Pelvic Pain + Dyspareunia Flashcards
In women the most common cause of pelvic pain is primary dysmenorrhoea. Some women also experience transient pain in the middle of their cycle secondary to ovulation (mittelschmerz).
What are the common acute causes of pelvic pain?
- Ectopic pregnancy → typical hx of 6-8wks amenorrhoea presents w/ lower abdo pain + later develop vaginal bleeding; shoulder tip pain + cervical excitation may be seen
- UTI → dysuria + freq are common but women may experience suprapubic burning secondary to cystitis
- Appendicits → pain initial in central abdo before localising to RIF; anorexia common; tachycardia, low-grade pyrexia, tenderness in RIF; Rosving’s sign
- PID → pelvic pain, fever, deep dyspareunia, vag discharge, dysuria, menstrual irregularities; cervical excitation may be found
- Ovarian torsion → sudden onset unilateral abdo pain; onset may coincide w/ exercise; N+V common; unilateral, tender adnexal mass on examination
- Miscarriage → vag bleeding + crampy lower abdo pain following period of amenorrhoea
What are the common chronic causes of pelvic pain?
- Endometriosis → chronic pelvic pain; dysmenorrhoea (pain often starts days before bleeding); deep dyspareunia; subfertility
- IBS → extremely common; abdo pain, bloating, bowel habit change; also lethargy, nausea, backache + bladder symptoms
- Ovarian cyst → unilateral dull ache, intermittent or during intercourse; torsion or rupture may lead to severe abdo pain; large cysts cause abdo swelling or pressure effects on bladder
- Urogenital prolapse → seen in older women; sensation of pressure, heaviness, ‘bearing-down’; urinary symptoms eg. incontinence, frequency, urgency
<em>Others: adenomyosis, fibroids</em>
What are psychological causes of pelvic pain?
- physical + sexual abuse
- child abuse
- depression
- anxiety
- rape
- other (personality disorders)
What are some specific investigations to conduct for pelvic pain?
- urine dip, MC+S → infective cystitis
- cervical swab → current STD
- pelvic USS → fibroids, adenomyosis, ovarian cysts
- cystoscopy → interstitial cystitis
- laparascopic biopsy → diagnosis of endometriosis/adenomyosis
- pelvic CT → any mass seen before on USS
Dyspareunia, or painful sexual intercourse, is a common symptom among women. Primary dyspareunia is characterised by pain associated with intercourse since the onset of sexual activity. Secondary dyspareunia is acquired over a patient’s sexual lifetime.
What is the difference between deep and superficial dyspareunia?
- superficial → painful intercourse localised to introital area, due to disorders of vulva + vestibule
- deep → often related to disorders in pelvis
The aetiology of dyspareunia differs depending on whether the pain is associated with the external genitalia (superficial dyspareunia) or with deeper pelvic structures (deep dyspareunia).
What are causes of superficial dyspareunia?
- dermatological → atopic dermatitis, contact dermatitis
- infectious → vulvovaginitis, herpes simplex, interstitial cystitis, UTI
- mucosal dysfunction → pelvic radiation, contraceptives, antidepressants, antihypertensives, primary inadequate lubrication, vaginal atrophy due to menopause
- structural → imperforate hymen, Barthonlin’s mass/abscess, vulvar dystrophies, perineal injury (episotomy), FGM
- musculoskeletal → vaginismus
- other → psychosexual, vestibulodynia/vulvodynia
What are the causes of deep dyspareunia?
- infectious/inflammatory → cervicitis, PID, endometriosis, hydrosalpinx
- structural → leiomyomata (AKA fibroids), adenomyosis, pelvic tumours, pelvic congestion
- musculoskeletal → levator ani spasm
- other → bladder/bowel disease (eg. IBS), psychosexual
Endometriosis is a common condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity. Around 10% of women of a reproductive age have a degree of endometriosis.
What are the clinical features of endometriosis?
- chronic pelvic pain
- dysmenorrhoea - pain often starts days before bleeding
- deep dyspareunia
- subfertility (found at 25% of laparoscopies)
- non-gynae: urinary symptoms eg. dysuria, urgency, haematuria; dyschezia (painful bowel movements)
Pelvic examination → reduced organ mobility (fixed + retroverted uterus); tender nodularity in the posterior vaginal fornix + visible vaginal endometriotic lesions may be seen
PR examination → nodule in rectovaginal septum
What is the pathology of endometriosis?
- deposits thicken cyclically causing an inflammatory reaction
- pain worse pre-menstrually + at onset of period
- chronic inflammation causes scarring + adhesions with grey/white appearance
- fibrosis of utero-sacral ligaments → pelvis may become ‘frozen’ → fixed pelvic organs
- deposits may occur on ovaries causing endometriotic (‘chocolate’) cysts
What are the investigations for endometriosis?
- laparoscopy = gold std, definitive
- little role of investigation in primary care (eg. USS) - if symptoms are significant the patient should be referred for a definitive diagnosis
- diagnosis confirmed w/ biopsy
What is the rationale behind the different investigations for endometriosis?
- TV USS → sets the ovarian endometrioma but may not detect early disease
- Rectal endoscopical USS → in pts w/ suspected deep pelvic endometriosis or involvement of colon/rectum
- MRI → extra-pelvic + rectovaginal implants but cost and utility high, so not commonly used
- MRI, 3D USS + hysterosalpingography → ideal for mullerian anomalies or for identifying any scarring/tubal blockage causing outflow tract obstruction
- CA-125 → lacks specificity + not shown to be useful
- Laparoscopic → preferred approach
For endometriosis, management depends on clinical features - there is poor correlation between laparoscopic findings and severity of symptoms.
What is the management for endometriosis?
- Expectant → treatment not indicated in asymptomatic women w/ mild disease
- First-line → NSAIDs and/or paracetamol for symptomatic relief
- Second-line → prevent hormonal stimulation of ectopic endometrium so use COCP (60 days no break), progestogens, mirena coil or GnRH analogues
-
Surgical → diathermy or laser; excision of endometrioma; assisted reproduction (often gets better after pregnancy)
- if fertility not desired → hysterectomy with bilateral salpingo-oophorectomy and excision of visible peritoneal disease
Over the counter analgesics may provide pain relief for pelvic pain with no known cause.
What are alternative therapies for chronic pelvic pain?
- stretching exercises, massage
- transcutaneous electrical nerve stimulation (TENS)
- spinal cord stimulation
- trigger point injections
- psychotherapy → CBT, biofeedback
- acupuncture
