Abdominal and pelvic pain Flashcards by J A

Define:
Acute pelvic pain
Chronic pelvic pain

What are the causes of mild acute pelvic pain?

Acute pelvic pain <3 months
Chronic pelvic pain <6 months, not associated with pregnancy, menstruation or sex

Menstruation

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What are the causes of acute pelvic pain?

Obstetric: Ruptured ectopic pregnancy, Incomplete or septic miscarriage

Gynae: Endometriosis, Acute PID, Ovarian cyst rupture/torsion, Ovarian malignancy

Other: Renal caliculi/infection
Appendicitis

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What are the causes of chronic pain?

Gynae: Endometriosis, Adenomyosis, Chronic PID, Adhesions, pelvic organ prolapse

Other: Diverticular disease, IBS, peritonitis UTI, interstitial cystitis, nerve entrapment

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What is in the assessment of pelvic pain?

History
Infection screen- Urine MC & S, endocervical swab, high vaginal swab
Transvaginal ultrasound/MRI
Diagnostic laproscopy
CA-125
Urine bHCG

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What are the red flags in the a pelvic pain history which prompt further investigations? (CLUE would indicate malignancy)

Bowel: bleeding per rectum, new onset bowel symptoms >50
Weight loss, suicidal ideation
Gynae: post-coital bleeding, irregular vaginal bleeding in >40, new onset pain in >50, palpable mass

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In endometriosis what are the common and rare places endometrial tissue can grow?

What are aetiological theories?

Common:
Ovaries, uterosacral ligament
Rectosigmoid colon, pouch of douglas
Bladder, distal ureter

Rare: umbilicus, C section scar, pleura, pericardium, CNS

Aetiology

retrograde menstruation
Foci/distant lesions via embolisation Hablans theory and Meyers theory Malignancy

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What is epidemiology, and risk factors for endometriosis?

CLUE endometriosis is oestrogen dependent condition

Most common in reproductive ages, rare under 20’s
Regresses during menopause, and pregnancy
Common in nulliparrous women

Risk factors:

Early menarche late puberty
Outflow obstruction to bleeding eg fallopain tube or uterine abnormalitiies
1st degree relative

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What are protective factors for endometriosis?

multiparity and OCP

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Clinical features of endometriosis?

Chronic cyclical pain 
Deep dyspauerenia 
Dyscherizia 
Subfertility 
Sudden acute pain- rupture of endometrioma

Cylical haematuria, rectal bleeding, bleeding from umbilicus: Severe disease
Asymptomatic

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What are the findings of endometriosis on bimanual pelvic examination?

Retroverted immobile uterus
Thickness and tenderness behind uterus or adnexa
Retrovaginal nodule may be felt digitally on speculum or vaginal exam

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Investigations for endometriosis

Acute: FBC, urine MC+S, endocervical swab

1.Transvaginal ultrasound- exclude endometrioma
Transvaginal MRI- if peritoneal endometriosis or adenomyosis suspected

Diagnostic laparoscopy- gold standard!!! You can explore the pelvic cavity I guess and adhesions
CA 125- exclude ovarian malignancy

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What are the lesions which are found on diagnostic laparoscopy in endometriosis
Active
Less active
Severe

Active- red punctuate marks on peritoneum
Less active- white brown scars
Severe- adhesions/ endometrioma

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Medical management of Endometriosis, and how long is it given for?

Abolish cyclity:
COCP
GnRH analogues with HRT add back therapy

Glandular atrophy- medroxyprogesterone acetate (oral), depot, Mirena IUS, Danazol (not used much cos androgenic SEs)

Given for 6 months

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Surgical management of endometriosis?

Laproscopy- adhesiolysis, cystectomy (improve fertility)
Hysterectomy with salpingooopherectomy
pelvic clearance

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What are the complications of endometriosis?

Endometrioma
Inflammation- fibrosis-adhesions- frozen pelvis
Subfertility
Increased risk of breast and ovarian cancer
Increased risk of IBD
Increased risk of autoimmune and atopic disorders

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What is adenomyosis?

Presence of myometrium within endometrium

adenomyotic nodules cause proliferation and hyperplasia of myometrium cause slow growing adenomyoma tumour

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Epidemiology and associations of adenomyosis?

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Begins in 40’s and more common in multiparrous women

Associated with fibroids, endometriosis

Clinical features of adenomyosis?

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Cyclical pelvic pain
Secondary subfertility (present in 40’s)
Menorrhogia, more frequent periods, spotting, staining
———- Above differentiates between endometriosis and adenomyosis

Investigations adenomysosis?

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Transvaginal MRI, and transvaginal venous ultrasonography

Management of adenomyosis?

