Phillips - Chronic Pelvic Pain Flashcards
1
Q
Name 5 causes of 3rd trimester bleeding.
A
- OB EMERGENCY:
1. Placenta previa
2. Placental abruption
3. Labor
4. Vaso previa
5. Trauma
2
Q
Placenta previa: risk factors, presentation, resolution
A
-
Placenta overlying cervical os, in the way of the baby coming through cervix
1. Zygote implants low in uterine cavity instead of high in the endometrial fundus (ant or post) - RISK FACTORS: previous previa
1. Multiparous: big uterine cavity
3. Previous Cesarean: scarring, mixed signals - PRESENTATION: painless bleeding, but may be hemorrhage (look for telltale signs)
1. Not having contractions
2. Wake up in pool of blood, or bleed in toilet - RESOLUTION: when cervix opens up naturally, in prep for labor, small rip in plate defining vessels from uterus to placenta for O2 can tear and bleed
1. This is maternal blood, and can be serious
2. Requires Cesarean delivery
3. Rarely fetal anemia; may require transfusion
3
Q
What is the most important thing in evaluating chronic pelvic pain?
A
- HISTORY
- Is the pain truly chronic? -> duration and timing
- Is it cyclic (associated with menses)?
- Sometimes pt will describe daily pain, but worse around menses -> this is considered chronic pain
- May describe suprapubic area, genital, or back pain
- NOTE: be empathetic concerning pt’s pain; must be distressing for her, or she would not have come to the doctor for it
4
Q
What are some of the things that can cause chronic pelvic pain?
A
- Endometriosis: dysmenorrhea, scarring, pain
- PID
- Leiomyomata
- Ovarian cysts
- Adhesions
- Often times hard to pinpoint -> GI, GU, MSK causes also possible (other things in this vicinity)
5
Q
What are some of the clues to look for when evaluating for chronic pelvic pain (by dx)?
A
- Endometriosis: pain should worsen with menses, may have dyspareunia, age in 30’s
- GI: diarrhea and constipation (irritable bowel); 40’s, think about diverticulitis, diverticulosis
- GU: frequency and pain (interstitial cystitis or UTI)
- PID: rather acute and bilateral -> exam will reveal tenderness in adnexal region
- Adhesions: history of PID or pelvic surgeries
- NM: pain with moving or lifting -> pain going into back, one-sided, runs down the leg
6
Q
How can you localize the pain?
A
- Women assume anything below umbilicus and above knees must be related to uterus/tubes or ovaries
- After history and physical, may order a pelvic US: usually comes back normal, but this may help reassure your patient
7
Q
Do fibroids or ovarian cysts cause pain?
A
- No!
- Fibroids only cause pain if they are large, and pressing on other organs
- Woman has a cyst every time she ovulates, and they can be quite large (4-6cm)
1. Very rarely do these cause pain, so hard to understand how a small one could cause this degree of pain
8
Q
How do you avoid aiding drug seeking pts?
A
- Many pts get started on narcotics by doctors who fail to make diagnosis, and are now addicted
- NEVER START NARCOTICS FOR CHRONIC PAIN
- Stay sympathetic, counsel, and offer non-narcotic treatments for NM pain, like NSAID’s, Tylenol
9
Q
Why should you ask women with chronic pelvic pain about previous sexual abuse?
A
- Women may present with somatization if they have had past trauma (part of a post-traumatic stress syndrome)
1. Person will focus trauma and experiences on a particular organ
2. May be back pain for men, headache for M and F, pelvic area for F - Ask, and people will talk -> make it clear that you believe they are having pain
10
Q
Should you do a laparoscopy?
A
- Pt with pain that is not getting better -> offer laparoscopy, or a look into the pelvis, as last resort
- Looking for: endometriosis, adhesions to bowel or pelvis -> studies also show women get better if they are told that their “pelvis is clean”
1. Endometriosis: may find bc you can’t feel it on exam, and may not see on US -> if you find this and scarring, you can dx and proceed with a treatment plan
2. Adhesion to bowel: may cause pain if they pull on peritoneal structures
11
Q
What about a laparotomy?
A
- AVOID at all costs
- Surgeries beget adhesions, which cause pain, and result in more surgeries -> may end up in your office at 38, after her 4th surgery, w/o uterus, tubes, and ovaries, but still with pain
- This is a terrible road to go down w/o evaluating what might have been drug seeking, a behavior health issue, or somatization
12
Q
Who should be involved in CPP treatment?
A
- Team effort:
1. Gyn
2. Urologist: to ensure not IC (cystoscopy and tx)
3. PT: pelvic floor conditions, NM abnormalities
4. Pain mgmt centers if narcotics involved
5. Psychiatry: to learn to cope
13
Q
What is adenomyosis? Presentation? Dx?
A
- Similar to endometriosis -> endometrial glands, stroma, and blood in the wall of the uterus
1. HISTO: muscular tissue representing uterus + stroma + clear endometrial glands (attached) - Patients may COMPLAIN OF pelvic pain, pressure, dysmenorrhea, menorrhagia
1. Exam: “boggy uterus” -> enlarged, tender - DIAGNOSIS can only be made by pathology after hysterectomy
1. US really just a guess until pathology done
14
Q
What is the tx for adenomyosis?
A
- First-line: prevent ovulation -> OCP’s, NSAID’s
1. This will prevent bleeding
2. Depo provera also an option - If severe, and med mgmt has failed, then hysterectomy
15
Q
What kind of things do you want to ask about when taking a history for dyspareunia?
A
- How long? Forever vs. recent onset -> structural (chronic) vs. infection (acute)
- When? -> on insertion, on deep penetration, on vigorous intercourse, after intercourse
- Is it bad enough that it is interfering with sex and your relationship?
1. In other words, is it concerning? Or serious?
