Published on March 16, 2014
Acute Pelvic Pain History,Examination,Differential Diganosis and Pelvic Pain
Introduction • Pelvic pain is discomfort in the lower abdomen – Below the umbilicus • may originate in – reproductive organs (cervix, uterus, uterine adnexa) – or other organs ● Urological ● Gastrointestinal ● Musculoskeletal ● Neuropathic ● Other • Sometimes the cause is unknown
Objectives 1. Understand the definition & terminology 2. Identify the causes & form a differential diagnosis 3. Clinically evaluate a patient with this problem
Causes Pelvic pain 1. Gynae cause • Cyclical • Discrete 2. Non-gynae cause • Other organs
• Pelvic region
• Female pelvis
Definitions • Acute pelvic pain: symptom of underlying tissue injury. • Chronic pelvic pain: pain becomes the disease – Recurrent, unrelated to menses, intercourse, pregnancy Chronic pain: pain lasting 6 months or longer. • Chronic pelvic pain syndrome: chronic pelvic pain causing emotional and behavioral changes.
Pelvic Inflammatory Disease • Upper genital tract infection – Endometritis – Salpingitis – Oophritis – Parametritis – Tubo-ovarian abscess – Pelvic peritonitis
Types • Acute – Mild – Moderate – Severe • Chronic
Causes • Primary – STI: chlamydia, trachomatis, neisseria gonorrhoea – Ascending endogenous anaerobes: bacteria, mycoplasma hominis – Latrogenic: IUD insertion, D & C, manual removal of placenta – Following delivery or miscarriage • Secondary – Frrom nearby organs – Through blood stream
Defence mechanism against ascending infection • Vulva – Closure of introitus by labia – Secretion of apocrine gland of vulva has fungicidal effect • Vagina – Closure of apposition of its anterior and posterior walls – Well developed stratified squamous epithelium,unbroken by entrance of glands – Mucosal immune response
• Cervix – Functional closure by cervical mucous • Uterus – Periodic shadding of endometrium – Harbour non-pathogenic anaerobic streptococci
Patient Identification • Name: • Age: • Gravida , Parity • Address • Marrietal status • Her Husband name and work
History Example • Date and time of admission • Complaint: Pain over abdomen especially on LIF, pain: intermittent, gripping, and then sudden severe on LIF and radiate to back • Aggreviate by lying and relieve by lateral position • No history of relivant pain before • Mass over LIF but not notice until pain
• Vaginal White Discharge: 5 days before pain • No post coital pain • LMP: • EDD: • MBD: • Age of menache: ___ year, no history of amenorrhoea, or dysmenorrhoea • No history of AN care, and ATT
• No fever, no fating attack, no labour pain • No bowel and urinary symptoms: no frequency,urgency, dysuria, UTI • No associate with BPV • No loss PV • History of constipation off and on(+)
• Before 2nd pregnancy, OC pill x 5 year , and stopped x 1 year with regular menstruation • POH: – P1- year, NVD at home, alive, birth weight about 1 kg, no complication 1st,2nd,3rd stage complication – G2- unexpected but wanted
Investigation • Blood for CP • USG scan: twisted tumour over LIF and EGA 14 weeks gestation(viable single fetus)
• Mass: urgently surgeried, no complication after surgery such as rupture scar, haemorrhage, or infevtion • To differentiate other differential: – Loss of appitide(+) but no significant weight loss – No infection, or PID disorder: UTI – No history of miscarriage, no vaginal ulcer, no vaginal bleeding – No foul smelling discharged • Provisional Dx: year, G2, P1+0, twisted ovarian cyst with viable 14 weeks pregnancy
Examination Example • Well alert, and good cooperation, no dysponea, no anaemia and jaundice • Abdomen: soft, uterus 14 weeks size, mass(10x8cm) in Lt lower abdomen, mobile, firm, no tender • No FF, No RT • Bowel sound (+) • No loss PV
• VE: – Cervix- firm, close. – Uterus- 14 weeks size, cleft between mass and uterus(+) – Lower pole of mass: felt in Rt cul, tender Lt cul, POD- clear – No loss PV • Provisional Dx: year, G2, P1+0, twisted ovarian cyst with viable 14 weeks pregnancy
