Chronic Pelvic Pain

Question 1

What is endometriosis?

Answer 1

Presence and growth of tissue similar to the endometrium outside the uterus.

Question 2

In whom is endometriosis most common?

Answer 2

1-2% of women – most common between 30-45. Nulliparous women.

Question 3

What is the aetiology of endometriosis?

Answer 3

• 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

Question 4

Sites of endometriosis?

Answer 4

• Peritoneum, Pouch of Douglas, Ovary/tubes, utero-sacral ligaments, Bladder
• Myometrium (adenomyosis)
• More distant foci – i.e. lungs

Question 5

What is most severe form of endometriosis?

Answer 5

Frozen pelvis - entire pelvis rendered immobile by adhesions

Question 6

History in endometriosis?

Answer 6

• 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

Question 7

Examination in endometriosis?

Answer 7

PV

• Tenderness and/or thickening behind uterus or in adnexa.
• Uterus fixed, retroverted and immobile (due to adhesions)
• Mild –> may be normal

Question 8

Investigations in endometriosis?

Answer 8

Diagnosis only made with laparoscopy +/- biopsy.

TV USS
• Exclude ovarian endometrioma and may suggest presence of adenomyosis.

Question 9

Medical management of endometriosis?

Answer 9

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.

Question 10

Surgical management of endometriosis?

Answer 10

• 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.

Question 11

Definition of PID?

Answer 11

inflammation of the upper urogenital tract

Question 12

Causes of PID?

Answer 12

• Neisseria gonorrhoeae
• Chlamydia trachomatis
• Bacterial vaginosis associated organisms
• Other organisms (streptococci, staphylococci, E coli)
• Mycoplasma genitalium
• Mycobacterium tuberculosis

BUT always treat as STI initially

Question 13

Complications of PID?

Answer 13

• 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

Question 14

History in PID?

Answer 14

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

Question 15

Examination in PID?

Answer 15

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

Question 16

Investigations in PID?

Answer 16

• 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

Question 17

Diagnostic criteria for PID?

Answer 17

Lower abdominal pain plus one of…
Adnexal pain, cervical motion tenderness or adnexal mass

(Pyrexia >38, leucocytosis, ESR >15)

Question 18

General management of PID?

Answer 18

• 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.

Question 19

Abx therapy in PID?

Answer 19

• 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