Pelvic pain Flashcards
history
• Keep in mind: Onset, Inciting events, Duration, Character, Radiation,
Provocation/Palliation, Correlation with changes in
habits/meds/exposures.
• Prior diagnosis, Prior procedures, Prior family medical diagnosis
• Correlating symptoms of bowel, bladder, or menstrual changes
• For premenopausal women, a menstrual history & menstrual profile
whats included in the menstrual profile?
• Consider menarche, Cycle length, Variability, Menstrual flow,
Dysmenorrhea, Cramping, Pain patterns, Radiation,
Concomitant changes in bowel or bladder
physical exam
• Look at the patient, get an overall assessment.
• Head to toe, skin, back, spine, abdomen, pelvic exam- look and feel,
urine and bowel evaluation as appropriate.
• Abdomen- overall, then by quadrant, think of ‘what lies beneath’ ..
• Pelvic exam- try to follow a consistent pattern- begin externally,
look carefully at the tissues, evaluate for infectious processes, feel
the cervix, the cul de sac, the uterus, the ovaries.
what are examples of cyclic pain?
Mittelschmerz , Endometriosis, Dysmenorrhea
what are examples of noncyclic pain?
• Interstitial cystitis, Diverticulosis, or a Hernia
• Endometriosis:
Ectopic endometrial glands and stroma.
Adenomyosis:
Glands and stroma, invading into the walls of the uterus.
Post Ablation Syndrome:
Collection of menstrual fluid behind scar in the
uterine cavity
Leiomyoma:
A cloning phenomena, where proliferation of cells can enlarge
the uterus, the adnexa, or the supporting ligaments of the uterus. These
may be intramural, pedunculated, subserosal, ligamentous, cervical, or
intracavitary.
Catamenial-
Menstrual related, linked to endometriosis.
Theories regarding endometriosis:
- Coelomic metaplasia- Metaplasia of cells has been
- demonstrated from ovarian and peritoneal surfaces.
- (Matsuura, et al 1999) Pluripotential cells are present on
- peritoneal or pleural surfaces.
- Retrograde menstruation-Retrograde flow of endometrial cells
- through the tubes, onto pelvic surfaces.
Ovarian cysts-
a dynamic and elastic occurrence in the
functioning ovary. Cysts may be physiologic, endometriotic,
teratoma, benign, borderline, or cancerous (serous, mucinous,
germ cell). Painful with rupture, bleeding, leaking of fluid, or
ovulation. (Mittelschmerz)
ovarian torsion
Rotation of the ovary on its suspensory
ligaments. Usually precipitated by a cyst or mass, frequently
greater than 5 cm.
Ovarian Remnant-
this occurs when ovarian tissue regenerates or
grows in response to gonadotropins. May be seen as a cyst or mass,
increased estradiol levels in bilateral ovarian removal. More frequent
on the left side.
what are the most common reason for cyclic pain
complaints.
ovarian cysts
what decreases risk of ovarian cysts, ovarian and uterine cancer?
OCP
Fallopian tube issues
• Torsion or ischemia of the tube is rare. Tubal cysts or paratubal
cysts do occur, and may be hard to distinguish on imaging.
what are most tubal issues due to?
obstruction of flow or infection –
hematosalpinx (blood), pyosalpinx (pus), hydrosalpinx (fluid).
These cause pain by distension. Like any irritated hollow
viscous, stimulation of the lumen an cause
contraction/cramping.
Pelvic Inflammatory Disease (PID)
Salpingitis due to infection.
This can lead to peritonitis, abscess, or sepsis. Pain, fever,
elevated WBC, ESR, peritoneal symptoms. STI or ascending
infections can occur.
ectopic pregnancy
Pain is usually caused by distension or rupture.
what level of hCG should transvaginal sonography show sign of IUP?
hCG of >1200 mIU/mL,
what level of hCG should transabdominal sonography show sign of IUP?
