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PELVIC PAIN (ACUTE PELVIC PAIN (most important gynae conditions are…
PELVIC PAIN
ACUTE PELVIC PAIN
most important gynae conditions are ectopic preg, miscarriage, PID and torsion or rupture of ovarian cysts
if urine preg test neg - a high vaginal swab, endocervical swab and FBC should be performed for evidence of infection
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if diagnosis unclear and pain not resolving, diagnostic laparoscopy may be warranted
an innocent cause of pain is exp mid cycle with ovulation, the so called mittelschmerz - pain is usually sudden in onset, can be quite severe and if persistent in each cycle = will respond to ovulation suppression with COC
ddx for CPP
skeletal - degenerative joint disease, scoliosis, spondylolisthesis, osteitis pubis
myofascial - fascitis, nerve entrapment syndrome, hernia
urinary tract - UTI, calculus, interstitial cystitis
psych - somatization, psychosexual dysfunction, depression
GI - adhesions, appendicitis, constipation, diverticular disease, IBS
neuropathic - pudendal nerve entrapment, spinal cord neuropathies
Gynae - endometriosis, adhesions (chronic pelvic infection), adenomyosis, leiomyoma, pelvic congestion syndrome, ovarian cysts
CHRONIC PELVIC PAIN
intermittent or constant pain in lower abdo or pelvis of at least 6mths duration, not occurring exclusively with menstruation or intercourse and not associated with preg
an association with dysmenorrhoea, dyspareunia, irregular menstruation, abnormal vaginal discharge, an underlying gynaecological problem
altered bowel habit, excess flatulence or flatus, constipation or diarrhoea point to GI problem, particularly IBS
PREDISPOSITIONS: phys and sexual abuse, pelvic pathology - endometriosis, adhesions and pelvic varices
40% of women with CPP dont have identifiable biological cause, despite extensive ix - often involves a diagnostic laparoscopy
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diagnostic laparoscopy - additional tests depend on symptoms (cystoscopy, bladder biopsy, dye test, hysteroscopy)
adhesions (dense, vascular) likely to cause pain
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other pathology eg PID, ovarian cysts
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bimanual exam may reveal uterine or adnexal enlargement = suggest pelvic mass, fibroids or an ovarian cyst
cervical excitation - pain associated with digital displacement of the cervix - is associated with ectopic preg and pelvic infection
tenderness or pain elicited by bimanual palpation of the pelvic organs = suggest inflam = infective eg chlamydia or noninfective eg endometriosis
a fixed immobile uterus suggests multiple adhesions and nodularity within the uterosacral ligaments (sometimes palpable only by combined rectovaginal exam) can be a feature of endometriosis
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OTHER CAUSES
If ix are neg and remains sig diag doubt about whether a pain is gynae or not = consider 3mth trial of ovarian suppression with a GnRH analogue - if symptoms reduce = true gynae cause - possibility of adenomyosis - hysterectomy = long term improvement
most commonly ACUTE - due to appendicitis, misscarriage, ectopic
important to take detailed mens hx - freq, character of vag bleed
take sexual hx - sup or deep dyspareunia, contraception, STI
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chronic pelvic infection assoc with high incidence of tubal damage and consequently an increased incidence of ectopic pregnancy, infertility or CPP
may be due to relapse of infection because of inadequate treatment, reinfection from untreated partner, post-infection tubal damage or further acquisition of STIs
OVARIAN CYSTS -majority benign - particularly those of acute pain
pain - torsio, cyst rupture or bleeding occurring into a cyst
torsion needs surgical removal