Gynaecology: Pelvic Pain Flashcards
Define chronic pelvic pain?
- Pain in the lower abdomen or pelvis
- At least 6 months duration
- Can be intermittent or constant
- And does not occur exclusively with menstruation, intercourse, or pregnancy
What pathophysiological causes can lead to pain becoming chronic?
- Local factors e.g. TNF alpha being released, affecting peripheral nerves
- CNS changes which may magnify pain signal
- Visceral hyperalgesia- alteration in visceral sensation and function
What are the possible causes of chronic pelvic pain in women?
Gynae:
- Endometriosis
- Adenomyosis
- PID
- Adhesions
Non-Gynae
- Interstitial Cystitis
- IBS/IBD
- MSK causes
- Nerve entrapment
N.B: Social and psych factors are always relevatn to a chronic pain presentation!
What is interstitial cystitis?
- Chronic pain syndrome affecting the bladder.
- Causing intense pelvic pain, urge to urinate, frequent urination, pain during sex
- Unclear aetiology and no known cure
- Link to depression, fibromyalgia and IBS
What is endometriosis?
- Definition = Presence of endometrial glands and stroma like lesions outside of the uterus (predominantly in the pelvis)
- Can also cause peritoneal lesions, implants or cysts in the ovaries
- Responds to cyclical hormone changes and bleeds during menstruation
What is adenomyosis?
- Definition = presence of endometrial tissue within the myometrium
- Diagnosed by histology after hysterectomy
- USS and MRI can be used prior to that
Who generally suffers with Endometriosis/ Adenomyosis
- 10-15% of reproductive age women
- Make up 70% of cases of chronic pelvic pain
- More common in infertile women
- Rare in post-menopausal women as oestrogen dependent
How would a patient with endometriosis or adenomyosis present?
Pain during:
- Menstruation (dysmenorrhea)
- Intercourse (dyspareunia)
- Defecation (dyschezia)
- Urination (dysuria)
HMB, PCB, IMB, Lower abdo pain, Rectal bleeding
What can be seen on examination in women with endometriosis or adenomyosis?
In most cases NAD.
Can see:
- Thickened uterine ligaments
- Fixed retroverted uterus
- Uterine or ovarian enlargement
On laparoscope you can see:
- Powder burn deposits
- Red flame lesions
- Scarring
How is endometriosis managed medically?
Medical (all suppress ovulation therefore not appropriate if trying to conceive):
- COCP
- Continuous progesterone therapy (MPA)
- GnRH analogues
- HRT
- Tranexamic acid for the bleeding
What is an alternative to Tranexamic acid?
Mefenamic acid
How is endometriosis managed surgically?
Laparoscopically:
- Diathermy
- Laser treatment
Definitive management = TAH+ BSO (risk of injury to the bladder/ bowel/ ureters, risk of subtotal hysterectomy)
If the cause of chronic pelvic pain is adhesions, what sort of adhesions should be targeted for therapy?
Surgical division of adhesions is unlikely to relieve pain by itself unless in cases of:
- Vascular adhesions (treated with division)
- Residual ovary syndrome
- Trapped ovary syndrome
How are residual/trapped ovary syndrome managed?
Ideally: Surgical removal, if not can give GnRH analogues to suppress hormones causing pain (not as effective)
How can conditions like IBS and Interstitial cystitis contribute to chronic pelvic pain?
- Can be the only cause
- Can be a secondary cause- as efferent neurological dysfunction causes IC/IBS in the presence of different chronic pain.
How can you diagnose someone with IBS?
Using the Rome 3 criteria:
- Continuous or recurrent abdo pain or discomfort for at least 3 days a month in the last 3 months
- Onset at least 6 months previously
- 2 of: Improvement with defecation, Onset associated with change in stool frequency, Onset associated with change in stool form
How is IBS treated?
Antispasmodics: Mebeverine hydrochloride
What sort of MSK problems can cause chronic pelvic pail?
