Pelvic Mass / Pain Flashcards
PAINFUL PERIODS
history
- Pain – location, character, duration
- GI symptoms – nausea, vomiting, diarrhoea, constipation, pain associated to bowel opening
- Urinary symptoms – dysuria, frequency
- Menstrual history – age of menarche, typical cycle length and regularity, normal period duration and symptoms, tampons / pads (how many, how often change, use together, flooding), effects on school and other activities
- Treatment – have they tried NSAIDs etc, was it effective
- Medical history – surgery, family history (endometriosis)
- Sexual history – first intercourse, male/femal partners, route of intercourse, contraception, history of symptoms of STI, vaccination, pain or bleeding during sex
PAINFUL PERIODS
examination
Abdominal examination • Palpable masses • Location of tenderness • Auscultate for bowel bounds • Previous scars
Pelvic examination
• Not in adolescent who has never been sexually active
• Only indicted if; sexually active and not responding to conventional treatment or organic pathology suspected
• Speculum examination
• Bimanual examination
• STI testing
PRIMARY DYSMENORRHOEA
- age of presentation
- responds well to…
- concerning features
- making a diagnosis
- Presents in teenage years
- NSAIDs
- dyspareunia, post coital bleeding, vaginal discharge, menorrhagia, unilateral pain
- Diagnosis of exclusion
•Abdominal USS if; palpable abdominal mass, not responding to treatment
• Consider bloods to rule out: FBC, ferritin and iron studies, ESR, CRP
causes of secondary dysmenorrhoea
Endometriosis
Adenomyosis
OVARIAN CYST
- what is it
- who gets it
- Fluid filled sac in ovary. Small cysts nor concerning unless symptomatic, resolution usually seen on US after a few weeks (scan after 12 weeks)
Potentially malignant – RMI (risk of malignancy index) - Common in premenopausal women
OVARIAN CANCER
- where does it derive from
- risk factors
- protective factors
- associated genes
- Derive from surface epithelial irritation during ovulation
- More ovulation = increased risk, nulliparity, early menarche, late menopause, HRT, smoking, obesity
- multiparity, combined contraceptives, breastfeeding
- BRCA1 +2 / HNCCP – lynch 2 syndrome
OVARIAN CANCER
risk of malignancy index and how is it calculated
risk stratification tool in patients with suspected ovarian cancer
RMI = U X M X CA125
M = menopausal status (1=premenopausal / 3= post menopausal)
U = ultrasound score -mulilocular cyst, solid area, metastases, ascites, bilateral lesions - (1 feature = 1 point / 2 or more features = 3 points
OVARIAN CYST
clinical features
- Incidental and asymptomatic – scanning for other reasons eg pregnancy
- Chronic pain – may develop secondary to pressure on bladder or bowel causing frequency of constipation – may manifest as dyspareunia or cyclical pain in patients with endometriosis
- Acute pain – bleeding into the cyst, rupture or torsion
- Bleeding per vagina
OVARIAN CYST
classification
- Divided into non-neoplastic and neoplsastic
- Simple ovarian cyst only contains fluid
- Complex ovarian cyst can be irregular and can contain solid material, blood, or have septations or vascularity
- Non neoplastic – functional (follicular cyst <3cm / corpus luteal cyst <5cm) OR Pathological (endometrioma aka chocolate cysts / polycystic ovaries these contain more than 12 antral follicles or volume >10ml, ring of pearls sign, seen in PCOS / theca lutein cyst due to raised hCG such as molar pregnancy
- Benign neoplastic – epithelial (serous cystadenoma, mucinous cystadenoma, brenner tumour) / benign germ cell tumours (mature cystic teratoma) / sex cord stromal tumours (fibroma)
OVARIAN CYST
management in premenopausal women
- CA125 doesn’t need to be undertaken when diagnosis of simple cyst has been made by US as it can be raised by anything irritating the peritoneum so there are many benign triggers.
