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Gynae, Breast & Sexual Health > Pelvic pain, Dyspareunia & endometriosis > Flashcards

Pelvic pain, Dyspareunia & endometriosis Flashcards

1
Q

>50% of pelvic pain that is not very specific (common) will have no demonstrable pathology after investigation.

What is the pain triad in gynae that makes you think pathology?

A

cyclical

  1. Dysmenorrhoea (painful periods)
  2. deep dyspareunia (pain on deep sex)
  3. pelvic pain
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2
Q

What are the gynae ddx for pelvic pain?

A
  • Endometriosis and adenomyosis 
  • Adhesions including chronic PID, chlamydia
  • Uterine Fibroids 
  • Tubal pathology - hydrosalpinx, pyosalpinx
  • Ovarian Cysts - bleeding, torsion, rupture
  • Ectopic pregnancy
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3
Q

What are the urological ddx for pelvic pain?

A
  • Cystitis/UTI
  • Urinary tract calculi
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4
Q

What are the MSK ddx for pelvic pain?

A
  • Joints
  • Muscular pain
  • Psoas abscess
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5
Q

What are the GI ddx for pelvic pain?

A
  • Appendicitis
  • Strangulated hernia
  • Sigmoid colon pathologies - diverticulitis, obstruction
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6
Q

A patient presents with Crampy abdominal pain, 48-72hrs around menstrual period, worst at onset of menses

Associated with - malaise, N&V, diarrhoea, dizziness

What is the (1) aetiology (2) causes of these?

A

(1) Aetiology:

  • 2nd half of cycle, no fertilisation, CL regresses, fall in E2 & P –> prostaglandin release from endometrial cells
  • Spiral artery vasospasm –> ischaemic necrosis & shedding of superficial layer of endometrium
  • Increased myometrial contractions (from PGs)
    • so PGs and P&E fall = vasospasm and contractions

(2) Causes:

  • Primary -
    • no underlying pathology,
    • thought to be due to excessive release of prostaglandins (PGF2a & PGE2) by endometrial cells;
    • DIAGNOSIS OF EXCLUSION
  • Secondary -
    • to pathology
    • e.g. endometriosis, adenomyosis, PID, adhesions
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7
Q

What are the RFs for dysmenorrhoea?

A
  • Early menarche,
  • long menstrual phase,
  • heavy periods,
  • smoking,
  • nuliparity
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8
Q

What below/above whatt age is dysmenorrhoea not usually due to obvious pathology.

What can you do for them if its not an otbvious pathology i.e. it is functional?

A
  • <20yrs is usually not due to obvious pathology [>20y/o consider other causes}
  • i.e. it is functional
    • –> stop smoking,
    • –> hot water bottles
    • –> NSAIDS (1st line) e.g. mefanamic acid
      • (inhib PGs that contract arteries and uterus)
    • –> put on the pill
      • ​e.g. continuous COCP for 6months (stop P&Oest drop –> PG)
    • –> TENS
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9
Q

What below/above whatt age is dysmenorrhoea not usually due to obvious pathology.

What pathology do you need to investigate?

A

> 20 y/o consider

  • Endometriosis - more dyspareunia more likely endometrium
    • Rx (STOP THEM BLEEDING):
      • COCP (tricycle),
      • progestagens (continuous),
      • GnRH analogues
    • Laparoscopy for failed medical treatment or for women trying to get pregnant
  • Adenomyosis - endometrial tissue in myometrium –> hurts & bleeding!
    • Rx: *Mirena coil –> switches off ectopic endometrium
    • Surgery
  • PID
    • Ix: high vaginal & endocervical swabs
    • Rx: doxycycline (chlamydia),
    • Metronidazole (anaerobes),
    • ceph (Gonnorhoea)
  • Adhesions
    • ​especially if previous pelvic surgery –> cervical stenosis
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10
Q

What is the primary and secondary managment of dysmenorrhoea?