Clinical Feature(Acute) • Abdominal and pelvic pain • Deep dyspareunia • Chronic vaginal and cervical white discharge • Heavy and intermenstrual bleeding per vagina • Urinary symptoms-frequency,urgency,dysuria • Constitutional symptom- fever,malaise,nausea,vomitting,constipation
• General: Pyrexia • Abdominal examination: – Distension of lower abdomen – Tenderness, rebound tenderness – Rigidity, guarding • VE: – Mucopurulent discharge through cervix – Cervical motion tenderness – Uterine tenderness – Adnexal tenderness – Unilateral or bilateral adnexal swelling
Complication – Cervicitis – Endometritis – Salpinitis – Salpingo-oophritis – Pelvic peritonitis – Peritubal and peri-ovarian adhesion – Inflammatory tubo-ovarian mass with omental adhesion – Tubo-ovarian abscess
Differential Diagnosis • Ectopic pregnancy • Endometriosis • Ovarian accident – Torsion – Rupture • Appendicitis • Ovulation pain(bleeding corpus luteum) • UTI - Pyelitis, cystitis • Other cause of acute abdomen - inflammatory bowel disease, bowel torsion • Psychosomatic pain
Rule out pregnancy! REPRODUCTIVE AGE GROUP
Pain related to menstrual cycle • Pain related to menstrual cycle • Primary dysmenorrhoea • Endometriosis • Pelvic inflammatory disease • Mittleschmerz • Unrelated to menstruation • Pelvic inflammatory disease • Endometriosis • Fibroids • Cysts
• Peritoneal Lesions and an Ovarian Endometrioma Due to Endometriosis
Symptoms • Cramping pain – may be localized or radiate• Can be continuous• Dysmenorrhoea – usually secondary• Dyspareunia• Abnormal menstruation• Infertility• Others – bowel, urinary, systemic
• Pathophysiology of Pain and Infertility Associated with Endometriosis
• Radiographic Images of Endometriomas
• Major Guidelines from Professional Societies for the Diagnosis and Management of Endometriosis-Related Pain and Infertility
• Medical and Surgical Therapies for Endometriosis-Related Pelvic Pain
Definition • Ectopic endometrial tissue within the myometrium • Older age group than endometriosis patients • Associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium
Symptoms • Similar to endometriosis and other pelvic pathology – Pain more likely to be suprapubic – More likely to have abnormal bleeding • Usually older patient • Less likely to be infertile • May have secondary infertility • Previous pregnancies or procedures to uterus • Mimic fibroids – frequently coexist
• Adenoma & fibroids
• Adenomyosis vs endometriosis
• Laparoscopically Resected Uterine Adenomatoid Tumor with CoexistingEndometriosis: Case ReportNobuyuki Sakurai, MD, PhD, Yasuhiro Yamamoto, MD, Yasuyuki Asakawa, MD, PhD, Hideki Taoka, MD, Kei Takahashi, MD, PhDand Kaneyuki Kubushiro, MD, PhDJournal of Minimally Invasive GynecologyVolume 18, Issue 2, Pages 257-261 (March 2011)DOI: 10.1016/j.jmig.2010.11.009 Copyright © 2011 AAGL Terms and Conditions
Definition • Noncancerous growths of the uterus • Often appear during childbearing years • Also called fibromyomas, leiomyomas or myomas • Mostly discovered incidentally
Symptoms • Heavy menstrual bleeding – Usually cyclical – Prolonged menstrual periods – seven days or more of menstrual bleeding – More likely to be associated with anaemia • Pelvic pressure or pain • Frequent urination • Constipation• Backache or leg pains
• Multiple fibroids
Pain • Rarely, a fibroid can cause acute pain – when it outgrows its blood supply • Deprived of nutrients, the fibroid degenerates • Causing pain and fever • Pedunculated fibroids can trigger pain by twisting on its stalk and cutting off its blood supply
• Pelvic inflammatory disease/pelvic infectionPID
Definition • Pelvic inflammatory disease (PID) - infection of the female reproductive organs• Occurs when sexually transmitted bacteria spread from the vagina to the uterus and upper genital tract • Important to avoid because it can result in infertility or ectopic pregnancy • Prompt treatment of a sexually transmitted disease can help prevent PID.