- Lactate dehydrogenase, alphafetoprotein and hCG should be measured in all women under 40 due to possible germ cell tumours
- Rescan a cyst in 6 weeks
- If persistent or over 5cm consider laparascopic cystectomy or oophorectomy
OVARIAN CYST
management in post menopausal women
- If low RMI <25 – follow up for 1 year with US and CA125 if less than 5cm
- Moderate RMI 25-250 – bilateral oophorectomy and if malignancy found staging required
- High RMI >250 – referral for staging laparotomy
FIBROIDS
what are they
- Leiomyomas
- Benign smooth muscle tumours of uterus
- Most common benign tumours in women with estimated incidence of 20-40%
- Low risk of becoming malignant
FIBROIDS
pathophysiology
- Arise from myometrium and classified according to position
- Intraluminal – common and confined to myometrium of the uterus
- Submucosal – develops immediately endometrium of uterus and protrudes into uterine cavity
- Subserousal – protrudes into and distorts serousal surface of uterus. They may be peuculated
- Growth stimulated by oestrogen
FIBROIDS
risk factors
- Obesity
- Early menarche
- Increasing age
- Family history
- Ethnicity – African americans
FIBROIDS
clinical features
- Pressure symptoms+/- abdominal distention – urinary frequency of chronic retention
- Heavy menstrual flow
- Subfertility – obstructive effect
- Acute pelvic pain – rare- may occur in pregnancy due to red degeneration
FIBROIDS
examination and investigetions
Examination
• Solid mass or enlarged uterus
• Usually non tender
Investigations
• Imaging
• Pelvic ultrasound
• MRI
FIBROIDS
management
- Tranexamic or mefenamic acid
- Hormonal contraceptives - COCP, POP, mirena IUS
- GnRH analogues - suppress ovulation including temporary menopause state, useful pre-operatively to reduce siz and lower complications / used for 6 month – risk of osteoporosis
- Selective progesterone receptor modulators (ulipristal/esmya) – reduce size and menorrhagia, useful preo-operatively or alternative to surgery
- Surgery – hysterectomy and transcervical resection of fibroid, myomectomy, uterine artery embolization, hysterectomy
ADENOMYOSIS
what is it and main symptoms
- Presence of functional endometrial tissue within myometrium of uterus
- Benign invasion of middle layer of uterine wall
- Main symptoms – menorrhagia and dysmenorrhoea, frequently occurs with fibroids
ADENOMYOSIS
aetiology and pathophysiology
- Present of endometrial tissue with myometrium of uterus
- Occurs when endometrial stoma communicates with underlying myometrium after uterine damage
- Occurs in association with; pregnancy and childbirth, caesarean section, uterine surgery, surgical management of miscarriage or termination of pregnancy
- Invasion of endometrium can be focal or diffuse and commonly in posterior wall of uterus
- When collection of endometrial glands form grossly visible nodules – described as adenomyoma
ADENOMYOSIS
risk factors
- High parity
- Utrine surgery eg any endometrial curettage, endometrial ablation
- Previous caesarean section
- Hereditary
ADENOMYOSIS
clinical features
- Menorrhagia
- Dysmenorrhoea – progressive, beginning as cyclical pain but worsen to daily pain
- Deep dyspareunia
- Irregular bleeding
- Symmetrically enlarged tender uterus palpable
ADENOMYOSIS
differentials
- Assess based on history for other conditions
- Endometriosis
- Fibroids
- Endometrial hyprplasia
- Endometrial polyp
- Pelvic inflammatory disease
- Hypothyroidism and coagulation disorder
ADENOMYOSIS
investigations
- Histological after hysterectomy
- Transvaginal ultrasound
- MRI – shows endo-myometrial junctional zone
ADENOMYOSIS
management
- Only curtive treatment is hysterectomy
- NSAIDs
- Hormone therapy – COCP, progestogens, gonadotropin releasing hormone agonists, aromatase inhibiters
- Non hormonal treatments- uterine artery embolization – short and mediam term to avoid hysterectomy and preserve fertility. Aim to block blood supply to adenomyosis, causing it to shrink
- Endometrial ablation and resection
- Laparoscopic excision and MR guided focused ultrasound
ECTOPIC PREGNANCY
- what is it
- incidence
- most common sites
- less common sites
- Pregnancy implanted outside the uterine cavity
- 1 in 80-90 pregnancies
- ampulla and isthmus of fallopian tube
- ovaries, cervix, peritoneal cavity
ECTOPIC PREGNANCY
risk factors
previous ectopic, pelvic inflammatory disease, endometriosis, intrauterine devise or system, progesterone oral contraceptive or inplant, tubal ligation or occlusion, pelvic surgery especially tubal, assisted reproduction
ECTOPIC PREGNANCY
clinical features
• Pain (lower abdominal/pelvic) with or without bleeding
• History of amenorrhoea
