Pelvic Pain and Masses Flashcards
Common conditions that can cause acute abdominal pain
appendicitis, cholecystitis, choledocholithiasis, diverticulitis, pancreatitis, bowel, perforation, mesenteric ischemia, ischemic colitis, intestinal obstruction
three categories of gynocologically cause abdominal pain
acute cases in nonpregnant
chronic problems in nonpregnant
acute cases in pregnant
PID, adnexal torsion, ruptured ovarian cyst, horrhage corpus luteum cyst, ovarian torsion, endometriosis, tubovarian abscess all fall into what category of gynecologic cause of abdominal pain
acute causes in nonpregnant
Dynmenorrhea, Mittelscherz, Endometriosis, obstruction mullerian duct abnormalities, leiomyomas, cancer, pelvic congestion syndrome all fall under the category of what gynecologic cause of abdominal pain
chronic causes in nonpregnant
ectopic pregnancy, retained products of conception, septic abortion, and ovarian torsion all fall under what category of gynecologic cause of abdominal pain
acute causes in pregnancy
what do you want to include in your history when assessing a patient with abdominal pain
LMP, menstrual history, sexual history, family history
pain associated with menstural cycle
dysmenorrhea
primary vs secondary dysmenorrhea
primary has no pathologic findings.
Secdonary as some associated findings/pathology.
What is the etiology of dysmenorrhea?
increased production of endometrial prostaglandin → increases uterine tone and uterine contraction during menses
Patient presents with low midline cramping pain during peak flow; occasionally associated with nausea, vomiting, diarrhea, headahce, flushing, fatigue
primary dysmenorrhea
what symptoms would warrant further workup in primary dysmenorrhea?
dysmenorrhea before age 25
abnormal pelvic exam
infertility
Treatment for primary dysmenorrhea
NSAID, Cox 2 inhibitor
oral contraceptive, depo, levonorgestrel IUD
What fall under the category of secondary dysmenorrhea?
endometriosis, adenomyosis, uterine fibroids, ovarian cysts, ovarian torsion
abnormal growth of endometrial tissue outside of the uterus → irritates surrounding tissue and may develop scar tissue or adhesions
endometriosis
Endometriosis is the leading cause for what 2 things
chronic pelvic pain and infertility
when will a patient with endometriosis have the most pain?
occurs around cycle
What is believed to be the etiology of endometriosis?
retrograde menstruation
what can pelvic exam reveal in patient with endometriosis?
tender nodules in cul-de-sac or rectovaginal septum, decreased uterine mobility, cervical motion tenderness, adnexal mass or tenderness
How is endometriosis diagnosed?
histology of lesions removed at surgery
What is the preferred medical management for endometriosis?
hormonal therapy → lowers hormone levels and prevents cyclic stimulation of endometrial implants → induces atrophy
what is approved in treating endometriosis associated pain?
progestins → oral norethindrone acetate and subQ DMPA (Depo)
GnRH agonist
What are some side effects seen in GnRH agonists?
vasomotor symptoms and bone demineralization
What is the androgenic drug that may be used for endometriosis associated pain?
danazol
What are side effects of Danazol?
decreased breast size, weight gain, acne, hirsutism
If a patient with endometriosis desires fertility what is the preferred treatment management?
laparoscopic ablation of endometrial implants
If a patient with endometriosis does not desire fertility and/or if the pain is too bad, what is the preferred treatment??
total abdominal hysterectomy and bilaterial salpingo-oophrectomy
add HRT if premenopausal
Symptoms of endometriosis
dysmenorrhea, dyspareunia, pain with BM/urination, excessive bleeding, infertility
Term for endometrial tissues that grows into the muscular wall of the uterus
adenomyosis
Symptoms of adenomyosis
heavy/prolonged menstrual bleeding, dysmenorrhea, menstrual cramps throughout period, dyspareunia, blood clots pass during period
How will adenomyosis present on pelvic exam?
enlarged and tender uterus
What is the treatment for adenomyosis?
