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Obstetrics & Gynaecology > Pelvic Pain and Dyspareunia > Flashcards

Pelvic Pain and Dyspareunia Flashcards

1
Q

Causes of post-coital bleeding

A

Cervical cancer, ectropion or infection

Trauma

Atrophic vaginitis

Polyps

Endometrial cancer

Vaginal cancer

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2
Q

Causes of pelvic pain

A

Urinary tract infection

Dysmenorrhoea (painful periods)

Irritable bowel syndrome (IBS)

Ovarian cysts

Endometriosis

Pelvic inflammatory disease (infection)

Ectopic pregnancy

Appendicitis

Mittelschmerz (cyclical pain during ovulation)

Pelvic adhesions

Ovarian torsion

Inflammatory bowel disease (IBD)

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3
Q

What are fibroids?

A

Benign tumours of the smooth muscle of the uterus

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4
Q

Presentation of fibroids

A

Often asymptomatic

Heavy menstrual bleeding (most common)

Prolonged menstruation, lasting more than 7 days

Abdominal pain, worse during menstruation

Bloating or feeling full in the abdomen

Urinary or bowel symptoms due to pelvic pressure or fullness

Deep dyspareunia

Reduced fertility

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5
Q

Investigations for fibroids

A

Hysteroscopy

Pelvic USS for larger fibroids

MRI before surgical management (to quantify size, shape and blood supply)

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6
Q

Management of fibroids less than 3mm

A 
MEDICAL:
Mirena coil (1st line)

Symptomatic management with NSAIDs and TXA

COCP

Cyclical oral progestogens

SURGICAL:
Endometrial ablation

Resection of submucosal fibroids during hysteroscopy

Hysterectomy

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7
Q

Management of fibroids >3mm

A

MEDICAL:
Symptomatic management with NSAIDs and tranexamic acid

Mirena coil

COCP

Cyclical oral progestogens

SURGICAL:
Uterine artery embolisation

Myomectomy

Hysterectomy

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8
Q

Complications of fibroids

A

Heavy menstrual bleeding, often with iron deficiency anaemia

Reduced fertility

Pregnancy complications, such as miscarriages, premature labour and obstructive delivery

Constipation

Urinary outflow obstruction and urinary tract infections

Red degeneration of the fibroid

Torsion of the fibroid, usually affecting pedunculated fibroids

Malignant change to a leiomyosarcoma is very rare (<1%)

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9
Q

What is ‘red degeneration’?

A

Ischaemia, infarction and necrosis of fibroid due to disrupted blood supply

More likely to occur in larger fibroids (above 5cm)

2nd and 3rd trimester

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10
Q

Pregnant woman with a history of fibroids presenting with severe abdominal pain and a low-grade fever

A

Red degeneration

Supportive management with rest, fluids and analgesia

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11
Q

Define endometriosis

A

Ectopic endometrial tissue outside the uterus

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12
Q

Presentation of endometriosis

A

Can be asymptomatic

Cyclical abdominal or pelvic pain

Deep dyspareunia

Dysmenorrhoea

Infertility

Cyclical bleeding from other sites, such as haematuria

Urinary symptoms

Bowel symptoms

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13
Q

Diagnosis of endometriosis

A

Pelvic USS

Laparoscopic surgery (can also be therapeutic)

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14
Q

Staging of endometriosis

A

Stage 1: Small superficial lesions

Stage 2: Mild, but deeper lesions than stage 1

Stage 3: Deeper lesions, with lesions on the ovaries and mild adhesions

Stage 4: Deep and large lesions affecting the ovaries with extensive adhesions

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15
Q

Initial management of endometriosis

A

Establishing a diagnosis

Providing a clear explanation

Listening to the patient, establishing their ideas, concerns and expectations and building a partnership

Analgesia as required for pain (NSAIDs and paracetamol first line)

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16
Q

Hormonal management of endometriosis

A

COCP, which can be used back to back without a pill-free period if helpful

Progesterone only pill

Medroxyprogesterone acetate injection (e.g. Depo-Provera)

Nexplanon implant

Mirena coil

GnRH agonists

17
Q

Surgical management of endometriosis

A

Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)

Hysterectomy

18
Q

What is adenomyosis?

A

Endometrial tissue inside the myometrium

19
Q

Presentation of adenomyosis

A

Asymptomatic

Painful periods (dysmenorrhoea)

Heavy periods (menorrhagia)

Pain during intercourse (dyspareunia)

Infertility or pregnancy-related complications

20
Q

Diagnosis of adenomyosis

A

TVUSS

MRI or TA USS second line

Histological examination is gold standard

21
Q

Management of adenomyosis

A

Dependent on symptoms, age and plans for pregnancy

Mirena coil (first line)

COCP

Cyclical oral progestogens

If contraception not wanted:
TXA when no associated pain (antifibrinolytic - reduces bleeding)
Mefenamic acid when associated pain (NSAID - reduces bleeding and pain)

22
Q

Adenomyosis associations in pregnancy

A

Infertility

Miscarriage

Preterm birth

Small for gestational age

Preterm premature rupture of membranes

Malpresentation

Need for caesarean section

Postpartum haemorrhage

23
Q

Presentation of ovarian cysts

A

Most are asymptomatic and found incidentally

Pelvic pain

Bloating

Fullness in abdomen

Palpable pelvic mass (very large)

24
Q

Features of ovarian cysts that may suggest malignancy

A

Abdominal bloating

Reduced appetite

Early satiety

Weight loss

Urinary symptoms

Pain

Ascites

Lymphadenopathy

25
Q

Management of ovarian cysts

A

Possible ovarian cancer - 2WW

Manage based on size

<5cm should resolve within 3 cycles

5-7cm refer for yearly US monitoring

> 7cm consider MRI pr surgical evaluation

Surgical removal (laparoscopic)

26
Q

Complications of ovarian cysts

A

Torsion

Haemorrhage into the cyst

Rupture with bleeding into the peritoneum

27
Q

What is Meig’s syndrome?

A

Triad of:

Ovarian fibroma (a type of benign ovarian tumour)

Pleural effusion

Ascites

28
Q

Woman presenting with a pleural effusion and an ovarian mass

A

Meig’s syndrome

Remove tumour = complete resolution of effusion and ascites

29
Q

What is ovarian torsion?

A

Ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply (the adnexa)

30
Q

What usually causes ovarian torsion?

A

Usually ovarian mass larger than 5cm e.g. cyst or tumour

More likely to occur with benign tumours

More likely to occur during pregnancy

Can occur in younger girls with longer infundibulopelvic ligaments

31
Q

Presentation of ovarian torsion

A

Sudden onset severe unilateral pelvic pain.

Progressively worse

Nausea & vomiting

Localised tenderness and palpable mass

32
Q

Management of ovarian torsion

A

Emergency admission

Laparoscopic surgery (untwist or remove affected ovary)

33
Q

Complications of ovarian torsion

A

Delay in treatment can result in loss of function of that ovary

If necrotic ovary not removed - infection, abscess, sepsis

May rupture causing peritonitis or adhesions

34
Q

Diagnosis of ovarian torsion

A

Pelvic USS initial investigation of choice (TV ideal)

Whirlpool sign (free fluid in pelvis)

Oedema of ovary

Definitive diagnosis is with laparoscopic surgery

Obstetrics & Gynaecology (13 decks)

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