A
  • Primary -
    • NSAIDs,
    • paracetamol,
    • COCP (stop ovulation)
  • Secondary -
    • analgesia,
    • treat underlying cause,
    • stop bleeding
      • (COCP, progest, GnRH analogues e.g. goserelin)
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11
Q

A patient is experiencing pain during or after sexual intercourse, (which can be classified as superficial affecting the vagina, clitoris or labia,) or deep with pain experienced within the pelvis. 

What is this symptoms name & What are the riskfactors for this symptom?

A

Dyspareunia

Epidemiology: ~10-20%, (may be an underestimate)

Risk factors:

  • female genital mutilation (FGM),
  • suspected PID and endometriosis,
  • peri/postmenopausal status,
  • depression or anxiety states and
  • history of sexual assault
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12
Q

A patient is experiencing pain during or after sexual intercourse, (which can be classified as superficial affecting the vagina, clitoris or labia,) or deep with pain experienced within the pelvis. 

What clinical workup is needed for dyspareunia?

A
  • SOCRATES pain + relationship to intercourse, associated chronic pelvic pain symptoms
    • Reproductive + PMH
    • Psychosexual (hx of sex assault/FGM) hx for superficial dyspareunia
  • O/E: abdo, pelvic exam
    • Lower genital tract lesions
      • (e.g. skin disorder, scarring, anatomical abnormality)
    • Vaginismus
      • (involuntary contraction of vaginal muscles during  vaginal examination)
    • Areas of tenderness within the lower and upper genital tract and evidence of pelvic disease (internal exam + abdo)
      • (masses, tenderness, fixity of organs)
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13
Q

A patient is experiencing pain during or after sexual intercourse, (which can be classified as superficial affecting the vagina, clitoris or labia,) or deep with pain experienced within the pelvis. 

From the clinical workup it could be elicited if pain is more psychosexual, superficial dyspareunia or deep dyspareunia (though exluce through O/E etc).

  • What Ix and Rx do you do for superficial dyspareunia?
  • What Ix and Rx do you do for deep dyspareunia?
A
  • Superficial dyspareunia (vulval pathology)
    • skin disorder, scarring, anatomical abnormality, vaginismus
      • Ix: consider a biopsy of lower genital tract lesions and swabs; 
      • Rx: treat any identifiable cause
  • Deep dysparenuia (PID, ENDOMETRIOSIS):
    • _​_Ix: Consider transvaginal ultrasound scan (TVUSS), swabs & laparoscopy
    • Rx: treat as for chronic pelvic pain - pain control, hormonal, surg etc
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14
Q

A patient is experiencing intermittent pain in the lower abdomen/ pelvis for least 6 months

the pain is not occuring exclusively with menstruation (dysmenorrhoea) or intercourse and not associated with pregnancy…

What is this condition and the Ix for it?

A

Chronic pelvic pain (>6m) and not dysparenunia or dysmenorrhoea & woman isnt pregnant…

  • Genital tract swabs
    • (all sexually active women should be offered STI screening)
  • Pelvic US
  • MRI
    • (further assessment of masses e.g. deep infiltrating endometriosis)
  • Laparoscopy
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15
Q

A patient is experiencing intermittent pain in the lower abdomen/ pelvis for least 6 months

the pain is not occuring exclusively with menstruation (dysmenorrhoea) or intercourse and not associated with pregnancy…

What is the Rx for this condition?

A

Chronic pelvic pain Rx:

  • General advice -
    • diet, hydration, exercise and sexual health
  • Analgesia -
    • NSAID’s, opiates and paracetamol to control pain
  • Hormonal treatment (normal exam & US) -
    • Suppress ovarian function for 3-6 months before having a diagnostic laparoscopy. (e.g. rule out dysmenorrhoa/hysterectomy and SOH benefit, rule out endometriosis)
      • E.g. COCP, systemic and local (LNG-IUS) progestogens and GnRH-analogues (goserelin)
  • Surgical treatment structural pathology
    • Laparoscopic removal of adnexal masses, treatment of endometriosis and adhesion lysis. 
  • Consider referral to pain management team or specialist pelvic pain clinic
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16
Q

What is the definition of endometriosis?

