Transcript Pelvic Pain - Back to Medical School

Mr James Campbell
Overview
 Causes of pelvic pain
 Gynaecological terminology
 Common gynae. pathologies
 Chronic pelvic pain
 Case study
Causes of pelvic pain
• Gynaecological –
– Dysmenorrhoea
– Endometriosis
– Adenomyosis
– Infection
– Fibroids
– Post-operative pain
– Ectopic pregnancy
Causes of pelvic pain
 Gastrointestinal
 IBS
 Inflammatory bowel disease
 Diverticulitis
 Colon / rectal carcinoma
 appendicitis
Causes of pelvic pain
• Urological
– Painful bladder syndrome
– Bladder infection
• Musculoskeletal
– Referred pain from lower back
• Psychological
Depression; sexual abuse
Terminology
 Dysmenorrhoea
 pain associated with menstruation
 Primary / spasmodic
 not associated with organic pathology
 Secondary / congestive
 due to organic pathology
Dysmenorrhoea
• Prostaglandin
production
– Myometrial
contractions
– Decreased blood flow
– PAIN
Dyspareunia
 Pain associated with intercourse
 Superficial – pain at / around the labia
 Deep – pelvic pain (associated with organic pathology)
Endometriosis
 Deposits of endometrial tissue outside the uterine
cavity
 Most common sites are the ovary (chocolate cysts) and
uterosacral ligaments
Aetiology
 Implantation theory
 Retrograde menstruation
 Coelomic metaplasia theory
 Mullerian duct
 Peritoneal and pleural cavities
 Ovaries
 (all derive from the coelomic epithelium)
Symptoms and signs
• Dysmenorrhoea
• Dyspareunia
• Sub-fertility
• Menstrual dysfunction
– Signs in severe disease
•
•
•
Fixed tender uterus
Adnexal mass
Nodular POD
Investigations
 Laparoscopy
 USS / MRI
 Tissue biopsy
Management
• Conservative
– Analgesia (+ counselling)
• Medical
– Hormonal agents
• Surgical
– Laparoscopic ablation
– Cystectomy
– Hysterectomy
Adenomyosis
 Endometrial tissue within the myometrium
 Main risk factor is high parity
 Causes HMB and dysmenorrhoea
Pelvic inflammatory disease
• Chlamydia
• Gonococcus
• Lower abdominal pain
• Deep dyspareunia
• Abnormal bleeding / discharge
• IMB in young patient think chlamydia
PID - examination
 Cervical discharge / tenderness
 Adnexal mass
Management
• Investigations –
– Temperature
– Bloods
– Swabs
– Urinary PT
– USS
• Treatment
– Antibiotics (oral / IV)
– Partner tracing / treatment
Ovarian cysts
 Simple / complex
 Benign / malignant
Cysts are painless unless  Twist – torted ovary
 Haemorrhage
 Rupture
 They are very large and cause pressure
Ectopic pregnancy
• Symptoms –
– Acute unilateral lower abdominal pain
– Bleeding
– Collapse
• Investigations
– PT / serial HCG’s
– USS
• Management
– Supportive / medical / surgical
• Collapse in young woman think ectopic
Fibroids
 Benign tumours of the myometrium
 Common – 1 in 3 over 30 years
 Hormone dependent
 Symptoms related to size and position
Fibroids
 Asymptomatic
 HMB
 Pressure
 Pain rarely occurs
 Usually associated with complications


Degeneration
torsion
Chronic pelvic pain
 Can arise form any system either de novo or following
acute pelvic pain
 “pain not occurring with menses, intercourse or
pregnancy causing distress and /or disability that has
persisted for greater than 6 months”
Types of chronic pelvic pain
• Organic –
•
Due to tissue damage (endometriosis)
• Psychological –
•
Can occur without tissue damage
• Cancer
• Benign
•
Occurs despite tissue healing (adhesions)
Case study
 45 yr old woman attends the clinic with pelvic pain of 2
years duration
 Consultant is away and you are in charge
History
• Intermittent pain / 2-3 episodes daily
• Unrelated to menses
• Bilateral / no associated factors
• Heavy periods
• Sexually active / on cerazette
• LSCS 1990 / appendicectomy 2006
• Mother had hysterectomy
• No bowel / urinary dysfunction
Examination
 Speculum
 Normal
 Bimanual
 Bulky uterus
 No adnexal masses
Investigations
 PT – negative
 Swabs – negative
 USS –
 Multiple small intramural fibroids, largest 2cm, ovaries
normal
Differential diagnosis
• Surgery related pain
• Fibroids / endometriosis
• IBS
• Psychological
• Diagnosis – made at laparoscopy
– Post operative adhesions / ovarian entrapment
Ovarian adhesions
Pelvic pain
 Thanks for your attention.
 Questions?