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GYN Pain Flashcards

1
Q

Etiologies of Pelvic Pain

A
  • Musculoskeletal
  • Gynecological
  • Urological
  • Gastrointestinal
  • Neurological
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2
Q

Causes of Acute Periumbilical Pain

A
  • Appendicitis (early)
  • SBO
  • Gastroenteritis
  • Mesenteric ischemia
  • AAA rupture or dissection
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3
Q

Causes of Acute Suprapubic Pain

A
  • Irritable bowel disease
  • Ovarian tumor/torsion
  • Ectopic pregnancy
  • PID
  • Tubo-ovarian abscess
  • Dysmenorrhea
  • Colonic disease
  • Diverticulitis
  • Cystitis
  • Nephrolithiasis
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4
Q

Acute Pelvic Pain

A
  • Requires aggressive management

- May be life threatening

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5
Q

Chronic Pelvic Pain

A
  • Non-cyclical pain 6+mo in duration
  • Localized to anatomic pelvis, anterior ABD wall at or below umbilicus, lumbosacral back/buttocks
  • Of severity to cause disability and medical care
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6
Q

GYN Causes of Pelvic Pain: Pregnancy-related

A
  • Ectopic pregnancy
  • Threatened, inevitable, or incomplete miscarriage
  • IUP with corpus luteum bleed
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7
Q

GYN Causes of Pelvic Pain: NOT Pregnancy-related

A
  • Acute PID
  • Rupture of ovarian cyst
  • Adnexal torsion
  • Degenerating/necrosing fibroids or ovarian tumors
  • Primary dysmenorrhea
  • Mittelschmerz
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8
Q

Non-GYN Causes of Pelvic Pain

A
  • Appendicitis
  • Diverticulitis
  • IBS
  • Urinary tract disorders (cystitis, pyelonephritis, renal calculi)
  • Mesenteric lymphadenitis
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9
Q

Assessing Pelvic Pain

A
  • Contraceptive Hx: Risk of PID or ectopic is reduced by 50% in patients taking oral contraceptives or using barrier methods
  • Fever, chills, ABD/Pelvic involvement
  • Vaginal/cervical discharge; cervical/uterine motion & tenderness; adnexal masses
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10
Q

PID: Risk Factors

A
  • 15-25yo
  • Sexual partner with symptoms of urethritis
  • Prior Hx of PID
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11
Q

Conditions Associated w/Tender Adnexal Masses

A
  • May indicate:
    • Ectopic
    • Tubo-ovarian abscess
    • Cyst w/torsion
    • Hemorrhage or rupture
    • Abscess in appendix or colon
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12
Q

Conditions Associated with Uterine Enlargement

A
  • Pregnancy
  • Leiomyomas
  • Adenomyosis
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13
Q

Lab/Diagnostic Tests for Pelvic Pain

A
  • UPT
  • CBC
  • UA/Cultures
  • GC/Chlamydia
  • Pelvic US
  • Diagnostic laparoscopy
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14
Q

Common Reproductive Pelvic Pain

A
  • GI: Appendicitis; Bowel obstruction; diverticulitis; gastritis; inguinal hernia; IBS; mesenteric venous thrombosis; perirectal abscess
  • GYN: Adenomyosis, degenerating/necrosing fibroid; ectopic; endometriosis; mittelschmertz; ovarian cyst/torsion; PID; tubo-ovarian abscess
  • Urinary: Cystitis, pyelonephritis; lithiasis
  • Other: AAA; lead poisoning; malingering; drug seeking; porphyria; SCD; somatization
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15
Q

Common Adolescent Pelvic Pain

A
  • Similar to reproductive age
  • Imperforate hymen
  • Transverse vaginal septum
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16
Q

Common Postmenopausal Pelvic Pain

A
  • Similar to reproductive pain minus ectopic and ovarian torsion
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17
Q

Common Pregnant Pelvic Pain

A
  • Corpus luteum hematoma
  • Ectopic
  • Placental abruption
  • Ovarian torsion
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18
Q

Common Postpartum Pelvic Pain

A
  • Endometritis

- Ovarian vein thrombosis

19
Q

Sonogram for Pelvic Pain

A
  • Can exclude the Dx of ectopic

- Can Dx PID, ovarian torsion, acute appendicitis

20
Q

CT for Pelvic Pain

A
  • Can detect bowel, reproductive, and urinary disorders

- More sensitive than ABD X-ray

21
Q

Acute Pelvic Pain + Reproductive Age

A
  • Always assume a woman of reproductive age is pregnant until proven otherwise!!!
  • Do Serum hCG or UPT: If (+) then determine location of pregnancy (IUP vs. ectopic)
22
Q

Mgmt. of Ectopic Pregnancy

A
  • Methotrexate 50mg/m2 IM

- Surgery

23
Q

Ectopic Pregnancy: S/S

A
  • Shock
  • ABD pain
  • Absence of menses or irregular vaginal bldg.
  • Risks: PID (esp. w/chlamydia as causative organism)
24
Q