- Any damage to any of the pelvic joints
- Damage to the muscles in the abdominal wall or pelvic floor
- Pelvic organs prolapse
- ‘Trigger points’, localised areas of deep tenderness, chronic muscle contraction
How should MSK caused chronic pelvic pain be managed?
- Analgesia
- Physiotherapy
- Nerve modulation
- Anti depressants
What is nerve entrapment?
- A highly localised, sharp, stabbing or aching pain
- Exacerbated by particular movements
- Persisting beyond 5 weeks or occurring after a pain free interval
- Common after procedures
How is nerve entrapment managed?
In a chronic pain clinic, probably with:
- Analgesia
- Physiotherapy
- Nerve modulation
- Antidepressants (possibly)
What social and psychological issues can lead to or aggravate chronic pelvic pain?
- Child abuse
- Sexual abuse
- Depression
- Anxiety
- Somatisation
- Women reporting both child and adult sexual abuse reported higher levels of menstrual pain, painful intercourse, chronic pelvic pain
- Treatment is individualised care
How could you initially assess a patient presenting with suspected chronic pelvic pain?
- HoPC- establish pattern of pain
- Any associations with psych factors, bladder or bowel factors
- Link with menstruation, bleeding
- Effect of movement and posture (MSK or nerve)
- Rule out any red flags (ectopic, miscarriage, cancer, ovarian torsion)
- If definitely chronic but still unclear, potentially keep a pain diary for a few months
What are you looking for on examination of a patient with chronic pelvic pain?
- Focal tenderness
- Abdominal masses
- Full internal exam
- Enlargement, distortion, prolapse
What investigations would you consider in a woman with chronic pelvic pain?
- STI screening!!
- TVS, to identify and assess any masses
- MRI can be useful for adenomyosis
- Laparoscopy can be useful but is controvertial
Generically, how would you treat chronic pelvic pain?
- Treat the cause
- Cyclical pain should always be trialled on hormone treatment for 3-6 months before having diagnostic laparoscopy
- IBS with antispasmodics and lifestyle changes
- Pain relief
- Can refer to dedicated chronic pelvic pain team
What is PID?
- Ascending upper genital tract infection
- Can arise de novo, can come from instrumentation but almost always comes from an STI
What are the symptoms of PID?
Symptoms progress as the infection ascends…
Cervicitis occurs first, causing:
- Vaginal discharge
- Inflammation
- Tenderness
Endometritis can occur, causing:
- Menstrual irregularity
- Midline abdo pain
If a tubal infection occurs you could see:
- Low bilateral abdo pain
- Adnexal swelling, tenderness
- Erythema, oedema, exudate
Intra-abdominal complications are seen last:
- Peritonitis
- Periappendicitis
What are the most common causative organisms of PID?
CHLAMYDIA accounts for the largest number of cases (2-3x as many as G)
- Gonorrhoea also very common
- Gardnerella vaginalis
- Anaerobes
- Mycoplasma genitalium
How long does it take for Chlamydia to develop into PID
Roughly 12 months, 10-40% of untreated cases become PID.
Weirdly risk increases with subsequent infections, potential hypersensitivity reaction.
What are the long term consequences of PID?
- Infertility (damage to reproductive organs especially tubes)
- Increased risk of ectopic pregnancy
- Chronic pelvic pain (v hard to manage)
- Tubo-Ovarian abscess (more common with G)
- Fitz-Hugh Curtis syndrome
What is Fitz Hugh Curtis syndrome?
Rare complication of PID arising from liver capsule inflammation, leading to adhesions.
Symptoms = STI symptoms, RUQ pain, Perihepatitis
What are the risk factors for PID?
Sexual:
- Younger woman (increased chance of sexual activity)
- Multiple partners
- New partner
- Previous PID
Gynae:
- Coil insertion
- TOP /Miscarriage
- Uterus instrumentation
- Douching
What are the symptoms of PID?
- Lower abdo pain (normally bilateral)
- Deep abdominal pain during intercourse
- Abnormal PV discharge, can be purulent
- Abnormal bleeding (IMB, PCB)
- Fever
- Chills
But may be totally asymptomatic! Can still cause permanent damage to genital tract
What are the clinical signs of PID?
