CSS.12.Gyn.AbdPain

Question 1

What are the five leading diagnoses for acute pelvic pain in females?

Answer 1

ectopic pregnancy, hemorrhagic ovarian cyst, PID, appendicitis, adnexal torsion

Question 2

what lab test should all women of reproductive age with pelvic pain get?

Answer 2

hCG

Question 3

what is the best initial modality for imaging pelvic pathology and why?

Answer 3

ultrasound, identifies ovarian pathology, notes malignancy, notes any early pregnancy complications

Question 4

Name 14 common gynecologic causes of acute pelvic pain

Answer 4

spontaneous abortion; ectopic pregnancy; PID; endometritis; salpingitis; tubo-ovarian abscess; degenerating leiomyomas; endometriosis; dysmenorrhea; mittelschmerz; ruptured ovarian cysts; ovarian torsion; pelvic adhesive disease

Question 5

Name 8 GI/GU causes of acute pelvic pain

Answer 5

UTI, nephroureterolithiasis; interstitial cystitis; gastroenteritis; appendicitis; diverticulitis; IBD, IBS

Question 6

what are some important history questions to ask a reproductive aged female with acute pelvic pain

Answer 6

age of menarche, LMP start date, duration of flow, quantification of flow, time interval between menses, intermenstrual bleeding, sexual history, contraceptive techniques, h/o pregnancy, h/o STIs, h/o abnormal paps/other gyn procedures

Question 7

what physical exam should you include when evaluating a reproductive aged female with pelvic pain?

Answer 7

abdominal exam to evaluate for surgical abdomen, pelvic exam to include direct visualization of cervix, cervical motion tenderness, bimanual of uterine size, pelvic masses, possible rectovaginal exam to look for masses

Question 8

what labs should you obtain when evaluating a reproductive aged female with pelvic pain?

Answer 8

beta-hcg, CBC, BMP, LFTs, UA

Question 9

what is the most common age group affected by ovarian torsion?

Answer 9

<50 y/o

Question 10

what associated diagnosis is usually found with ovarian torsion?

Answer 10

usually associated with ovarian or tubal tumor, with risk of torsion increasing linearly with tumor size. MCC = dermoid tumors

Question 11

what patient population is more likely to present with ovarian torsion associated with normal sized ovaries rather than tumors?

Answer 11

children and early adolescents

Question 12

what is the risk of associated malignant tumor with ovarian torsion?

Answer 12

< 2%

Question 13

why is ovarian torsion pain sometimes colicky (comes and goes in waves)?

Answer 13

some ovarian torsions are intermittent, with pain coming in waves, especially associated with activity

Question 14

what is the underlying pathophysiology of ovarian torsion?

Answer 14

torsion of the ovary’s vascular pedicle, initially venous flow is more affected than arterial flow, causing ovarian engorgement –> arterial flow compromised –> ischemia, necrosis, peritonitis

Question 15

what is the limitation of doppler-ultrasound when evaluating for ovarian torsion?

Answer 15

there can be diminished or absent blood flow in normal adnexa too

Question 16

what lab and ultrasound findings should you make you suspect ectopic pregnancy?

Answer 16

hCG > 1500-2000 with empty uterus (no intrauterine gestational sac)

Question 17

what should you do if a patient has an hCG < 1500 but you are suspecting ectopic pregnancy?

Answer 17

get serial hCGs over 48 hours, they will rise in ectopic pregnancy but not with normal pregnancy

Question 18

what two cervical findings on physical exam are a/w PID?

Answer 18

cervical motion tenderness and mucopurulent cervical discharge

Question 19

what are the 2 MCC of PID and how is it treated?

Answer 19

gonorrhea and chlamydia, qqf polymicrobial. Tx = abx, qqf surgery to drain tuboovarian abscesses

Question 20

how do hemorrhagic and ruptured ovarian cysts present?

Answer 20

similarly to ovarian torsion, acute onset pain, adnexal mass on ultrasound, usu a/w more pelvic fluid, no fever, no leukocytosis

Question 21

how do you treat hemorrhagic and ruptured ovarian cysts?

Answer 21

conservative, U/S abnormalities usu resolve within 6 weeks, any hemodynamic instability requires surgical intervention

Question 22

what type of ovarian masses can be removed endoscopically and why?

Answer 22

cystic masses can be removed endoscopically b/c they can be decompressed in the endobag

Question 23

why should you take care not to rupture an endocatch bag when removing a malignant ovarian tumor?

Answer 23

b/c this upstages the malignancy and increases the risk of requiring postop chemo

Question 24

what type of incision is usually adequate for most benign pelvic pathology? How can it be extended prn?

