PELVIC MASS AND PAIN Flashcards
What is chronic pelvic pain?
Any pain in the lower abdomen or pelvis that lasts more than 6 months
In what proportion of chronic pelvic pain cases is a laparoscopy done and found no obvious cause?
In 1/3rd of cases
How common is chronic pelvic pain?
Common
Affects 1 in 6 women
Causes of chronic pelvic pain?
Endometriosis
PID
Interstitial cystitis - bladder inflammation
Ovarian cyst
Womb or ovarian cancer
Adenomyosis
Uterine fibroids
Adhesions
Pelvic venous congestion
Trapped or damaged nerves in pelvic area
Pelvic organ prolapse
MSK pain
IBS
Depression
Traumatic experiences e.g. sexual or physical abuse
Acute causes of pelvic pain in women?
UTI
Pelvic inflammatory disease
Ovarian cyst rupture or torsion
Appendicitis
Peritonitis
Ectopic pregnancy
Miscarriage
Ovulation pain - mittelschmerz
Flare up of a chronic condition e.g. endometriosis
dysmenorrhea
What can cause pelvic adhesions?
Endometriosis
Previous surgery
Previous infection
Pelvic pain which varies markedly over the menstrual cycle is likely to be attributable to what?
A hormonal driven condition e.g. endometriosis
Investigating chronic pelvic pain?
Daily pain diary for 2-3 menstrual cycles to help identify any provoking factors or temporal associations
Abdominal and pelvic examination
Screen for infection if sexually active
TVUSS and MRI for adnexal masses, adenomyosis
Diagnostic laparoscopy is “gold standard” for diagnosing pelvic pain and can see endometriosis
CA125 if any Sx of ovarian cancer
What is mittelschmerz and when does it occur?
Transient pelvic pain in the middle of their cycle
Caused by ovulation!
How does ovarian torsion present?
Sudden onset unilateral lower abdominal pain
May coincide with exercise
N&V are common
On examination - unilateral tender adnexal mass
How might an ovarian cyst present?
Unilateral dull ache which may be intermittent or only occur during intercourse. Torsion or rupture may lead to severe abdominal pain
Large cysts may cause abdominal swelling or pressure effects on the bladder
What is ovarian torsion?
Partial or complete torsion of the ovary on its supporting ligaments that may, in turn, compromise the blood supply
What is an adnexal torsion?
When there is torsion of the ovary and the fallopian tube
Risk factors for ovarian torsion?
Having an ovarian cyst is the biggest RF!
Being of a reproductive age
Pregnancy
Ovarian hyperstimulation syndrome
Vaginal examination findings in ovarian torsion?
Adnexial tenderness
USS findings for ovarian torsion?
Free fluid or a whirlpool sign
Management and diagnosis of ovarian torsion?
Laparoscopy - fixation
If necrotic then oophorectomy
What should you do if a woman has cyclic pelvic pain?
Offer a therapeutic trial of hormonal treatment e.g. GnRH analogues for 3-6 months before a diagnostic laparoscopy
Appropriate analgesia
Link between pelvic pain and physical/sexual/emotional abuse?
There is a link to chronic pelvic pain syndrome
Dyspareunia causes?
Infections - thrush, STI
Menopausal atrophic vaginitis
Lack of sexual arousal
Vaginal dryness e.g. sjogren’s syndrome
Vaginismus
Genital irritation or allergy caused by spermicides, latex condoms, soaps etc
Bartholin’s cyst
Lichen sclerosus or lichen planus
FGM
Congenital vaginal abnormalities
Rape and sexual assault
PID
Endometriosis
Fibroids
IBS
Constipation
Bladder pain e.g. UTI or interstitial cystitis
Most common cause of pelvic pain?
Primary dysmenorrhea
What is acute pelvic pain in women of a reproductive age with a positive pregnancy test until proven otherwise?
Ectopic pregnancy
How common is dyspareunia?
1 in 13 women in the UK - 7.5%
What is the broad ligament?
What is it made up of?
A flat sheet of peritoneum associated with the uterus and ovaries
Made up of mesometrium, mesovarium and mesosalpinx
What is the ovarian ligament connected to?
Connects the ovary to the side of the uterus
It lies within the broad ligament
What is the function of the suspensory ligament of the ovary?
It extendards outwards from the ovary to the lateral abdo and wall
Contains the ovarian vessels and nerves
Function of the round ligament?