- Lower abdominal tenderness, usually bilateral
- Abnormal or purulent discharge
- Cervical motion tenderness (same stimulus as causing pain on intercourse)
- Adnexal tenderness
- Adnexal mass
- Fever greater than 38 degrees.
- Contact bleeding from the cervix (evidence of cervicitis)
What investigations would you order for a woman with potential PID?
Pregnancy test! Abdo pain = ectopic until proven otherwise.
Test for: - Chlamydia Trachomatis - Neisseria gonorrhoeae - Mycoplasma Genitalium (presence supports diagnosis, negative STI swabs do not rule out PID)
ESR/CRP/WCC.
Definitive diagnosis is by laparoscopy, only done in a few cases, little use for imaging methods.
At what point do you start treating a PID case?
Immediately and based on clinical findings; do not wait for swabs to come back as you can get swab negative PID.
Very low threshold for treatment due to fertility risks: sexually active woman + new onset bilateral lower abdo pain + tenderness on bimanual exam = Empirical treatment (assuming pregnancy excluded)
How do you manage a patient with PID?
- Rest
- Analgesia
- Broad spectrum antibiotics (IV if temp is greater than 38)
- Admit for observation if severe disease, if pregnant or suspected tubo-ovarian abscess
- Abstain from sex until both patient and partner have completed treatment.
- Review after 3 days and escalate to IV antibiotics if no improvement
- Review in 2-4 weeks to ensure symptoms have resolved, check antibiotics compliance and follow up on contracts.
What is the most common outpatient treatment regime for PID?
500mg IM Ceftriaxone
+
100mg Doxycycline, BD PO for 14 days
+
400mg Metronidazole BD PO for 14 days
Name an alternative outpatient antibiotic regime for PID?
400mg Moxifloxacin OD PO for 14 days.
What is the most common inpatient treatment regime for PID?
IV Ceftriaxone 2g daily +
IV Doxycycline 100mg bd
–>
Oral Metronidazole 400mg bd, 14 days +
Oral Doxycycline 100mg bd for 14 days
What treatment should be offered to partners of women diagnosed with PID?
Current male partner:
- Offer screening for CT/NG
- Broad spectrum Abx e.g. Oral Doxy for one week
Any other partner in last 6 months:
- Offer screening
What are some causes of acute pelvic pain in women?
Obstetric emergencies must be rule out first:
- Ectopic
- Miscarriage
Gynae:
- Torsion of ovarian cyst
- Degeneration of fibroids
- PID flare up
- Hematocolpos
- Hematometra
- Endometriosis
Non-gynae:
- MSK pain
- Bowel pain (IBD)
- Appendicitis
- UTI/ Uteric caculi/ Cystitis
What gynae conditions can cause acute pelvic pain in pregnant women?
Most common are:
- Torsion of ovarian cyst
- Degeneration of fibrois
- Flare up of PID
What women are at greater risk of ovarian cyst torsion?
All women are really but more common in:
- Younger women
- Postmenopausal women
- Women who’ve just given birth
What is the adnexa?
Region adjoining the uterus, contains the ovaries, fallopian tube, associated vessels, ligaments, connective tissue.
What five features are used clinically to score risk of ovarian torsion in a woman presenting with acute pelvic pain?
1) Unilateral lumbar/abdo pain
2) Pain duration >8 hours
3) Vomiting
4) Absence of leucorrhoea (non-blood discharge)/ metrorrhagia (irregular bleeding)
5) Ovarian cyst larger than 5cm on ultrasound
What are the symptoms of ovarian torsion?
- Pelvic or abdo pain which fluctuates or radiates to loin/thigh
- Nausea
- Vomiting
(N.B: distinguishable from PID by the presence of nausea and vomiting)
What are the clinical signs of ovarian torsion?
General:
- Pyrexia
- Tachycardia
Abdominal examination:
- Generalised tenderness
- Localised guarding
- Rebound
Vaginal examination:
- Cervical excitation
- Adnexal tenderness
- Adnexal mass
How is ovarian torsion managed?
