Presentation: Pelvic Pain Flashcards
What provides innovation to the vulva, perineum and lower vagina?
Pudendal nerve. S2 - S4
What innervates the uterus, tubes, ovaries and visceral peritoneum?
Autonomic nervous system T10 - L1
What processes may lead to pelvic pain?
- distension / contraction of an organ
- stretching of an organ capsule
- irritation of the parietal peritoneum
- ischaemic tissues
- inflammation, neoplasia or fibrosis stimulating nerves
DDx for gynaecological causes of pelvic pain?
- Cyclical (see other card)
- Endometriosis / adenomyosis
- PID
- PCOS
- Residual ovary, ovarian remnant syndrome
- Neoplasia
- Pelvic venous congestion
- Levator muscle spasm
- Pelvic adhesions
What are non - gynaecological causes of pelvic pain?
- GIT (diverticulitis, malignancy, BO, IBD, IBS)
- Urinary tract (calculus, infection, retention malignancy, interstitial cystitis)
- MSK (OA, prolapsed disc, fibro, myofascial pain, peripartum MSK pain, psoas muscle pain)
CFx cyclical pelvic pain?
Dysmenorrhoea during cycle. Often associated with endometriosis and adenomyosis
What are the cyclical causes of pelvic pain?
- dysmenorrhoea
- ovulation pain
- endometriosis
- adenomyosis
- excacervbation of other aetiologies (e.g. IBS and interstitial cystitis)
What are the CFx of ovulation pain?
- acute onset of pain is followed by dull ache for several hours
- pain corresponds to LH peak (1 day pre ovulation)
- prostaglandin F2 causes contractility of ovarian perifollicular smooth muscle
How is PID diagnosed?
- only 60% correctly diagnosed on Hx
- Dx = laparoscopy
What are the sequelae of PID?
- chronic infection
- pelvic pain
- dyspareunia
- menstrual changes
- infertility
- ectopic pregnancy
What are the features of malignant neoplasia causing pelvic pain?
- weight loss
- nausea
- abdo / pelvic pain
- ascites
- lymphadenopathy
- irregular mass in pelvis
What is the proposed aetiology of pelvic venous congestion?
May be due to oestrogen causing dilation of thin walled unsupported pelvic veins
What is the most informative investigation for pelvic pain?
Laparoscopy
What radiological investigations can be useful in evaluating pelvic pain?
- US pelvis
- XR lumbar spine / hip joints
- other if ? non gyn cause
What non radiological investigations can be helpful in evaluating pelvic pain?
- MSU
- Chlamydia swabs
- laparoscopy
Mx chronic pelvic pain?
- Exclude and treat treatable causes
- Pharm (NSAIDs, OCP, GnRH agonist)
- PT
- Psych: pain clinics and management
- pain assessment forms for long term management
What is the definition of chronic pelvic pain?
Non specific pelvic pain of more than 6 months duration that may or may not be relieved with analgesia. Associated with occult somatic pathology, laparoscopically evident pathology and non somatic disorders.
Describe the innervation of the individual pelvic organs.
Mullerian origin organs (uterus, tubes, upper vagina) transmit stimuli via SNS T10 - L1.
What are the most common causes of acute pelvic pain related to reproductive organs?
Elevan most common:
- Mittelschmerz
- Functional ovarian cysts
- Intrauterine pregnancy
- Ectopic pregnancy
- Pelvic infections
- Uterine tumours
- Adnexal neoplasia
- Ovarian torsion
- Endometriosis
- Adenomyosis
- Dysmenorrhoea
What are the features of follicular cysts?
Follicular cysts result from failure of egg release from a mature follicle during ovulation.
- Sx: aching in RIF or LIF.
- PEx: enlarged cystic ovary on exam or US
- Sequelae: resolution, torsion / rupture with pain, rupture with haemorrhage and surgical evaluation
How may uterine tumours cause pelvic pain?
E.g. leiomyomas / leiomyosarcomas
- torsion
- necrosis
- stretching visceral peritoneum of uterus
- pressure against surrounding intra abdo structures
How may adnexal neoplasia cause pelvic pain?
- Haemorrhage
- necrosis
- torsion
- rupture
How may ovarian torsion present?
-Constant or severe and intermittent A/w -N/V -diaphoresis -severe pelvic pain
What is the progression of blood supply interruption in ovarian torsion?
venous supply ceases first resulting in enlargement. arterial obstruction follows causing necrosis
How do pelvic adhesions cause pelvic pain?
-Mechanical components postulated as source of pain; patients experience pain via mechanical stimulation (stretching) of visceral nociceptors
What is vital to first ask about when evaluating pelvic pain?
LMP and exclude pregnancy
How are myofascial trigger points detected?
- Painful on compression (jump sign)
- May produce characteristic referred pain and autonomic phenomenon (tearing, choryza, tinnitus etc)
How are myofascial trigger points treated?
-Hyperstimulation
-Analgesia (stretch and cold spray)
-Needling with local injection
-TENS
-accupuncture
Act as counter irritants altering central gate resulting in a prolonged response
