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Y4 reproductive health > Pelvic pain > Flashcards

Pelvic pain Flashcards

1
Q

Acute pelvic pain causes

A

Ectopic pregnancy

Urinary tract infection

Appendicitis

Pelvic inflammatory disease

Ovarian torsion

Miscarriage

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2
Q

Chronic pelvic pain causes

A

Endometriosis & adenomyosis

Irritable bowel syndrome

Ovarian cyst

Urogenital prolapse

MSK, nerve entrapment

Adhesions

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3
Q

Chronic pain management principles

A

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

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4
Q

Ectopic pregnancy

A

Implantation of a fertilised ovum outside the uterus results in an ectopic pregnancy

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5
Q

Ectopic pregnancy hx

A

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

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6
Q

Ectopic pregnancy examination findings

A

Abdominal tenderness

Cervical excitation

Adnexal mass → NICE advise NOT to examine due to increased risk of rupturing pregnancy

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7
Q

Ectopic pregnancy risk factors

A

Damage to tubes (PID)

Previous ectopic

Endometriosis

IUCD

POP

IVF

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8
Q

Ectopic pregnancy ix

A

Pregnancy test

Transvaginal USS

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9
Q

Ectopic pregnancy expectant mx

A

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

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10
Q

Ectopic pregnancy medical mx

A

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

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11
Q

Ectopic pregnancy surgical mx

A

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)
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12
Q

Ectopic pregnancy complications

A

Tubal abortion

Tubal absorption

Tubal rupture

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13
Q

PID

A

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

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14
Q

PID aetiology

A

STIs - chlamydia trachomatis, neisseria gonorrhoea, mycoplasma genitalium

Non-STIs - anaerobes (prevotella, atopobium, leptotrichia), gardnerella vaginalis, vaginal flora introduced by surgery, IUD

Polymicrobial

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15
Q

PID risk factors

A

No use of barrier contraception

Previous episodes

Earlier age at first intercourse

Multiple sexual partners

Immunocompromised

Co-existing endometriosis

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16
Q

PID clinical features

A

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

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17
Q

PID ddx

A

Gynae - ectopic, ovarian cyst, endometriosis

UTI

GI - inflammatory bowel, appendicitis, irritable bowel

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18
Q

PID ix

A

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

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19
Q

PID mx

A

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

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20
Q

PID sexual partners

A

Current male partner - screening for chlamydia & gonorrhoea, doxy 7 days

Partners within 6 months - offer screening

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21
Q

PID complications

A

Perihepatitis (Fitz-Hugh Curtis syndrome) - more commonly associated with CT PID

Infertility

Chronic pelvic pain

Ectopic pregnancy

Tubo-ovarian abscess

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22
Q

Fitz-Hugh-Curtis syndrome

A

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

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23
Q

Ovarian cyst

A

Fluid filled sac within the ovary

Common; especially in the premenopausal patients where benign, physiological cysts predominate throughout the menstrual cycle

24
Q

Ovarian cyst clinical features

A

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

25
Q

Functional ovarian cyst

A

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

26
Q

Pathological ovarian cyst

A

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

27
Q

Epithelial tumours

A

Serous cystadenoma - most common type of malignant ovarian tumour

Mucinous cystadenoma - often multioculated & usually unilateral

Brenner tumour - unilateral with a solid grey/yellow appearance

28
Q

Benign germ cell tumours

A

Mature cystic teratoma (dermoid cysts) - usually occur in young women and occur frequently in pregnancy; can contain teeth, hair, skin & bone

29
Q

Sex-cord stromal tumours

A

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
30
Q

Ovarian cyst pre-menopausal women mx

A

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

31
Q

Ovarian cyst postmenopausal women mx

A

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

32
Q

Ovarian torsion

A

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

33
Q

Ovarian torsion risk factors

A

Ovarian mass

Being of reproductive age

Pregnancy

Ovarian hyperstimulation syndrome

34
Q

Ovarian torsion clinical features

A

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

35
Q

Ovarian torsion ix and mx

A

USS - free fluid or a whirlpool sign (not required if torsion is first diagnosis)

Admit, IV fluids & analgesia

Laparoscopy is usually both diagnostic & therapeutic

36
Q

Threatened miscarriage

A

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

37
Q

Missed (delayed) miscarriage

A

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

38
Q

Inevitable miscarriage

A

Heavy bleeding with clots and pain

Cervical os is open

Inevitable foetus will be lost

39
Q

Incomplete miscarriage

A

Not all products of conception have been expelled

Pain and vaginal bleeding

Cervical os is open

40
Q

Complete miscarriage

A

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

41
Q

Miscarriage aetiology

A

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

42
Q

Miscarriage ix

A

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
43
Q

Miscarriage general mx

A

Revolves around ensuring complete removal of foetal material

If woman is rhesus-, they may require anti-D prophylaxis

44
Q

Miscarriage expectant mx

A

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

45
Q

Miscarriage medical mx

A

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

46
Q

Miscarriage surgical mx

A

Vacuum aspiration or surgical management in theatre

Vacuum aspiration is done under local anaesthetic as an outpt

47
Q

Recurrent miscarriage

A

Defined as a loss of 3 or more consecutive pregnancies

48
Q

Recurrent miscarriage ix

A

Blood tests - antiphospholipid antibodies, thrombophilia screen

Cytogenic analysis of products of conception

Pelvic USS to identify uterine abnormalities

49
Q

Recurrent miscarriage mx

A

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
50
Q

Endometriosis

A

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

51
Q

Endometriosis risk factors

A

Early menarche

FHx of endometriosis

Short menstrual cycles

Long duration of menstrual bleeding

Heavy menstrual bleeding

Defects in the uterus or fallopian tubes

52
Q

Endometriosis clinical features

A

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)

53
Q

Endometriosis ix

A

Gold standard = laparoscopy

  • chocolate cysts
  • adhesions
  • peritoneal deposits

Pelvic USS can also help determine the severity of endometriosis

54
Q

Endometriosis mx

A

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
55
Q

Fibroid degeneration

A

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

56
Q

Haematocolpos

A

Paediatric

Cyclical pain, no bleeding

O/E - bluish membrane at introitus

Mx - admit, I&D, cruciate incision

Y4 reproductive health (11 decks)

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