Pelvic Pain and Dyspareunia

Question 1

Investigating Acute Pelvic Pain

Answer 1

History: Pain SOCRATES, LMP, contraception, recent UPSI, vaginal discharge or bleeding, bowel and urinary symptoms, precipitating factor
Haemodynamic status, abdo exam, pelvic exam: Discharge, excitation, tenderness, masses
Investigations: Urinary/Serum HCG, MSU, High vaginal cervical and endocervical chlamydia
Bloods: FBC, G+S XM if Ectopic suspected, CRP
Pelvic USS, AXR, CT or MRI appropriate, diagnostic laparoscopy

Question 2

Gynaecological Causes of Acute Pelvic Pain

Answer 2

Early pregnancy: Ectopic, miscarriage, ovarian hyperstimulation syndrome
PID
Ovarian torsion, haemorrhage, rupture, abscess
Mittelschmerz: Ovulation pain
Primary Dysmenorrhoea
GI: Appendicitis, IBS, IBD, Mesenteric Adenitis, Diverticulitis, Hernia, Strangulation
Urological: UTI, Stone disease

Question 3

Chronic Pelvic Pain

Answer 3

Intermittent or constant pelvic pain in lower abdomen or pelvis >6/12 not occurring exclusively with menstruation or intercourse, and not associated with pregnancy

Question 4

Causes of Chronic Pelvic Pain

Answer 4

Endometriosis, Adenomyosis
Adhesions
Pelvic venous congestion
IBS, Constipation, Hernia
Interstitial cystitis, urethral syndrome, stone disease
Nerve entrapment, neuropathic pain, psychological associations

Question 5

Management of Chronic Pelvic Pain

Answer 5

Trial of GnRH analogues
Analgesia
COCP, Progestogens, GnRH analogues with Addback HRT

Question 6

Endometriosis

Answer 6

Presence of endometrial tissue outside of uterine cavity, oestrogen dependent
Believed to be due to retrograde menstruation, metaplasia of mesothelium, systemic or lymphatic spread or impaired immunity

Question 7

Presentation of Endometriosis

Answer 7

Infertility
Pain-often cyclical, severe dysmenorrhoea
Dyspareunia
Rectal bleeding and defecation pain can occur with invasion of rectal mucosa
Most common sites: pelvic (rectouterine, uterosacral, ovarian fossa, bladder, peritoneum
Important to establish nature of pain relative to menstrual cycle as well as associated symptoms

Question 8

Investigations of Endometriosis

Answer 8

TV USS, Laparoscopy with biopsy important for deep infiltrating lesions, endometriomas >3cm should be resected to rule out malignancy
Should not be performed within 3 months of hormone therapy which can lead to missed diagnosis
MRI, IVU or Barium Enema useful to access useful to access extent of involvement of other organs

Question 9

Indications for Laparoscopy

Answer 9

NSAID resistant lower abdominal pain, dysmenorrhoea, pain resulting in severe functional disability, infertility investigations

Question 10

Treatment of Endometriosis

Answer 10

Empirical treatment with COCP (1st line continuously) or Progestogens without Laparoscopic diagnosis is acceptable, NSAIDs are effective and used concurrently
This does not improve fertility in endometriosis
Other: GnRH analogues with Addback HRT, IUD, Danazol, Aromatase inhibitors

Question 11

Treating severe endometriosis

Answer 11

If severe, or failed medical treatment refer for laparoscopic surgery
Surgical removal improves spontaneous pregnancy rate in minimal/mild disease
Hysterectomy as last resort if severe and refractory to treatment

Question 12

Dyspareunia

Answer 12

Painful sexual intercourse

Can be on external surface of genitalia or deeper in the pelvis

Question 13

Causes of dyspareunia

Answer 13

Infections, Trauma, Anatomical anomalies
Hormonal-endometriosis, adenomyosis, oestrogen deficiency
Ovarian cysts, tumours, fibroids
Malignancy of genital tract-vaginal, cervical, uterine, ovaria
Vulvodynia: Diagnosis of exclusion