Pelvic pain Flashcards
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)
acute pelvic pain causes
PID appendicitis functional ovarian cyst Ovarian hyperstimulation syndrome fibroid torsion renal colic adnexal torsion
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
symptoms of adexal torsion
Pelvic or abdominal pain
Fluctuating
Radiating to loin or thigh
N/V
type of pain in adnexal torsion
intermittent, colicky, acute pain, nausea, vomiting, pyrexia
renal colic type of pain
loin to groin pain
unilateral
fibroid torsion type of pain
constant, severe pain
ovarian hyperstimulation syndrome
bloating
pelvic pain
N/V
signs of adnexal torsion
pyrexia tachycardia generalised abdominal tenderness localised guarding rebound cervical excitation adnexal tenderness adnexal mass
diagnosis of adnexal torsion
USG pelvis
tumour markers
raised CRP/ WCC
treatment of adnexal torsion
admit
IV fluids
pain relief
surgery
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
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
acute PID presentation
Asymptomatic
Lower abdominal pain
Pyrexia
Vaginal discharge- yellow or green
Dyspareunia
IMB and PCB
O/E: pyrexia, vaginal discharge, cervical excitation
investigations acute PID
Pregnancy test
FBC, CRP, WCC
MSU
Triple swabs
USG- pelvis, abdomen
X-RAY
Diagnostic laparoscopy
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
IC
NE
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
