Pelvic pain -ILA

Question 1

What is chronic pelvic pain?

Answer 1

intermittent or constant pelvic pain for over 6 months without exclusive association to the menstrual cycle, intercourse or pregnancy.

Question 2

What are some causes of acute pelvic pain in women?

Answer 2

Ovarian cyst – bursts or twists 
Pelvic inflammatory disease
Appendicitis 
Peritonitis 
UTI 
Constipation eg due to IBS, medication, diet, bowel obstruction 
Miscarriage 
Ectopic pregnancy 
Placenta abruption

Question 3

What are some causes of chronic pelvic pain in women?

Answer 3

Endometriosis – pain usually varies during cycle, associated with dysmenorrhea and dyspareunia 
Chronic PID 
Ibs 
Interstitial cystitis 
Fibroids 
IBD 
Hernia 
Nerve damage 
Diverticulitis 
Adenomyosis 
Adhesions – could be due to surgery, endometriosis or infection

Question 4

What investigations should you consider for acute pelvic pain?

Answer 4

Urinalysis, midstream specimen of urine (MSU).
High vaginal swab (HVS) for bacteria and endocervical swab.
Pregnancy test (UPT)
FBC. ?infection
Urgent ultrasound (if miscarriage or ectopic pregnancy is suspected)

Question 5

What investigatyions should you consider for chronic pelvic pain?

Answer 5

HVS for STIs and cervical swabs
Blood tests such as FBC and CRP may be useful for some women.
Ca125 measurement is appropriate if symptoms suggesting ovarian cancer are experienced. A new diagnosis of IBS in a woman aged over 50 years is suspicious.
Urinalysis and send MSU.
Transvaginal scanning (TVS) using ultrasound for adnexal masses.
Diagnostic laparoscopy as second line of investigation if can’t find whats wrong
Further urological investigations (eg, cystourethroscopy) and/or bowel investigations (eg, barium enema) may be required.

Question 6

What are some possible treatment for chronic pelvic pain?

Answer 6

Ovarian suppression

Migraine remedies

Relaxation techniques

Ovarian vein ligation

Radiological embolization

Treat cause

Question 7

A 21 year old nulliparous student presents via emergency admissions complaining of severe left iliac fossa pain. She is normally medically fit and well with no allergies and taking no regular medication. She had an IUCD fitted five days prior to admission for emergency contraception. Examination reveals a tender left iliac fossa with guarding, no rebound tenderness, and no masses.
What are the differentials?

Answer 7

Ectopic pregnancy - normally have short period of amenorrhoea 
Ovarian cyst 
Pelvic inflammatory disease 
Uterine rupture due to IUCD migration 
UTI 
Constipation

Question 8

A 28 year old woman is referred to the gynaecological out-patient department by her GP complaining of severe lower abdominal pain associated with dysmenorrhoea and dyspareunia. The pain starts three days before her period and ends one day after her period has finished. She had been taking the combined oral contraceptive pill since the age of 16 and stopped 3 years ago. She has not conceived during this time.
What are the differentials?

Answer 8

Endometriosis

Adenomyosis

Fibroids- can be cyclical

Chronic PID

Question 9

What signs do you look for on examination of endometriosis?

Answer 9

For endometriosis look for fixed retroverted uterus on bimanual exam
blue nodules on posterior fornix vagina on speculum
Nodular pelvic ligaments
Ovarian enlargemnt if an endometrioma
abdo masses

NEED laparoscopy to diagnose however as PID and adhesions can mimic endometrosis

Question 10

What do you see on laparoscopy if the patient has endometriosis?

Answer 10

burnt match stick head appearance

Question 11

What investigations do you do for endometriosis presentation?

Answer 11

Laparoscopy
Bloods for hormone profile
Trans abdominal ultrasound – may see chocolate cysts and endometriomas

Question 12

What is the management for endometriosis?

Answer 12

Offer hormone treatment - for endometriosis use tricyclic OCP, depot proverra, mirena coil, GnRH agonists eg zoladex

Ablation

Help with fertility

Question 13

What are the different types of ovarian cyst?

Answer 13

follicular cysts from PCOS
endometrioma
benign tumour eg teratoma
malignancy

Question 14

What are the sx of an ovarian cyst?

Answer 14

Dull aching pain, dyspareunia, p lower abdo, urinary and bowel sx
PCOS - hirtuism, amenorrhoea
Endometriosis - infertility and dysmonorrehoa

Question 15

What is ovarian torsion?

Answer 15

ovary twists around suspensory ligament - cut off bld supply - more chance occurring on R due to sigmoid colon on L taking up space so less
twist
presents: Sudden sharp, unilat and severe pain indicates complication, may be shoulder pain due to irritation of diaphragm from rupture of cysts’ contents into peritoneum
There is a tender palpable adnexal mass on bimanual exam. Ultrasound shows an enlarged, oedematous ovary with impaired blood flow.
N+V, fever

Question 16

Ix for ovarian torsion?

Answer 16

Rule out ectopic – pregnancy test
Rule out UTI - dipstick
consider appendicitis
USS with colour Doppler = diagnostic gold standard –> will see “whirlpool” sign

Question 17

mx of ovarian torsion?

Answer 17

Laparoscopy (diagnostic and therapeutic)

Plus analgesia and fluid resuscitation

Question 18

Presentation of ruptured ovarian cyst?

Answer 18

Ruptured ovarian cyst presents as sharp unilateral pain immediately following intercourse or strenuous exercise. Bimanual examination in non-severe cases is generally unremarkable but the lower abdomen is tender. Ultrasound shows free fluid in the pelvic cavity.