Pelvic Pain Flashcards by Ahmed Radwan

things to keep in mind when evaluating pelvic pain

OLDCAARTS (duh)
provocation/palliation
correlation w/ habits/meds/exposures

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what correlating sx should you ask about with a pt w/ pelvic pain

bowl sx, bladder sx, or menstrual changers

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things to consider in premenopausal patients presenting with pelvic pain

menarche
cycle length and variability
menstrual flow
dysmenorrhea
cramping
pain patterns
radiation
simultaneous changes in bowel or bladder

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define mittelschmerz

pain with oculation

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mittelschmerz, endometriosis, and dysmenorrhea are all examples of what type of pelvic pain

cyclic

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interstitial cystitis, diverticulosis, and hernias are all examples of what type of pelvic pain

non-cyclic

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what is it called when there are glands and stroma invading into the walls of the uterus

adenomyosis

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what is it called when there is ectopic endometrial glands and stroma

endometriosis

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define post-ablation syndrome

a collection of menstrual fluid behind the scar in the uterine cavity after an ablation

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define leiomyoma (fibroids)

a cloning phenomena where proliferation of cells can enlarge the uterus, adnexa, or supporting ligaments

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how do leiomyomas (fibroids) present

rapidly enlarging mass

- “fulness” and/or “heaviness”

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define catamenial

menstrual related, “cyclic”, linked to endometriosis

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define the coelomic metaplasia theory of endometriosis

endometriosis originates from the metaplasia of pluripotential cells from ovarian and peritoneal surfaces

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define the retrograde menstruation theory of endometriosis

endometriosis caused from retrograde flow of endometrial cells through the tubes onto pelvic surfaces

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clinical presentation of ovarian torsion

rapid onset of pain, nausea, and vomiting

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what normally precipitates ovarian torsion

a cyst or a mass, frequently greater than 5cm

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what events can cause an ovarian cyst to elicit pain

rupture
bleeding
leaking of fluid
ovulation (mittelschmerz)

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define ovarian remnant

small pieces of ovarian tissue are inadvertently left in the pelvic cavity following the surgical removal of one or both ovaries –> ovarian tissue regenerates or grows in response to gonadotropins
- may be seen as a cyst or mass

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describe the lab values in a pt with ovarian remnant

normal FSH and LH

- increased estradiol

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what is the most common reason for cyclic pain complaints

ovarian cysts

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effect of oral contraceptives on risk of ovarian cysts and ovarian and uterine cancer

decreases risk for all

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most tubal issues causing pelvic pain are due to ___

obstruction or flow or infection

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define hematosalpinx, pyosalpinx, and hydrosalpinx

hematosalpinx: bleeding in the fallopian tube
pyosalpinx: pus in the fallopian tube
hydrosalpinx: water in the fallopian tube

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how do hematosalpinx, pyosalpinx, and hydrosalpinx cause pain

by distension of the fallopian tube

- can cause contraction/cramping

sx and lab values of pelvic inflammatory disease in the fallopian tubes (salpingitis)

sx: pelvic pain and fever labs: elevated WBC and ESR

PID of the fallopian tubes (salpingitis) puts pts at risk for developing what other conditions

peritonitis, abscess, or sepsis

a transVAGINAL ultrasound will detect an intrauterine pregnancy at what HCG level

>1200 mIU/mL

a transABDOMINAL ultrasound will detect an intrauterine pregnancy at what HCG level

2000 mIU/mL

if a patient comes in with an HCG level of over 2000, but there is no visible gestational sac on transvaginal or transabdominal US, what can be suspected

ectopic pregnancy

what organisms commonly cause ascending infection leading to endometritis

- strep - mycoplasma - ureaplasma - haemophilus - anaerobes - STIs

what event commonly causes endometritis

childbirth | occurs postpartum

common cause of cervicitis

STI (trichomonas vaginalis)

negative effects of IUD

- cyclic pain - perforation - concomitant infection - inflammatory reaction - stimulation of a hollow organ

what are the pregnancy related causes of pelvic pain

threatened abortion, septic abortion, post-termination pain

define pelvic congestion

presence of dilated veins in the pelvis causing pain and congestion after vigorous activity, standing, intercourse, or menses - seen in the broad ligament, paratubular/ovarian supporting structures, paravaginally, or vulvar

define interstitial cystitis

defect in the protective layer of the bladder - related to frequency, burning pain, decreased bladder compliance ("stiff bladder"), UTI-like sx, and flares of increased sx

what is hunner's ulcer

not a true ulcer - areas are red, frequently w/ prominent or radial vessels - may be seen in interstitial cystitis

list the bladder related causes of pelvic pain (6)

