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Y4 Obs and Gynae > Gynaecology: Pelvic Pain > Flashcards

Gynaecology: Pelvic Pain Flashcards

1
Q

Define chronic pelvic pain?

A
  • Pain in the lower abdomen or pelvis
  • At least 6 months duration
  • Can be intermittent or constant
  • And does not occur exclusively with menstruation, intercourse, or pregnancy
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2
Q

What pathophysiological causes can lead to pain becoming chronic?

A
  • Local factors e.g. TNF alpha being released, affecting peripheral nerves
  • CNS changes which may magnify pain signal
  • Visceral hyperalgesia- alteration in visceral sensation and function
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3
Q

What are the possible causes of chronic pelvic pain in women?

A

Gynae:

  • Endometriosis
  • Adenomyosis
  • PID
  • Adhesions

Non-Gynae

  • Interstitial Cystitis
  • IBS/IBD
  • MSK causes
  • Nerve entrapment

N.B: Social and psych factors are always relevatn to a chronic pain presentation!

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4
Q

What is interstitial cystitis?

A
  • Chronic pain syndrome affecting the bladder.
  • Causing intense pelvic pain, urge to urinate, frequent urination, pain during sex
  • Unclear aetiology and no known cure
  • Link to depression, fibromyalgia and IBS
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5
Q

What is endometriosis?

A
  • Definition = Presence of endometrial glands and stroma like lesions outside of the uterus (predominantly in the pelvis)
  • Can also cause peritoneal lesions, implants or cysts in the ovaries
  • Responds to cyclical hormone changes and bleeds during menstruation
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6
Q

What is adenomyosis?

A
  • Definition = presence of endometrial tissue within the myometrium
  • Diagnosed by histology after hysterectomy
  • USS and MRI can be used prior to that
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7
Q

Who generally suffers with Endometriosis/ Adenomyosis

A
  • 10-15% of reproductive age women
  • Make up 70% of cases of chronic pelvic pain
  • More common in infertile women
  • Rare in post-menopausal women as oestrogen dependent
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8
Q

How would a patient with endometriosis or adenomyosis present?

A

Pain during:

  • Menstruation (dysmenorrhea)
  • Intercourse (dyspareunia)
  • Defecation (dyschezia)
  • Urination (dysuria)

HMB, PCB, IMB, Lower abdo pain, Rectal bleeding

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9
Q

What can be seen on examination in women with endometriosis or adenomyosis?

A

In most cases NAD.

Can see:

  • Thickened uterine ligaments
  • Fixed retroverted uterus
  • Uterine or ovarian enlargement

On laparoscope you can see:

  • Powder burn deposits
  • Red flame lesions
  • Scarring
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10
Q

How is endometriosis managed medically?

A

Medical (all suppress ovulation therefore not appropriate if trying to conceive):

  • COCP
  • Continuous progesterone therapy (MPA)
  • GnRH analogues
  • HRT
  • Tranexamic acid for the bleeding
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11
Q

What is an alternative to Tranexamic acid?

A

Mefenamic acid

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12
Q

How is endometriosis managed surgically?

A

Laparoscopically:

  • Diathermy
  • Laser treatment

Definitive management = TAH+ BSO (risk of injury to the bladder/ bowel/ ureters, risk of subtotal hysterectomy)

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13
Q

If the cause of chronic pelvic pain is adhesions, what sort of adhesions should be targeted for therapy?

A

Surgical division of adhesions is unlikely to relieve pain by itself unless in cases of:

  • Vascular adhesions (treated with division)
  • Residual ovary syndrome
  • Trapped ovary syndrome
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14
Q

How are residual/trapped ovary syndrome managed?

A

Ideally: Surgical removal, if not can give GnRH analogues to suppress hormones causing pain (not as effective)

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15
Q

How can conditions like IBS and Interstitial cystitis contribute to chronic pelvic pain?

A
  • Can be the only cause
  • Can be a secondary cause- as efferent neurological dysfunction causes IC/IBS in the presence of different chronic pain.
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16
Q

How can you diagnose someone with IBS?

A

Using the Rome 3 criteria:

  • Continuous or recurrent abdo pain or discomfort for at least 3 days a month in the last 3 months
  • Onset at least 6 months previously
  • 2 of: Improvement with defecation, Onset associated with change in stool frequency, Onset associated with change in stool form
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17
Q

How is IBS treated?

A

Antispasmodics: Mebeverine hydrochloride

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18
Q

What sort of MSK problems can cause chronic pelvic pail?

