Pelvic Pain Flashcards
Speculum exam
. Insert 45 degree angle for nulliparous women
. Insert w/ no angle for multiprous women
. Apply downward pressure
. Advance to top of vagina
. Open speculum until cervix comes into view
. Check for vaginal mucosa (has rugae), discharge, lesions/ulcers, cervix shape, size, lesions, and discharge
What can ectropion cervix be confused w/?
. Friable cervix or erosion
. Means there is columnar epithelium around hole and squamous epithelium around rest
Cervical cancer screening and risks
. Liquid based cytology
. Risks: HPV, multiple sexual partners, smokers, immunosuppression, age, SES, herpes, diethylstilbestrol exposure during pregnancy
Positions of uterus
. Anteverted . Midposition . Anteflexed , retroflexed . Retroverted
Common gynecologic complaints
. Pelvic pain . Abnormal discharge/odor . Abnormal uterine bleeding . Dysmenorrhea . Dyspareunia . Post coital pleading . Dysuria . Vulvar lesions . Vulvar itchiness
Causes of RLQ pelvic pain
. Appendicitis . Ectopic pregnancy . Ovarian cyst . Turbo-ovarian abscess . Ovarian torsion . PID . Nephrolithiasis
Causes of LLQ pelvic pain
. Diverticulitis . Ectopic pregnancy . Ovarian cyst . Turbo-ovarian abscess . Ovarian torsion . PID . Nephrolithiasis
Causes of central pelvic pain
. Endo . Cramps . PID . Cystitis . Painful bladder syndrome
Endometriosis
. Endometrial implants outside uterus
. Pain from inflammation and bleeding from implants
Pelvic inflammatory disease (PID)
. Ascending infection (chlamydia, gonorrhea, endogenous microorganisms) into uterus, Fallopian tubes, and ovaries
. Can lead to turbo-ovarian abscess
. Inc. risk future infertility
. Inc. risk ectopic pregnancies
Ectopic pregnancy
. Improperly implanted pregnancy
. Most common in Fallopian tube
. Can occur cornual, at C-section scar, abdominal, pelvic, cervical, or ovarian
. Risk factors: PID, prior ectopic pregnancy, tubal surgery, IUD, assisted reproductive technology
Ovarian cysts
. Usually benign
. Follicular cysts most common
. Hemorrhagic cysts
. Small, less than 6 cm, resolve on own
Ovarian torsion
. Ovary twists on own pedicle
. Obstructs blood flow to ovary through ovarian a.
. Risk factors: ovarian cyst over 5cm, malignancy, ovulation induction treatment
STI infection screening guidelines
. Chlamydia and gonorrhea: pregnancy, yearly under 25 and sexually active, 25 y/o w/ new sexual partner, NAATs on vagina, cervix, and urine
. Syphillis: in pregnancy, if high relish sexual behaviors, HIV+
. HIV: pregnancy, when requesting STI screening, can opt-out
. Hep B: pregnancy, high risk behaviors, HIV
. Hep C:, high risk behaviors, HIV+, born btw 1945-1965
. Genital herpes: not recommended
Premenstrual syndrome
. Painful cramping due to prostaglandin release
. 70% experience primary dysmenorrhea in lifetime
Hemorrhagic cysts
. Follicular cysts that tear a little and fill with blood
. Can be more painful
Normal Vaginal discharge
. Fluctuates w/ changes in hormones
. Egg-white during ovulation
. Thicker during second half of menstrual cycle when progesterone is high
Abnormal vaginal discharge
. Weird odor, irritation
. Not associated w/ changes in menstrual cycle
. Most common causes: bacterial vaginosis, trichomonas, and candidiasis
Bacterial vaginosis
. Bacterial overgrowth: Gardnerella vaginalis
. Symptoms: unpleasant odor, thin discharge, burning w/ intercourse
. Itchiness and irritation
. Discharge gray or white thin discharge, fishy
. Lab evaluation: Wet mount for clue cells, KOH, whiff test, pH over 4.5
Trichomonas
. Sexually transmitted protozoan
. Symptoms: malodorous discharge, pain w/ intercourse, pain w/ urination, itchiness
. Discharge: yellowish-green frothy
. Labs: wet mount for trichomonas
Vulvovaginal candidiasis
. Overgrowth of yeast (candida albicans)
. Symptoms: puritis, vaginal pain, pain w/ urination, pain w/ intercourse
. Discharge: white and curdy
. Labs: KOH shows branching hyphae
Menarche
