Pelvic Pain Flashcards by MA CARMELA CONCEPCION SALES

Sudden sharp pain in the pelvis that becomes

more generalised indicates_______

rupture of an ectopic

pregnancy or an ovarian cyst.

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The principal afferent pathways of the pelvic

viscera arise from _______ to _______

T10–12, L1 and S2–4

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Genital Causes of acute lower abdominal and

pelvic pain in women

Acute salpingitis
Pelvic peritonitis
Bleeding
Rupture or torsion of ovarian cyst
Threatened or incomplete abortion
Rupture or aborting tubal ectopic pregnancy
Rupture or bleeding endometrioma

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non- Genital Causes of acute lower abdominal and

pelvic pain in women

Acute appendicitis
Bowel obstruction
Urinary tract infection (cystitis)
Ureteric colic (calculus)

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Functional Causes of acute lower abdominal and

pelvic pain in women

Primary dysmenorrhoea

Retrograde menstruation

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Chronic pelvic pain is constant or recurrent pain of at

least_______

6 months’ duration

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It is the reason for up to 40% of gynaecological

laparoscopies

Chronic pelvic pain

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it is difficult to distinguish clinically between
endometriosis of the uterus (adenomyosis) and _______________Both conditions are associated
with dysmenorrhoea and a tender normal-sized
uterus

pelvic

congestion syndrome.

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It is the commonest cause
of intraperitoneal haemorrhage. There is usually a
history of a missed period but a normal menstrual
history may be obtained in some instances.

Ectopic pregnancy

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RF for ectopic pregnancy

— previous ectopic pregnancy
— previous PID
— previous abdominal or pelvic surgery,
especially sterilisation reversal
— IUCD use
— in-vitro fertilisation/GIFT

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amenorrhoea (65–80%) + lower
abdominal pain (95 + %) + abnormal vaginal
bleeding (65–85%)

ectopic pregnancy

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Pain patterns of ectopic pregnancy

Pain may radiate to rectum (lavatory sign),

vagina or leg

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Vaginal examination of patients with ectopic pregnancy

• Vaginal examination:
— tenderness on bimanual pelvic examination
(pain on cervical provocation i.e. cervical
motion tenderness)
— palpable adenxal mass
— soft cervix

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In EP, Serum β -hCG assay________ (invariably
positive if a significant amount of viable
trophoblastic tissue present

> 1500 IU/L

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Transvaginal ultrasound can diagnose at
______ weeks (empty uterus, tubal sac, fluid in
cul-de-sac)

5–6

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Ectopic pregnancy diagnosis

Pregnancy test
β-hCG assay
Transvaginal ultrasound
Laparoscopy

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tx of EP

Treatment may be conservative (based on
ultrasound and β -hCG assays); medical, by injecting
_______ into the ectopic sac;
_________ for severe cases

methotrexate

laparoscopic
removal; or laparotomy

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Post management

Successful pregnancy _______
Subsequent risk of ectopic pregnancy ______

60–65%

10–15%

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When the Graafian follicle ruptures a small amount
of blood mixed with follicular fluid is usually
released into the pouch of Douglas. What is this phenomenon called?

Ruptured ovarian (Graafian)
follicle (mittelschmerz)

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Pain character of Ruptured ovarian (Graafian)

follicle (mittelschmerz)

Deep pain in one or other iliac fossa (RIF > LIF)
Often described as a ‘horse kick pain’
Pain tends to move centrally
Relieved by sitting or supporting lower abdomen

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Benign ovarian tumours, particularly ________may be asymptomatic but will cause pain if
complicated

ovarian

cysts,

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_______ tend to rupture just prior to ovulation or

following coitus.

ovarian cyst

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What is the dx

Patient usually 15–25 years
Sudden onset of pain in one or other iliac fossa
May be nausea and vomiting
No systemic signs
Pain usually settles within a few hours

Ruptured ovarian cyst

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When to do conservative MX for Ruptured ovarian cyst

— simple cyst <4 cm
— internal haemorrhage
— minimal pain

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When to do lap sx for ovarian cyst?

— complex cysts — large cysts — external bleeding

Torsions are mainly from ______ and, when right-sided, may be difficult to distinguish from acute pelvic appendicitis

dermoid cysts

SSx of torsion of ovarian cyst

* Severe cramping lower abdominal pain * Diffuse pain * Pain may radiate to the flank, back or thigh * Repeated vomiting * Exquisite pelvic tenderness

_______ has an incidence of 10 cases per 10 000 women per year and accounts for 5% of all cancers in women and 20% of all gynaecological cancers

Ovarian cancer

Ovarian cancer tends to remain asymptomatic for a long period. No age group is spared but it becomes progressively more common after _______

``` 45 years (peak incidence 60–65 years) ```

RF for ovarian CA

* Age * Family history (first-degree relatives) * Nulliparity

Protective factors for ovarian CA

* COC pill | * Pregnancy

T or F Any ovary that is easily palpable is usually abnormal (normal ovary rarely >4 cm).

Dx of ovarian CA

``` • Ultrasound ± colour Doppler • Tumour markers such as CA-125, β -hCG (choriocarcinoma) and alpha-fetoprotein are becoming more important in diagnosis and managemen ```

Dysmenorrhoea (painful periods) may commence with the onset of the menses (menarche) when it is called ______ or later in life when the term ________ is applied

primary dysmenorrhoea, secondary dysmenorrhoea

This is menstrual pain associated with ovular cycles without any pathologic findings. The pain usually commences within 1–2 years