Diagnosis is clinical.
Ultrasound of pelvis would show it but normally not necessary. CRP and WCC will be raised but rarely bother.
What is the management of ovarian torsion?
- Admit
- Give IV fluids
- Appropriate pain relief
- Surgery (ideally just remove cyst and untwist ovary but if necrotic laparoscopic salpingectomy)
What is Fibroid degeneration?
Degeneration of a fibroid due to excessive growth that outmatches blood supply or mechanical compression of feeder arteries
How would fibroid degeneration present?
- Likely past history of fibroids
- Palpable mass
- Raised inflammatory markers
How do you manage fibroid degeneration?
Ideally (especially in pregnancy) managed conservatively:
- Pain relief
- Hydration
- Antibiotics
Emergency surgery if due to PEDUNCULATED (wandering) fibroid torsion.
If suspicious of sarcoma –> Hysterectomy
How would PID present?
Most are actually asymptomatic.
Of those that do present:
- Lower abdo pain
- Pyrexia
- Vaginal discharge (yellow or green)
- Dyspareunia
- IMB, PCB
- No nausea or vomiting (that’s more torsion)
O/E:
- Pyrexia
- Vag discharge
- Cervical excitation
Apart from Chlamydia and Neisseria, what are some common causative organisms of PID?
- E Coli
- Peptococcus
- Pelvic TB
- Gardnerella vaginalis
- Mycoplasma genitalium
- Strep Pyogenes
Apart from Chlamydia and Neisseria, what are some common causative organisms of PID?
- E Coli (most common cause in non-sexually active women)
- Peptococcus
- Pelvic TB
- Gardnerella vaginalis
- Mycoplasma genitalium
- Strep Pyogenes
What are the risk factors for PID?
Sexual:
- Not using barrier C
- Multiple sexual partners
- New sexual partner
Medical History:
- Endometriosis
- Previous PID
- Diabetes
- Immunocompromised
How do you investigate a woman with suspected PID?
- Pregnancy test
- FBC, CRP, WCC
- MSU sample
- Triple swabs
- Ultrasound of pelvis/abdomen (look for TO abscess)
- X-ray/Diagnostic laparoscopy maybe
What are the components of the triple swab?
Endocervical NAAT which tests for C and G.
Endocervical charcoal media swab, tests for G
High Vaginal charcoal media swab, tests for:
- Bacterial vaginosis
- Trichomonas vaginalis
- Candida
- Group B strep
How do you manage TO Abscess?
- Admit
- Start on IV antibiotics
- If indications for sepsis, manage according to S6P
If no sepsis
- 4 hourly obs
- Daily FBC and CRP
- Continue IV antibiotics
- Daily senior clinical review
- Review microbiology and refine antibiotics
When clinically improving:
- Switch to oral antibiotics
- Discharge
What are the main two points of TOA management?
- IV antibiotics until improvement, switch to oral and send home
- 4 hourly obs monitoring + daily bloods (FBC, CRP) to make sure they don’t go septic
How do you manage PID outpatient?
Triple swab, even if negative treat based on pain + signs of infection + history.
Single dose IM Ceftriaxone (500mg) followed by…
- 100mg Doxycycline and
- 400mg Metronidazole
… both twice daily, both orally and both for 14 days.
N.B: can’t drink when on Metro
When and how do you manage PID as an inpatient?
Severe disease, or Septic, or not responding to Outpatient.
- IV Ceftriaxone, 2g, daily Followed by... - 100mg oral doxy - 400g oral nitro Twice daily for 2 weeks.
What surgical management options are available in the management of PID?
Laparoscopy or Laparotomy for drainage.
What counselling should be given to a woman treated for PID?
- Warn about risk of ectopic pregnancy
- Subfertility
- Partner notification and possible treatment.
- Follow up
What is Haematocolpos?
Condition where the vagina becomes pooled with menstrual blood due to some sort of outflow obstruction.
Presents with absent periods and cyclical pain.
How do you manage Haematocolpos?
Cruciate incision to drain blood.