Medical and surgical

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Menorrhagia and pain: Mirena IUS, COCP

MedicalA: hysterectomy give trial of GnRH analogues to see if will be successful

What are ovarian cysts (clue include size) and what are the diff types of cysts?

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Fluid filled sacs larger than 3cm
Simple benign cysts (resolve within 3 months)
Endometrioma
Dermoid cysts

What are the complications associated with risks and which types of ovarian cysts are associated with each?

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Haemorrhage
Torsion- infarction of tube or ovary (dermoid more likely)
Rupture (more dermoid and endometrioma)

What are risk factors for ovarian cysts?

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Obesity 
Early mencarche  
Infertility 
tamoxifen therapy (causes cysts to persist) 
Family history- dermoid cysts

Clinical features of ovarian cysts (acute chronic)

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Acute:

fever, pain or intermitten pain: torsion rupture
peritonitis and shock
hypovalaemia- if haemorrhage
if ascites then malignancy

Chronic

abdo distention
pressure effects, frequency, varicose veins and leg oedema
Dyspaeurinia
dull ache in lower abdo or back

Investigations of ovarian cyst?

All pelvic pain tests first 1. Transvaginal ultrasound or MRI to visualise cyst - some may need diagnostic laparscopy to confirm 2. Fine needle aspiration and cytology 3. CA-125

Why would you not order CA-125 test if on ultraosund simple benign cysts and women is pre-menopausal?

Because of false positive rate

Management of ovarian cysts (clue is according to size of cysts)

if 5-7cm then yearly ultrasound if >10cm then laproscopic cystectomy if malignany then laparatomy

What is epidemiology of PID and risk factor?

Most common in 20-29 year olds RF: lower socioeconomic classes, frequent sexual partners, sexually active nulliparrous women, sex without barrier contraception

What is aetiology of PID (not bacteria) and which structures most likely to be affected?

Ascending infection from cervix, vagina Descending infection from appendicitis rarely Or introduction via uterine instrumentation, complications of childbirth or miscarriage Structures- most likely to cause endometritis, bilateral salpingitis and parametritis (ovaries not affected as much)

What is Fitz- Hugh curtis syndrome (clue occurs in PID?)

Inflammation of the liver capsule but not parenchyma results in adhesion formation between the liver and anterior abdominal wall Have RUQ pain

What bacteria are responsible for causing PID?

- 80% STI: chlamydia (asymptomatic if symptomatic then due to secondary bacterial infection) and gonorrhoea - Mycoplasma genitalium, flora (anaeorobic and aerobic) and aerobic streptococci - Bacterial vaginosis organisms- gardenella vaginallis

What are the clinical features of PID?

- Asymptomatic (may present later with subfertility menstrual problems) - Bilateral pelvic pain - Dyspaeurenia - Abnormal vaginal bleeding- menorrhagia, post-coital, intermenstrual - purulent vaginal discharge - Nausea and vomiting - Urinary symptoms

What are the examination findings of PID?

``` Tachycardia Fever >38degrees Bilateral adnexal tenderness, and abdominal tenderness Cervical motion tenderness- !!!!!!!!!! Palpable vaginal mass Discharge on speculum ```

Which sign helps differentiates PID from appendicitis?

Cervical motion tenderness

What investigations are indicate in PID?

All the ones for pelvic pain (pregnancy, infection screen) - FBC, (raised WCC and ESR and CRP) - pelvic ultrasound to exclude abscess - Gold standard: Laparoscopy with endometrial fimbrial biopsy

In PID, what features suggest that patient should be hospitilised and receive IV antiobiotics?

If systemically unwell (fever >38), pregnancy, pelvic peritonitis or signs of tubo-ovarian abscess (eg pt will have rigors)

What is the outpatient management of PID?

IM Ceftriaxone - once | Oral doxycycline and oral metranadizole 14 days

Inpatient management of PID?

IV Ceftriaxone, doxycline and metranadizole all single dose - continue IV for 24 hours after improvement - switch to oral doxycycline and metronadizole for 14 days

What are the complications of PID? (Acute and long term)

Acute: pelvic abscess, psyosalpinx Chronic: - Adhesions (subfertility, ectopic pregnancy) - chronic pelvic pain

In chronic PID what is present in the pelvic cavity?

dense pelvic adhesions | Fallopian tubes may be obstructed with psyosalpinx or hydrosalpinx

On examination what will be signs of chronic PID? Investigations

- Bilateral adnexal and abdo tenderness - Fixed retroverted uterus (due to adhesions) IX: TVS will show fluid surrounding fallopian tubes Laparscopy with fimbrial/endometrial biopsy culture tends to be negative

What is surgical management of chronic PID?

May require adhesiolysis, or salpingectomy

Abdominal and pelvic pain Flashcards

(42 cards)