1. UTI 2. urinary retention 3. bladder prolapse 4. interstitial cystitis 5. hunner's ulcer 6. bladder cancer

what ureter related causes of pelvic pain cause anterior pain, flank pain, and renal colic

anterior pain: stone moving towards the bladder flank: obstruction of ureter renal colic: intense contracture of ureter to move stone through

causes of ureteral obstruction or stenosis

fibrosis, injury, or endometriosis

list the bowel related causes of pelvic pain (5)

1. chronic constipation 2. IBD (crohn's, UC) 3. diverticular dz 4. dietary intolerance 5. appendicitis

why can IBS be effected by the menstrual cycle

shared nerve pathways in the pelvis in the presence of endometriosis

crohn's and UC: cyclic or noncyclic pelvic pain?

noncyclic

sx of appendicitis

mid-abdominal or RLQ pain, fever, anorexia, bloating | - perforation leads to increased peritoneal sx, shock, sepsis

list the musculoskeletal related causes of pelvic pain

1. abdominal wall hernias 2. incisional hernias 3. inguinal hernias 4. trauma

what is the most common hernia in women

indirect inguinal hernias

sx of hernia vs sx of incarcerated hernia

normal hernia: bulge, protrustion with strain, mass more prominent with strain or cough incarceration: pain, bowel obstruction sx, peritonitis, shock, sepsis

list the neurological related causes of pelvic pain (4)

1. radiation from spine 2. neuralgia from varicella zoster (shingles) 3. nerve entrapment (illioginguinal, genitofemoral) 4. pelvic floor neuralgia (pudendal neuralgia)

sx of pelvic floor neuralgia (pudendal neuralgia)

pain is deep in the pelvis and often affects ability to defecate or void - can be chronic, escalating, related to exercise, strain, lift, or surgery

causes of nerve entrapment leading to pelvic pain

can happen with spinal stenosis, but usually have antecedent trauma, injury, or surgery

define dyschezia

painful bowel evacuation

define dyspareunia

painful intercourse

define dyssnergia

disturbance of muscular/neuromuscular coordination

compare acute vs chronic pelvic pain

acute: sudden onset of lower abd pain, less than 3 months duration chronic: occurs in lower abd and present for 4 months or longer - neither related to, or separated from any organ system or menses

A-F ddx for pelvic pain | if you find the A-Z cards annoying feel free to rate them as a 5 and move on

``` A: adenomyosis B: bacteroides/abscess C: coelomic metaplasia D: diverticular dz E: ectopic pregnancy F: fallopian tube filling (hemato, hydro, pyo) ```

G-M ddx for pelvic pain | if you find the A-Z cards annoying feel free to rate them as a 5 and move on

``` G: gardnerella or ascending infection H: haemophilus and endometritis I: ileus J: jejunum K: kancerous changes L: leiomyoma M: mittelschmerz ```

N-S ddx for pelvic pain | if you find the A-Z cards annoying feel free to rate them as a 5 and move on

``` N: novasure and post ablation syndrome O: ovulation and ovarian cyst P: primary dysmenorrhea Q: quit contraception/pregnancy R: retrograde menstruation S: STI ```

T-Z ddx for pelvic pain | if you find the A-Z cards annoying feel free to rate them as a 5 and move on

``` T: torsion of ovary U: ulcerative colitis, IBD V: vascular congestion W: water blockage (bladder or ureter) X: eXuberant adhesions Y: yucky bugs Z: (for Z plasty) adhesion and their issues - hernias, infection, nerve entrapment ```