A
  • Any damage to any of the pelvic joints
  • Damage to the muscles in the abdominal wall or pelvic floor
  • Pelvic organs prolapse
  • ‘Trigger points’, localised areas of deep tenderness, chronic muscle contraction
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19
Q

How should MSK caused chronic pelvic pain be managed?

A
  • Analgesia
  • Physiotherapy
  • Nerve modulation
  • Anti depressants
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20
Q

What is nerve entrapment?

A
  • A highly localised, sharp, stabbing or aching pain
  • Exacerbated by particular movements
  • Persisting beyond 5 weeks or occurring after a pain free interval
  • Common after procedures
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21
Q

How is nerve entrapment managed?

A

In a chronic pain clinic, probably with:

  • Analgesia
  • Physiotherapy
  • Nerve modulation
  • Antidepressants (possibly)
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22
Q

What social and psychological issues can lead to or aggravate chronic pelvic pain?

A
  • Child abuse
  • Sexual abuse
  • Depression
  • Anxiety
  • Somatisation
  • Women reporting both child and adult sexual abuse reported higher levels of menstrual pain, painful intercourse, chronic pelvic pain
  • Treatment is individualised care
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23
Q

How could you initially assess a patient presenting with suspected chronic pelvic pain?

A
  • HoPC- establish pattern of pain
  • Any associations with psych factors, bladder or bowel factors
  • Link with menstruation, bleeding
  • Effect of movement and posture (MSK or nerve)
  • Rule out any red flags (ectopic, miscarriage, cancer, ovarian torsion)
  • If definitely chronic but still unclear, potentially keep a pain diary for a few months
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24
Q

What are you looking for on examination of a patient with chronic pelvic pain?

A
  • Focal tenderness
  • Abdominal masses
  • Full internal exam
  • Enlargement, distortion, prolapse
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25
Q

What investigations would you consider in a woman with chronic pelvic pain?

A
  • STI screening!!
  • TVS, to identify and assess any masses
  • MRI can be useful for adenomyosis
  • Laparoscopy can be useful but is controvertial
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26
Q

Generically, how would you treat chronic pelvic pain?

A
  • Treat the cause
  • Cyclical pain should always be trialled on hormone treatment for 3-6 months before having diagnostic laparoscopy
  • IBS with antispasmodics and lifestyle changes
  • Pain relief
  • Can refer to dedicated chronic pelvic pain team
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27
Q

What is PID?

A
  • Ascending upper genital tract infection

- Can arise de novo, can come from instrumentation but almost always comes from an STI

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28
Q

What are the symptoms of PID?

A

Symptoms progress as the infection ascends…

Cervicitis occurs first, causing:

  • Vaginal discharge
  • Inflammation
  • Tenderness

Endometritis can occur, causing:

  • Menstrual irregularity
  • Midline abdo pain

If a tubal infection occurs you could see:

  • Low bilateral abdo pain
  • Adnexal swelling, tenderness
  • Erythema, oedema, exudate

Intra-abdominal complications are seen last:

  • Peritonitis
  • Periappendicitis
29
Q

What are the most common causative organisms of PID?

A

CHLAMYDIA accounts for the largest number of cases (2-3x as many as G)

  • Gonorrhoea also very common
  • Gardnerella vaginalis
  • Anaerobes
  • Mycoplasma genitalium
30
Q

How long does it take for Chlamydia to develop into PID

A

Roughly 12 months, 10-40% of untreated cases become PID.

Weirdly risk increases with subsequent infections, potential hypersensitivity reaction.

31
Q

What are the long term consequences of PID?

A
  • Infertility (damage to reproductive organs especially tubes)
  • Increased risk of ectopic pregnancy
  • Chronic pelvic pain (v hard to manage)
  • Tubo-Ovarian abscess (more common with G)
  • Fitz-Hugh Curtis syndrome
32
Q

What is Fitz Hugh Curtis syndrome?

A

Rare complication of PID arising from liver capsule inflammation, leading to adhesions.

Symptoms = STI symptoms, RUQ pain, Perihepatitis

33
Q

What are the risk factors for PID?

A

Sexual:

  • Younger woman (increased chance of sexual activity)
  • Multiple partners
  • New partner
  • Previous PID

Gynae:

  • Coil insertion
  • TOP /Miscarriage
  • Uterus instrumentation
  • Douching
34
Q

What are the symptoms of PID?

A
  • Lower abdo pain (normally bilateral)
  • Deep abdominal pain during intercourse
  • Abnormal PV discharge, can be purulent
  • Abnormal bleeding (IMB, PCB)
  • Fever
  • Chills

But may be totally asymptomatic! Can still cause permanent damage to genital tract

35
Q

What are the clinical signs of PID?

