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Pelvic Pain

Pelvic Pain. Nirosha B alasingam Angel Fu September 4, 2014. Objectives. 1. Categorize causes of pelvic pain according to gynecological and non-gynecological origin (4235)

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Pelvic Pain

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  1. Pelvic Pain Nirosha Balasingam Angel Fu September 4, 2014

  2. Objectives • 1. Categorize causes of pelvic pain according to gynecological and non-gynecological origin (4235) • 2. Describe the following regarding pelvic inflammatory disease (PID): etiology, risk factors, signs and symptoms, findings on physical examination, investigations and management (10658)

  3. Case • A 35 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. • Vitals: temp 38.5 C, pulse 114 bpm, resp rate 22/min, BP 110/70 • O/E: Soft abdomen with right lower quadrant tenderness. Voluntary guarding is present but no rebound. Pelvic exam shows no cervical motion tenderness or uterine tenderness. Right adnexa is exquisitely tender and fullness is appreciated. • Investigation: WBC 17 x 109 (15% bands) Urine β-hCG negative. http://www.actionphysicaltherapy.com/

  4. Ddx Pelvic Pain

  5. Acute Pelvic Pain - Gynecological • Infectious • Acute PID • Endometritis • Uterine • Fibroid degeneration • Torsion of fibroid • Adnexal • Ruptured ovarian cyst • Ectopic pregnancy • Ovarian/tubal torsion • Pregnancy related • Threatened abortion • Labour • Placental Abruption

  6. Acute Pelvic Pain – Non-Gyne • GI • Appendicitis • Diverticulitis • IBD • Bowel obstruction • GU • UTI (cystitis/pyelonephritis) • Renal colic • MSK • Trauma • Hernia

  7. Chronic Pelvic Pain - Gynecological • Chronic PID • Endometriosis • Adenomyosis • Adhesions • Dysmenorrhea • Ovarian cyst • Pelvic congestion syndrome • Neoplasia

  8. Chronic Pelvic Pain – Non-Gyne • MSK • Pelvic floor myalgia • Myofascial pain • Hernia • Fibromyalgia • Neurologic Disorders • Neuralgia • Neoplasia • Psychiatric • Sexual/physical/psychological abuse • Depression • Anxiety • Somatization • GU • Intersititial cystitis/ painful bladder syndrome • Recurrent UTI • GI • IBS • IBD • Constipation • Partial bowel obstruction • Diverticulitis • Neoplasm

  9. Pelvic Inflammatory Disease

  10. Epidemiology • Definition: acute inflammation of upper genital tract which includes endometrium, fallopian tubes, ovaries, pelvic peritoneum and any nearby structures • In Canada, approximately 100,000 cases of symptomatic PID/year • 10-15% of women of reproductive age have had one episode of PID • Accounts for up to 20% of all gynecology-related hospital admissions

  11. Etiology • Can be caused by various organisms • Chlamydia trachomatis (1/3 of PID cases) • Neisseria gonorrheae(1/3 of PID cases) • Endogenous flora • Can be aerobic, anaerobic or both • E. coli, Staph, Strep, Enterococcus, Bacteroides, Peptostreptococcus, H. influenzae, G. vaginalis • Actinomycesisraelii • Gram-positive, non acid-fast anaerobe • Causative organism in 1-4% of IUD related PID • Others • TB • CMV

  12. Risk Factors • Age <30 years • Risk factors as for chlamydia and gonorrhea • History of previous STI • Contact with infected person • Sexually active individual <25 years • Multiple partners • New partner in the last 3 months • Lack of barrier protection use • Street involvement (homelessness, drug use) • Vaginal douching • IUD (within the first 10 days after insertion) • Invasive gynecologic procedures (D&C, endometrial biopsy)

  13. Signs, Symptoms and Physical Findings • Up to 2/3 asymptomatic: many subtle or mild symptoms • Common: • Fever >38.3oC • Lower abdominal pain and tenderness - most common symptom (>90% of patients with acute PID, usually constant and aggravated by motion) • Abnormal discharge: cervical or vaginal • uncommon • Nausea and vomiting (usually late symptoms) • Dysuria • Abnormal uterine bleeding (AUB) • Chronic disease (often due to chlamydia) • Constant pelvic pain • Dyspareunia • Palpable mass • Very difficult to treat, may require surgery

  14. PID Diagnosis PID should generally be diagnosed clinically based on symptoms and physical exam • Must have: • Lower abdominal pain • Plus one of: • Cervical motion tenderness • Adnexal tenderness • Plus one or more of: • High risk partner • Temperature > 38oC • Mucopurulent cervical discharge • Positive culture for N. gonorrheae, C. trachomatis, E. coli, or other vaginal flora • Cul-de-sac fluid, pelvic abscess or inflammatory mass on U/S or bimanual • Leukocytosis • Elevated ESR or CRP (not commonly used)

