11. Pelvic Pain

Question 1

approach to pt with pelvic pain

Answer 1

1. Hx
2. PE
3. DDx
4. Directed testing
5. Treatment plan

Question 2

what is important to note when taking hx of a premenopausal W with pelvic pain

Answer 2

menstrual history and menstrual profile

Question 3

what is menstrual profile

Answer 3

1. menarche
2. cycle length and variability
3. flow
4. dysmenorrhea
5. cramping/pain/radiation
6. changes in bowel or bladder

Question 4

PE of pt with pelvic pain

Answer 4

1. General appearance
2. Head to toe: skin, back, spine, abdomen, pelvic, bladder and bowel eval

Question 5

Glands and stroma, invading into the walls of the uterus.

Answer 5

adenomyosis

Question 6

DDx of cyclic pelvic pain

Answer 6

• 1. Endometriosis *** => ectopic glands and stroma
• 2. Mittelschmerz => pain with ovulation
• 3. Dysmenorrhea

Question 7

DDx of non-cyclic pelvic pain

Answer 7

1. Interstitial cystitis
2. Diverticulitis
3. Hernia

Question 8

MEnstrual related causes of pelvic pain

Answer 8

1. Endometriosis
2. Adenomyosis
3. Mittelschmerz
4. Post-ablation syndrome = menstrual fluid behind scar in uterus
5. Leiomyoma
6. Catamenial

Question 9

A cloning phenomena, where proliferation of cells can enlarge the uterus, the adnexa, or the supporting ligaments of the uterus. These may be intramural, pedunculated, subserosal, ligamentous, cervical, or intracavitary.

Answer 9

leiomyoma

Question 10

ectopic glands in stroma in other places of body

Answer 10

catamenial

Question 11

theories of endometriosis

Answer 11

1. Coelomic metaplasia = metaplasia of cells from ovarian and peritoneal surfaces
2. retrograde menstruation +> retrograde flow of endometrial cells through tubes and onto pelvic surfaces

Question 12

ovarian related causes of pelvic pain

Answer 12

1. Ovarian cysts
   
   1. painful with rupture, bleeding or leaking of fluid
2. OVarian torsion
   
   1. rotation on suspensory l; precipitated by cyst or mass that is >5cm
3. OVarian remnant = ovarian tissue regenerates/grows in response to gonadotropins, forming a cyst or mass.

Question 13

MC reason for cyclic pelvic pain

Answer 13

ovarian cysts

Question 14

how do OCS affect risk of ovarian cysts, ovarian and uterine cancer

Answer 14

decrease

Question 15

bilateral removal of ovaries causes what?

ovarian remnants most often on __ side

Answer 15

increased estradoil

L

Question 16

fallopian tube causes of pelvic pain

Answer 16

1. Obstruction of flow or infection (hematosalpinx = blood; pyosalpinx = pus; hydrosalpinx = fluid) are the MC.
   
   1. Pain with distension of lumen
2. PID Salpingitis
   
   1. peritonitis + abscess or spsis
   2. pain, fever, high WBC/EST
3. Ectopic PG
   
   1. pain w distension/rupture

Question 17

when can a IUP be detected on

- transvaginal sonography

- transabdominal US

Answer 17

• transvaginal sonography: >1200 mIU/mL hCG
• transabdominal US: >2000 mIU/mL hCG
  *

Question 18

Uterus causes of pelvic pain

Answer 18

1. endometritis
2. IUD
3. Threatened/septic abortions, post-term pain
   
   1. = pain when round ligament is stretched early in PG

Question 19

what is endometritis and what can cause

Answer 19

• infection of uterine cavity
• ascending infection with strep, myoplasma, ureaplasma, haemophilus, anaerobes

Question 20

cervicitis is most likely due to ___

Answer 20

STI

Question 21

vascular causes of pelvic pain

Answer 21

• 1. pelvic congestion: dilated veins in pelvis (broad ligament, paratubal/ovarian supporting structures, paravaginal/vulvar)
  
  • pain and congestion after activity, standing, sex or period

Question 22

noncyclic causes of pelvic pain due to bladder

Answer 22

1. UTI,
2. urinary retention
3. bladder prolapse

Pain = centra land related to bladder patterns

Question 23

A defect in the protective layer of the bladder => causing frequency, burning pain, decreased bladder compliance, UTI-like symptoms, and flares of increased symptoms

Answer 23

interstitial colitis

Question 24

what can be seen in intersitial colitis and is pathognomonic

Answer 24

Hunners uclers = red area with prominant radial vessels but nOT A TRUE ULCER

Question 25

UReter causes of bladder pain

Answer 25

1. Stone 1. =\> pain is anterior/flank pain d/t renal colic 2. Fibrosis, injury, endometriosis =\> ureteral obstruction or stenosis 1. lower abdomnal painm flank, lower back

Question 26

bowel related causes of pelvic pain; which are cyclic vs non

Answer 26

1. IBD (Crohns or UC) = non-cyclic 2. IBS = cyclic due to shared nerve pathways in presence of endometriouss 3. Diverticulitis, Chronic constipation, intolerance 1. pain, bloating and bowel discomfort 4. Appendiciits = mid-abdomina =\> RLQ pain 1. fever, anorexia, bloating and pain 2. perforation = sepsis and shock

Question 27

dx appendicitis

Answer 27

mc-buneys point: 1/3 of distance from ASIS to BB

Question 28

MC hernia in women

Answer 28

indirect inguinal

Question 29

nerological caues of bladder pain

Answer 29

1. Varicella Zoster (shingles) or Nerve entrapment (ilioingiinal/genitogemorial) 1. =\> lower ABD pain that radiates to groin/anteiror thigh and worse when extend back 2. Pelvic floor neuralgia/pudendal neuralgia 1. Pain in deep pelvis/ paravaginal/vaginal tissue: cant poop or pee and occurs when lifting or strain

Question 30

1. Dysuria 2. Dysmenorrhea 3. Dyscheziais 4. Dyspareunia 5. Dyssnergiais

Answer 30

1. Dysuria = painful urination 2. Dysmenorrhea = painful period 3. Dyscheziais = painful bowel movement = constiaption 4. Dyspareunia = painful sex 5. Dyssnergiais = disturb of musclar/neuromuscular coordinatio

Question 31

difference in acute and chronic pelvic pain

Answer 31

**acute** = sudden onset of lower adbominal pain less than 3 months **chronic** = lower abdominal pain that lasts 4 months or longer and is NOT related/seperate from organ system or menses