Female pelvic pain Flashcards
Definition of chronic pelvic pain
Chronic pelvic pain
- having intermittent or constant pain in the lower abdomen or pelvis of a woman
- last at least 6 months
- does not occur only with menstruation or intercourse
- not associated with pregnancy
Is a chronic pelvic pain a symptom or diagnosis?
chronic pelvic pain - it is a symptom
What ‘difficult questions’ to ask if a woman is presenting with chronic pelvic pain symptoms?
Remember to carefully introduce these questions - is that OK if I ask you some private/difficult questions? This will help me to guide the Dx and Mx
- are you sexually active?
- is it painful when you are having sex? where is the pain?
- any possibility of you being pregnant?
* also ask if the pain is associated with menstrual cycle
(3) important questions to ask when the women presents with symptoms of pelvic pain
- are they premenopausal or postmenopausal?
- can the pain be pregnancy related?
- is the pain hormonally driven by the menstrual cycle?
Pain innervation of the fundus (dermatome wise)
Fundus pain: T11 - L1
Dermatomal innervation of the cervix and upper vagina (pain innervation)
Cervix and upper vagina: S2 - S4
What does the pain in T12-S4 mean?
Pain in T12-S4
Uterus, rectum, cervix, vagina and bladder -> pain will be referred to the back, bottom, legs
- it will be a severe, difficult to localise pain
Is visceral pain easy to localise?
It is poorly localised - due to under-representation within the somatosensory cortex
What is a relation to visceral pain and autonomic NS sensations?
Nociceptors stretched -> possible autonomic NS sensations
*It may cause sweating and decreased BP
Visceral hypersensitivity
An injury to viscera -> viscera may respond by sensitisation of neurones -> neurotransmitter levels creating increased pain
! Important obs & gyn questions to ask in Hx (6) !
- inter-menstrual bleeding
- post-coital bleeding
- heavy menstrual bleeding
- LMP
- contraception
- sexual activity/ have you changed partner recently? *
*more likely to get PID
! GI related questions in Hx for woman with pelvic/abdo pain (6) !
- abdominal distension
- bloating
- diarrhoea/constipation
- colic, pain improving with defecation
- the appearance of stool/ has it changed with pain?
- does the menstruation make the pain worse?
! Urology related questions ! (8)
Urology:
- urinary frequency
- nocturia
- bladder pain
- urgency
- haematuria
- radiation/relief by voiding
- has there been Rx for UTI recently? was that proven UTI?
- is there temperature/loin pain?
Examination components for pelvic pain
Examination:
- temp and vital signs
- skin, MSK, pain
- lymph nodes, hernias, masses
- pelvic floor
- neuralgia (trigger points)
- PV: structure, bleeding
- discharge
- speculum
Investigations for: pelvic pain /abdo pain
(in women)
- urinary bHCG - to make sure we are not missing pregnancy or ectopic (of course if a woman is premenopausal)
- serum HCG -> if a woman is known (previous Hx) to have negative urine pregnancy tests but pregnant
- FBC, CRP, ESR -> markers of infection
*CRP - infections; ESR - inflammatory diseases
Other possible tests:
- faeces C+S (if diarrhoea; infections with Shigella/ salmonella/ Campylobacter)
- TFTs
- HbA1c and fasting glucose
Investigations (IBS NICE guideline)
IBS investigations:
- endomysial antibodies
- antigliaden antibodies
- colonoscopy (if new IBS in >50 years old)
- faecal calcoprotectinis -> positive in IBD and ocassionally in cancer but negative in IBS
Faecal calprotectin test - when is it useful
Faecal calprotectin:
- positive in IBD, occasionally in cancer
- negative in IBS
*often used in young person presenting with IBS symptoms (if they want to avoid colonoscopy)
* if the person is 50y old or more and presents with new onset of IBS -> do a colonoscopy
What symptoms may raise a suspicion of ovarian cancer?
Ovarian cancer symptoms are often non-specific
Suspect if:
- frequent/persistent bloating in women
- usually > 50 y old
- feeling full
- reduced appetite
- pelvic or abdominal pain
- increased urgency/frequency of passing urine
- >50 y old with new-onset IBS
- possibly (50%) may present with intra-menstrual/ post-menopausal bleeding
Investigations for ovarian cancer
- CA125
- USS
When do we refer a woman for 2WW pathway for ovarian Ca (NICE)?
Symptoms + Ca125 >35 iu/ml + USS with abnormality
*1 in 26 women referred will have an ovarian cancer
Two groups of genetic syndromes associated with ovarian ca
- BRACA
- HNPCC (Lynch syndrome) - usually colorectal cancer, but associated with ovarian ca too (ca: pancreatic, stomach, endometrial, ovarian)
Acute pelvic pain patient - examinations
- vaginal examination -> trigger points, masses, tenderness
- speculum -> to visualise the cervix, vagina, discharge
- chlamydia/gonorrhoea endo-cervical swab/ vulvo-vaginal swab
- urine sampling
Which one is more common: chlamydia or gonorrhoea
Chlamydia is more common
What are investigations for pelvic pain in secondary care?
- transvaginal USS scan (can be also done by GP) -> useful for detection of adnexal masses
- transvaginal MRI scan -> useful for Dx of adenomyosis
- diagnostic laparoscopy -> Dx of peritoneal endometriosis and adhesions
Why would we not consider laparoscopic investigation for endometriosis in someone with chronic pelvic pain?
- risk of death 1 in 10 000 to people with CPP
*still some forms of endometriosis may be missed
What is useful in ruling out UTI?
- no dysuria
- no frequency or urgency
how does bladder Ca may present on urinalysis?
- UTI symptoms
- haematuria
*bladder Ca presents most commonly with painless haematuria
UTI with macroscopic blood - what is the follow-up?
Pt needs to come back after treatment for the testing -> blood should be gone
*there may be blood in UTI due to bladder irritation (from inflammation)
How chronic bladder pain syndrome present?
With recurrent UTIs
Instruction for the patient for MSU testing (in case of urinary TB)
MSU for TB
3 early morning samples on different days
What Rx would be offered to a woman with cyclical pelvic pain in secondary care?
The trial of hormonal Rx for 3-6 months -> if that fails then diagnostic laparoscopy
Trial Rx for IBS
- antispasmodics
- diet changes to control symptoms
If a patient is coming with pain and we are investigating for its cause, what we need to remember about?
To help out with the pain - analgesia (!)
*if pain is not controlled -> referral to pain clinic