A

the presence of endometriotic tissue outside the uterus

  • Commonly -
    • ovaries, tubes, peritoneum, Pouch of Douglas, recto-vaginal septum, uterosacral ligaments
  • Less frequently -
    • surgical scars (C-section), bladder, bowel (inc. appendix, rectum)
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17
Q

The amount of pain caused by endometriosis is proportional to the severity of disease e.g. amount of endometriotic tussue outside the uterus.

T or F?

A

False!

  • There is wide variation in severity of endometriosis disease & it’s impact on pain
  • some poeple are relatively asymptomatic with extensive disease, some only have superficial endometriotic deposits with debilitating symptoms
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18
Q

What is the main hormone involved in driving endometriosis?

A

oestrogen!

  • TF endometriosis affects women of reproductive age
  • 10-12% of the general female population are estimated to have the disease
    • With
      • 20-50% of those undergoing fertility or chronic pain investigation
    • 40-60% of those with dysmenorrhoea. 
19
Q

What is the aetiology of endometriosis?

A
  1. RETROGRADE menstruation –> adherence, invasion and growth of tissue (adhesions, scarring)
    • e.g. into the fallopian tubes and abdo
  2. the mesothelial cells (peritoneal cells) undergo metaplasia = explains how it can develop in unusual places like the nasal cavity
  3. impaired immunity –> cells from retrograde mensturation fail to be destroyed by the immune response
20
Q

What are the RF’s for endometriosis?

A
  • Early menarche & long duration of menstrual bleeding, (also dysmenorrhoea)
  • FHx endometriosis,
  • short menstrual cycles
  • heavy menstrual bleeding,
  • defects in the uterus or fallopian tubes
21
Q

What are the pain symptoms of endometriosis e.g. where do you get pain?

A
  • can be Cyclical - at time of menstruation
    • ​(endometrial tissue responds to the menstrual cycle)
  • OR Constant which = adhesions from chronic inflammation
    • Severe dysmenorrhoea leading to time off work or school 
  • Deep dyspareunia
    • involvement of uterosacral ligaments
  • Dysuria 
  • Dyschezia pain on defaecation
    • and/or cyclical rectal bleeding - rectovaginal nodules with invasion of rectal mucosa 
22
Q

Besides pain, what are the other symptoms of endometriosis?

A
  • Subfertility
  • can have no symptoms; incidental findings
  • Sypmtoms are reduced during pregnancy and menopause (e.g. as is oestrogen dependent…)
23
Q

What maybe found O/E of speculim and bimanual of someone with endometriosis?

A
  • Normal if minimal disease
    • but note that pain and the extent of disease are not proportional
  • Speculum -
    • visible lesions in vagina or cervix = RARE though as = sign of deep infiltrating endometriosis
  • Bimanual -
    • classic sign = fixed, retroverted uterus
    • ‘frozen’ pelvis (from marked inflammation within the pelvic tissues)
    • adnexal masses or tenderness (e.g. Pouch of Douglas aka rectouterine pouch),
    • tender nodules palpable over the uterosacral ligaments,
      *
24
Q

a classic sign of endometriosis is a fixed, retroverted uterus…

What are the other ddx of this to be aware of though….?

A
  • PID,
  • uterine, ovarian or cervical malignancy
25
Q

Symptoms of endometriosis can vary depending on where the endometriotic tissue is present.

from the following symptoms, where is the endometriosis?

  • Cyclical haematuria 
  • Loin/Flank pain
A

Urinary tract!

the loin/flank pain is from ureteric obstruction

26
Q

Symptoms of endometriosis can vary depending on where the endometriotic tissue is present.

from the following symptoms, where is the endometriosis?

  • Dysmenorrhoea 
  • Lower abdominal and pelvic pain 
  • Dyspareunia 
  • Rupture/Torsion Endometrioma 
  • Low back pain 
  • Infertility 
A

Reproductive tract

27
Q

Symptoms of endometriosis can vary depending on where the endometriotic tissue is present.

from the following symptoms, where is the endometriosis?

  • Dyschezia 
  • Cyclical rectal bleeding 
  • Obstruction 
A

GI tract

28
Q

Symptoms of endometriosis can vary depending on where the endometriotic tissue is present.

from the following symptoms, where is the endometriosis?