• Vaginal bleed due to decidual breakdown in uterine cavity due to suboptimal beta-HCG where as bleeding from ruptured ectopic pregnancy is usually intra-abdominal not vaginal
• Shoulder tip pain – irritation of diaphragm (share C3-C5 dermatomes)
vaginal discharge – brown, akin to prune juice – due to decidua breaking down
• Localised abdominal tenderness
• Vaginal examination – cervical excitation and/or adnexal tenderness, fullness in pouch of douglas
• If ruptured – may be haemodynamically unstable (pallow, increased CRT, tachycardic, hypotension) with signs of peritonitis (abdominal rebound tenderness and guardig
ECTOPIC PREGNANCY
investigations
- Pregnancy test
- If+ve -> pelvic USS to detect if intrauterine if not seen offer transvaginal scan
- If pregnancy cannot be located on USS but beta HCG is positive = pregnancy of unknown location which can be either; very early intrauterine prganncy, miscarriage, ectopic pregnancy. serum beta HCG if >1500iU and no intrauterine pregnancy on transvaginal ultrasound consider ectopic until proven otherwise and diagnostic laparoscopy / if <1500iU and stable, take further blood in 48 hours – viable pregnancy level would double every 48 hours, in miscarriage it would half every 48 hours, if it dosnt follow either of these patterns ectopic cannot be excluded
ECTOPIC PREGNANCY
management
- A-E approach if unstable
- Medical: IM methotrexate and monitor serum beta HCG to ensure resolution
- Surgical: laparoscopic salpingectomy – remove ectopic and tube / Salpingotomy may be needed if contralateral tube is damaged from infection etc
- Conservative – watchful waiting, only suitiable in small proportion of women, monitor beta hcg every 48hrs, only in stable patients with well controlled pain and low baseline hcg, small unruptured ectopic on USS
PELVIC INFLAMMATORY DISEASE
what is it and who gets it
- Infection of upper genital tract in women affecting uterus, fallopian tubes and ovaries
- Highest prevelanc in sexually active 15-24 yr olds
PELVIC INFLAMMATORY DISEASE
pathophysiology
- Infective inflammation of endometrium, uterus, fallopian tubes, ovaries and peritoneum
- Due to spread of bacterial infection from vagina or cervix to upper genital tract
- Chlamydia trachomatis and Neisseria gonorrhoea – 25% cases / streptococcus bacteriodes and anaerobes
PELVIC INFLAMMATORY DISEASE
risk factors
- Sexually active
- Aged under 15-24
- Recent partner change
- Intercourse without contraceptive protection
- History of STIs
- Personal history of PID
- Instrumentation of cervix – gynaecological surgery, termnation of pregnancy, insertion of intrauterine contraceptive
PELVIC INFLAMMATORY DISEASE clinical features (examinations and differentials)
- Lower abdominal pain
- Deep dyspareunia
- Menstrual abnormalities (menorrhagia, dysmenorrhoea, intermenstrual bleeding
- Post coital bleeding
- Dysuria
- Abnormal vaginal discharge
- Advanced cases – severe lower abdo pain, fever, nausea and vomiting
- Examination – tenderness of uterus or cervical excitation, palpable mass
- Differentials – ectopic, ruptured ovarian cyst, endometriosis, UTI
PELVIC INFLAMMATORY DISEASE
investigations
- Identify infective organisms
- Endocervical swabs – gonorrhea and chlamydia
- High vaginal swabs – trichomonas vaginalis and bacterial vaginosis
- Swab testing via NAAT (nucleic acid amplification)
- Full STI screen (HIV, syphilis, gonorrhoea, chlamydia
- Urine dipstick – exclude UTI
- Pregnancy test
- Transvaginal USS – severe disease or diagnostic uncertainty
- Lapararoscopy - observe gross inflammatory changes and peritoneal biopsy
PELVIC INFLAMMATORY DISEASE
management
- Antibiotic
- 14 day broad spectrum with good anaerobic coverage eg doxygygline, ceftraizone, metronidazole, ofloxacin, metronidazole
- Consider analgesics eg paracetamol
- Rest and avoid sexual intercouse until antibiotics complete
- All sexual partners for last 6 months should be tested and treated to prevent recurrence and spread of infections
- Admit to hospital if: pregnant especially if risk of ectopic, severe symptoms eg nausea, vomiting, high fever, signs of pelvic peritonitis, unresponsive to oral antibiotics, need for IV therapy, need for emergency surgery or suspicial of alternative diagnosis
other differentials for painful periods
Constipation, colitis, UTI, STI, IBS
DIAGNOSTIC LAPAROSCOPY
what is it
Diagnostic laparoscopy is a surgical procedure that doctors use to view a woman’s reproductive organs. A laparoscope, a thin viewing tube similar to a telescope, is passed through a small incision (cut) in the abdomen. Using the laparoscope, the doctor can look directly at the outside of the uterus, ovaries, fallopian tubes, and nearby organs.