NSAID and hormonal contraceptive → hysterectomy if all fails
Most common benign neoplasm of female genital tract
uterine leiomyoma (fibroid)
Most common location for uterine fibroid → within the uterine wall
intramural
Uterine fibroid develops just under the lining of the uterine cavity
submucosal or pedunculated subucosal
uterine fibroid located near the outside of the uterus and may prodrude into the abdominal cavity
subserous or pedunculated subserois
Uterine fibroid found in the supporting structures
intra-ligamentois
Uterine fibroid that develops in the cervis
cervical
What is believed to be the cause of uterine fibroids?
muscle cells that transform and is stimulated to grow into benign tumor
When will uterine fibroids quit growing?
during menopause → usually hormonally responsive to estrogen and progesterone
What race has greater lifetime risk for fibroids?
AA > Caucasians
What are risk factors for fibroids?
AA, smoking, early menarche, nulliparity, EtOH use, HTN
Two most common symptoms of uterine fibroids and are what makes women seek treatment (otherwise asymptomatic)
abnormal uterine bleeding (heavier and longer)
pelvic pain/pressure
If a fibroid degenerates, how will the patient feel?
intense pain
How can uterine fibroids complicate pregnancy?
increase risk of miscarriage if they distort uterine cavity, possible preterm labor and delivery
What lab finding may you find in patient with uterine fibroid?
IDA
what imaging technique can you used to confirm and monitor the growth of uterine fibroid?
US
What imaging technique would you use to differentiate intramural and submucous myomas?
MRI
What imaging technique is used to confirm cervical or submucous myomas?
hysterography or hysteroscopy
What is the treatment for acute torsion of pedunculated myoma?
emergency surgery
If you are performing emergency surgery for uterine fibroid and the patient is severely anemic, what do you give them pre-operatively?
DMPA or GnRH agonist
What is the only emergency indication for myomectomy during pregnancy?
torsion
What would be indication for surgical removal of uterine fibroid?
patient symptoms and desire for fertility
What uterine fibroids require removal?
cervical myomas > 3-4 cm
pedunculated myoma that protrude through the cervix
How can you preoperatively reduce the size of myoma?
GnRH analogs
What is the curative treatment for uterine fibroid?
surgery
What treatment can a woman get for uterine fibroid if she desires fertility in the future? What are some risk factors?
myomectomy → recurrence is common and post OP pelvic adhesions
Three types of functional ovarian cysts
follicular, corpus luteum, theca luteum
This cyst is common in reproductive age women → forms when follicle fails to rupture and release the egg → often spontaneously resolves
follicular cyst
This cyst is common in reproductive age women → forms when corpus luteum fails to regress → may produce progesterone and may be hemorrhagic
corpus luteum cyst
when does follicular cyst become clinically significant?
large enough to cause pain or persists beyond one menstural cycle
Symptoms that patient with follicular cyst present with
lower abdominal/pelvic pain, irregular bleeding
What occurs when corpus luteum cyst develops?
when the follicle ruptures and releases the egg and if fluid accumulates when it is sealing off → cyst forms
What cyst is considered postovulatory?
corpus luteum cyst
What fertility drug increases risk for for cyst formation?
clomiphene (Clomid)
What are symptoms of corpus luteum cyst?
pain and missed period (produce progesterone longer than usual and delay menstruation)
The least common cyst and often associated with pregnancy (high HCG)
theca lutein cyst
Cyst containing tissue (such as hair, skin, teeth) since they are derived from germ cells (oocytes)
dermoid cyst
cyst that develops from ovarian tissue and may be filled with watery liquid or mucous → mostly benign
cystademonas
cyst that develops as a result of endometriosis tissue within the ovary → “Chocolate Cyst”
endometriomas
If ovarian cyst gets too large what is the patient at risk for?
torsion of ovary
What would occur that would require prompt intervention with a cyst?
rupture or bleed
What labs would you order for patient with ovarian cyst?
pregnancy test, CA 125
What is the only way to diagnosi ovarian cyst?
pelvic US
How do you diagnose and treat ovarian cyst?
laparoscopic surgery
How do you treat cysts and prevent others from forming?
watchful waiting
hormone therapy may prevent new cysts
ovary twists around supporting structures → occlusion of vascular supply to ovary →ischemia → pain
ovarian torsion
Two etiologies of ovarian torsion
complication of ovarian cyst and pregnancy is risk factor
signs and symptoms of ovarian torsion
sudden, acute abdominal/pelvic pain (constant or intermittent), pelvic tenderness
How do you diagnose ovarian torsion?
US with Doppler
How do you definitely diagnose and treat ovarian torsion ?
laparoscopy
How do you treat recurrent ovarian cysts that cause torsion?
salpingo-oophrectomy