2000 mIU/mL
Endometritis
is an infection of the uterine cavity. Multiple agents can cause
this. Ascending infection with Strep, Mycoplasma, Ureaplasma,
Haemophilus, anaerobes, or STI can be cause.
Cervicitis
related to STI
what issues can IUD cause?
pain, by its location, perforation, concomitant infection,
inflammatory reaction, or stimulation of a hollow organ.
pregnancy related uterine causes of pain
- threatened abortion
- septic abortion
- post termination
- stretching of round ligament
- adhesions from prior event
pelvic congestion
It is the presence of dilated
veins in the pelvis. These are seen in the broad ligament, the
paratubal/ovarian supporting tissues, paravaginal or vulvar.
when does pelvic congestion cause pain?
after vigorous activity,
standing, intercourse, or menses.
what are some bladder related causes of pain
UTI, Urinary retention, or bladder prolapse are non cyclic causes of pain.
Pain tends to be central, and may be related to bladder patterns.
Interstitial Cystitis (IC)
- A defect in the protective layer of the bladder. This
can be related to frequency, burning pain, decreased bladder compliance,
UTI-like symptoms, and flares of increased symptoms.
• Hunner’s Ulcer
may be seen in IC. This is pathognomonic. This disease
may be hard to diagnose. Not a true ulcer, these areas are red, frequently
with prominent or radial vessels.
what is a less frequent cause of bladder related pain?
bladder cancer
what can cause ureteral pain?
may be anterior as a stone moves toward the
bladder. With obstruction of the ureter, there can be flank pain.
Renal colic
is intense contracture of the ureter to move the
stone through.
what can cause ureteral stenosis or obstruction?
fibrosis, injury, or
endometriosis can also cause pain to the lower abdomen, flank,
or lower back.
what are bowel related causes of pelvic pain?
Chronic constipation, Inflammatory bowel disease such as Crohns, or
Ulcerative Colitis
-noncyclic
IBS
an be effected by the menstrual cycle. Possibly due to shared
nerve pathways in the pelvis- between the visceral organs
- in the
presence of endometriosis.
what can cause pain, bloating, and bowel related discomfort.
Diverticular disease, Chronic constipation, and dietary intolerance
Appendicitis
can cause mid- abdominal or right lower
quadrant pain. Usually associated with fever, anorexia,
bloating and pain. Perforation may lead to increased
peritoneal symptoms, shock and sepsis.
where is mcburneys point?
is about 1/3 the distance from the ASIS to the
umbilicus. This is associated with pain, possible rebound, with
Appendicitis.
what MSK issues can cause pelvic pain?
• Abdominal wall hernias, incisional hernias, inguinal hernias are
possible as causes of pain. There may be a bulge, protrusion
with strain, or mass that is more prominent with strain or
cough.
what can incarceration of a hernia cause?
can be pain, bowel obstruction
symptoms, peritonitis, shock, or sepsis with a possible mass in
the wall.
neuro related pelvic pain
• Radiation from the spine, neuralgia from Varicella Zoster (Shingles), nerve
entrapment (Illioinguinal/Genitofemoral) Nerve entrapment can happen with
spinal stenosis, but these nerve injuries usually have antecedent trauma,
injury, or surgery.
• Lower abdominal pain, radiation to the groin or anterior thigh, worsened
often with extension of the lower back.
• Pelvic floor neuralgia or pudendal neuralgia tend to effect the paravaginal
and vaginal tissues. Pain is deep in the pelvis and often effects ability to
defecate or void. This may be chronic, escalating, related to exercise,
strain, lift, or surgery.
dysuria
painful urination
dysmenorrhea
painful menses (primary or secondary)
dyschezia
painful bowel evacuation
dyspareunia
painful intercourse
dyssnergia
disturbance of muscular/neuromuscular coordination
acute pelvic pain
less than 3 months
chronic pelvic pain
4 months or longer.
-neither related to or separated from any organ system or menses
