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Y3 Lecture weeks > Female pelvic pain > Flashcards

Female pelvic pain Flashcards

1
Q

Definition of chronic pelvic pain

A

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
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2
Q

Is a chronic pelvic pain a symptom or diagnosis?

A

chronic pelvic pain - it is a symptom

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3
Q

What ‘difficult questions’ to ask if a woman is presenting with chronic pelvic pain symptoms?

A

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

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4
Q

(3) important questions to ask when the women presents with symptoms of pelvic pain

A
  • are they premenopausal or postmenopausal?
  • can the pain be pregnancy related?
  • is the pain hormonally driven by the menstrual cycle?
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5
Q

Pain innervation of the fundus (dermatome wise)

A

Fundus pain: T11 - L1

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6
Q

Dermatomal innervation of the cervix and upper vagina (pain innervation)

A

Cervix and upper vagina: S2 - S4

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7
Q

What does the pain in T12-S4 mean?

A

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
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8
Q

Is visceral pain easy to localise?

A

It is poorly localised - due to under-representation within the somatosensory cortex

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9
Q

What is a relation to visceral pain and autonomic NS sensations?

A

Nociceptors stretched -> possible autonomic NS sensations

*It may cause sweating and decreased BP

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10
Q

Visceral hypersensitivity

A

An injury to viscera -> viscera may respond by sensitisation of neurones -> neurotransmitter levels creating increased pain

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11
Q

! Important obs & gyn questions to ask in Hx (6) !

A
  • inter-menstrual bleeding
  • post-coital bleeding
  • heavy menstrual bleeding
  • LMP
  • contraception
  • sexual activity/ have you changed partner recently? *

*more likely to get PID

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12
Q

! GI related questions in Hx for woman with pelvic/abdo pain (6) !

A
  • 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?
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13
Q

! Urology related questions ! (8)

A

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?
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14
Q

Examination components for pelvic pain

A

Examination:

  • temp and vital signs
  • skin, MSK, pain
  • lymph nodes, hernias, masses
  • pelvic floor
  • neuralgia (trigger points)
  • PV: structure, bleeding
  • discharge
  • speculum
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15
Q

Investigations for: pelvic pain /abdo pain

(in women)

A
  • 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
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16
Q

Investigations (IBS NICE guideline)

A

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
17
Q

Faecal calprotectin test - when is it useful

A

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

18
Q

What symptoms may raise a suspicion of ovarian cancer?

A

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
19
Q

Investigations for ovarian cancer

A
  • CA125
  • USS
20
Q

When do we refer a woman for 2WW pathway for ovarian Ca (NICE)?

A

Symptoms + Ca125 >35 iu/ml + USS with abnormality

*1 in 26 women referred will have an ovarian cancer

21
Q

Two groups of genetic syndromes associated with ovarian ca

A
  • BRACA
  • HNPCC (Lynch syndrome) - usually colorectal cancer, but associated with ovarian ca too (ca: pancreatic, stomach, endometrial, ovarian)
22
Q

Acute pelvic pain patient - examinations

A
  • vaginal examination -> trigger points, masses, tenderness
  • speculum -> to visualise the cervix, vagina, discharge
  • chlamydia/gonorrhoea endo-cervical swab/ vulvo-vaginal swab
  • urine sampling
23
Q

Which one is more common: chlamydia or gonorrhoea

A

Chlamydia is more common

24
Q

What are investigations for pelvic pain in secondary care?

A
  • 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
25
Q

Why would we not consider laparoscopic investigation for endometriosis in someone with chronic pelvic pain?

A
  • risk of death 1 in 10 000 to people with CPP

*still some forms of endometriosis may be missed

26
Q

What is useful in ruling out UTI?

A
  • no dysuria
  • no frequency or urgency
27
Q

how does bladder Ca may present on urinalysis?

A
  • UTI symptoms
  • haematuria

*bladder Ca presents most commonly with painless haematuria

28
Q

UTI with macroscopic blood - what is the follow-up?

A

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)

29
Q

How chronic bladder pain syndrome present?

A

With recurrent UTIs

30
Q

Instruction for the patient for MSU testing (in case of urinary TB)

A

MSU for TB

3 early morning samples on different days

31
Q

What Rx would be offered to a woman with cyclical pelvic pain in secondary care?

A

The trial of hormonal Rx for 3-6 months -> if that fails then diagnostic laparoscopy

32
Q

Trial Rx for IBS

A
  • antispasmodics
  • diet changes to control symptoms
33
Q

If a patient is coming with pain and we are investigating for its cause, what we need to remember about?

A

To help out with the pain - analgesia (!)

*if pain is not controlled -> referral to pain clinic

Y3 Lecture weeks (65 decks)

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