A female pelvic laparoscopy is often recommended when other diagnostic tests, such as ultrasound and X-ray, cannot confirm the cause of a condition. Your doctor might use laparoscopy to:
• Find the cause of pain in the pelvic and abdominal regions
• Examine a tissue mass
• Confirm endometriosis or pelvic inflammatory disease
•Look for blockage of the fallopian tubes or for other causes of infertility
ENDOMETRIOSIS
pathophysiology
- Chronic condition
- Endometrial tissue located at sites other than uterine cavity
- Occur in ovaries, pouch of douglas, uterosacral ligaments, pelvic peritoneum, bladder, umbiius and lungs
- 25-40yrs
- Theory – retrograde menstruation – endometrial cells travel backwards from uterine cavity through fallopian tubes and deposit on pelvic organs where they seed and grow. These cells may be able to travel to distant sites through lymphatic system and vasculature
- Endometrial tissue is sensitive to oestrgen to symptom depends on individuals menstrual cycle
- Bleeding from ectopic tissue during menstruation causing pain and bloating/distenstion at ectopic stes.
- Repeated inflammation and scarring can lead to adhesions
- Sympoms reduced during pregnancy and menopause
ENDOMETRIOSIS
risk factors
- Early menarche
- Family history
- Short menstrual cycles
- Long duration of menstrual bleeding
- Defects in uterus or fallopian tubes
ENDOMETRIOSIS
clinical features
- Cyclic pelvic pain which occurs at time of menstruation
- If adhesions have formed then pain can be constant
- Dysmenorrhoea, dyspareunia, dysuria, dyschezia (difficult, painful defecating), subfertility
- If at distant sites may have focal symptoms of bleeding eg ectopic endometrial tissue in lungs may produce features of haemothorax at time of menstruation
- Bimanual examination: fixed, retroverted uterus, uterosacral ligament nodules, general tenderness
- Differentials: pelvic inflammatory disease
- Ectopic pregnancy
- Fibroids
- IBS
ENDOMETRIOSIS
investigation
- Laparoscopy – differentiate between endometriosis and chronic infection
- Chocolate cycts
- Adhesions
- Peritoneal depositis
- Pelvic ultrasound scan – determine severity of endometriosis – ‘kissing ovaries’
ENDOMETRIOSIS
pain management
- Analgesia
* NSAIDs
ENDOMETRIOSIS
ovulation management
- Suppressing ovulation for 6-12 months can cause atrophy of endometriosis lesions and cuase reduction in symptoms
- Low dose COCP or norethisterone
- Injected hormones
- Intrauterine device eg mirena coil
ENDOMETRIOSIS
surgical managment
- Used if endometriosis symptoms seriously affect patients life
- Excision, fulgaration, laser ablation aim to completely remove the ectopic endometrial tissue in the peritoneum, uterine muscle and pouch of douglas to reduce pain
- Relapses almost always occur an surgery may need t be repeated
- Ultimate management may be hysterectomy and removal of ovaries with replacemet of hormones until menopause
