Pelvic and Ovarian disorders Flashcards
What is chronic pelvic pain?
- pain of at least 6 months duration that occurs below the umbillicus
- significantly impacts a woman’s daily fxning and relationships
- episodic-cyclic, recurrent pain that is interspersed with pain-free intervals
- continuous non-cyclic pain
- frustrates both pt and her clinician
- many times etiology not found or tx of presumed etiology fails: pain becomes the illness
How common is it to have no obvious pathology in chronic pelvic pain? Procedures used in these pts?
- 1/3 have no obvious pelvic pathology
- comprises of up to 10% of outpt gyn visits
- accounts for 40% of GYN laparoscopies
- accounts for 20% of hysterectomies
- approx 70,000 hysterectomies are performed annually due to chronic pelvic pain
Differential of chronic pelvic pain?
- 6 major sources: gyn GI urological psych musculoskeletal neuor - complete hx of pt's pain and good ROS
Etiologies of chronic pelvic pain?
episodic:
- dyspareunia
- midcycle pelvic pain (mittelschmerz)
- dysmenorrhea
continuous:
- endometriosis (mostly cyclic pain)
- adenomyosis
- chronic salpingitis (PID)
- adhesions
- loss of pelvic support
MC gyn etiologies of chronic pelvic pain?
- endometriosis is MC (1/3 CPP)
- PID 30% of women with PID develop CPP
- dysmenorrhea
- adenomyosis
- adhesions
- ovarian cysts
- ovarian cancer
RFs for CPP?
- hx of sexual abuse or trauma
- previous pelvic surgery
- hx of PID
- endometriosis
- personal or family hx of depression
- hx of other chronic pain syndromes
- hx of alcohol or drug abuse
- sexual dysfxn
Hx of pt with CPP?
- pain duration greater than 6 mo
- incomplete relief by most previous tx, including surgery and non-narcotic analgesics
- significantly impaired fxning at home or work
- signs of depression such as early morning awakening, wt loss, and anorexia
- pain out of proportion to pathology
- hx of childhood abuse, rape or other sexual trauma
- hx of sexual abuse
- current sexual dysfxn
- previous consultation with one or more health care providers and dissatisfaction with their management of her condition
PE of pt with CPP?
- systematic PE of abdominal, pelvic and rectal areas focusing on location and intensity of pain
- attempt to reproduce the pain
- note general appearance, demeanor, and gait..may suggest severity of pain and possible neuromusc. etiology
- if a fever: acute process
- if vomiting: acute process
- inspect and note any well healed scars
- palpate scars for incisional hernias
- palpate for femoral and inguinal hernias
- palpate for any unsuspected masses
What are abdominal sxs of a more acute process of pelvic pain?
- rebound tenderness (peritoneal irritation)
- increased abdominal pain on palpation with tension of rectus muscles
- straight leg raise:
decreases - pelvic origin
increases - abdominal wall or myofascial origin
What may be seen on speculum and bimanual/rectum exam in pt with CPP?
speculum: cervicitis - source of parametrial irritation
bimanual/rectal:
-tender pelvic or adnexal mass, abnormal bleeding, tender uterine fundus, cervical motion tenderness - then think acute process such as PID, ectopic pregnancy, or ruptured ovarian cyst
-non-mobility of uterus - presence of pelvic adhesions
- existence of adnexal mass, fullness, tenderness
- cul-de-sac nodularities = endometriosis
- ID any areas that reproduce deep dyspareunia
- palpate the coccyx, both internally and externally (rectal exam)
Dx tests for CPP?
- should be selected discriminately as indicated by findings of H&P
- avoid unecessary and repetitive dx testing
- serum HCG
- UA
- wet prep/KOH
- cervical cultures/GC and chlamydia
- CBC with diff
- ESR
-stool guaiac if + then do GI w/u - US to ID pelvic masses
- dx laparascopy may ID:
acute or chronic salpingitis, ectopic pregnancy, hydrosalpinc, endometriosis, ovarian tumors and cysts, torsion, appendicitis, adhesions
Tx of CPP?
