Pelvic Pain Flashcards by Emily Mosher

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

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What can ectropion cervix be confused w/?

. Friable cervix or erosion

. Means there is columnar epithelium around hole and squamous epithelium around rest

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Cervical cancer screening and risks

. Liquid based cytology
. Risks: HPV, multiple sexual partners, smokers, immunosuppression, age, SES, herpes, diethylstilbestrol exposure during pregnancy

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Positions of uterus

. Anteverted
. Midposition
. Anteflexed
, retroflexed
. Retroverted

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Common gynecologic complaints

. Pelvic pain
. Abnormal discharge/odor
. Abnormal uterine bleeding 
. Dysmenorrhea
. Dyspareunia
. Post coital pleading 
. Dysuria 
. Vulvar lesions 
. Vulvar itchiness

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Causes of RLQ pelvic pain

. Appendicitis 
. Ectopic pregnancy
. Ovarian cyst
. Turbo-ovarian abscess
. Ovarian torsion 
. PID
. Nephrolithiasis

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Causes of LLQ pelvic pain

. Diverticulitis 
. Ectopic pregnancy 
. Ovarian cyst
. Turbo-ovarian abscess
. Ovarian torsion 
. PID
. Nephrolithiasis

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Causes of central pelvic pain

. Endo 
. Cramps 
. PID
. Cystitis 
. Painful bladder syndrome

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Endometriosis

. Endometrial implants outside uterus

. Pain from inflammation and bleeding from implants

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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

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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

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Ovarian cysts

. Usually benign
. Follicular cysts most common
. Hemorrhagic cysts
. Small, less than 6 cm, resolve on own

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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

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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

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Premenstrual syndrome

. Painful cramping due to prostaglandin release

. 70% experience primary dysmenorrhea in lifetime

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Hemorrhagic cysts

. Follicular cysts that tear a little and fill with blood

. Can be more painful

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Normal Vaginal discharge

. Fluctuates w/ changes in hormones
. Egg-white during ovulation
. Thicker during second half of menstrual cycle when progesterone is high

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Abnormal vaginal discharge

. Weird odor, irritation
. Not associated w/ changes in menstrual cycle
. Most common causes: bacterial vaginosis, trichomonas, and candidiasis

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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

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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