Pelvic Pain

Mireille BoivinAlissa Chehade

MD2017September 3, 2015

Disclaimer!

We are Francophones! We try our best to pronounce words correctly, but we apologize in advance if we don’t.

Before we start

A great big thanks to UpToDate for the info!! (Just discovered them this year… they’re pretty awesome!)

Scenario

A 34 yo G2P2 woman comes to the ER with 8 hours of increasing right lower quadrant pain, inability to tolerate oral intake, and nausea. She is sexually active and uses Depo-Provera for contraception. She was treated for gonorrhea and reports compliance with treatment. Her temperature is 38.5°C, pulse is 114 bpm, respirations 22/min and BP is 110/70. On examination, her abdomen is soft with right lower quadrant tenderness. Voluntary guarding is present without rebound. Pelvic examination shows no cervical motion tenderness or uterine tenderness. The right adnexa is exquisitely tender and fullness is appreciated. Her WBC count is 17 and there are 15% bands. Urine ßHCG is negative.

What’s important?

A 34 yo G2P2 woman comes to the ER with 8 hours of increasing right lower quadrant pain, inability to tolerate oral intake, and nausea. She is sexually active and uses Depo-Provera for contraception. She was treated for gonorrhea and reports compliance with treatment. Her temperature is 38.5°C, pulse is 114 bpm, respirations 22/min and BP is 110/70. On examination, her abdomen is soft with right lower quadrant tenderness. Voluntary guarding is present without rebound. Pelvic examination shows no cervical motion tenderness or uterine tenderness. The right adnexa is exquisitely tender and fullness is appreciated. Her WBC count is 17 and there are 15% bands. Urine ßHCG is negative.

Pelvic Pain

2 types!Someone want to guess?

Gynecologic vs Non Gynecologic(and technically there’s obstetric too…)

Non gynecologic

The common ones:• Appendicitis• Acute cystitis• Diverticulitis• Urinary tract calculi• Abdominal wall trauma

Gynegologic

The common ones, -ve ßhCG:• PID and tuboovarian abscess• Hemorrhage, rupture, or torsion of an ovarian

neoplasm• Torsion or degeneration (slow death) of a uterine

leiomyoma• Endometritis• Dysmenorrhea• Ovarian hyperstimulation syndrome (women

undergoing gonadotropin treatment)

Gynecologic cont’d

The common ones, +ve ßhCG• Ectopic pregnancy (or heterotopic pregnancy)• Miscarriage• Early pregnancy (may be accompanied by

nausea and vomitting)

[Gynecologic/]Obstretic

• Labour• Uterine rupture• Abruptio placenta• Endometritis• Ovarian vein thrombosis• Diastasis of the pubic symphysis

Gynecological/Obstetrical Cont’d

• The other ones:– Pregnancy complications– Abortion– Neoplasm– Ovarian cyst– Salpingitis– Torsion of adnexa– Rupture of ovarian cyst– Endometriosis

We’re in the ER, what do we do???

Run away because we’re scared and we’ve decided we don’t like third year…

No, actually, what do we do?

• Vitals!• Is she in shock? Because if she is, we better

deal with her right away!• Does she have peritoneal signs? We gotta

deal right away with her too!• She probably needs a surgical intervention…

What do we do? Cont’d

• If she seems pretty stable, we can move on to the history.

• What do we ask?

What do we ask?

• Tell me about the pain! (Ok, technically not a question, but still pretty useful)– Location– Onset and duration– Character– History of pain/similar pain?

• Review of systems to see if there are associated symptoms can be useful in narrowing our diagnosis

What do we ask? Cont’d

• Gynecologic/obstetrical history can help point toward a gynecologic/obstetrical etiology– Includes LMP, menstrual pattern, contraception, sexual

history, STIs, Pap test results, GTPAL• Past medical history and past surgical history are

useful as well.• Don’t forget social history! (include substance abuse,

history of domestic violence, high risk behaviour)• Family history can be useful as well (ex. coagulation

disorders or sickle cell disease)

Now that we’ve bombarded her with questions, what do we do?

We were told to try to do a physical but instead we run and get the resident because girls have cooties and we don’t want to get cooties.

What do we actually do?

• [Vital signs]• General apperance-does she look like she has a lot

of pain?• General exam but more focused on abdominal and

pelvic exams– Pelvic includes inspection, speculum exam, tests for

Gono/Chlam and vaginal discharge if present, bimanual exam to feel uterus, adnexae, possible masses, rectovaginal exam to evaluate posterior cul-de-sac (pouch of Douglas), rectovaginal septum and rectal tone

Next steps

We were told to do lab tests but we can’t navigate that paper with all the abbreviations so we get our staff.

Real next steps• For woman of reproductive age, what can we

absolutely not forget?– ßhCG

• The other lab tests should be decided with regards to our diagnosis– Useful ones can include:• CBC with differential (high WBC can be infection or

inflammation/necrosis from adnexal torsion or degenerating leiomyoma)• Urinalysis, +/- culture (if urinalysis shows hematuria or

pyuria)• Nucleic acid amplification (Gono/Chlam)

Imaging?

YES!! Dark room, no patients, no cooties… that’s my type of thing!

