Pelvic Pain and Dyspareunia Flashcards
Causes of post-coital bleeding
Cervical cancer, ectropion or infection
Trauma
Atrophic vaginitis
Polyps
Endometrial cancer
Vaginal cancer
Causes of pelvic pain
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)
What are fibroids?
Benign tumours of the smooth muscle of the uterus
Presentation of fibroids
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
Investigations for fibroids
Hysteroscopy
Pelvic USS for larger fibroids
MRI before surgical management (to quantify size, shape and blood supply)
Management of fibroids less than 3mm
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
Management of fibroids >3mm
MEDICAL:
Symptomatic management with NSAIDs and tranexamic acid
Mirena coil
COCP
Cyclical oral progestogens
SURGICAL:
Uterine artery embolisation
Myomectomy
Hysterectomy
Complications of fibroids
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%)
What is ‘red degeneration’?
Ischaemia, infarction and necrosis of fibroid due to disrupted blood supply
More likely to occur in larger fibroids (above 5cm)
2nd and 3rd trimester
Pregnant woman with a history of fibroids presenting with severe abdominal pain and a low-grade fever
Red degeneration
Supportive management with rest, fluids and analgesia
Define endometriosis
Ectopic endometrial tissue outside the uterus
Presentation of endometriosis
Can be asymptomatic
Cyclical abdominal or pelvic pain
Deep dyspareunia
Dysmenorrhoea
Infertility
Cyclical bleeding from other sites, such as haematuria
Urinary symptoms
Bowel symptoms
Diagnosis of endometriosis
Pelvic USS
Laparoscopic surgery (can also be therapeutic)
Staging of endometriosis
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
Initial management of endometriosis
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)
Hormonal management of endometriosis
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
Surgical management of endometriosis
Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)
Hysterectomy
What is adenomyosis?
Endometrial tissue inside the myometrium
Presentation of adenomyosis
Asymptomatic
Painful periods (dysmenorrhoea)
Heavy periods (menorrhagia)
Pain during intercourse (dyspareunia)
Infertility or pregnancy-related complications
Diagnosis of adenomyosis
TVUSS
MRI or TA USS second line
Histological examination is gold standard
Management of adenomyosis
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)
Adenomyosis associations in pregnancy
Infertility
Miscarriage
Preterm birth
Small for gestational age
Preterm premature rupture of membranes
Malpresentation
Need for caesarean section
Postpartum haemorrhage
Presentation of ovarian cysts
Most are asymptomatic and found incidentally
Pelvic pain
Bloating
Fullness in abdomen
Palpable pelvic mass (very large)
Features of ovarian cysts that may suggest malignancy
Abdominal bloating
Reduced appetite
Early satiety
Weight loss
Urinary symptoms
Pain
Ascites
Lymphadenopathy
Management of ovarian cysts
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)
Complications of ovarian cysts
Torsion
Haemorrhage into the cyst
Rupture with bleeding into the peritoneum
What is Meig’s syndrome?
Triad of:
Ovarian fibroma (a type of benign ovarian tumour)
Pleural effusion
Ascites
Woman presenting with a pleural effusion and an ovarian mass
Meig’s syndrome
Remove tumour = complete resolution of effusion and ascites
What is ovarian torsion?
Ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply (the adnexa)
What usually causes ovarian torsion?
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
Presentation of ovarian torsion
Sudden onset severe unilateral pelvic pain.
Progressively worse
Nausea & vomiting
Localised tenderness and palpable mass
Management of ovarian torsion
Emergency admission
Laparoscopic surgery (untwist or remove affected ovary)
Complications of ovarian torsion
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
Diagnosis of ovarian torsion
Pelvic USS initial investigation of choice (TV ideal)
Whirlpool sign (free fluid in pelvis)
Oedema of ovary
Definitive diagnosis is with laparoscopic surgery