Causes • Unsafe sexual practices • IUDs may increase risk of PID • Barrier method, such as a condom, reduces the risk • Bacteria may also enter the reproductive tract as a result of an IUD insertion, childbirth, miscarriage, abortion or endometrial biopsy • Most common – Chlamydia – Gut organisms – Fungal
• Liver adhesions
• Uterine adhesions
Complications • EP • Infertility • Chronic pelvic pain
Symptoms • Pain in the lower abdomen and pelvis • Heavy vaginal discharge with an unpleasant odor • Irregular menstrual bleeding • Dyspareunia • Low back pain • Fever, fatigue, diarrhea or vomiting• Painful or difficult urination
• Differential Diagnosis for Chronic Pelvic Pain – Gynecologic • Endometriosis • Adhesions – Endometriosis – PID • Adenomyosis • Leiomyomata – Gastrointestinal • Irritable bowel • Inflammatory bowel disease • Chronic appendicitis •Diverticulosis •Meckel’s diverticulum
HOCI • Rule out pregnancy • Gynecologic history – onset, duration, location, and character of pain – gravity, parity, menstrual history, history of STI – Severity of pain & its relationship to the menstrual cycle • Important associated symptoms – include vaginal bleeding – vaginal discharge – symptoms of hemodynamic instability (eg, dizziness, light- headedness, syncope or near- syncope)
Types of pain • Visceral pain • Referred Pain • Somatic Pain • Myalgia • Hyperalgesia • Neuroinflammation
System review • Seek symptoms suggesting possible causes – morning sickness, breast swelling or tenderness, or missed menses (pregnancy) – fever and chills (infection) – abdominal pain, nausea, vomiting, or change in stool habits (GI disorders) – urinary frequency, urgency, or dysuria (urinary disorders)
Past history • Note history of – Infertility – ectopic pregnancy – pelvic inflammatory disease – Urolithiasis – Diverticulitis/GI prolems • Any previous abdominal or pelvic surgery should be noted
Physical examination • Begins with review of vital signs for signs of instability – eg, fever, hypotension • Focus on abdominal and pelvic examinations • Begin with inspection
• Thrombosis of the Inferior Vena Cava and Dilated Veins of the Trunk
Abdominal examination • Palpation for – Tenderness – Masses – peritoneal signs • Location of pain and any associated findings may provide clues to the cause • Rectal examination is done to check for tenderness, mass, and occult blood.
Pelvic examination • Inspection of external genitals, speculum examination, and bimanual examination • Cervix - inspected for discharge, uterine prolapse, and cervical stenosis or lesions • Bimanual examination - assess cervical motion tenderness, adnexal masses or tenderness, and uterine enlargement or tenderness
Investigations • Pregnancy tests • Urinalysis • Ultrasonography • Blood tests
• Ultrasound hydosalpinx
• Lap endometriosis
• KEY POINTS
Key points 1. Pelvic pain is common and may have a gynecologic or nongynecologic cause. 2. Pregnancy should be ruled out in women of childbearing age. 3. Quality, severity, and location of pain and its relationship to the menstrual cycle can suggest the most likely causes. 4. Dysmenorrhea is a common cause of pelvic pain but is a diagnosis of exclusion
• References • The Merck Manual – Pelvic Pain • Mayo Clinic - mayoclinic.com/health/chronic- pelvic- pain/DS0
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