Pelvic Pain Flashcards
Describe acute pelvic pain
Well- defined onset Short duration Rest is helpful Variable intensity Anxiety is common Symptom is usually associated with a disease
Describe chronic pelvic pain
Ill-defined onset Unpredictable duration Rest not helpful Persistent Depression is common May not be able to identify underlying disease process
What are the benign causes of pelvic pain
Uterine - fibroid degeneration/torsion - dysmenorrhoea and adenomyosis - extrusion of foreign body e.g. IUD, endometrial cast and prolapsed polyp Ovarian - cyst rupture - cyst haemorrhage - adnexal torsion Tubal - abscess/PID - hydrosalpinx Vulvovaginal - infection e.g. herpes or thrush - bartholin's cyst/abscess - vulvodynia/vaginismus - skin disease e.g. lichen sclerosis and lichen planus Other - endometriosis - psychological - PID - pelvic adhesions
Epidemiology of ovarian cysts
In pre-menopausal women - normal part of ovulation
4% of women by 65 admitted due to ovarian cyst
What cyst events can cause acute pelvic pain
Cyst rupture
Cyst haemorrhage
Adnexal torsion
Describe the risk of malignancy in ovarian cysts
Increases with age (0.4-0.4 up to 60/100,000 between premenopausal and women aged 60-80)
Around 90% of all cysts are benign
Risk of Malignancy index (seen in benign condition notes)
Describe cyst rupture/haemorrhage
Can commonly occur in functional cysts
- between days 20 and 28 of the menstruation cycle
Bleeding can be severe and cause hypovolaemia
Describe ovarian torsion
Often ovary and tube together - more common on the right
Risk factors
- type of cyst
- size of cyst
- weight
May result in loss of ovary if blood supply is compromised
What could you expect on history and examination in an ovarian rupture/haemorrhage
Sudden lower abdominal pain
+/- nausea/vomiting
Pain maximum at onset
Normally well on examination - unless large bleed causing shock (rare)
What could you expect on history and examination in an ovarian torsion
Pain is acute/intermittent, builds over time, and increases in severity as ovary becomes ischaemia
Anorexia
Nausea and vomiting
Pyrexia
Tachycardia
Peritonism
Cervical excitation on vaginal examination
What investigations are required in ?ovarian torsion/rupture/haemorrhage
Urine - pregnancy test - dipstick and MSU for urinary tract infection Bloods - WCC and CRP increase during torsion Vaginal/cervical swabs - ?PID USS pelvic - ?hemoperitoneum - torsed ovary (increased in size and oedema) - other cause e.g. appendix mass
What is the management of ovarian torsion/rupture/haemorrhage
Expectant - analgesia and observe - repeat scan 6 weeks to confirm resolution Laparoscopy IF - haemodynamic compromise - uncertain compromise - torsion suspected - no symptom relief if 48 hours or more since presentation - blood supply to ovary/tube compromised
What is pelvic inflammatory disease
Caused by ascending infection from cervix/vagina into upper genital tract
- most commonly
What nomenclatures are associated with pelvic inflammatory disease
Endometriosis
Salpingitis
Tubo-ovarian abscess
Pelvic peritonitis
What are the complications of pelvic inflammatory disease
Infertility 20%
Ectopic pregnancy 10%
Chronic pelvic pain 20%
What are the most common causative organisms involved in pelvic inflammatory disease
Chlamydia trachomatis Neisseria gonorrhoea Mycoplasma hominis Anaerobic Bacterial vaginosis The causative organism is not always found
Clinical features of pelvic inflammatory disease
Asymptomatic (around 2/3rds of women) PCB or IMB Vaginal purulent discharge Anorexia Deep dyspareunia General malaise Fever >38 Lowe abdominal pain - acute abdomen (abscess)
Investigations for ?pelvic inflammatory disease
Examination - increases heart rate, increased temperature and decreased blood pressure - abdo distension and tenderness - rebound and guarding - RUQ tenderness Speculum - mucopurulent cervicitis Bimanual exam - cervical excitation - adnexal tenderness and fullness Pregnancy test Bloods - FBC, CRP - raised in severe disease Swabs TVUSS - tubo-ovarian abscess
Management of pelvic inflammatory disease
Early antibiotics treatment improves the outcome
- follow local protocols
Partner testing with treatment +/- contact tracing
- abstain until until treatment is complete
Surgery if no improvement
What is endometriosis and adenomyosis
Presence of endometrial tissue outside of the uterus
Adenomyosis if endometrial tissue specifically within the myometrium
Aetiology of endometriosis
Theories - exact cause is uncertain Seeding of endometrial cells form - retrograde menstruation - during surgery e.g. endometriosis in C-section scars Peritoneal metaplasia
Where is endometriosis commonly found?
Bowel - sigmoid colon, caecum and appendix
Peritoneum - pouch of douglas, perineal body, pelvic peritoneum and bladder/uterovesical peritoneum
Ligaments - round ligament and uterosacral ligament
Genital tract - ovary, myometrium, vulva, bartholin’s gland, cervix, vagina and uterine tubes
What are the clinical features of endometriosis
Severe dysmenorrhoea Heavy menstrual bleeding Chronic fatigue Infertility Asymptomatic Dyspareunia Ovulation pain Cyclical symptoms of bladder/bowel Pain on defecation
What investigations are required in ?endometriosis
Examination - fixed, immobile retroverted uterus - thickened uterosacral ligaments +/- nodules - adnexal masses (endometrioma) - enlarged and boggy uterus (adenomyosis) TV USS - identified endometrioma MRI - identifies tissue infiltration Laparoscopy - gold standard - also allows treatment and assessment of tubal patency
How is endometriosis managed?
Same as heavy menstrual bleeding (suppression of endometrial activity)
- medical = mirena, COCP, POP, GnRH analogues, depo-provera
- surgical = diathermy, remove endometrioma, assess tubal patency, hysterectomy and/or oophorectomy
What is chronic pelvic pain syndrome
Chronic/constant lower abdominal pain for 6 months or more
- unrelated to menstrual cycle
No discernible cause
Allow time to get better
How is chronic pelvic pain syndrome managed
Investigation and treatment of any non-gynaecological causes when appropriate - e.g. IBS, interstitial cystitis and neuropathies MDT team - chronic pain services - psychology - physiotherapy - psychosexual therapy - self-help groups
