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N825 > GYN Pain > Flashcards

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
Q

Acute Appendicitis: S/S

A
  • Leukocytosis, usually neutrophilia
  • Periumbilical pain, migrating to RLQ
  • septic inflammation
  • N/V
  • Anorexia
  • Rebound tenderness
26
Q

Ovarian Torsion: S/S

A
  • 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
Q

Ruptured Corpus Luteal Cyst

A
  • Bilateral or unilateral pain
  • Pain cannot be distinguished from ectopic without hCG
  • Self-limiting
  • US for Dx
28
Q

Chronic Pelvic Pain: S/S

A
  • 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
Q

Chronic Pelvic Pain: Nerve Facts

A
  • 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
Q

Chronic Pelvic Pain Differential Dx: GYN

A
  • Endometriosis (most common cause of CPP)
  • Adenomyosis
  • Leiomyoma
  • Adhesions
  • Ovarian cyst
  • Chronic PID
  • Pelvic relaxation
  • Endometrial/cervical polyps
  • IUD
31
Q

Chronic Pelvic Pain Differential Dx: Non-GYN

A
  • Urological: Interstitial cystitis, urethral disorders
  • Systemic: Fibromyalgia, depression, substance abuse
  • GI: IBS, diverticulitis, Constipation, hernia, cancer
32
Q

Endometriosis Management: 1st Line

A
  • 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
Q

Endometriosis Management: 2nd Line

A
  • 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
Q

Endometriosis Management: Surgical

A
  • Laparoscopy

- Hysterectomy

35
Q

Endometriosis: S/S

A
  • 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
Q

Dysmenorrhea: Facts

A
  • Painful menses
  • Uterine cramping
  • MOST common GYN problem
37
Q

Primary Dysmenorrhea: Facts

A
  • 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
Q

Primary Dysmenorrhea: S/S

A
  • 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
Q

Secondary Dysmenorrhea: Facts

A
  • Acquired menstrual pain later in life (>25yo)
  • R/t pathology (PID, Polyps, myomas, endometriosis, Copper IUD, adenomyosis)
  • Hx of pain free cycles
40
Q

Secondary Dysmenorrhea: S/S

A
  • 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
Q

Dysmenorrhea: Hx

A
  • 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
Q

Dysmenorrhea: PE

A
  • 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
Q

Dysmenorrhea: Labs

A
  • 1st = no specific labs

- 2nd = CBC, hCG, Cultures (PID)

44
Q

Dysmenorrhea Differential

A
  • Similar to CPP

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