PELVIC & OVARIAN DISORDERS Flashcards
ovarian torsion
complete or partial rotation of ovary on its ligamentous supports
- often impedes blood supply
⦁ ovary typically rotates around both the infundibulopelvic ligament & utero-ovarian ligament
when fallopian tube twists along with the ovary - torsion = called
adnexal torsion
- 50-60% of patient’s ovarian torsion = was secondary to an
ovarian mass
_______ ovarian torsion more common
right more common than left
why is right ovarian torsion more common than left
perhaps because right utero-ovarian ligament is longer than the left, or that presence of sigmoid colon on left side helps prevent it
presentation of ovarian torsion
⦁ abrupt onset of acute, severe, unilateral, lower abdominal & pelvic pain
⦁ often associated with N/V
⦁ often the severe pain comes on suddenly with a change in position
⦁ a unilateral, extremely tender adnexal mass is found in > 90% of patients
⦁ many patients noted intermittent previous episodes of similar pain for several days to several weeks
- often confused with appendicitis
Diagnosis of ovarian torsion
color flow Doppler US
Treatment for ovarian torsion
⦁ early diagnosis = can often be managed with conservative surgery
⦁ if necrosis is developing = need unilateral salpingo-oophorectomy = TOC (removal of FT & ovary)
what is chronic pelvic pain (CPP)?
Pain of AT LEAST 6 MONTHS duration that occurs below the umbilicus
CPP = chronic pelvic pain is Pain of AT LEAST __________ duration that occurs below the umbilicus
6 MONTHS
Chronic Pelvic Pain
- episodic-cyclic, recurrent pain that is interspersed with pain-free intervals
- or continuous non-cyclic pain
often times the etiology is not found or the treatment of the presumed etiology fails: and pain becomes the illness
most common gynecological cause of chronic pelvic pain
ENDOMETRIOSIS
ETIOLOGIES OF CPP
ETIOLOGIES OF CPP o EPISODIC ⦁ dysparuenia ⦁ midcycle pelvic pain (Mittelschmerz) ⦁ dysmenorrhea
o CONTINUOUS ⦁ Endometriosis (mostly cyclic pain) ⦁ Adenomyosis ⦁ Chronic salpingitis (PID) ⦁ Adhesions ⦁ Loss of pelvic support
RISK FACTORS FOR CPP
⦁ hx of sexual abuse/trauma ⦁ previous pelvic surgery ⦁ hx of PID ⦁ endometriosis ⦁ personal or family hx of depression ⦁ hx of other chronic pain syndromes (fibromyalgia) ⦁ hx of alcohol / drug abuse ⦁ sexual dysfunction
HISTORY OF CPP
- pain duration > 6 months
- incomplete relief from most treatments - including surgery & non-narcotic analgesics
- significantly impairs work/home
- signs of depression such as early morning awakening, weight loss, anorexia
- pain out of proportion to pathology
- hx of childhood abuse/rape/sexual trauma
- hx of substance abuse
- current sexual dysfunction
- previous consultation with 1+ providers & dissatisfaction with treatment/management
more of an acute process and not CPP
- fever
- vomiting
- rebound tenderness
- increased abdominal pain on palpation with tension of rectus muscles
straight leg raise on PE with CPP
⦁ decreased pain = think pelvic origin
⦁ increased pain = think abdominal wall or myofascial origin
PE for CPP
- inspect & note any well healed scars (may be CPP from surgery)
- palpate for any hernias (incisional, femoral, inguinal) & masses
o Do speculum exam; cervicitis?
o Bimanual / rectal exam - any masses, abnormal bleeding, tender
⦁ cervical motion tenderness = think acute process - such as PID, ectopic, or ruptured ovarian cyst
⦁ nonmobility of uterus = presence of pelvic adhesions
⦁ cul-de-sac nodularities = endometriosis
labs for CPP
⦁ serum hcg
⦁ UA
⦁ wet prep/KOH
⦁ cervical cultures / Gonorrhea & chlamydia
⦁ CBC with diff
⦁ ESR
⦁ Stool guiac - if positive = do GI workup
imaging for CPP
⦁ ULTRASOUND - to identify pelvic masses
⦁ Diagnostic Laparoscopy - may identify: acute or chronic salpingitis, ectopic pregnancy, hydrosalpinx, endometriosis, ovarian tumors/cysts, torsion, appendicitis, adhesions
CPP TREATMENT
- treat the underlying cause = #1 treatment
- psychosocial interventions
- Meds
⦁ avoid long-term narcotic use
⦁ NSAIDS
⦁ antidepressants
⦁ oral contraceptives
o Surgical Interventions
⦁ diagnostic & therapeutic laparoscopy
⦁ hysterectomy
PID
- **ASCENDING spread of bugs - spread of micro-organisms from vagina or cervix to the endometrium / fallopian tubes / ovaries & contiguous structures
- **ASCENDING spread of bugs - spread of micro-organisms from vagina or cervix to the endometrium / fallopian tubes / ovaries & contiguous structures
PID
Pain of AT LEAST 6 MONTHS duration that occurs below the umbilicus
CHRONIC PELVIC PAIN
Outpatient visits for PID have declined, primarily due to aggressive __________ screening
chlamydia
RISK FACTORS FOR PID
⦁ young age at onset of sexual activity ⦁ new, multiple, or symptomatic partners ⦁ unprotected sex ⦁ hx of PID ⦁ gonorrhea/chlamydia or hx of gonorrhea/chlamydia ⦁ current vaginal douching ⦁ insertion of IUD (within first 3 weeks) ⦁ BV ⦁ sex during menses
most cases of PID are _______
polymicrobial
MOST COMMON PID PATHOGENS
⦁ N. gonorrhoeae - 30-40%
⦁ C. trachomatis - 20-40%
⦁ others = streptococci, staphylococci, enterobacteria, anaerobes, gardnerella vaginalis, strep agalactiae
PATHWAY OF ASCENDING INFECTION (PID)
- cervicitis –> endometritis –> salpingitis / oophoritis / tubo-ovarian abscess –> peritonitis
COMPLICATIONS WITH PID
- approx 10-20% of women with a single PID episode will experience sequelae, including
⦁ ectopic pregnancy
⦁ infertility
⦁ tubo-ovarian abscess
⦁ chronic pelvic pain
⦁ Fitz-Hugh-Curtis syndrome (perihepatitis)
Tubal infertility occurs in 50% of women after ________________ episodes of PID
3
____________ occurs in 50% of women after 3 episodes of PID
tubal infertility
