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

 


– 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

 


– 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
    • 1st line:
      • OCP (estrogen-progestin)
      • IM medroxyprogestrone
      • Mirena IUS
    • 2nd 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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