A
  • Lower abdominal tenderness, usually bilateral
  • Abnormal or purulent discharge
  • Cervical motion tenderness (same stimulus as causing pain on intercourse)
  • Adnexal tenderness
  • Adnexal mass
  • Fever greater than 38 degrees.
  • Contact bleeding from the cervix (evidence of cervicitis)
36
Q

What investigations would you order for a woman with potential PID?

A

Pregnancy test! Abdo pain = ectopic until proven otherwise.

Test for:
- Chlamydia Trachomatis
- Neisseria gonorrhoeae
- Mycoplasma Genitalium
(presence supports diagnosis, negative STI swabs do not rule out PID)

ESR/CRP/WCC.

Definitive diagnosis is by laparoscopy, only done in a few cases, little use for imaging methods.

37
Q

At what point do you start treating a PID case?

A

Immediately and based on clinical findings; do not wait for swabs to come back as you can get swab negative PID.

Very low threshold for treatment due to fertility risks: sexually active woman + new onset bilateral lower abdo pain + tenderness on bimanual exam = Empirical treatment (assuming pregnancy excluded)

38
Q

How do you manage a patient with PID?

A
  • Rest
  • Analgesia
  • Broad spectrum antibiotics (IV if temp is greater than 38)
  • Admit for observation if severe disease, if pregnant or suspected tubo-ovarian abscess
  • Abstain from sex until both patient and partner have completed treatment.
  • Review after 3 days and escalate to IV antibiotics if no improvement
  • Review in 2-4 weeks to ensure symptoms have resolved, check antibiotics compliance and follow up on contracts.
39
Q

What is the most common outpatient treatment regime for PID?

A

500mg IM Ceftriaxone

+

100mg Doxycycline, BD PO for 14 days

+

400mg Metronidazole BD PO for 14 days

40
Q

Name an alternative outpatient antibiotic regime for PID?

A

400mg Moxifloxacin OD PO for 14 days.

41
Q

What is the most common inpatient treatment regime for PID?

A

IV Ceftriaxone 2g daily +
IV Doxycycline 100mg bd

–>

Oral Metronidazole 400mg bd, 14 days +
Oral Doxycycline 100mg bd for 14 days

42
Q

What treatment should be offered to partners of women diagnosed with PID?

A

Current male partner:

  • Offer screening for CT/NG
  • Broad spectrum Abx e.g. Oral Doxy for one week

Any other partner in last 6 months:
- Offer screening

43
Q

What are some causes of acute pelvic pain in women?

A

Obstetric emergencies must be rule out first:

  • Ectopic
  • Miscarriage

Gynae:

  • Torsion of ovarian cyst
  • Degeneration of fibroids
  • PID flare up
  • Hematocolpos
  • Hematometra
  • Endometriosis

Non-gynae:

  • MSK pain
  • Bowel pain (IBD)
  • Appendicitis
  • UTI/ Uteric caculi/ Cystitis
44
Q

What gynae conditions can cause acute pelvic pain in pregnant women?

A

Most common are:

  • Torsion of ovarian cyst
  • Degeneration of fibrois
  • Flare up of PID
45
Q

What women are at greater risk of ovarian cyst torsion?

A

All women are really but more common in:

  • Younger women
  • Postmenopausal women
  • Women who’ve just given birth
46
Q

What is the adnexa?

A

Region adjoining the uterus, contains the ovaries, fallopian tube, associated vessels, ligaments, connective tissue.

47
Q

What five features are used clinically to score risk of ovarian torsion in a woman presenting with acute pelvic pain?

A

1) Unilateral lumbar/abdo pain
2) Pain duration >8 hours
3) Vomiting
4) Absence of leucorrhoea (non-blood discharge)/ metrorrhagia (irregular bleeding)
5) Ovarian cyst larger than 5cm on ultrasound

48
Q

What are the symptoms of ovarian torsion?

A
  • Pelvic or abdo pain which fluctuates or radiates to loin/thigh
  • Nausea
  • Vomiting

(N.B: distinguishable from PID by the presence of nausea and vomiting)

49
Q

What are the clinical signs of ovarian torsion?

A

General:

  • Pyrexia
  • Tachycardia

Abdominal examination:

  • Generalised tenderness
  • Localised guarding
  • Rebound

Vaginal examination:

  • Cervical excitation
  • Adnexal tenderness
  • Adnexal mass
50
Q

How is ovarian torsion managed?

