O&G - Pelvic pain

Question 1

22 y/o female

pc: pelvic pain for 24hrs, uncomfortable

Obs: 110bpm, BP 100/65, temp 37.2

What could be causing her pain?

Answer 1

Bowel
- constipation, diverticulitis, appendicitis

Gynae
- ovarian cyst, torsion, dysmenorrhea, endometriosis, pelvic adhesions

Pregnancy
- miscarriage, ectopic pregnancy, pre term labour

STI
- pelvic inflammatory disease

Question 2

22 y/o female

pc: pelvic pain for 24hrs, uncomfortable
hpc: pain for long time, comes on before her periods, eases by end of period. no heavy clots. occasional dysparunia

what features may help differentiate the cause of abdominal and pelvic pain on examination?

Answer 2

Abdominal
- Rebound or guarding : peritonism (appendicitis, PID, ovarian torsion, endometriosis)

• localisation of pain: unilateral suggests ovarian pain
• shifting dullness: ascites in ovarian cancer
• Mass: hernia, fibroids

Pelvic
- pain in pouch of douglas

• unilateral or general pelvic discomfort
• endometriotic nodules posterior fornix
• pelvic mass: ovarian cyst, unilateral or bilateral, ectopic pregnancy
• cervical excitation (PID or ectopic)

Question 3

22 y/o female

pc: pelvic pain for 24hrs, uncomfortable
hpc: pain for long time, come son before her periods, eases by end of period. no heavy clots. occasional dysparunia

Dr suspects endometriosis.

What further investigations can be performed for endometriosis?

Answer 3

• pelvic ultrasound can exclude other pathologies such as ovarian cysts or large pelvic endometriosis deposits
• diagnostic laparoscopy and biopsy is gold standard

Question 4

management options for endometriosis?

Answer 4

• combined oral contraceptive
• danazol (weak androgen) and progestogens effective
• danazol may have side effects: acne, hair growth
• GnRH analogues

Question 5

list four differential diagnoses to endometriosis?

Answer 5

1. Pelvic inflammatory disease : dyspareunia, pelvic pain, abnormal and/or heavy bleeding
2. Ectopic pregnancy: dyspareunia, pelvic pain, abnormal bleeding
3. Fibroids: pelvic pain, HMB,
4. IBS: abdominal pain, dyspareunia and bloating

Question 6

gold standard investigation for diagnosis in endometriosis?

Answer 6

laparoscopy

Question 7

typical findings on laparoscopy of endometriosis?

Answer 7

• chocolate cysts
• adhesions
• peritoneal deposits

Question 8

management of endometriosis?

Answer 8

Pain: NSAID, analgesia

Ovulation: COCP, mirena

Surgery: excision, laser ablation