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Gynaecology > Pelvic pain > Flashcards

Pelvic pain Flashcards

1
Q

Pelvic pain differentials

A 
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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2
Q

acute pelvic pain causes

A 
PID
appendicitis
functional ovarian cyst
Ovarian hyperstimulation syndrome
fibroid torsion
renal colic
adnexal torsion
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3
Q

adnexal torsion scoring system

A

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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4
Q

symptoms of adexal torsion

A

Pelvic or abdominal pain

Fluctuating

Radiating to loin or thigh

N/V

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5
Q

type of pain in adnexal torsion

A

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

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6
Q

renal colic type of pain

A

loin to groin pain

unilateral

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7
Q

fibroid torsion type of pain

A

constant, severe pain

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8
Q

ovarian hyperstimulation syndrome

A

bloating
pelvic pain
N/V

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9
Q

signs of adnexal torsion

A 
pyrexia
tachycardia
generalised abdominal tenderness
localised guarding
rebound
cervical excitation
adnexal tenderness
adnexal mass
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10
Q

diagnosis of adnexal torsion

A

USG pelvis
tumour markers
raised CRP/ WCC

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11
Q

treatment of adnexal torsion

A

admit
IV fluids
pain relief
surgery

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12
Q

fibroid degeneration management

A

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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13
Q

acute PID risk factors

A

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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14
Q

acute PID presentation

A

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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15
Q

investigations acute PID

A

Pregnancy test

FBC, CRP, WCC

MSU

Triple swabs

USG- pelvis, abdomen

X-RAY

Diagnostic laparoscopy

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16
Q

out-patient PID mx

A

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

17
Q

in-patient PID mx

A

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

18
Q

haematocolpos features

A

Cyclical pain

No bleeding

Examination bluish membrane at intrioitus

I&D, cruciate incision

19
Q

chronic pelvic pain features

A

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

20
Q

pathophysiology of chronic pelvic pain

A

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

21
Q

causes of chronic pelvic pain

A

E&A

MSK

PID

Adhesions

Social and psychological factors

IBS

IC

NE

22
Q

endometriosis incidence

A

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)

23
Q

endometriosis aetiology

A

Precise aetiology remains unclear

Retrograde menstruation (Sampson’s theory)

Coelomic metaplasia (Meyer’s theory)

Mullerian remnants

24
Q

clinical presentation of endometriosis

A

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

25
Q

clinical examination of endometriosis

A

NAD

Thickened uterosacral ligaments

Fixed retroverted uterus

Uterine/ ovarian enlargement

Forniceal tenderness

Uterine tenderness

26
Q

medical management of endometriosis

A

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

27
Q

surgical management of endometriosis

A

Laparoscopic- diathermy, laser

TAH + BSO:
Risk of bladder, ureteric, bowel injury
Risk of subtotal hysterectomy
Role of HRT

28
Q

adhesions types

A

Vascular adhesions

Residual ovary syndrome

Trapped ovary syndrome

Treatment:

May be division of vascular adhesions

Removal of residual ovary

29
Q

ROME III criteria for IBS

A

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

30
Q

treatment of IBS

A

antispasmodic

mebeverine hydrochloride

31
Q

MSK pain

A

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

32
Q

treatment of MSK pain

A

Analgesia

Physiotherapy

Nerve modulation

Antidepressant

33
Q

nerve entrapment

A

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

34
Q

management of nerve entrapment

A

Analgesia

Physiotherapy

Nerve modulation

Antidepressant

35
Q

initial assessment of chronic pelvic pain

A

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

36
Q

examination for chronic pelvic pain

A

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

37
Q

investigations for chronic pelvic pain

A

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

38
Q

treatment for chronic pelvic pain

A

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

Gynaecology (10 decks)

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