PID: S/S

A
  • Pain USUALLY bilateral
  • Cervical motion tenderness
  • Fever
  • Cervical discharge
  • May also have tubo-ovarian abscess
  • Elevated ESR and CRP (more sensitive for PID than WBC or ESR)
25
Acute Appendicitis: S/S
- Leukocytosis, usually neutrophilia - Periumbilical pain, migrating to RLQ - septic inflammation - N/V - Anorexia - Rebound tenderness
26
Ovarian Torsion: S/S
- Seen in adolescent and reproductive aged women - Pain is progressive but may wax and wane w/ N/V - Pain is USUALLY unilateral - May have Hx of transitory pain - Pelvic US can confirm - Tx: Laparoscopy
27
Ruptured Corpus Luteal Cyst
- Bilateral or unilateral pain - Pain cannot be distinguished from ectopic without hCG - Self-limiting - US for Dx
28
Chronic Pelvic Pain: S/S
- Non-cyclical pain of at least 6mo - Localized to the pelvis, below the umbilicus and can include the anterior ABD wall, lower back, and buttocks - Causes functional disability - May require medical care - May be r/t endometriosis or interstitial cystitis - Many have Hx of Sexual or physical abuse
29
Chronic Pelvic Pain: Nerve Facts
- Pain arising from the visceral and somatic system - Structures are supplied by thoracic spine and below - Somatic pelvic pain (T12-S5) - Visceral pelvic pain (T10-S5)
30
Chronic Pelvic Pain Differential Dx: GYN
- Endometriosis (most common cause of CPP) - Adenomyosis - Leiomyoma - Adhesions - Ovarian cyst - Chronic PID - Pelvic relaxation - Endometrial/cervical polyps - IUD
31
Chronic Pelvic Pain Differential Dx: Non-GYN
- Urological: Interstitial cystitis, urethral disorders - Systemic: Fibromyalgia, depression, substance abuse - GI: IBS, diverticulitis, Constipation, hernia, cancer
32
Endometriosis Management: 1st Line
- Expectant mgmt.: asymptomatic; no known prevention - NSAIDs: for mild s/s (IBU 800 q6hr PRN; Naproxen 500mg then 250mg qid PRN) - OCPs: minimal/mild s/s * * May give long cycles (3-4mo continuous without break) - OCPs + NSAIDs
33
Endometriosis Management: 2nd Line
- Daily progestin (MDPA 5-10mg or NGS or NE) - Depot MDPA IM q2wk for 2mo at 100mg/dose, then qmo for 4mo at 200mg/dose - Mirena - Danazol 200, 400, or 800mg/d for up to 6-9mo * * Side effects of hypoestrogenic state: acne, oily skin, deepening voice (not reversible), wt gain, edema and lipprotein changes - Lupron or Zoladex (GnRHAs) good results * * hypoestrogenic state w/some bone loss (can do add-back therapy to prevent bone loss)
34
Endometriosis Management: Surgical
- Laparoscopy | - Hysterectomy
35
Endometriosis: S/S
- S/S vary - Uterosacral ligament abnormalities: * * thickening * * focal tenderness * * lateral displacement of the cervix * * CMT * * Fixed retroverted uterus (common due to adhesions in cul-de-sac - Tender adnexal masses - Progressive dyspareunia
36
Dysmenorrhea: Facts
- Painful menses - Uterine cramping - MOST common GYN problem
37
Primary Dysmenorrhea: Facts
- Typically begins in adolescence - Initially, painless cycles (anovulatory) - Then regular menses with painful period - Absence of pathology - Excessive production of prostaglandins - Increased uterine contractions
38
Primary Dysmenorrhea: S/S
- Onset: 6mo after menarche - Lower ABD/pelvic pain begins wit period and lasts 8-72hr (sharp, cramping, colicky) * * Radiates to lower back, thighs, or groin - Lower back pain - Medial/anterior thigh pain - HA/fatigue/syncope - Diarrhea/N/V/bloating
39
Secondary Dysmenorrhea: Facts
- Acquired menstrual pain later in life (>25yo) - R/t pathology (PID, Polyps, myomas, endometriosis, Copper IUD, adenomyosis) - Hx of pain free cycles
40
Secondary Dysmenorrhea: S/S
- Pain a few days prior to period - Pain may be present at ovulation, continues through period - May experience pain w/intercourse - Pain increases with age - Dull, lower ABD aching radiating to back or thighs - Bloating/fullness - Heavy menstrual flow - Infertility - Vaginal D/C - May not be relieved by NSAIDs
41
Dysmenorrhea: Hx
- Menstrual - Detailed description of pain - 1st typically begins in adolescence - 2nd after age 25 - Pain relief measures - Duration of pain - Other Sx - Contraceptive Hx - Reproductive Hx
42
Dysmenorrhea: PE
- Complete PE (1st and 2nd) - Young adolescent, not sexually active: Pelvic not necessary (1st) - If sexually active: pelvic (1st) - No Menses? --> Pelvic (1st) - 2nd = always pelvic
43
Dysmenorrhea: Labs
- 1st = no specific labs | - 2nd = CBC, hCG, Cultures (PID)
44
Dysmenorrhea Differential
- Similar to CPP

N825 (16 decks)

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