Primary (functional) dysmenorrhoea

Conservative Mx of Primary dysmen

* Vitamin B1 (thiamine) 100 mg daily * COC (low-oestrogen triphasic pills preferable) 5 * progestogen-medicated IUCD

A Cochrane review found that the most beneficial | medication was the NSAIDs, and____ and ______

vitamin B1 and | magnesium also proved effective

_________ is menstrual pain for which an organic cause can be found. It usually begins after the menarche after years of pain-free menses; the patient is usually over 30 years of age

Secondary dysmenorrhoea

Commonest causes of Secondary dysmenorrhoea

* endometriosis (a major cause) * PID (a major cause) * IUCD * submucous myoma * intra-uterine polyp * pelvic adhesions

Pelvic adhesions may be the cause of pelvic pain, infertility, dysmenorrhoea and intestinal pain. They can be diagnosed and removed ________

laparoscopically

______ is the condition where ectopically located endometrial tissue (usually in dependent parts of the pelvis and in the ovaries

Endometriosis

What are the factors affecting EM

responds to female sex hormone stimulation by proliferation, haemorrhage, adhesions and ultimately dense scar tissue changes

dysmenorrhoea + menorrhagia + | dyspareunia = abdominal/pelvic pain

endometriosis

Signs of EM

• Fixed uterine retroversion • Tenderness and nodularity in the pouch of Douglas/retrovaginal septum • Uterine enlargement and tenderness

________ this is endometriosis of the myometrium affecting the endometrial glands and stroma

Adenomyosis:

The symptoms of adenomyosis are similar to endometriosis plus an enlarging _____

tender uterus

Gold standard for dx of EM

• Usually by direct visual inspection at laparoscopy | (the gold standard) or laparotom

What is the use of curettage in EM Dx

• Curettage, which shows small sensory C nerve | fibres in the endometrium

OCPs are used for the Tx of EM to:

To induce amenorrhoea (only twothirds | respond to drugs

OCPs used in the Tx of EM

— levonorgestrel-releasing IUCD (Mirena) 5 yearly and indefinite — danazol (Danocrine)—for 3–6 months — COC: once daily continuously—long term — progestogens (e.g. medroxyprogesterone acetate—Depo-Provera) or orally 10 mg bd for up to 6 months — GnRH analogues (e.g. goserelin, 3.6 mg SC implant every 28 days for up to 6 months, nafarelin

____________PID is a major public health problem and is the most important complication of STIs among young wome

Acute

CX of PID

tubal obstruction, | infertility and ectopic pregnancy

What is the dx * Fever ≥ 38 ° C * Moderate to severe lower abdominal pain

Acute PID

What is the dx * Ache in the lower back * Mild lower abdominal pain

Chronic PID

Diagnostic criteria for acute PID All three of the following should be present 1 2 3

1 Lower abdominal tenderness (with or without rebound) 2 Cervical motion tenderness 3 Adnexal tenderness (may be unilateral) plus

Diagnostic criteria for acute PID One of the following should be present 1 Temperature _____ 2 White blood cell count_______ 3 Purulent fluid obtained via culdocentesis 4 Inflammatory mass present on bimanual pelvic examination and/or sonography 5 ESR ≥ 15 mm/h or CRP >1.0 mg/dL 6 Isolation of ________ 7 Histological evidence of infection (e.g. plasma cells)

≥ 38°C ≥ 10 500/mm2 N. gonorrhoeae and/or C. trachomatis

Exogenous organisms: those which are community acquired and initiated by sexual activity. They include the classic STIs including

``` Chlamydia trachomatis (most common causative organism) and Neisseria gonorrhoeae ```

Endogenous infections: these are normal | commensals of the lower genital tract, especially

Escherichia coli and Bacteroides fragilis

Portal of entry of endogenous infection

The commonest portals of entry are | cervical lacerations and the placental site

These organisms cause an ascending infection and can spread direct or via lymphatics to the broad ligament, causing __________

pelvic cellulitis

organism associated with prolonged IUD use

Actinomycosis: due to prolonged IUCD use. Look | for Actinomyces israelii on culture

Sex partners of women with PID should be treated | with agents effective against ________

C. trachomatis and N. | gonorrhoeae.

Mild to moderate infection Tx for PID (treated as an | outpatient

ceftriaxone 500 mg (in 2 ml 1% lignocaine) IM or 500 mg IV, as a single dose (for gonorrhoea) plus azithromycin 1 g (o), as 1 dose plus metronidazole 400 mg (o) 12 hourly for 14 days

moderate to severe infection Tx for PID (treated as an | outpatient

ceftriaxone 1 g IV daily plus azithromycin 500 mg IV daily plus metronidazole 500 mg IV 12 hourly until there is substantial clinical improvement, when the oral regimen above can be used for the remainder of the 14 days

Tx of actinomyces

amoxycillin 500 mg tds + metronidazole 400 mg | bd for 14 days. Ensure IUCD is removed

In any woman whose normal activities are disturbed by dysmenorrhoea unrelieved by NSAIDs,_______ should be suspected

endometriosis

If an ectopic pregnancy is suspected and there are no facilities for resuscitation, digital vaginal examination should be deferred for it may provoke _____

rupture.

Acute abdominal and pelvic pain in the presence of a | negative β-hCG is most often due to an ______

ovarian cyst

A positive β-hCG plus an empty uterus and an adnexal mass are the classic diagnostic features of _________

ectopic pregnancy

Pelvic Pain Flashcards

(69 cards)