Pelvic pain and pelvic inflammatory disease Flashcards
What is pelvic inflammatory disease?
infection/inflammation of of female reproductive organs: uterus, fallopian tubes, ovaries and surrounding tissues
How is a diagnosis of PID made?
CLINICAL diagnosis (backed up by lab tests)
What are some symptoms of PID?
Lower abdo pain (usually bilateral)
Deep dyspareunia
Abnormal vaginal bleeding: IMB, PCB and menorrhagia
Abnormal vaginal or cervical discharge: usually purulent
Where does PCB generally originate from?
cervix (common sign of STI)
BUT
could be due to other causes e.g. trauma following intercourse with dry vagina
What examinations would you do on a woman who presents with new onset abdo pain, abnormal bleeding, dyspareunia?
Abdominal exam
Speculum
Bimanual palpation
What does LSI stand for?
Last sexual intercourse
What does PSI stand for?
Previous sexual intercourse
How would you investigate a 17 yr old girl with 2/52 Hx od lower abdo/pelvic pain, pain during sex, dysuria but no other urinary symptoms; PLUS OE: bilateral lower abdo tenderness, cervical motion tenderness and L adenexum tenderness?
Urine: urine dip (and MSU), urinary PT
VV swabs: chlamydia and gonorrhoea (NAAT)
High vaginal swab: Candida, BV, TV
Endocervical swab: gonorrhoea (culture)
Bloods: HIV and syphillis
(other general health bloods)
Would you treat someone with suspected chlamydia/PID if they are symptomatic before you had their swab results?
YES
If a test result comes back negative for chlamydia and gonorrhoea, does this exclude the diagnosis of PID?
no
75% of PID is not caused by an STI
What are the PID clinical criteria?
Lower abdominal pain
PLUS
pyrexia leucocytosis ESR > 15 Adnexal pain Cervical motion tenderness Adnexal mass
What are some complications of PID?
Ectopic pregnancy
Tubal factor infertility
Chronic dyspareunia and pelvic pain
Fitz-Hugh-Curtis syndrome (perihepatitis)
In women <30yrs (with/without indicative sexual history), what is RUQ pain suggestive of?
Perihepatitis (rather than cholecystitis)
Why don’t you delay treatment of PID?
Multiple episodes of PID or treatment is delayed = INCREASED RISK OF INFERTILITY
How would you manage PID?
Rest (in severe disease)
Analgesia
Admission for IV therapy in more severe disease
No sex until both they and their partner have completed treatment and follow up
What medication would you prescribe for someone with PID?
Ceftriaxone 500 mg im followed by
Doxycycline 100mg bd po 14 days
Metronidazole 400mg bd po 7-14 days
OR
Ofloxacin 400mg bd po 14days
plus
Metronidazole 400mg bd po 14 days
Trying to cover: gonorrhoea, chlamydia and anaerobes
Can women with PID go on to have children?
Most women - if there are recurrent or prolonged untreated episodes, fertility may be effected
What are some causes of PID?
Neisseria gonorrhoea
Chlamydia trachoma’s
BV associated organisms
Other organisms (streptococci, staphylococci, E coli)
Mycoplasma genitalium
Mycobacterium tuberculosis
BUT! Always treat as an STI initially.
If a patient comes in experiencing heavy and painful periods, what should you ask them about?
Bleeding: Normal cycle (incl. LMP and regularity)
When changes occurred
IMB or PCB
discharge
Pain - when is it worst, before to after menses
dyspareunia
Bladder Sx
Obstetric Hx
Sexual Hx
PMHx
DHx (incl. allergies)
What are the two types of dyspareunia?
superficial and deep
superficial - on penetration
deep - pain deep in abdo/pelvis
What is endometriosis?
Ectopic endometrial tissue - endometrial material in the pelvis
What is adenomyosis?
Endometrial tissue in myometrium
What are some symptoms of endometriosis?
dysmenorrhoea/cyclical pelvic pain
dyspareunia
urinary symptoms
rectal/anal Sx
What are some risk factors for endometriosis?
C-section
TOP
Does macroscopic appearance of endometriosis tally with severity of symptoms?
no
What are some common sites of endometriosis?
Peritoneum Pouch of Douglas (POD) Ovary / Tubes Ligaments Bladder Myometrium
How would you investigate endometriosis?
USS - endometrioma (can’t see scar tissue)
Laparoscopy
How would you treat endometriosis medically?
Analgesics – NSAIDs (symptom relief)
Oral Contraceptives (ovarian suppression)
Mirena IUS (endometrial +- ovarian supp)
GnRH analogues (ovarian suppression) eg prostap, gonapeptyl
How would you treat endometriosis surgically?
Laparoscopic ablation of endometriotic spots e.g. diathermy
Laparoscopic resection of active lesions/scar tissue
Laparoscopic cystectomy/oophorectomy
Hysterectomy – concerns re age and will need HRT
What is chronic pelvic pain?
Intermittent or constant pain in the lower abdomen or pelvis of at least 6 months’ duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy.
What other conditions might be associated with chronic pelvic pain?
IBS
Interstitial cystitis
What is one of the main causes for non-gynae pelvic pain?
constipation
How would you manage a woman with chronic pelvic pain?
TV Scan
Trial of OCP/GnRH analogues for 3-6 months
Mirena
Antispasmodics, analgesia, referral to pain clinic
Laprascopy
What are some acute GYNAE causes of pelvic pain?
Ectopic pregnancy
Ovarian cyst accident
Primary dysmennorhoea
Mittleschmerz
What are some of the symptoms of an ovarian cyst accident?
gradual onset
exclusively unilateral dyspareunia
palpation pain
What is mittleschmerz?
menstrual pain due to fluid around ovum
What are some acute NON-GYNAE causes of pelvic pain?
Gastrointestinal: appendicitis
IBS/IBD
Strangulated hernia
Urological:
UTI
Calculi
What are some GYNAE causes of chronic pelvic pain?
Pelvic adhesions
Fibroids
Cervical stenosis
Asherman’s syndrome
NB Dysmenorrhoea is common!
1° = No cause
2° = underlying cause
What are some NON-GYNAE causes of chronic pelvic pain?
Gastrointestinal: Constipation
hernias
IBS / IBD
Urological:
Interstitial cystitis
Calculi
What are some symptoms that may lead you to think about constipation in pelvic pain?
colicky pain, exacerbated by stress,
L sided/posterior fornix