  • Cyclical pain, swelling and bleeding  of umbilicus / surgical scars
A

surgical scars, umbilicus

29
Q

Symptoms of endometriosis can vary depending on where the endometriotic tissue is present.

from the following symptoms, where is the endometriosis?

  • Cyclical Haemoptysis 
  • Haemopneumothorax
A

lung

30
Q

What are the differentials for endometriosis e.g. pain that can be constant if there are adhesions from chronic inflammation, dysuria, deep dysparenuia (uterosacral infolvement), dyschezia?

A
  • PID (dyspareunia, pelvic pain, abnormal bleeding),
  • ectopic pregnancy,
  • fibroids,
  • IBS (ddx from dyschezia e.g. pain on defecation)
31
Q

What do 2 bilateral endometriomas adhering together in endometriosis give the sign of?

[NB: this is seen on laparoscopy - the gold standard for endometriosis diagnosis along with biopsy}

A

kissing ovaries

[Endometrioma is a type of cyst formed when endometrial tissue grows in the ovaries. It affects women during the reproductive years and may cause chronic pelvic pain associated with menstruation.]

32
Q

What is the name of the cysts seen on laparoscopy (the gold standard) for endometriosis?

A

chocolate cysts

(and kissing ovaries, think of valentines day)

33
Q

When should an MRI be used in endometriosis?

A

if bowel involvement is suspected

OR

presurgical planning in difficult cases

[otherwise laparoscopy is GS + biopsy for histological confirmation)

34
Q

What investigations should be done into endometriosis?

A
  • TV US - useful for ovarian endometriotic cysts or rectal disease
    • Poor at identifying other parameters of disease
    • Normal US does not exclude
  • MRI - if bowel involvement is suspected or pre-surgical planning in difficult cases
  • CA125 may be raised but should not be used as a screening test
  • Laparoscopy (gold standard) + biopsy for histological confirmation
    • Should be avoided within 3 months of hormonal therapy, as this leads to under diagnosis
    • “Chocolate cysts”
    • Adhesions Peritoneal deposits
    • “Kissing ovaries” - bilateral endometrioma are adherent together
35
Q

Diagnosis of endometriosis takes 6 yrs on average, why is this?

A

due to variation in presentation

some patients will be happy to have a positive laparascopy e.g. one with findings because it validates their symptoms

36
Q

2 conditions are also present in 80% of patients with endometriosis, what are these?

A
  • IBS
  • Constipation
37
Q

How do you Rx endometriosis?

A
  • Treat coexisting disease e.g. IBS and constipation (present in 80% of cases)
  • Pain - NSAIDs or analgesic ladder for symptom control
  • Ovulation - suppressing ovulation can cause atrophy of endometriomas & reduction in symptoms (as they are oestrogen hormone respondant)
    • COCP
    • Progestogens (norethisterone) can be used or injected hormones
    • Mirena coil
    • GnRH analogues (goserelin)
  • Surgery - if seriously affecting patient’s life
    • Excision, fulgaration (diathermy) & laser ablation aim to remove ectopic tissue
  • Adhesion-lysis can help remove symptoms
  • Hysterectomy and BSO is the ultimate management
38
Q

What is the name given to infection of the upper genital tract in females (inc, uterus, fallopian tubes & ovaries)

occurs in ~280/100,000 person years.

  1. What is the higest prevalence age?
  2. Why does this occur?
A

Pelvic inflammatory disease

= Infective inflammation of the endometrium, uterus, fallopian tubes (salpingitis), ovaries & peritoneum

  1. highest prevalence in sexually active women aged 15-24
  2. –> spread of bacterial infection from vaginal or cervix to upper genital tract,
    • although in MANY CAUSES NO BUG IS EVER ISOLATED,
    • *Chlamydia > gonorrhoea > ureaplasa > mycoplasma
    • *RF = iatrogenic instrumentation of genital tract (give prophylactic doxycycline)
39
Q

A patient presents with:

