Pelvic pain Flashcards
Acute pelvic pain causes
Ectopic pregnancy
Urinary tract infection
Appendicitis
Pelvic inflammatory disease
Ovarian torsion
Miscarriage
Chronic pelvic pain causes
Endometriosis & adenomyosis
Irritable bowel syndrome
Ovarian cyst
Urogenital prolapse
MSK, nerve entrapment
Adhesions
Chronic pain management principles
Treat underlying cause
Cyclical pain - therapeutic trial using hormonal mx for a period of 3-6 months before having a diagnostic laparoscopy
IBS - antispasmodics & lifestyle changes
Optimise pain relief
Referral to dedicated chronic pelvic pain team
Ectopic pregnancy
Implantation of a fertilised ovum outside the uterus results in an ectopic pregnancy
Ectopic pregnancy hx
Hx of 6-8 weeks amenorrhoea w/ lower abdo pain & vaginal bleeding
Lower abdominal pain - due to tubal spasm, typically the first symptom, pain is usually constant & may be unilateral
Vaginal bleeding - less than a normal period, may be dark brown in colour
Hx of recent amenorrhoea - 6-8 weeks from the start of last period
Peritoneal bleeding → shoulder tip pain & pain on defecation/urination
Dizziness, fainting or syncope
Symptoms of pregnancy may be reported
Ectopic pregnancy examination findings
Abdominal tenderness
Cervical excitation
Adnexal mass → NICE advise NOT to examine due to increased risk of rupturing pregnancy
Ectopic pregnancy risk factors
Damage to tubes (PID)
Previous ectopic
Endometriosis
IUCD
POP
IVF
Ectopic pregnancy ix
Pregnancy test
Transvaginal USS
Ectopic pregnancy expectant mx
Size < 35mm, unruptured, asymptomatic, no fetal heartbeat, hCG < 1000IU/L
Compatible if another intrauterine pregnancy
Expectant management - involves closely monitoring the patient over 48 hours & if b-hCG levels rise again/symptoms manifest intervention is performed
Ectopic pregnancy medical mx
Size < 35mm, unruptured, no significant pain, no fetal heartbeat, hCG < 1,500IU/L
Not suitable if another intrauterine pregnancy
Involves giving methotrexate & can only be done if the patient is willing to attend follow-up
Ectopic pregnancy surgical mx
Size > 35mm, can be ruptured, pain, visible fetal heartbeat, hCG > 5,000 IU/L, compatible with another intrauterine pregnancy
Salpingectomy or salpingotomy
- salpingectomy - first line for women with no other risk factors for infertility
- salpingotomy - considered for women with risk factors for infertility eg. contralateral tube damage
- 1 in 5 require further treatment (methotrexate +/- salpingectomy)
Ectopic pregnancy complications
Tubal abortion
Tubal absorption
Tubal rupture
PID
Used to describe infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries & surrounding peritoneum
Usually the result of ascending infection from the endocervix
PID aetiology
STIs - chlamydia trachomatis, neisseria gonorrhoea, mycoplasma genitalium
Non-STIs - anaerobes (prevotella, atopobium, leptotrichia), gardnerella vaginalis, vaginal flora introduced by surgery, IUD
Polymicrobial
PID risk factors
No use of barrier contraception
Previous episodes
Earlier age at first intercourse
Multiple sexual partners
Immunocompromised
Co-existing endometriosis
PID clinical features
Lower abdominal pain - typically bilateral
Fever, rigors, chills, night sweats
Deep dyspareunia
Abnormal vaginal bleeding - IMB, PCB, HMB
Vaginal/cervical discharge - yellow or green
Cervical excitation - pain on movement of cervix
RUQ pain (Fitz-Hugh-Curtis syndrome)
Can be asymptomatic
PID ddx
Gynae - ectopic, ovarian cyst, endometriosis
UTI
GI - inflammatory bowel, appendicitis, irritable bowel
PID ix
Pregnancy test
Bloods - FBC, CRP, WCC → only abnormal in moderate/severe PID
Urine dip +/- MSU
USG - pelvis
Endocervical/vaginal swab - often negative
Microscopy of vaginal/cervical discharge
Screen for chlamydia & gonorrhoea
PID mx
Low threshold for treatment
PO ofloxacin + PO metronidazole OR IM ceftriaxone + PO doxycycline + PO metronidazole (no alcohol)
In patient - IV ceftriaxone + IV doxycycline following by standard PO doxy + metronidazole
Surgical treatment - laparotomy for drainage
Removal of IUD should be considered
PID sexual partners
Current male partner - screening for chlamydia & gonorrhoea, doxy 7 days
