Pelvic pain Flashcards by Shaili Kadambande

Pelvic pain differentials

Urinary tract infection
Dysmenorrhoea (painful periods)
Irritable bowel syndrome (IBS)
Ovarian cysts
Endometriosis
Pelvic inflammatory disease (infection)
Ectopic pregnancy
Appendicitis
Mittelschmerz (cyclical pain during ovulation)
Pelvic adhesions
Ovarian torsion
Inflammatory bowel disease (IBD)

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acute pelvic pain causes

PID
appendicitis
functional ovarian cyst
Ovarian hyperstimulation syndrome
fibroid torsion
renal colic
adnexal torsion

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adnexal torsion scoring system

1: unilateral lumbar or abdominal pain
2: pain duration >8 hours
3: vomiting
4: absence of leucorrhea/ metrorrhagia
5: ovarian cyst >5cm by ultrasound

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symptoms of adexal torsion

Pelvic or abdominal pain

Fluctuating

Radiating to loin or thigh

N/V

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type of pain in adnexal torsion

intermittent, colicky, acute pain, nausea, vomiting, pyrexia

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renal colic type of pain

loin to groin pain

unilateral

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fibroid torsion type of pain

constant, severe pain

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ovarian hyperstimulation syndrome

bloating
pelvic pain
N/V

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signs of adnexal torsion

pyrexia
tachycardia
generalised abdominal tenderness
localised guarding
rebound
cervical excitation
adnexal tenderness
adnexal mass

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diagnosis of adnexal torsion

USG pelvis
tumour markers
raised CRP/ WCC

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treatment of adnexal torsion

admit
IV fluids
pain relief
surgery

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fibroid degeneration management

Palpable mass

Inflammatory markers raised

Conservative especially in pregnancy:
Pain relief
Hydration
Antibiotic

Emergency surgery due to pedunculated fibroid torsion

Suspicious of sarcoma hysterecomy

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acute PID risk factors

Non use of barrier contraception

Previous episodes

Earlier age at first intercourse

Multiple sexual partners

Diabetes

Immunocompromised

Co-existing endometriosis

Reported in non sexually active women

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acute PID presentation

Asymptomatic

Lower abdominal pain

Pyrexia

Vaginal discharge- yellow or green

Dyspareunia

IMB and PCB

O/E: pyrexia, vaginal discharge, cervical excitation

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investigations acute PID

Pregnancy test

FBC, CRP, WCC

MSU

Triple swabs

USG- pelvis, abdomen

X-RAY

Diagnostic laparoscopy

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out-patient PID mx

Even if triple swabs are negative, It doesn’t exclude PID

Outpatient- mild to moderate

IM ceftriaxone 500mg single dose followed by oral doxycycline 100mg twice daily plus metronidazole 400mg twice daily for 14 days

in-patient PID mx

IV ceftriaxone 2g daily plus I.v doxycycline 100mg twice daily

Followed by oral doxycycline 100mg twice daily plus oral metronidazole 400mg twice daily for a total of 14 days

Surgical treatment: laparoscopy/ laparotomy for drainage

Counselling: risk of ectopic, subfertility

Follow up

Partner notification and treatment

haematocolpos features

Cyclical pain

No bleeding

Examination bluish membrane at intrioitus

I&D, cruciate incision

chronic pelvic pain features

Intermittent or constant pain

In the lower abdomen or pelvis

At least 6 months in duration

Not occurring exclusively with menstruation or intercourse and not associated with pregnancy

pathophysiology of chronic pelvic pain

Acute pain- resolves when tissue heals

Chronic pain- additional factors contribute hence pain persists longer

Local factors at the site of pain:
Chemokines and TNFa affect peripheral nerves
CNS response: persistent pain lead to changes within the CNS which eventually magnify the original signal
Visceral hyperalgesia- alteration in visceral sensation and function

causes of chronic pelvic pain

E&A

MSK

PID

Adhesions

Social and psychological factors

IBS

endometriosis incidence

10-15% of all women of reproductive age and 70% of women with chronic pelvic pain

More common in women with infertility

Rare in post-menopausal women (oestrogen-dependent)

endometriosis aetiology

Precise aetiology remains unclear

Retrograde menstruation (Sampson’s theory)

Coelomic metaplasia (Meyer’s theory)

Mullerian remnants

clinical presentation of endometriosis

Painful periods (dysmenorrhea)

Painful intercourse (dyspareunia)

Painful defecation (dyschezia)

Painful urination (dysuria)

Heavy periods

Lower abdominal pain persistent

IMB and PCB

Epitaxis, rectal bleeding

Little correlation between symptom severity and disease severity

clinical examination of endometriosis

NAD Thickened uterosacral ligaments Fixed retroverted uterus Uterine/ ovarian enlargement Forniceal tenderness Uterine tenderness

medical management of endometriosis

All hormonal medical therapies suppress ovulation COCP Continuous progestogen therapy (MPA) GnRH analogues (nasal spray/ implants) +/- HRT 'add back' therapy Danazol Mefenamic acid/ tranexamic acid

surgical management of endometriosis

Laparoscopic- diathermy, laser TAH + BSO: Risk of bladder, ureteric, bowel injury Risk of subtotal hysterectomy Role of HRT

adhesions types

Vascular adhesions Residual ovary syndrome Trapped ovary syndrome Treatment: May be division of vascular adhesions Removal of residual ovary

ROME III criteria for IBS

Continuous or recurrent abdominal pain or discomfort on at least 3 days a month in the last 3 months Onset at least 6 months previously Associated with at least 2 of the following: Improvement with defecation Onset associated with a change in frequency of stool Onset associated with a change in the form of stool

treatment of IBS

antispasmodic | mebeverine hydrochloride

MSK pain

Joints in the pelvis Damage to the muscles in the abdominal wall or pelvic floor Pelvic organ prolapse may also be a source of pain Trigger points- localised areas of deep tenderness- chronic muscle contraction

treatment of MSK pain

Analgesia Physiotherapy Nerve modulation Antidepressant

nerve entrapment

Highly localised, sharp, stabbing or aching pain Exacerbated by particular movements, and persisting beyond 5 weeks oc occuring after a pain free interval 3.7 % in Pfannensteil scars

management of nerve entrapment

Analgesia Physiotherapy Nerve modulation Antidepressant

initial assessment of chronic pelvic pain

Keep all factors in mind History- pattern of the pain Association- psychological, bladder and bowel symptoms, and the effect of movement and posture Rule out red flags symptoms Prospective pain diary for 2-3 months Effect on quality of life and function Symptoms based diagnostic criteria- 98% of iBS

examination for chronic pelvic pain

Abdominal and pelvic Focal tenderness Trigger points- abdominal wall and/or pelvic floor Enlargement, distortion or tethering, or prolapse Sarcoiliac joints of the symphysis pubis

investigations for chronic pelvic pain

STI screening TVS- identify and assess adnexal mass TVS and MRI- useful tests to diagnose adenomyosis The role of MRI in diagnosing small deposits of endometriosis is uncertain Laparoscopy: Not second line after therapeutic intervention- peritoneal disease Not helpful for IBS, IC and adenomyosis diagnosis Carries risk of death 1:10,000 and organ injury 2.4:1,000

treatment for chronic pelvic pain

Treat the cause Cyclical pain should be- therapeutic trial using hormonal treatment for a period of 3-6months before having a diagnostic laparoscopy IBS- antispasmodics and lifestyle changes Optimise pain relief Referral to dedicated chronic pelvic pain team