o Deep dyspareunia
o Abnormal vaginal bleeding including IMB, PCB & menorrhagia
o Abnormal vaginal or cervical discharge – usually purulent
Examination in PID?
General obs
o Tachycardia, fever
Abdo examination
o Lower abdominal peritonism
Bimanual exam
o Bilateral adnexal tenderness and cervical excitation (motion tenderness)
o Pelvic abscess may be palpable vaginally
Speculum
Investigations in PID?
- Pregnancy test
- Urine dipstick + MSU
- Vulvovaginal swab (VVS – around outside, better than cervical swab) for chlamydia and gonorrhoea, HVS (for BV, TV and candida) plus endocervical swab for gonorrhoea culture
- Temperature?
- Bloods for HIV and syphilis
- Bloods for FBC, ESR/CRP, LFT’s
Diagnostic criteria for PID?
Lower abdominal pain plus one of…
Adnexal pain, cervical motion tenderness or adnexal mass
(Pyrexia >38, leucocytosis, ESR >15)
General management of PID?
- Rest in severe disease
- Analgesics
- Admission for intravenous therapy in more severe disease
- No sex until both they and their partner have completed treatment and follow up
Don’t need to remove IUD - but more close follow up.
Abx therapy in PID?
• Ceftriaxone 500 mg IM followed by…
• Doxycycline 100mg BD PO 14 days
+/- (Metronidazole 400mg BD PO 7-14 days)
OR
• Ofloxacin 400mg bd po 14days
• Metronidazole 400mg bd po 14 days