Imaging

• U/S!!– It’s pretty good at letting us see things without

really endangering anyone… especially if it turns out she’s pregnant

– It’s also useful if she needs surgery, it can help guide the surgeon

• CT and MRI may be used if needed (obviously, MRI is preferred if she’s pregnant)

X-Ray

• Pretty rare, not very useful

Laparoscopy

• If we really need to, i.e. if diagnosis is still unclear

• If the diagnosis includes something life-threatening or organ-threatening on which we need to act ASAP

Reminder of scenario

A 34 yo G2P2 woman comes to the ER with 8 hours of increasing right lower quadrant pain, inability to tolerate oral intake, and nausea. She is sexually active and uses Depo-Provera for contraception. She was treated for gonorrhea and reports compliance with treatment. Her temperature is 38.5°C, pulse is 114 bpm, respirations 22/min and BP is 110/70. On examination, her abdomen is soft with right lower quadrant tenderness. Voluntary guarding is present without rebound. Pelvic examination shows no cervical motion tenderness or uterine tenderness. The right adnexa is exquisitely tender and fullness is appreciated. Her WBC count is 17 and there are 15% bands. Urine ßHCG is negative.

What do we think this girl has?

Without knowing the answer to all our history-taking questions…It’s looking like PID…

What is PID?

• Acute infection of the upper genital tract structures, involving any or all of the uterus, fallopian tubes, and ovaries. May involve neighboring pelvic organs.

• Accounts for 20% of all gynecology-related hospital admissions.

What is the most common cause of PID?

a. Chlamydia trachomatisb. N. gonorrheaec. Endogenous florad. TB

Etiology

• Chlamydia trachomatis: most common sexually transmitted organism associated with PID.

• N. gonorrheae– Gonorrhea and chlamydia often co-exist

• Vaginal flora including anaerobic organisms, enteric gram-negative rods, streptococci, genital mycoplasms, and Gardnerella vaginalis.

• Actinomycetes may be isolated in patients with IUD.

Risk factors

• Age <30 yr

• Risk factors as for chlamydia and gonorrhea

• Vaginal douching

• IUD (within first 10 d after insertion)

• Invasive gynecologic procedures (D&C,

endometrial biopsy)

Clinical Presentation

• Up to 2/3 asymptomatic: many subtle or mild symptoms

Common Less common

- Fever > 38.3C- Lower abdominal pain and tenderness- Abnormal discharge: cervical or vaginal

- Nausea and vomiting- Dysuria- AUB

Clinical Presentation

• Chronic disease (often due to chlamydia)– Constant pelvic pain– Dyspareunia– Palpable mass – Very difficult to treat, may require surgery

Physical examination

Clinical diagnosis can be made in women who are sexually active or at risk for STIs if : – Pelvic or lower abdominal pain

And one of the following: – Cervical motion tenderness– Uterine tenderness– Adnexal tenderness

Investigations

• Bloodwork: β-hCG (must rule out ectopic pregnancy), CBC, blood cultures if suspect septicemia

• Urinalysis• Speculum and bimanual exam• Ultrasound (for pelvic or tubovarian abcess,

hydrosalpinx)• Laparoscopy (gold standard, for definitive

diagnosis)

When do we start the antibiotics?

a. As soon as we suspect PID (clinical diagnosis)b. After we’ve had the results of the ultrasound

showing a pelvic abscessc. After having the definitive diagnosis with

laparoscopy d. When diagnosis is confirmed with a biopsy

showing endometritis

Management

• Must treat with polymicrobial coverage • Goals are to relieve acute symptoms,

eradicate current infection and minimize the risk of long term complications

Management

• Mostly managed as outpatient unless: – Lack of response or tolerance to oral medications– Pelvic abscess on ultrasound– Pregnancy– Severe illness (high fever, N/V, severe pain)– Possible need for surgical intervention or

diagnostic exploration for alternative etiology

Antibiotherapy

Inpatient: – IV cefoxitin (2 grams every 6 hours) plus PO

doxycycline (100 mg twice daily for 14 days)– Intravenous therapy continued for a minimum of

48 hours.

Outpatient: – Single IM dose of cefoxitin (2 grams) plus a single

dose of oral probenecid (1 gram) plus oral doxycycline (100 mg twice daily for 14 days)

Surgical management

• Percutaneous drainage of abscess under U/S guidance

• When no response to treatment, laparoscopic drainage

• If failure, treatment is surgical (salpingectomy, total abdominal hysterectomy/bilateral salpingo-oophorectomy)

Which of the following is a long-term sequelae of PID?

a. Infertilityb. Ectopic pregnancy c. Chronic pelvic paind. All of the above

Source

UPTODATE. “Evaluation of acute pelvic pain in women”, UpToDate, 2013, ref 1 September 2015,http://www.uptodate.com/contents/evaluation-of-acute-pelvic-pain-in-women?source=search_result&search=pelvic+pain&selectedTitle=1%7E150Clinical features and diagnosis of pelvic inflammatory disease, UpToDate, Oct 7, 2014 http://www.uptodate.com/contents/clinical-features-and-diagnosis-of-pelvic-inflammatory-disease?source=search_result&search=pelvic+inflammatory+disease&selectedTitle=2~150Pelvic inflammatory disease: Treatment, UpToDate, Aug 6, 2015 http://www.uptodate.com/contents/pelvic-inflammatory-disease-treatment?source=search_result&search=pelvic+inflammatory+disease&selectedTitle=1~150