. Average age 12.5
. 21-35 days btw menses
. Irregular in first 2 yrs
. Up to 80mL blood normal
Dysmenorrhea
. Pain w/ cycle
. Primary: inc. prostaglandins causing cramping, 70% have this
. Secondary: endo, PID, polyps, or adenomyosis
Premenstrual syndrome
. Fatigue common
.5 days before menses and resolve w/in 4 days of start of menses
Amenorrhea
. Absence of periods
. Primary: never had period
. Secondary: stopped due to pregnancy, lactation, menopause, low body weight, or PCOS
Abnormal uterine bleeding
. Polymenorrhea: less than 21 days btw cycles
. Oligomenorrhea: over 35 days btw cycles
. Menorrhagia: excessive menstrual flow
. Metrorrhagia: bleeding btw cycles
. Postcoital bleeding: polyps, cancer, chlamydia
Weird bleeding structural causes
PALM . Polyps . Adenomyosis . Leiomyoma . Malignancy
Weird bleeding nonstructural causes
COEIN . Coagulopathy . Ovulatory dysfunction . Endometrial . Iatrogenic . Not yet classified
Menopause
. Lack of menses for 12 months
. Normal after 40
. Average is 51.5 y/o
. Vasomotor symptoms through perimenopause and beyond
Postmenopausal bleeding
. Any bleeding after diagnosis of menopause
. Warning sign for endometrial cancer
. Most common cause is atrophy
Abnormalities of vulva and vagina
. Epidermoid cyst
. Yellowish appearance
. Blocked opening of gland
. Resolved w/ compress or Sitz bath
Condyloma acuminatum
. Warty lesions
. HPV 6 and 11
. Cauliflower like appearance
. Will resolve on own, but can use cream
Syphilis
. Chancre: about 21 days after exposure, painless ulcer, resolves w/o treatment
. Condyloma Latum: secondary syphilis, large, raise, oval or round, gray or white Papules
Genital herpes
. HSV 1 or 2
. Traditionally HSV 1 is oral and HSV 2 is genital
. Large cross over now btw types
. Shallow, painful ulcers
. More frequent recurrence w/ HSV 2
. Culture these and send PCR for diagnosis
Vulvar carcinoma
. Normal appearing vulva w/ chronic itchiness or irritation
. Can have hyperpigmentation, erythema, or ulceration
. HPV associated
Bartholin gland cyst
. Gland gets blocked and fills w/ fluid
. Sitz baths
. Incision and drainage
. Word catheter drains them (stick balloon inside of cyst and leave catheter in for 6 weeks so fluid can drain out)
Bartholin gland abscess
. Gland gets infected
. More erythematous and drains purulent fluid
. Causes: trauma, gonococci, anaerobes, and C. Trachomatis
. treat w/ I&D and antibiotics
Cervicitis
. Purulent or yellow drainage from external cervix
. Typicall from C. Trachomatis or N. Gonorrhoeae
. Cervix friable
Diethylstilbestrol exposure in utero
. Given to women btw 1938-1971 to dec. risk of miscarriage
. Columnar epithelium covers cervix
. Inc. risk of clear cell carcinoma of cervix (not HPV associated)
. Girls from women that took it have its
Cervical cancer
. People 50% not screened before diagnosis
. 10% hadn’t been screened in over 5 yrs
. Gardasil-9 : cover 9 strains of HPV shot btw 9-12 y/o (can be given up to 45 y/o), 2 step if under 15, 3 step if over 15
. 90% effectiveness for invasive cervical cancer
. 93.6% effective for high grade neoplasia
Cervical cancer screening ages under 21
Not recommended
Cervical cancer 21-29 screening
. Every 3 yrs
. When high risk HPV, used as reflex test only when pap result is ASC-US
Cervical cancer screening 30-65
. Co-testing w/ pap and HPV every 5 yrs
. Cytology alone every 3 yrs
. Option to use as reflex test in co-tested patients whose pap is neg. but HPV is pos.
Cervical cancer screening over 65
. Discontinued if patient has adequate neg. prior to screening results and no history of CIN2+
. Continue age-based screening in patient w/ history of CIN2, CIN3, or adenocarcinoma in Situ
Cystocele
. Ant. Portion
. Bladder starts to bulge and fall into area of vagina
Rectocele
. Post. Side of vagina bulging out
Carnuncle
. Columnar cells start growing outside of urethra
Adenomyosis
. Blood vessels from stroma of uterus invade into myometrium
