HIGH-YIELD FACTS IN - Pelvic Pain ppsx

173

CHRONIC PELVIC PAIN

Definition and Criteria

≥ 6 months of pain

Incomplete relief by medical measures

Altered activities due to pain (e.g., missed work, homebound, depres￾sion, sexual dysfunction)

Etiologies

Leiomyoma

Endometriosis

Adhesions, adenomyosis

Pelvic inflammatory disease (PID)

Infections other than PID

Neoplasia

Workup

1. Detailed history (focusing on above etiologies):

Temporal pattern

Radiation

Associated symptoms

Past surgeries

Last menstrual period (LMP)

2. Physical exam:

Look for:

Masses

Cervical motion tenderness

Gastrointestinal (GI) complaints

Neurological testing

3. Relation of pain to basal body temperature elevation (to rule out mit￾telschmerz pain associated with ovulation)

4. Blood work:

Complete blood count (CBC)

Pregnancy test

HIGH-YIELD FACTS IN

Pelvic Pain

Pelvic pain accounts for

12% of hysterectomies,

40% of diagnostic

laparoscopies, and 40% of

2° and 3° office visits.

Chronic pelvic pain:

Think of “leapin’ ” pain.

Leiomyoma

Endometriosis

Adhesions, adenomyosis

Pelvic inflammatory

disease (PID)

Infections other than PID

Neoplasia

PID is the most common

cause of chronic pelvic pain.

STS (serotest for syphilis)

Urinalysis (UA)

Occult blood

Blood culture

5. Radiographic studies:

Abdominal and vaginal sonogram

Computed tomography (CT)

Magnetic resonance imaging (MRI)

Barium enema

Bone scan

Renal sonogram/intravenous pyelogram (IVP)

6. Colonoscopy and/or cystoscopy (should be perfomed if all above are

inconclusive)

7. Rule out psychosomatic pain.

8. Diagnostic laparoscopy

ACUTE PELVIC PAIN

Differential of Acute Pelvic Pain

Appendicitis

Ruptured ovarian cyst (most common)

Ovarian torsion/abscess

PID

Ectopic pregnancy

(spells “A rope”)

See Table 17-1.

Etiologies

Same etiologies as above plus the following:

GYN—all require surgery:

Ruptured ovarian cyst (life threatening)

Adnexal torsion

Tubo-ovarian abscess (life threatening)

OB:

Ectopic pregnany (life threatening)—requires surgery

Abortion (spontaneous, threatened, incomplete)

GI/GU:

Diverticulitis

Appendicitis (life threatening)—requires surgery

Urinary tract infection (UTI)

Inflammatory bowel disease (IBD), irritable bowel syndrome (IBS)

Workup

1. History

2. Physical exam (cervical motion tenderness, adnexal tenderness, and

abdominal tenderness are all signs of PID)

3. Labs:

Pregnancy test (positive might indicate ectopic pregnancy or abor￾tion)

174

HIGH-YIELD FACTS Pelvic Pain

Mittelschmerz is pelvic pain

associated with ovulation.

Laparoscopy is the final,

conclusive step in

diagnosing pelvic pain, but

it should only be done once

psychogenic causes are

considered carefully.

You always want to

immediately rule out life￾threatening and emergent

conditions:

Appendicitis

Ectopic pregnancy

Ovarian abscess

Ruptured ovarian cyst

Differential of acute pelvic

pain:

“A ROPE”

Appendicitis

Ruptured ovarian cyst

Ovarian torsion/abscess

PID

Ectopic pregnancy

Pain severe for the patient

to seek emergent medical

attention must be quickly

worked up because of the

various life-threatening

etiologies.

CBC (PID or appendicitis might give elevated WBCs)

UA (leukocytes indicate possible UTI)

4. Pelvic sonogram (will show cysts and possibly torsion)

5. Diagnostic laparoscopy

175

HIGH-YIELD FACTS Pelvic Pain

TABLE 17-1. Differential Diagnosis of Acute GYN Pelvic Pain

Clinical and Laboratory Findings

Pregnancy Nausea and

Disease CBC UA Test Culdocentesis Fever Vomiting

Ruptured Hematocrit Red blood Positive. High No Unusual

ectopic low after cells rare Beta-hCG hematocrit

pregnancy treatment of low for Defibrinated,

hypovolemia gestational nonclotting

age sample with

no platelets

Crenated red

blood cells

Salpingitis/PID Rising white White blood Generally Yellow, turbid Progressively Gradual

blood cell cells negative fluid with worsening; onset with

count occasionally many white spiking ileus

present blood cells

and some

bacteria

Hemorrhagic Hematocrit Normal Usually Hematocrit No Rare

ovarian cyst may be low negative generally

after < 10%

treatment

of

hypovolemia

Torsion of Normal Normal Generally Minimal clear No Rare

adnexa negative fluid if

obtained

early

Degenerating Normal or Normal Generally Normal clear Possibly Rare

leiomyoma elevated negative fluid

white blood

cell count

Reproduced, with permission, from Pearlman MD, Tintinalli JE, eds. Emergency Care of the Woman. New York: McGraw-Hill,

1998: 508.

Ruptured cyst is the most

common cause of acute

pelvic pain.

176

HIGH-YIELD FACTS Pelvic Pain

NOTES