Originates at the uterine horns and attaches to the labia majora, passing through the inguinal canal
Supports and anchors the uterus
(This often causes pelvic pain during pregnancy)
Ligaments of the pelvis?
Iliolumbar ligament
Sacrospinous ligament
Sacrotuberous ligament
What is pelvic venous congestion syndrome?
When varicose veins develop around the ovaries
Causes chronic pelvic pain unrelated to menstruation or pregnancy
What is vaginismus?
The body’s automatic reaction to the fear of vaginal penetration
Involuntary muscle spasms in the vagina when something enters it
Possible treatments for vaginismus?
Psychosexual therapy
Relaxation techniques
Pelvic floor exercises
Sensation focus
Vaginal trainers
What can cause vaginismus?
fearing that your vagina is too small
a bad first sexual experience
an unpleasant medical examination
believing sex is shameful or wrong
a painful medical condition, like thrush
Features of sexual abuse in a child?
pregnancy
sexually transmitted infections, recurrent UTIs
sexually precocious behaviour
anal fissure, bruising
reflex anal dilatation
enuresis and encopresis
behavioural problems, self-harm
recurrent symptoms e.g. headaches, abdominal pain
What is lichen simplex?
Whats its characterised by?
What causes it?
A chronic itchy skin disorder
Characterised by well demarcated, erythematous patches and plaques of thick, leathery skin
Caused by the chronic ‘itch-scratch’ cycle-> repetitive excoriation and scratching
What is lichen sclerosus?
Where does it usually affect?
Who normally gets it?
An inflammatory condition that usually affects the genitalia
More common in elderly females
How does lichen sclerosus present?
White patches that may scar
Prominent itch
May result in dyspareunia or dysuria
Management and follow up of lichen sclerosus?
Topical steroids and emollients
Follow up due to increased risk of vulval cancer. If there is clinical suspicion of VIN or cancer then biopsy
What is lichen planus?
How does it present?
A skin disorder of unknown aetiology, likely immune-mediated
Itchy, papular rash common on palms, soles, genitalia and flexor surfaces of arms.
Rash is often polygonal in shape with white-lines on the surface (wickhams striae)
Koebner phenomenon may be seen
Oral involvement in 50% - white-lace pattern on buccal mucosa
Thinning of nail plate and longitudinal ridging
Management of lichen planus?
Potent topical steroids
Benzydamine mouthwash or spray for oral lichen planus
What is Bartholin’s cyst?
When the ducts become blocked and the Bartholin’s glands expand to form a cyst
Sometimes linked to STIs or other bacterial infections
Who do Bartholin’s cyst most typically affect?
Sexually active women aged 20-30
Why are Bartholin’s cyst unlikely in children and after menopause?
Bartholin’s glands dont usually start functioning until puberty
They also commonly shrink after menopause
Types of benign ovarian cysts?
Physiological cysts
Benign germ cell tumours
Benign epithelial tumours
Benign sex cord stromal tumours
What should you do with any complex ovarian cyst?
Biopsy to exclude malignancy
Name of benign germ cell tumour?
Dermoid cyst - aka mature cystic teratomas!
What is the most common benign ovarian tumour in a woman under the age of 30?
Dermoid cysts (mature cystic teratoma)
most common benign epithelial ovarian tumours?
Serous cystadenoma
Mutinous cystadenoma
Less common - brenner tumour
2 types of physiological ovarian cysts?
Follicular cyst
Corpus luteum cyst
benign sex cord stromal oavrian tumour
Fibroma - most common
Sertoli-leydig tumour
What is the most common type of ovarian cyst?
Follicular cysts
What causes follicular cysts?
Prognosis?
Non-rupture of the dominant follicule, or failure of atresia in a non-dominant follicle
Commonly regress after several menstrual cycles
What is a corpus luteum cyst?
Is it more or less likely to present with intraperitoneal bleeding than follicular cysts?
If the corpus luteum doesnt break down as usual then it can fill with blood or fluid and form a cyst
More likely!
What is an endometrioma?
Aka a chocolate cyst
Present in those with endometriosis
There is bleeding into the cyst resulting in that appearance
Outline features of the ovarian cysts in PCOS?
When the ovaries contain more than 12 antral follicles or an ovarian volume greater than 10ml
Classic ‘ring of pearls’ sign if seen on USS
What are theca lutein cysts?
Rare, benign lesions responsible for gross cystic enlargement of ovaries during pregnancy
They result as a consequence of markedly raised hCG e.g. in a molar pregnancy
They regret upon resolution of the raised hCG
