Pelvic Pain Flashcards
What is the definition of acute pelvic pain
Pelvic or lower abdominal pain of 24-48 hours duration
What is the basic vital you should take in a patient with pelvic pain?
Temperature
What abdominal exams should you do in a patient with pelvic pain?
- organomegaly
- masses
- rebound tenderness
- McBurney’s sign
—— point RLQ that is 1/3 the distance from the ASIS to umbilicus
What should you be looking for with a pelvic exam of a patient with pelvic pain?
- pain
- masses/ lesions
- vaginal discharge
What diagnostic testing might you consider with pelvic pain?
- Beta hCG (ALWAYS R/O Pregnancy!!!)
- CBC (elevated WBC?)
- ESR/CRP (inflammation?)
- Vaginal/cervical culture (infection?)
- DNA probe (STI?)
- Ultrasound (ovarian-related? fibroids?)
- Laparoscopy (cysts? endometriosis?)
Definition of chronic pelvic pain (CPP)
Pain in the pelvic area or lower quadrants for 6 months or longer
May be intense, disruptive and debilitating, diffuse or localized - lacks apparent somatic etiology
Accompanied by significant alterations in quality of life and disturbance of mood
What is the most common age for patient with CPP
20-35
How is CPP diagnosed?
Diagnosis of exclusion
What is the prevalence of CPP related to hysterectomies, laparoscopies, and secondary/tertiary outpatient gynecological exams?
12% of hysterectomies
40% of all laparoscopies
15-40% of all secondary/tertiary outpatient gynecological exams
What should be included in the history of a patient with CPP?
- Description and timing of pain in other areas
- Menstrual hx
- Sexual history- consensual and nonconsensual
- Work/leisure habits
- Problems with other systems
- Previous pelvic or abdominal infections
- Previous diagnostic or operative procedures
- Other current or past gynecological disorders
- Psychosocial history
- Family Hx: *Genetic predisposition to depression
What would be part of the physical exam in a patient with CPP?
- complete vitals, thyroid, abdominal, musculoskeletal
- pelvic, bimanual
What would be part of the laboratory in a patient with CPP?
CBC, ESR, STI DNA probe/culture, UA/culture, PAP smear
What other studies might be done for a patient with CPP?
- psychiatric evaluation, social work evaluation,
psychological testing - Pelvic ultrasound, hysteroscopy, biopsy, laparoscopy, abdominal xray, CT, MRI when deemed necessary
- complete list of other physician consults, dx, tx and outcomes
What is the role of laparoscopy with CPP?
- Diagnostic confirmation
- Histologic documentation
- Minimally invasive surgical treatment
- Patient reassurance
What is endometriosis?
Progressive disease
- Presence of endometrial glands and stroma outside the uterus
One of the leading causes of chronic pelvic pain
What are the etiologic theories for endometriosis?
- genetic
- retrograde menstruation
- altered immune function
- environmental exposures
What is the prevalence of endometriosis? What age is most common?
15% of reproductive aged women (M/C 25-30)
Rare in premenarche or menopausal women
What are the risk factors for endometriosis?
- Family History (8.1% mom, 5.1% sister, cousins)
- Shorter menstrual cycles
- Longer menstruation flow
- Increased serum estrogens
- Obesity (excess estrogen)
- Lack of exercise
- High fat diet
- Stress factors
What might be the clinical presentation of a patient with endometriosis?
- Pelvic Pain —— ovulation, before/during menses - Dyspareunia - Infertility —— often asymptomatic & discovered upon work up - Low back/leg pain —— indicates involv. of uterosacral ligaments & cul-de-sac - Severe dysmenorrhea - Irregular or heavy menstruation —— often due to ovarian involvement
What are some other symptoms that may be involved with endometriosis?
- Rectal discomfort/pain
- Nausea, vomiting, diarrhea w/ menses
- Pain with urination
- Pain with bowel movements
- Bleeding from bladder and/or bowels
- Endometriomas (more often in older women)
—— Ruptured endometrioma (from blood buildup) —> sudden, debilitating pain; may require surgery with possible oophorectomy
What are the three classification of endometriosis with respect to fertility and pain?
- Infertility issues with or without pelvic pain
- Pelvic pain & want to preserve fertility
- Pelvic pain & have completed childbearing
How is endometriosis diagnosed?
Laparoscopy is GOLD STANDARD
— appearance of blue-grey “powder” burned lesions
—Extent of disease on lap does not correlate well with pain, dyspareunia, or likelihood of pregnancy following treatment
- Serum CA-125 levels have been proposed
— sensitivity/specificity ~ 85%/20-50% - Imaging studies, ie ultrasound or MRI–not highly sensitive
Presumptive tx w/o visual/histologic dx OK per ACOG
What analgesics may be recommended for endometriosis?
- NSAIDs
- Narcotics
What endocrine therapy may be recommended for endometriosis?
- Progesterone (oral, IUD)
- OCP’s
- GnRh agonists (LUPRON)
- Danazol (synthetic testosterone) decreases
- antiproliferative effect on endometrium
- amenorrhea
- Arimidex (aromatase inhibitor) decreases inf lammation and growth in endometriosis and significantly reduced pain
