Pelvic Pain Flashcards
Sudden sharp pain in the pelvis that becomes
more generalised indicates_______
rupture of an ectopic
pregnancy or an ovarian cyst.
The principal afferent pathways of the pelvic
viscera arise from _______ to _______
T10–12, L1 and S2–4
Genital Causes of acute lower abdominal and
pelvic pain in women
Acute salpingitis Pelvic peritonitis Bleeding Rupture or torsion of ovarian cyst Threatened or incomplete abortion Rupture or aborting tubal ectopic pregnancy Rupture or bleeding endometrioma
non- Genital Causes of acute lower abdominal and
pelvic pain in women
Acute appendicitis
Bowel obstruction
Urinary tract infection (cystitis)
Ureteric colic (calculus)
Functional Causes of acute lower abdominal and
pelvic pain in women
Primary dysmenorrhoea
Retrograde menstruation
Chronic pelvic pain is constant or recurrent pain of at
least_______
6 months’ duration
It is the reason for up to 40% of gynaecological
laparoscopies
Chronic pelvic pain
it is difficult to distinguish clinically between
endometriosis of the uterus (adenomyosis) and _______________Both conditions are associated
with dysmenorrhoea and a tender normal-sized
uterus
pelvic
congestion syndrome.
It is the commonest cause
of intraperitoneal haemorrhage. There is usually a
history of a missed period but a normal menstrual
history may be obtained in some instances.
Ectopic pregnancy
RF for ectopic pregnancy
— previous ectopic pregnancy — previous PID — previous abdominal or pelvic surgery, especially sterilisation reversal — IUCD use — in-vitro fertilisation/GIFT
amenorrhoea (65–80%) + lower
abdominal pain (95 + %) + abnormal vaginal
bleeding (65–85%)
ectopic pregnancy
Pain patterns of ectopic pregnancy
Pain may radiate to rectum (lavatory sign),
vagina or leg
Vaginal examination of patients with ectopic pregnancy
• Vaginal examination:
— tenderness on bimanual pelvic examination
(pain on cervical provocation i.e. cervical
motion tenderness)
— palpable adenxal mass
— soft cervix
In EP, Serum β -hCG assay________ (invariably
positive if a significant amount of viable
trophoblastic tissue present
> 1500 IU/L
Transvaginal ultrasound can diagnose at
______ weeks (empty uterus, tubal sac, fluid in
cul-de-sac)
5–6
Ectopic pregnancy diagnosis
- Pregnancy test
- β-hCG assay
- Transvaginal ultrasound
- Laparoscopy
tx of EP
Treatment may be conservative (based on
ultrasound and β -hCG assays); medical, by injecting
_______ into the ectopic sac;
_________ for severe cases
methotrexate
laparoscopic
removal; or laparotomy
Post management
- Successful pregnancy _______
- Subsequent risk of ectopic pregnancy ______
60–65%
10–15%
When the Graafian follicle ruptures a small amount
of blood mixed with follicular fluid is usually
released into the pouch of Douglas. What is this phenomenon called?
Ruptured ovarian (Graafian) follicle (mittelschmerz)
Pain character of Ruptured ovarian (Graafian)
follicle (mittelschmerz)
- Deep pain in one or other iliac fossa (RIF > LIF)
- Often described as a ‘horse kick pain’
- Pain tends to move centrally
- Relieved by sitting or supporting lower abdomen
Benign ovarian tumours, particularly ________may be asymptomatic but will cause pain if
complicated
ovarian
cysts,
_______ tend to rupture just prior to ovulation or
following coitus.
ovarian cyst
What is the dx
- Patient usually 15–25 years
- Sudden onset of pain in one or other iliac fossa
- May be nausea and vomiting
- No systemic signs
- Pain usually settles within a few hours
Ruptured ovarian cyst
When to do conservative MX for Ruptured ovarian cyst
— simple cyst <4 cm
— internal haemorrhage
— minimal pain
When to do lap sx for ovarian cyst?
— complex cysts
— large cysts
— external bleeding
Torsions are mainly from ______ and, when
right-sided, may be difficult to distinguish from acute
pelvic appendicitis
dermoid cysts
SSx of torsion of ovarian cyst
- Severe cramping lower abdominal pain
- Diffuse pain
- Pain may radiate to the flank, back or thigh
- Repeated vomiting
- Exquisite pelvic tenderness
_______ has an incidence of 10 cases per 10 000
women per year and accounts for 5% of all cancers
in women and 20% of all gynaecological cancers
Ovarian cancer
Ovarian cancer tends to remain asymptomatic for
a long period. No age group is spared but it becomes
progressively more common after _______
45 years (peak incidence 60–65 years)
RF for ovarian CA
- Age
- Family history (first-degree relatives)
- Nulliparity
Protective factors for ovarian CA
- COC pill
* Pregnancy
T or F
Any ovary that is easily palpable is usually
abnormal (normal ovary rarely >4 cm).