Answer 24

Pfannensteil, can be extended to Cherny incision by detaching rectus muscles from their tendinous insertions

Question 25

What type of incision should you perform for suspected malignant GYN pathology?

Answer 25

midline laparotomy

Question 26

After how many hours of ovarian torsion does the risk of ovarian necrosis increase?

Answer 26

after 24 hours

Question 27

Which patients should you strongly consider ovarian conservation over salpingoophorectomy when treating ovarian torsion?

Answer 27

children, adolescents, and women early in their reproductive years

Question 28

Name two ways to assess ovarian perfusion intraoperatively

Answer 28

IV fluoroscein injection and ovarian bivalving

Question 29

what are the benefits of ovarian bivalving after detorsion?

Answer 29

After the untwisting of ischemic adnexa, ovarian bivalving is an effective technique to decrease ovarian intracapsular pressure, increase arterial perfusion, and facilitate adnexal reperfusion and recovery.

Question 30

what is the biggest postop risk associated with ovarian conservation in the case of ovarian torsion?

Answer 30

risk of ovarian necrosis --> peritonitis & systemic infection, therefore closely follow postop

Question 31

what are the indications for ovarian cystectomy

Answer 31

allows for ovarian conservation, indicated for benign pathology or if diagnosis is uncertain

Question 32

what are the basic steps of ovarian cystectomy?

Answer 32

1) expose & stabilize ovarian mass; 2) linear or elliptical incision of the serosa over the top of the antimestenteric portion of the mass (bovie or scalpel); 3) blunt/sharp dissection to identify underlying tumor (avoid tumor rupture); 4) control bleeding; 5) can either leave serosa open or reapproximate

Question 33

what should you do if you have a rupture of an ovarian tumor during removal?

Answer 33

if tumor rupture occurs, ensure all portions of the cyst wall are removed

Question 34

where does the most significant bleeding occur with removal of the ovarian mass?

Answer 34

at the base of the tumor where ovarian vessels enter the ovarian hilum

Question 35

what should you do if you cannot control bleeding after removal of ovarian mass / ovarian cystectomy?

Answer 35

can perform oophorectomy if unable to control bleeding

Question 36

name four indications for salpingoophorectomy

Answer 36

malignant pathology; nonviable ovarian tissue following torsion; definitive management of recurrent benign pathology; and in postmenopausal patients

Question 37

name the 7 key steps to salpingoophorectomy

Answer 37

1) expose pelvic sidewall, identify infundibulopelvic & round ligaments; 2) incise peritoneum 1cm lateral to infundibulopelvic ligament and develop pararectal space; 3) ID important structures in the RP: ureter, external iliac artery, internal iliac artery, external iliac vein; 4) create window thru peritoneum to isolate ovarian veins from ureter; 5) ligate and divide ovarian vessels; 6) ovary and fallopian tube in anterior traction while transecting inferior peritoneal attachments towards uteroovarian ligament; 7) ligate fallopian tube and uteroovarian ligaments close to uterina cornua

Question 38

name a potential pitfall during salpingoophorectomy that can lead to ureteral injury

Answer 38

failure to properly develop pararectal space and identify ureter

Question 39

what maneuver can be performed if tumor size or adhesions prohibit adequate visualization during salpingoophorectomy?

Answer 39

controlled tumor decompression or partial debulking to improve visualization

Question 40

what are the four risks of leaving an incidentally found adnexal mass while performing an ovarian cystectomy / salpingoophorectomy?

Answer 40

future tumor rupture, hemorrhage, torsion, risk of malignant degeneration

Question 41

what is the management of an incidentally-found ovarian cyst < or = 5cm in a reproductive-aged female?

Answer 41

usually functional and will self-resolve without nintervention

Question 42

what are three characteristics of incidentally-found adnexal masses that increase risk of malignant potential?

Answer 42

solid tumors; masses greater than or equal to 10cm in size; associated with excrescences (lumps, swelling, nodules)

Question 43

what is the relationship between the uterine artery and the ureter?

Answer 43

water under the bridge: uterine artery crosses over the ureter

Question 44

what is the tunnel of Wertheim?

Answer 44

the ureter enters the tunnel of Wertheim when passing under the uterine artery and heads towards the cervical os (basically where the ureter enters paracervical tissue)

Question 45

how long postop after salpingoophorectomy or ovarian cystectomy should a patient be under "pelvic rest"

Answer 45

4-6 weeks of pelvic rest postop

Question 46

what are the effects of unilateral salpingoophorectomy on fertility?

Answer 46

minimal impact on fertility as long as contralateral ovary and fallopian tube are normal, may reach menopause earlier