Pelvic and Ovarian Disorders Flashcards
What is chronic pelvic pain?
5
- Pain of at least 6 months’ duration that occurs below the umbilicus
- Significantly impacts a woman’s daily functioning and relationships
- Episodic-cyclic, recurrent pain that is interspersed with pain-free intervals
- Continuous non-cyclic pain
- Many times etiology not found or treatment of presumed etiology fails: pain becomes the illness
Six major sources need to be considered for pelvic pain?
6
- Gynecological
- Gastrointestinal
- Urological
- Psychological
- Musculoskeletal
- Neurological
Etiologies of Chronic Pelvic Pain
- episodic? 3
- Continuous? 5
- Episodic
- dyspareunia
- midcycle pelvic pain (Mittelschmerz)
- dysmenorrhea - Continuous
- Endometriosis (mostly cyclic pain)
- adenomyosis
- chronic salpingitis (PID)
- adhesions
- loss of pelvic support
- What is the most common gynecological cause of CPP?
2. What are other gynecological causes? 6
- Endometriosis
- PID: 30% of women w/ PID develop CPP
- Dysmenorrhea
- Adenomyosis
- Adhesions
- Ovarian cysts
- Ovarian cancer
Risk Factors for
Chronic Pelvic Pain
8
- History of sexual abuse or trauma
- Previous pelvic surgery
- History of PID
- Endometriosis
- Personal or family history of depression
- History of other chronic pain syndromes
- History of alcohol and drug abuse
- Sexual dysfunction
Chronic Pelvic Pain: History findings
9
- Pain duration > 6 months
- Incomplete relief by most previous treatments, including surgery and non-narcotic analgesics
- Significantly impaired functioning at home or work
- Signs of depression such as early morning awakening, weight loss, and anorexia
- Pain out of proportion to pathology
- History of childhood abuse, rape or other sexual trauma
- History of substance abuse
- Current sexual dysfunction
- Previous consultation with one or more health care providers and dissatisfaction with their management of her condition
Chronic Pelvic Pain: Physical Exam
7
- Systematic PE of abdominal, pelvic, and rectal areas, focusing on the location and intensity of the pain
- Attempt to reproduce the pain
- Note general appearance, demeanor, and gait… may suggest the severity of the pain and possible neuromuscular etiology.
- inspect & note any well healed scars
- palpate scars for incisional hernias
- Palpate for femoral and inguinal hernias
- Palpate for any unsuspected masses
Chronic Pelvic Pain: Physical Exam
-Abdominal symptoms of more acute process? 5
- rebound tenderness (peritoneal irritation)
- increased abdominal pain on palpation with tension of the rectus muscles
- straight leg raise
- Decrease…. pelvic origin
- increase …. abdominal wall or myofascial origin - Fever?…acute process
- Vomiting?…acute process.
Chronic Pelvic Pain: Physical Exam
1. Speculum exam: What would be the source of parametrial irritation?
- Bimanual/rectal exam: What may be findings for this? 5
- If you see these symptoms what should you think? 3
- Palpate the ________, both internally and externally
- Cervicitis
- tender pelvic or
- adnexal mass,
- abnormal bleeding,
- tender uterine fundus,
- cervical motion tenderness
- Think acute process such as
- PID,
- ectopic pregnancy, or
- ruptured ovarian cyst - coccyx
What would the following findingd on bimanual/rectal exam show:
- Non-mobility of uterus?
- Cul-de-sac nodularities?
- Identify any areas that reproduce what?
- Cerival motion tenderness also called?
- presence of pelvic adhesions
- endometriosis
- deep dyspareunia
- Chandelier sign
Diagnostic Tests for Chronic Pelvic Pain
8
- Should be selected discriminately as indicated by the findings of the H & P
- Avoid unnecessary and repetitive diagnostic testing
- Serum HCG
- UA
- Wet prep/KOH
- Cervical cultures/GC and chlamydia
- CBC with diff
- ESR
- Stool guaiac…if + do GI w/u
- Ultrasound to identify pelvic masses
CPP: Diagnostic laparascopy may identify?