T
Dx of ovarian CA
• Ultrasound ± colour Doppler • Tumour markers such as CA-125, β -hCG (choriocarcinoma) and alpha-fetoprotein are becoming more important in diagnosis and managemen
Dysmenorrhoea (painful periods) may commence
with the onset of the menses (menarche) when it is
called ______ or later in life when
the term ________ is applied
primary dysmenorrhoea,
secondary dysmenorrhoea
This is menstrual pain associated with ovular cycles
without any pathologic findings. The pain usually
commences within 1–2 years
Primary (functional) dysmenorrhoea
Conservative Mx of Primary dysmen
- Vitamin B1 (thiamine) 100 mg daily
- COC (low-oestrogen triphasic pills preferable) 5
- progestogen-medicated IUCD
A Cochrane review found that the most beneficial
medication was the NSAIDs, and____ and ______
vitamin B1 and
magnesium also proved effective
_________ is menstrual pain for
which an organic cause can be found. It usually
begins after the menarche after years of pain-free
menses; the patient is usually over 30 years of
age
Secondary dysmenorrhoea
Commonest causes of Secondary dysmenorrhoea
- endometriosis (a major cause)
- PID (a major cause)
- IUCD
- submucous myoma
- intra-uterine polyp
- pelvic adhesions
Pelvic adhesions may be the cause of pelvic pain,
infertility, dysmenorrhoea and intestinal pain. They
can be diagnosed and removed ________
laparoscopically
______ is the condition where ectopically
located endometrial tissue (usually in dependent parts
of the pelvis and in the ovaries
Endometriosis
What are the factors affecting EM
responds to female sex
hormone stimulation by proliferation, haemorrhage,
adhesions and ultimately dense scar tissue changes
dysmenorrhoea + menorrhagia +
dyspareunia = abdominal/pelvic pain
endometriosis
Signs of EM
• Fixed uterine retroversion
• Tenderness and nodularity in the pouch of
Douglas/retrovaginal septum
• Uterine enlargement and tenderness
________ this is endometriosis of the
myometrium affecting the endometrial glands and
stroma
Adenomyosis:
The symptoms of adenomyosis are similar to endometriosis plus an enlarging _____
tender uterus
Gold standard for dx of EM
• Usually by direct visual inspection at laparoscopy
(the gold standard) or laparotom
What is the use of curettage in EM Dx
• Curettage, which shows small sensory C nerve
fibres in the endometrium
OCPs are used for the Tx of EM to:
To induce amenorrhoea (only twothirds
respond to drugs
OCPs used in the Tx of EM
— levonorgestrel-releasing IUCD (Mirena) 5
yearly and indefinite
— danazol (Danocrine)—for 3–6 months
— COC: once daily continuously—long term
— progestogens (e.g. medroxyprogesterone
acetate—Depo-Provera) or orally 10 mg bd
for up to 6 months
— GnRH analogues (e.g. goserelin, 3.6 mg SC
implant every 28 days for up to 6 months,
nafarelin
____________PID
is a major public health problem and is the most
important complication of STIs among young wome
Acute
CX of PID
tubal obstruction,
infertility and ectopic pregnancy
What is the dx
- Fever ≥ 38 ° C
- Moderate to severe lower abdominal pain
Acute PID
What is the dx
- Ache in the lower back
- Mild lower abdominal pain
Chronic PID
Diagnostic criteria for acute PID
All three of the following should be present
1
2
3
1 Lower abdominal tenderness (with or without rebound)
2 Cervical motion tenderness
3 Adnexal tenderness (may be unilateral) plus
Diagnostic criteria for acute PID
One of the following should be present
1 Temperature _____
2 White blood cell count_______
3 Purulent fluid obtained via culdocentesis
4 Inflammatory mass present on bimanual pelvic
examination and/or sonography
5 ESR ≥ 15 mm/h or CRP >1.0 mg/dL
6 Isolation of ________
7 Histological evidence of infection (e.g. plasma cells)
≥ 38°C
≥ 10 500/mm2
N. gonorrhoeae and/or C. trachomatis
Exogenous organisms: those which are community
acquired and initiated by sexual activity. They
include the classic STIs including
Chlamydia trachomatis (most common causative organism) and Neisseria gonorrhoeae
Endogenous infections: these are normal
commensals of the lower genital tract, especially
Escherichia coli and Bacteroides fragilis
Portal of entry of endogenous infection
The commonest portals of entry are
cervical lacerations and the placental site
These
organisms cause an ascending infection and
can spread direct or via lymphatics to the broad
ligament, causing __________
pelvic cellulitis
organism associated with prolonged IUD use
Actinomycosis: due to prolonged IUCD use. Look
for Actinomyces israelii on culture
Sex partners of women with PID should be treated
with agents effective against ________
C. trachomatis and N.
gonorrhoeae.
Mild to moderate infection Tx for PID (treated as an
outpatient
ceftriaxone 500 mg (in 2 ml 1% lignocaine) IM or
500 mg IV, as a single dose (for gonorrhoea)
plus
azithromycin 1 g (o), as 1 dose
plus
metronidazole 400 mg (o) 12 hourly for 14 days
moderate to severe infection Tx for PID (treated as an
outpatient
ceftriaxone 1 g IV daily
plus
azithromycin 500 mg IV daily
plus
metronidazole 500 mg IV 12 hourly until there is substantial clinical improvement,
when the oral regimen above can be used for the
remainder of the 14 days
Tx of actinomyces
amoxycillin 500 mg tds + metronidazole 400 mg
bd for 14 days. Ensure IUCD is removed
In any woman whose normal activities are
disturbed by dysmenorrhoea unrelieved by
NSAIDs,_______ should be suspected
endometriosis
If an ectopic pregnancy is suspected and there
are no facilities for resuscitation, digital vaginal
examination should be deferred for it may provoke
_____
rupture.
Acute abdominal and pelvic pain in the presence of a
negative β-hCG is most often due to an ______
ovarian cyst
A positive β-hCG plus an empty uterus and an
adnexal mass are the classic diagnostic features of
_________
ectopic pregnancy