Partners within 6 months - offer screening
PID complications
Perihepatitis (Fitz-Hugh Curtis syndrome) - more commonly associated with CT PID
Infertility
Chronic pelvic pain
Ectopic pregnancy
Tubo-ovarian abscess
Fitz-Hugh-Curtis syndrome
Adhesions form between the anterior liver capsule & anterior abdominal wall/diaphragm
LFTs are usually normal
Abdominal USS should be performed to rule out the presence of stones
Definitive diagnosis & treatment → laparoscopy & administration of abx
Ovarian cyst
Fluid filled sac within the ovary
Common; especially in the premenopausal patients where benign, physiological cysts predominate throughout the menstrual cycle
Ovarian cyst clinical features
Often found incidentally on pelvic ultrasound scans
Occasionally, ovarian cysts can cause vague symptoms:
- pelvic pain
- bloating
- fullness in abdomen
- palpable pelvic mass - mucinous cystadenoma
Acute pelvic pain - torsion, haemorrhage or rupture of the cyst
Functional ovarian cyst
Follicular cysts - normally < 3cm, represent the developing follicle in the first half of the menstrual cycle
Corpus luteal cysts - normally < 5cm, occur in the luteal phase of the menstrual cycle after the formation of the corpus luteum
Pathological ovarian cyst
Endometrioma (chocolate cyst) - present in those with endometriosis, bleeding into the cyst resulting in appearance
Polycystic ovaries - USS diagnosis, ‘ring of pearls’ signs
Theca lutein cyst - result of a consequence of markedly raised hCG eg. molar pregnancy
Epithelial tumours
Serous cystadenoma - most common type of malignant ovarian tumour
Mucinous cystadenoma - often multioculated & usually unilateral
Brenner tumour - unilateral with a solid grey/yellow appearance
Benign germ cell tumours
Mature cystic teratoma (dermoid cysts) - usually occur in young women and occur frequently in pregnancy; can contain teeth, hair, skin & bone
Sex-cord stromal tumours
Fibroma - most common type
- Meig’s syndrome - triad of ovarian fibroma, pleural effusion, ascites
- typically occurs in older women
- removal of the tumour results in complete resolution of the effusion and ascites
Ovarian cyst pre-menopausal women mx
CA125 does not need to be undertaken when the diagnosis of a simple ovarian cyst has been made on USS
LDH, AFP, hCG measured → possibility of germ cell tumours
Rescan cyst in 6 weeks, if persistent the monitor with USS & CA125 3-6 monthly and calculate RMI
Persistent/over 5cm - laparoscopic cystectomy/oophorectomy
Ovarian cyst postmenopausal women mx
Low RMI - follow up for 1 year with USS & CA125 if less than 5cm
Moderate RMI - bilateral oophorectomy (if malignancy found → staging required)
High RMI - referral for staging laparotomy
Ovarian torsion
May be defined as the partial/complete torsion of the ovary on its supporting ligaments that may in turn compromise the blood supply
Fallopian tube → adnexal torsion
Ovarian torsion risk factors
Ovarian mass
Being of reproductive age
Pregnancy
Ovarian hyperstimulation syndrome
Ovarian torsion clinical features
Usually the sudden onset of deep-seated colicky abdominal pain
Associated with vomiting and distress
Fever may be seen in a minority (possibly secondary to adnexal necrosis)
Vaginal examination may reveal adnexial tenderness
Ovarian torsion ix and mx
USS - free fluid or a whirlpool sign (not required if torsion is first diagnosis)
Admit, IV fluids & analgesia
Laparoscopy is usually both diagnostic & therapeutic
Threatened miscarriage
Mild symptoms of bleeding with the foetus retained within the uterus as the cervical os is closed
‘threat of miscarriage’ → not certain
Little/no pain
USS reveals foetus is present intrauterine
Missed (delayed) miscarriage
Gestational sac which contains a dead fetus < 20 weeks without the symptoms of expulsion
Mother may have light vaginal bleeding/discharge & the symptoms of pregnancy which disappear
Cervical os is closed
Inevitable miscarriage
Heavy bleeding with clots and pain
Cervical os is open
Inevitable foetus will be lost
Incomplete miscarriage
Not all products of conception have been expelled
Pain and vaginal bleeding
Cervical os is open
Complete miscarriage
