Pelvic pain Flashcards
What is/are features of dysmenorrhoea?
Pelvic pain occurring peri-menstruation
May be lower abdominal pain (usually midline), back pain, groin pain or radiate to groin/flanks
Includes dyschezia (pain on defecation), pain with full rectum (sharp, shooting pain), dysuria, dysparaunia
Typically occurs ~24hrs prior to menses and increases in severity for 2-3 days and then improves
What are the definitions of acute and chronic pelvic pain?
Acute = pelvic/lower abdominal pain lasting <3mths
Chronic = pelvic/lower abdominal pain lasting >6m, intermittent or constant, but not occuring exclusively with menstruation, intercourse or pregnancy
What are DDx for dyspareunia?
Superficial
- Thrush
- Skin - atrophic vaginitis, lichen sclerosis or dermatitis of vulva
- vestibulodynia, vaganismus
Deep
- endometriosis
- PID
- adenomyosis
- adhesions
- ovarian cysts
*psychosocial
What are the clinical features of endometriosis?
Dysmenorrhoea Dyschezia and other bowel symptoms Dysuria Deep dyspareunia Subfertility
Lower abdominal tenderness Nodules - vaginal or in POD on VE Cervical motion tenderness Immobile uterus - adhesions Adnexal mass/tenderness - endometrioma
How is endometriosis diagnosed?
Mainly clinically
Laparoscopy gold standard for diagnosis - visualisation + histology
U/S - deep infiltrative lesions can be detected, endometriomas (chocolate cysts, ground glass appearance, on ovaries), bowel prep increases visibility (reduces shadowing), quality is user dependent (specialist training)
What are the pharmacological management options for endometriosis?
Pharmacological
- Analgesia
1. Cyclical NSAIDs (naproxen, ibuprofen, mefenamic acid) - Suppress hormonal activity
1. Continuous COCP - effective in long term but takes time to become as effective as GnRH-analogues
2. Progestins - high dose oral/systemic progestins can be used esp. when C/I to oestrogen (i.e. depot proveria), thin endometrium and reduce prostaglandins
3. GnRH-analogues - only used for 6/12 due to bone loss, very effective but usually use as prelude to surgery, can help ‘break cycle’ and allow other Rx to be more effective
*usually combine NSAIDs + hormonal contraceptive
What are the theories for causes of endometriosis?
Sampson’s theory = menstrual reflux
- Reflux of menstrual blood leads to deposition and development of endometriosis
- Many women have this and no endo - therefore other contributing factors
Transformation = Coelomic metaplasia
-Hormonal influence and factors released during menstration/with menstrual reflux induce cellular changes
Embryological implantation
Mechanical transplantation i.e. with surgery
What are the surgical Rx options for endometriosis?
Laparoscopic surgery
- Ablate - superficial lesions
- Mainstay = resection of lesions and removal of endometriomas
What is the natural hx of endometriosis?
Affects ~10-15% women
Peak age 25 - 35 yrs
Symptoms resolve with menopause
What are the surgical Rx options for endometriosis?
Laparoscopic surgery
- Ablate - superficial lesions
- Mainstay = resection of lesions and removal of endometriomas
Where does endometriosis most commonly occur?
Uretosacral ligaments
POD
Ovaries
Can occur ‘anywhere’ but usually confined to pelvis - ureters, bladder, bowel, peritoneal wall etc
What are the clinical features of adenomyosis?
Menorrphagia, dysmenorrhoea
Bulky, tender uterus
How can adenomyosis be diagnosed?
U/S - asymmetrical thickening, venetian blind shadowing
Definitive diagnosis requires hysterectomy + histology
What are the risk factors for adenomyosis?
Increasing age (ceases after menopause) Increasing parity/gravidy
What are the treatment options for adenomyosis?
Same as per endo - NSAIDs, COCP, high dose systemic progestins, GnRH analogues
Surgical - Endometrial ablation, myomectomy, hysterectomy
What is primary dysmenorrhoea and general features?
Pain occurring with periods from onset (generally commences 1-2 years after menarche)
Dull, crampy pai in the low abdomen/pelvic area which can radiate to groin or back, may be associated with N+V, headachesm syncope and flushing
No pathological cause found
Pain will reduce with increasing age, parity and use of the OCP
What is the mechanism for primary dysmenorrhoea?
Local production of prostaglandins which cause increased uterine contractions
Both lead to transient uterine ischaemia - pain
What examination and Ix should be performed in primary dysmenorrhoea?
Abdominal exam
Pelvic examination - do not perform in adolescence who have not been sexually active
TV U/S - exclude endometriosis
STI screen
Pap smear
What are the management options for primary dysmenorrhoea?
Expectant/do nothing
Heat packs, B1 and Mg daily may have some effect
Cyclical NSAIDs (menefamic acid, naproxen) +/- COCP, progestin’s, mirena – reduce prostoglandin production
Definitive - hysterectomy
What is secondary dysmenorrhoea and general features?
Menstrual pain that commences years after onset of menarche
Typically starts >30yr
Pain typically begins 3-4 days before menses and becomes more severe during menstruation
What are the ddx for secondary dysmenorrhoea?
Endometriosis, adenomyosis
Polyps
PID
What are key history features to be elicited with patient presenting with dysmenorrhoea?
- Age
- Age of menstruation, normal menstruation cycle
- Current menstruation pattern
- Onset of dysmenorrhoea and chronicity - primary vs. secondary dysmenorrhoea, acute vs. chronic
- Define pain - quality, severity, cyclical vs. constant vs. exclusively with period, location & radiation (abdo midline, low abdo, pelvic, rectal, groin, back)
- Relationship and timing with cycle - before/after onset of bleeding, improves or worsens during period
- Other pain - dyschezia, dysuria, dyspareunia (deep vs. superficial)
- Abnormal bleeding - IMB, PCB
- other bowel/bladder symptoms - IBS, incontinence, storage or voiding symptoms, bleeding
- Associated features - pelvic mass, distention/bloating, weight loss, night sweats, fevers, discharge
- Sexual hx risk factors
- Gynaecological hx - previous diagnoses or Ix, pap smear history, STI hx
