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