A

Diagnosis is clinical.

Ultrasound of pelvis would show it but normally not necessary. CRP and WCC will be raised but rarely bother.

51
Q

What is the management of ovarian torsion?

A
  • Admit
  • Give IV fluids
  • Appropriate pain relief
  • Surgery (ideally just remove cyst and untwist ovary but if necrotic laparoscopic salpingectomy)
52
Q

What is Fibroid degeneration?

A

Degeneration of a fibroid due to excessive growth that outmatches blood supply or mechanical compression of feeder arteries

53
Q

How would fibroid degeneration present?

A
  • Likely past history of fibroids
  • Palpable mass
  • Raised inflammatory markers
54
Q

How do you manage fibroid degeneration?

A

Ideally (especially in pregnancy) managed conservatively:

  • Pain relief
  • Hydration
  • Antibiotics

Emergency surgery if due to PEDUNCULATED (wandering) fibroid torsion.

If suspicious of sarcoma –> Hysterectomy

55
Q

How would PID present?

A

Most are actually asymptomatic.

Of those that do present:

  • Lower abdo pain
  • Pyrexia
  • Vaginal discharge (yellow or green)
  • Dyspareunia
  • IMB, PCB
  • No nausea or vomiting (that’s more torsion)

O/E:

  • Pyrexia
  • Vag discharge
  • Cervical excitation
56
Q

Apart from Chlamydia and Neisseria, what are some common causative organisms of PID?

A
  • E Coli
  • Peptococcus
  • Pelvic TB
  • Gardnerella vaginalis
  • Mycoplasma genitalium
  • Strep Pyogenes
57
Q

Apart from Chlamydia and Neisseria, what are some common causative organisms of PID?

A
  • E Coli (most common cause in non-sexually active women)
  • Peptococcus
  • Pelvic TB
  • Gardnerella vaginalis
  • Mycoplasma genitalium
  • Strep Pyogenes
58
Q

What are the risk factors for PID?

A

Sexual:

  • Not using barrier C
  • Multiple sexual partners
  • New sexual partner

Medical History:

  • Endometriosis
  • Previous PID
  • Diabetes
  • Immunocompromised
59
Q

How do you investigate a woman with suspected PID?

A
  • Pregnancy test
  • FBC, CRP, WCC
  • MSU sample
  • Triple swabs
  • Ultrasound of pelvis/abdomen (look for TO abscess)
  • X-ray/Diagnostic laparoscopy maybe
60
Q

What are the components of the triple swab?

A

Endocervical NAAT which tests for C and G.

Endocervical charcoal media swab, tests for G

High Vaginal charcoal media swab, tests for:

  • Bacterial vaginosis
  • Trichomonas vaginalis
  • Candida
  • Group B strep
61
Q

How do you manage TO Abscess?

A
  • Admit
  • Start on IV antibiotics
  • If indications for sepsis, manage according to S6P

If no sepsis

  • 4 hourly obs
  • Daily FBC and CRP
  • Continue IV antibiotics
  • Daily senior clinical review
  • Review microbiology and refine antibiotics

When clinically improving:

  • Switch to oral antibiotics
  • Discharge
62
Q

What are the main two points of TOA management?

A
  • IV antibiotics until improvement, switch to oral and send home
  • 4 hourly obs monitoring + daily bloods (FBC, CRP) to make sure they don’t go septic
63
Q

How do you manage PID outpatient?

A

Triple swab, even if negative treat based on pain + signs of infection + history.

Single dose IM Ceftriaxone (500mg) followed by…
- 100mg Doxycycline and
- 400mg Metronidazole
… both twice daily, both orally and both for 14 days.

N.B: can’t drink when on Metro

64
Q

When and how do you manage PID as an inpatient?

A

Severe disease, or Septic, or not responding to Outpatient.

- IV Ceftriaxone, 2g, daily
Followed by...
- 100mg oral doxy
- 400g oral nitro
Twice daily for 2 weeks.
65
Q

What surgical management options are available in the management of PID?

A

Laparoscopy or Laparotomy for drainage.

66
Q

What counselling should be given to a woman treated for PID?

A
  • Warn about risk of ectopic pregnancy
  • Subfertility
  • Partner notification and possible treatment.
  • Follow up
67
Q

What is Haematocolpos?

A

Condition where the vagina becomes pooled with menstrual blood due to some sort of outflow obstruction.

Presents with absent periods and cyclical pain.

68
Q

How do you manage Haematocolpos?

A

Cruciate incision to drain blood.

Y4 Obs and Gynae (13 decks)

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