- tx underlying cause
- psychosocial interventions
- meds:
avoid long term narcotic use
NSAIDs
antidepressants
OCPs - surgical interventions: dx and therapeutic laparoscopy
hysterectomy
Alt interventions for CPP?
- biofeedback
- stress management techniques
- self-hypnosis
- relaxation therapy
- transcutaneous nerve stimulation (TNS)
- trigger pt injections
- spinal anesthesia
- nerve blocks
What is PID?
- clinical syndrome assoc with ascending spread of microorganisms from vagina or cervix to endometrium, fallopian tubes, ovaries, and contiguous structures
- comprises of spectrum of inflammatory disorders including any combo of: endometritis, salpingitis, turbo-ovarian abscess, and pelvic peritonitis
PID: incidence and prevalence?
- occurs in approx 1 mill US women annually
- annual cost approx: $2 bill
- hospitalizations for acute PID steadily declined from approx 70,000 cases/yr in 1998 to 38,000 cases/yr in 2010
- outpt visits for PID also have declined primarily due to aggressive pop. based chlamydia screening and tx programs nationwide
RFs for PID?
- young age at onset of sexual activity
- new, multiple or sx partners
- unprotected sexual intercourse
- hx of PID
- gonorrhea or chlamydia or a hx of gonorrhea or chlamydia
- current vaginal douching
- insertion of IUD (w/in fist 3 wks)
- bacterial vaginosis
- sex during menses
Etiology of PID microbiology?
- most cases are polymicrobial
- MC pathogens:
N. gonorrhoeae - recovered from cervix in 30-40% of women with PID
C. trachomatis - recovered from cervix in 20-40% of women with PID - overgrowth of microorganisms that comprise vaginal flora: streptococci, staph, enterobacteriacea, anerobes, gardenella vaginalis, strep. agalactiae
Pathway of ascendant infection to PID?
go from cervicitis to endometritis to salpingitis/oophoritis/tubo-ovarian abscess to peritonitis
Complications of PID?
- approx 10-20% of women with a single episode of PID will experience sequela including:
ectopic preg.
infertility
tubo-ovarian abscess
chronic pelvic pain
fitz-hugh-curtis syndrome (perihepatitis) - tubal infertility occurs in 50% of women after 3 episodes of PID
What is the minimum criteria for dx of PID?
- uterine/adnexal tenderness or
- cervical motion tenderness (Positive chandelier sign)
Additional criteria to increase specificity of dx of PID?
- temp over 101F
- abnormal cervical or vaginal mucopurulent d/c (positive swab test)
- presence of WBCs on saline wet prep
- elevated ESR
- elevated CRP
- gonorrhea or chlamydia test positive
More specific criteria for dx PID?
- transvaginal US
- pelvic CT or MRI
- laparoscopy
- endometrial bx
PID tx considerations?
- tx should be instituted as early as possible to prevent long term sequelae
- need to tx sexual partners if +GC/chlamydia
- educate pt to avoid sexual activity until she and partner complete tx
- need close f/u to ensure cure
Tx for PID?
Regimens must provide coverage for N. gonorrhpeae, C. trachomatis, anaerobes, gram - bacteria and streptococci
- outpt first line:
ceftriaxone 250 mg IM single dose, and azithro 1 g PO once wkly x 2 wks
or
ceftriaxone and doxy 100 mg orally bid for 14 days
or
cefoxitin 2 g IM in single dose and probenecid 1 g orally in single dose and doxy 100 mg orally 2x a day for 14 days
- any of the above regimens with or w/o
metronidazole 500 mg orally bid for 14 days
F/U care for pt with PID?
- pts should demonstrate substantial improvement w/in 72 hrs
- pts who don’t improve usually reqr hospitalization, additional dx tests, and surgical intervention
- some experts recommend rescreening for C. trachomatis and N. gonorrhoeae 4-6 wks after completion of therapy in women with documented infection with these pathogens