Intrauterine pregnancy which has now fully miscarried, with all products of conception expelled & uterus empty
Os usually closed
May have been alerted to the miscarriage by pain & bleeding
Miscarriage aetiology
Idiopathic
Foetal pathology - genetic disorder, abnormal development, placental failure
Maternal pathology - uterine abnormality, cervical incompetence, PCOS, poorly controlled diabetes, poorly controlled thyroid disease & anti-phospholipid syndrome
Miscarriage ix
Transvaginal USS - establish whether there are any foetal components within the uterine cavity & whether foetal heartbeat can be detected
Serial serum hCG measurements:
- levels fall → foetus will not develop/there has been a miscarriage
- only slight increase/plateau in hCG levels → ectopic pregnancy
- normal increase in hCG → foetus is growing normally, but does not exclude ectopic pregnancy
Miscarriage general mx
Revolves around ensuring complete removal of foetal material
If woman is rhesus-, they may require anti-D prophylaxis
Miscarriage expectant mx
Waiting for a spontaneous miscarriage
First-line & involves waiting for 7-14 days for the miscarriage to complete spontaneously
Medical or surgical management may be offered
Miscarriage medical mx
Missed miscarriage
- PO mifepristone - progesterone receptor antagonist
- 48 hours later, misoprostol unless the gestational sac has already been passed - prostaglandin analogue
- bleeding not started within 48 hours after misoprostol treatment → contact their healthcare professional
Incomplete miscarriage
- single dose of misoprostol
Antiemetics & pain relief
Pregnancy test at 3 weeks
Miscarriage surgical mx
Vacuum aspiration or surgical management in theatre
Vacuum aspiration is done under local anaesthetic as an outpt
Recurrent miscarriage
Defined as a loss of 3 or more consecutive pregnancies
Recurrent miscarriage ix
Blood tests - antiphospholipid antibodies, thrombophilia screen
Cytogenic analysis of products of conception
Pelvic USS to identify uterine abnormalities
Recurrent miscarriage mx
Tailed to contributing pathology:
- genetic disorder - refer to a clinical geneticist for genetic counselling
- donor egg/sperm
- continuing pregnancy attempts with prenatal diagnosis
- uterine structural abnormality - surgical mx
- cervical incompetence - USS monitoring
- anti-phospholipid syndrome - heparin or low-dose aspirin
Endometriosis
Chronic condition in which endometrial tissue is located at sites other than the uterine cavity
Can occur in the ovaries, pouch of Douglas, uterosacral ligaments, pelvic peritoneum, bladder, umbilicus & lungs
Endometriosis risk factors
Early menarche
FHx of endometriosis
Short menstrual cycles
Long duration of menstrual bleeding
Heavy menstrual bleeding
Defects in the uterus or fallopian tubes
Endometriosis clinical features
Cyclical pelvic pain, occurring at the time of menstruation
Dysmenorrhoea, dyspareunia, dysuria, dyschezia, subfertility
Endometriosis at distant sites may experience focal symptoms of bleeding → ectopic endometrial tissue in the lungs = haemothorax
O/E - fixed, retroverted uterus; uterosacral ligament nodules, general tenderness
(enlarged, tender & boggy uterus = adenomyosis)
Endometriosis ix
Gold standard = laparoscopy
- chocolate cysts
- adhesions
- peritoneal deposits
Pelvic USS can also help determine the severity of endometriosis
Endometriosis mx
Based on the individual requirements of each patient
Pain - can be managed through analgesia or NSAIDs
Ovulation - low dose COCP/norethisterone; mirena can also be used
Surgery - excision, fulgaration & laser ablation aim to completely remove the ectopic endometrial tissue in the peritoneum, uterine muscle & pouch of Douglas to reduce pain
- surgery may have to be repeated
- ultimate mx = hysterectomy & removal of ovaries
Fibroid degeneration
Degeneration due to excessive growth that outmatches blood supply or mechanical compression of feeder arteries
Constant dull ache responding to opioids
Ix - palpable mass, inflammatory markers raised
Mx - conservative esp. in pregnancy, emergency surgery due to pedunculated fibroid torsion
Haematocolpos
Paediatric
Cyclical pain, no bleeding
O/E - bluish membrane at introitus
Mx - admit, I&D, cruciate incision