  15. Investigations • Ultrasound • May be normal • Free fluid in cul-de-sac • Pelvic or tubo-ovarian abscess • Hydrosalpinx (dilated fallopian tube) • Laparoscopy (gold standard) • For definitive diagnosis: may miss subtle inflammation or tubes or endometritis • Blood work • β-hCG (must rule out ectopic pregnancy) • CBC • blood cultures if suspect septicemia • Urinalysis • Speculum exam, bimanual exam • Vaginal swab for Gram stain, C&S • Cervical cultures for N. gonorrheae, C. trachomatis • Endometrial biopsy will give definitive diagnosis (rarely done)

  16. Laparascopy

  17. Case Revisited • A 35 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. • Vitals: temp 38.5 C, pulse 114 bpm, resp rate 22/min, BP 110/70 • O/E: Soft abdomen with right lower quadrant tenderness. Voluntary guarding is present but no rebound. Pelvic exam shows no cervical motion tenderness or uterine tenderness. Right adnexa is exquisitely tender and fullness is appreciated. • Investigation: WBC 17 x 109 (15% bands). Urine β-hCG negative.

  18. Treatment/Management - Inpatient • Must treat with polymicrobial coverage • Inpatient if: • Moderate to severe illness or atypical infection • Adnexal mass, tubo-ovarian or pelvic abscess • Unable to tolerate oral antibiotics or failed oral therapy • Immunocompromised • Pregnant • Adolescent – first episode • Surgical emergency cannot be excluded (e.g. ovarian torsion) • PID is secondary to instrumentation

  19. Treatment/Management - Inpatient • Recommended treatment: • Cefoxitin 2g IV q6h or cefotetan 2g IV q12h + doxycycline 100mg IV/PO q12h OR • Clindamycin 900 mg IV q8h + gentamicin 2mg/kg IV loading dose then gentamicin 1.5 mg/kg q8h maintenance dose • Continue IV antibiotics for 24 h after symptoms have improved then doxycycline 100 mg PO bid to complete 14 days • Percutaneous drainage of abscess under U/S guidance • When no response to treatment, laparoscopic drainage • If failure, treatment is surgical (salpingectomy, TAH/BSO)

  20. Treatment/Management – Outpatient • Must treat with polymicrobial coverage • Outpatient if: • Typical findings or mild to moderate illness • Oral antibiotics tolerated • Compliance ensured • Follow-up within 48-72 hours (to ensure symptoms not worsening)

  21. Treatment/Management – Outpatient • Recommended treatment: • Ceftriaxone 250 mg IM x1 + doxycycline 100 mg PO bid x 14 days OR • cefoxitin2mg IM x 1 + probenecid 1g PO + doxycycline 100mg PO bid x 14 days +/- metronidazole 500mg PO BID x 14 days • Consider removing IUD after a minimum of 24 hours of treatment • Reportable disease • Treat partners • Consider re-testing for C. trachomatis and N. gonorrheae4-6 weeks after treatment if documented infection

  22. Complications of Untreated PID • Chronic pelvic pain due to chronic PID – long term pelvic pain from adhesions and hydrosalpinges • Abscess, peritonitis; e.g. ruptured tubo-ovarian abscesses – may develop following incomplete treatment of acute PID • Adhesion formation and intestinal obstruction • Ectopic pregnancy – due to intraluminal scarring and distortion of the fallopian tubes • Infertility – due to intraluminal obliteration of the fallopian tubes • 1 episode of PID  13% infertility • 2 episodes of PID  36% infertility • Disseminated infections (sepsis/bacteremia, septic arthritis, endocarditis, arthritis, meningitis) • Fitz-Hugh-Curtis syndrome = perihepatic inflammation and adhesions

  23. Summary • Pelvic pain can be classified as acute vs chronic, gynecological vs non-gynecological • Most common gynecological cause of acute pelvic pain is PID • PID is a common problem • 10-15% of reproductive age women have had at least 1 episode of PID • Accounts for 20% of gynecology-related admission • PID is most commonly caused by multiple microorganisms (polymicrobial) • Risk factors: multiple partners, history of STI, lack of barrier method, age < 30, new partner in last 3 months, street involvement, IUD use, vaginal douching, invasive gynecological procedure

  24. Summary • Signs and Symptoms: Lower abdominal pain, cervical motion tenderness, adnexal tenderness, fever, cervical/vaginal discharge, leukocytosis, etc • Investigation: CBC, β-hCG, urinalysis, speculum and bimanual exam, culture and swabs, U/S, laparoscopy (gold standard) • Treatment: Outpatient if mild-moderate disease and reliable patient. Treat with antibiotics with polymicrobial coverage. • Complications include chronic pelvic pain, infertility, abscess, adhesions, ectopic pregnancy, Fitz-Hugh-Curtis syndrome

  25. References • Toronto Notes • Obstetrics and Gynecology at a Glance • UptoDate • Pubic Health Agency of Canada

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