8
- acute or chronic salpingitis
- ectopic pregnancy
- hydrosalpinx
- endometriosis
- ovarian tumors and cysts
- torsion
- appendicitis
- adhesions
Treatment of Chronic Pelvic Pain
3
May have a surgical interventions? 2
- Treat underlying cause
- Psychosocial interventions
- Medications
- diagnostic and therapeutic laparoscopy
- hysterectomy
Medications for CPP? 3
Avoid what? 1
- NSAIDs
- antidepressants
- oral contraceptives
- Avoid long-term narcotic use
CPP: Alternative interventions
8
- biofeedback
- stress management techniques
- self-hypnosis
- relaxation therapy
- transcutaneous nerve stimulation (TNS)
- trigger-point injections
- spinal anesthesia
- nerve blocks
Pelvic Inflammatory Disease
1. What is it?
- Comprises a spectrum of inflammatory disorders including any combination of what? 4
- Clinical syndrome associated with ascending spread of microorganisms from the vagina or cervix to the endometrium, fallopian tubes, ovaries, and contiguous structures.
Comprises a spectrum of inflammatory disorders including any combination of:
- endometritis,
- salpingitis,
- tubo-ovarian abscess, and
- pelvic peritonitis.
PID Risk Factors
9
- Young age at onset of sexual activity
- New, multiple, or symptomatic partners
- Unprotected sexual intercourse
- History of PID
- Gonorrhea or chlamydia, or a history of gonorrhea or chlamydia
- Current vaginal douching
- Insertion of IUD (within 1st 3 weeks)
- Bacterial vaginosis
- Sex during menses
PID Microbial Etiology
2
- Overgrowth of microorganisms that comprise the vaginal flora such as? 6
- N. gonorrhoeae: recovered from cervix in 30%-40% of women with PID
- C. trachomatis: recovered from cervix in 20%-40% of women with PID
- streptococci,
- staphylococci,
- Enterobacteriaceae,
- anerobes,
- gardenella vaginalis,
- strep. agalactiae.
PID: Pathway of Ascendant infection?
4
- Cervicitis
- Endometritis
- Salpingitis/ oophoritis/ tubo-ovarian abscess
- Peritonitis
Complications of PID
5
Approximately 10-20% of women with a single episode of PID will experience sequelae, including:
1. ectopic pregnancy
2. Infertility
3. Tubo-ovarian abscess
chronic pelvic pain
4. Fitz-hugh-curtis syndrome (perihepatitis)
5. Tubal infertility occurs in 50% of women after three episodes of PID
Minimum Criteria in the Diagnosis of PID
2
- Uterine/adnexal tenderness or
2. Cervical motion tenderness (positive Chandelier Sign)
Additional Criteria to Increase Specificity of Diagnosis
6
More Specific Criteria 4
- Temperature >38.3°C (101°F)
- Abnormal cervical or vaginal mucopurulent discharge
- Presence of WBCs on saline wet prep
- Elevated erythrocyte sedimentation rate (ESR)
- Elevated C-reactive protein (CRP)
- Gonorrhea or chlamydia test positive
- Transvaginal ultrasound
- Pelvic CT or MRI
- Laparoscopy
- Endometrial biopsy
General PID Considerations
1. Treatment should be instituted when?
- Need to treat sexual partners if what?
- Educate patient to avoid what?
- as early as possible to prevent long term sequelae
- +GC/Chlamydia
- sexual activity until she and partner complete treatment.
- Need close f/u to ensure cure.
PID Treatment
1. Regimens must provide coverage of what? 5
- Outpatient first line therapy?
(3 combinations) + (may add what?)
- N. gonorrhoeae,
- C. trachomatis,
- anaerobes,
- Gram-negative bacteria, and
- streptococci
- Ceftriaxone 250 mg IM in a single dose, AND azithromycin 1 g PO once weekly x 2 weeks
- Ceftriaxone 250 mg IM in a single dose AND doxycycline 100 mg orally 2 times a day for 14 days
- Cefoxitin 2 g IM in a single dose AND Probenecid 1 g orally in a single dose, AND Doxycycline 100 mg orally 2 times a day for 14 days
-WITH OR WITHOUT
Metronidazole 500 mg orally 2 times a day for 14 days