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GU > Pelvic Pain > Flashcards

Pelvic Pain Flashcards

1
Q

What is the definition of acute pelvic pain

A

Pelvic or lower abdominal pain of 24-48 hours duration

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2
Q

What is the basic vital you should take in a patient with pelvic pain?

A

Temperature

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3
Q

What abdominal exams should you do in a patient with pelvic pain?

A
  • organomegaly
  • masses
  • rebound tenderness
  • McBurney’s sign
    —— point RLQ that is 1/3 the distance from the ASIS to umbilicus
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4
Q

What should you be looking for with a pelvic exam of a patient with pelvic pain?

A
  • pain
  • masses/ lesions
  • vaginal discharge
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5
Q

What diagnostic testing might you consider with pelvic pain?

A
  • 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?)
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6
Q

Definition of chronic pelvic pain (CPP)

A

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

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7
Q

What is the most common age for patient with CPP

A

20-35

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8
Q

How is CPP diagnosed?

A

Diagnosis of exclusion

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9
Q

What is the prevalence of CPP related to hysterectomies, laparoscopies, and secondary/tertiary outpatient gynecological exams?

A

12% of hysterectomies
40% of all laparoscopies
15-40% of all secondary/tertiary outpatient gynecological exams

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10
Q

What should be included in the history of a patient with CPP?

A
  • 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
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11
Q

What would be part of the physical exam in a patient with CPP?

A
  • complete vitals, thyroid, abdominal, musculoskeletal

- pelvic, bimanual

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12
Q

What would be part of the laboratory in a patient with CPP?

A

CBC, ESR, STI DNA probe/culture, UA/culture, PAP smear

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13
Q

What other studies might be done for a patient with CPP?

A
  • 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
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14
Q

What is the role of laparoscopy with CPP?

A
  • Diagnostic confirmation
  • Histologic documentation
  • Minimally invasive surgical treatment
  • Patient reassurance
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15
Q

What is endometriosis?

A

Progressive disease
- Presence of endometrial glands and stroma outside the uterus

One of the leading causes of chronic pelvic pain

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16
Q

What are the etiologic theories for endometriosis?

A
  • genetic
  • retrograde menstruation
  • altered immune function
  • environmental exposures
17
Q

What is the prevalence of endometriosis? What age is most common?

A

15% of reproductive aged women (M/C 25-30)

Rare in premenarche or menopausal women

18
Q

What are the risk factors for endometriosis?

A
  • 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
19
Q

What might be the clinical presentation of a patient with endometriosis?

A 
- 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
20
Q

What are some other symptoms that may be involved with endometriosis?

A
  • 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
21
Q

What are the three classification of endometriosis with respect to fertility and pain?

A
  • Infertility issues with or without pelvic pain
  • Pelvic pain & want to preserve fertility
  • Pelvic pain & have completed childbearing
22
Q

How is endometriosis diagnosed?

A

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

23
Q

What analgesics may be recommended for endometriosis?

A
  • NSAIDs

- Narcotics

24
Q

What endocrine therapy may be recommended for endometriosis?

A
  • 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
25
Q

What surgery may be done with endometriosis?

A
  • laparoscoic resection, excision, electrocoagulation, laser
  • Total abdominal hysterectomy w/ salpingo oophorectomy (TAHBSO)
26
Q

Is there good data that suggest surgery or medical treatment is better for pain or maintenance of fertility?

A

No good data

And No evidence that tx of asymptomatic pts
preserves/improves fertility

27
Q

What are some CAM treatments for endometriosis?

A
  • Immune modulation (decrease histamine = vitamin C, E)
  • Hormone balance (chaste tree, progesterone cream) & treat the LV
  • Pain relief; decrease PGE-2, natural COX-2 inhibitiors
28
Q

What are some nutrition changes for a patient with endometriosis?

A
  • high fiber
  • essential fatty acids
    —— Black currant oil/evening primrose oil = GLA —> block the release of cytokines and prostaglandins involved in uterine muscle contraction and cramping
    —— fish oil, containing EPA/DHA, can decrease intraperitoneal PGE2 and PGF2-alpha production & endometrial implants (ferti steril 1988)
  • foods to avoid (largely theorectical)
    —— sugar, caffeine, dairy, alcohol, salt, wheat, fat
29
Q

With CPP, Historical factors present in only ___% of women with adhesions

Higher probability if pain is localized

Adhesiolysis associated with improvement in ___-___%
of CPP cases

A

50

60-90

30
Q

Chronic PID dx in __% of laparoscopies for CPP

A

5

31
Q

What MSK historical keys may be associated with CPP

A
  • pain altered by position changes
  • hx of pain or trauma to low back to lower extremity
  • Spasm of pelvic f loor muscles
  • normal laparoscopy????
32
Q

What MSK structural observations may be associated with CPP?

A
  • exaggeration of lumber curve & anterior pelvic tilt
  • pelvic alignment, iliac crest height variable, leg
    length discrepancies
  • unilateral standing habits
  • slouched sitting or standing
  • obesity
  • scoliosis

GU (7 decks)

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