Pelvic Pain Approach

– History –

• CC:
  • Site: where? Unilateral\bilateral? Radiates anywhere else?
  • Onset: first time? When? Sudden\gradual? Continuous\intermittent? What were you doing?
  • Duration: how long does it last?
  • Timing: specific time of the day\night? Cyclic? How frequent?
  • Character: dull, sharp, stabbing, burning, pressure-like?
  • Aggravating\relieving factors: menses, defecation, urination, intercourse, position, painkillers?
  • Severity: 1-10 scale? Wakes you up from sleep? Interfering w\ ADL?

• Associated sx:
  • Constitutional: fever, fatigue, weight loss, chills, night sweats, appetite?
  • Gyn: vaginal discharge, painful menstruation, PMS, post-coital pain\bleed?
  • Urine: dysuria, hematuria, urinary incontinence\retention?
  • GI: N\V, diarrhea\constipation, pain with defecation, blood in stool?

• Obstetric Hx:
  • Gravida? Para? Abortions? Living?
    • If prev: mode of delivery? Fetal\maternal complications?

• Gynecological Hx:
  • Menstrual Hx: age of menarche? Regular\heavy\painful periods? Intermenstrual bleeding?
  • Contraception use, IUCD?
  • Gynecological procedures, IVF\induction of ovulation?

• PMHx:
  • Diseases:
    • Chronic ds (HTN, DM\GDM, DLP)
    • Malignancy, infections
    • Gyn (STDs, PID, fibroids, endometriosis)
  • Medications: abx, steroids, anticoagulants, folate, herbal
  • Surgery, hospitalization, trauma
  • Allergies

• FMHx:
  • Similar complaint?
  • Same diseases as in PMHx?

• Social Hx:
  • Occupation, marital status, sexual activity, children?
  • Smoking, alcohol, recreational drugs?
  • Travel Hx
  • Diet, exercise

 

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– Physical Exam –

• WIPE, blah blah, chaperone
• Vital signs: pulse, BP, temperature
• General inspection: weight, distress, pallor
• Abdominal exam: inspection, palpation, percussion, auscultation
• Vaginal exam:
  • Inspect: ulcers, scars, urethral\vaginal discharge, swellings
  • Palpate: Bartholin’s gland (5-7 O’clock of labia minora)

• Speculum exam:
  • Inspect: erosions, erythema, discharge\bleeding, polyps
  • Obtain a pap smear

• Bimanual exam:
  • Vaginal walls: tone, moisture, temperature -> “normal tone, moist, warm”
  • Cervix: character, mobility, texture, tenderness -> “firm, mobile, smooth, non-tender”
  • Uterus (by placing the other hand on the lower abdomen): size, position, mobility, tenderness -> “normal size, anteverted, mobile, non-tender”
  • Adnexa (ovaries + oviducts): enlargement, tenderness
  • Remove fingers to check of discharge or blood
  • To complete -> rectovaginal exam

 

– Differential Diagnosis –

Gynecological	Non-gynecological
–  PID –  Endometriosis –  Ectopic pregnancy –  Ovarian torsion\cyst rupture	–   Cystitis –   Appendicitis –   Diverticulitis –   IBD\IBS

 

– Investigations –

• Pregnancy test: urine\serum B-hCG
• CBC
• U\A, urine culture
• Vaginal wet mount
• NAAT (chlamydia, gonorrhea)
• Imaging: transvaginal US, CT\MRI

 

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– Endometriosis Overview –

Physical signs:

• Tender nodularity of uterosacral ligament
• Tender cul-de-sac on rectovaginal exam
• Retroverted uterus
• Firm, fixed adnexal mass (endometrioma)

 

Definitive diagnosis via laparoscopy:

• Direct visualization of typical lesions:
  • Mulberry spots (most common): brownish-black hemosiderin deposits
  • “Powder-burn” lesions on peritoneal surfaces (old hemorrhage nodules)
  • White lesions: fibromuscular scarring
  • “Chocolate cyst” of the ovaries: endometrioma
• Biopsy and histology -> 2 or more of:
  • Endometrial epithelium\glands\stroma, hemosiderin-laden macrophages

 

Treatment:

• Medical:
  • NSAIDs
  • 1^st line:
    • OCP (estrogen-progestin)
    • IM medroxyprogestrone
    • Mirena IUS
  • 2^nd line:
    • GnRH agonist (leuprolide)
      • Use for < 6 mo due to bone loss. But can be used > 12 mo w\ add-back progestin or estrogen
      • SE: hot flashes, vaginal dryness, reduced libido
    • Danazol (weak androgen)
      • SE: wt gain, fluid retention, acne, hirsutism, voice change

• Surgical:
  • Conservative (preserves fertility): laparoscopy -> adhesion lysis, ovarian cystectomy of endometrioma
    • Best time to get pregnant? Immediately after conservative surgery
  • Definitive (fertility not desired): bilateral salpino-oophorectomy ± hysterectomy

 

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