  • bilateral lower abdominal pain/tenderness, deep dyspareunia, menstrual abnromalities (e.g. menorrhagia, dysmenorrhoa, IMB), PCB, dysuria (painful urination), abnormal vaginal discharge (esp if purulent or w/unexpected odor) & even recently been experiencing more SEVERE syx = fever & N&V
  • O/E: there is adnexal & uterine tenderness, cervicitis, cervixal excitation. Abnormal discharge is noted and a palpable mass in the lower abdomen.
  1. What are the RF’s for this condition?
A
  1. RFs:
    • sexually active, 15-24yrs,
    • recent partner change,
    • intercourse without barrier contraceptive protection,
    • hx STIs,
    • hx PID,
    • *iatrogenic instrumentation of genital tract (give prophylactic doxycycline) (C>G>ureaplasa>mycoplasma)
40
Q

A patient with PID is experiencing RUQ pain as well as the lower abdo pain. What syndrome could the RUQ pain be indiciative of?

A

Fitz-Hugh Curtis syndrome

= peri-hepatitis in PID that typically causes RUQ pain

41
Q

A female patient presents with:

bilateral lower abdominal pain/tenderness, deep dyspareunia, menstrual abnromalities (e.g. menorrhagia, dysmenorrhoa, IMB), PCB, dysuria (painful urination), abnormal vaginal discharge (esp if purulent or w/unexpected odor) & recently even been experiencing more SEVERE syx = fever & N&V

O/E: there is adnexal & uterine tenderness, cervicitis, cervixal excitation. Abnormal discharge is noted and a palpable mass in the lower abdomen.

  1. What are the LT sequelae of this condition?
A

LT sequelae:

  1. adhesions
  2. tubal subfertility (1/10 w. PID)
  3. ectopic pregnancy
  4. chronic pelvic pain inc. dyspareunia
  5. tubo-ovarian abscess (pelvic collection of pus)
  6. peri-hepatitis that typically causes RUQ pain (Fitz-High Curtis syndrome)
42
Q

A female patient presents with:

bilateral lower abdominal pain/tenderness, deep dyspareunia, menstrual abnromalities (e.g. menorrhagia, dysmenorrhoa, IMB), PCB, dysuria (painful urination), abnormal vaginal discharge (esp if purulent or w/unexpected odor) & recently even been experiencing more SEVERE syx = fever & N&V

O/E: there is adnexal & uterine tenderness, cervicitis, cervixal excitation. Abnormal discharge is noted and a palpable mass in the lower abdomen.

  1. What are the DDx for this condition?
  2. What investigations should be done?
A

DDx:

  • Ectopic pregnancy,
  • ruptured ovarian cyst,
  • endometriosis,
  • UTI,
  • acute appendicitis,
  • IBS

Ix:

  1. Swabs -
    • Endocervical (gonorrhoea, chlamydia)
    • High vagina (TV, BV)
  2. STI bloods - HIV, syphilis
  3. Urine dip +/- MSU [check for UTI]
    • Pregnancy test
  4. TVUS if severe disease or diagnostic uncertainty [ectopics, ruptured ovarian cyst]
  5. Laparoscopy [endometriosis, acute appendicits]
43
Q

When someone comes in with pelvic pain, when should you admit them to hospital?

A
  1. If pregnant and especially if there is a risk of ectopic pregnancy.
  2. Severe symptoms: nausea, vomiting, high fever.
  3. Signs of pelvic peritonitis.
  4. Unresponsive to oral antibiotics, need for IV therapy.
  5. Need for emergency surgery or suspicion of alternative diagnosis.
44
Q

What is the management of PID?

A

2wks doxycycline 100mg PO + ceftriaxone IV + metronidazole IV

[e.g. covers, C & G and anaerobes]

  • IV for 2-3D, 14d of all 3 oral at home
  • (or ofloxacin & metronidazole)

& conservative/painkillers:

  • Analgesics, rest, avoid sexual intercourse until abx complete & partner(s) are treated
  • All sexual partners from the last 6 months should be tested & treated 

Gynae, Breast & Sexual Health (7 decks)

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