Pelvic Pain

Background

  • Can be acute or chronic (>6 months)
  • Often associated with dyspareunia which can be superficial or deep
  • Most women will experience mild pelvic pain at some point in their lives e.g. period pain (most common); fibroids etc
  • When evaluating pelvic pain, bear in mind relation to abdominal structures and evaluation of abdominal pain

History

  • Evaluate the pain in all patients
    • Site, Onset, Character, Radiation, Associated symptoms, Timing (Acute vs Chronic), Exacerbating/Relieving factors, Severity (SOCRATES)
      • Is the pain unilateral or bilateral? (Bilateral suggests inflammatory disease)
        • Left sided pelvic pain (Diverticulitis, kidney stone, ruptured ovarian cyst)
        • Pain from the umbilicus to the lower right quadrant (Appendicitis)
        • Right sided pelvic pain (Appendicitis, kidney stone, ovarian torsion, ruptures ovarian cyst)
        • Radiation to groin (Kidney stone, ovarian torsion)
      • Does the pain come on at any particular time?
        • Midcycle pain (period pain- Mittelschmerz)
      • In Acute pain it is particularly important to ask about associated symptoms such as:
        • Dysmenorrhoea (Endometriosis, Fibroids)
        • Dyspareunia (PID, Endometriosis, ovarian cyst)
        • Dysuria (PID, UTI)
        • Haematuria (Kidney stones, UTI)
        • Nausea/vomiting (Appendicitis, ovarian torsion)
        • Urinary frequency (UTI)
        • Irregular bleeding (Ectopic pregnancy, fibroid)
        • Vaginal Discharge (PID)
    • In Chronic pain it can be more important to determine whether there is organic disease or whether this is functional pain (If yes to the following, this is more likely to be organic)
      • Is the pain consistently localised?
      • Is the pain cyclical? (Endometriosis)
      • Does the pain awaken you from sleep?
      • Is the pain brought on by any triggers? In particular, eating or defaecation, movement or position. Is there any dyspareunia?
      • Have you lost any weight?
      • Any irregular bleeding/post-menopausal bleeding?
  • It is important to ask about bowel symptoms (change in habit, any PR bleeding); also ask about psychiatric symptoms e.g. mood (chronic pain is often associated with depression)
  • Take a full gynaecological and obstetric history (including contraception)
  • Take a full sexual history, PMHx and RHx, FHx, SHx etc

Examination

  • Look for any vital signs of infection/ovarian cyst rupture/torsion e.g. temperature, tachycardia, hypotension
  • Perform an abdominal examination (including PR if appropriate)
    • Look for any masses/tender areas
      • If there is a tender area, press on it gently (warn the patient first) and ask the patient to raise their legs off the bed.  If pain worsens, this is more likely to be a superficial/myofascial pain rather than visceral.
  • Perform a gynaecological examination
    • Look for any abnormal appearances of the external genitalia, vaginal wall and cervix (including discharge/blood) and check if they are painful/tender
    • You may want to take an endocervical swab +/- smear at this point
    • Look for perhaps a fixed retrovert uterus (PID and adhesions); any adnexal masses (may be difficult to palpate), cervical excitation.

Investigations

  • Blood tests
    • FBC, CRP (Infection)
    • β-HCG (Pregnancy, ectopic)
    • If there is a clinical suspicion of cancer, CA125 should be checked
  • Endocervical swab for chlamydia/gonorrhoea
  • Urinalysis and MSSU
  • USS scan can be used to evaluate masses and the uterus, as well as possible appendicitis
    • Other imaging e.g. MRI may be useful after
  • Endometrial biopsy may or may not be indicated (usually if there is associated irregular bleeding)
  • Diagnostic Laparoscopy is the gold standard but is last resort

Causes

  • Acute
    • Pregnancy-related
      • Miscarriage
      • Ectopic pregnancy
      • Rupture of corpus luteum cyst
      • Premature labour
      • Placental abruption
      • Uterine rupture
    • Gynaecological
      • Ovulatory pain
      • Dysmenorrhoea
      • Endometriosis
      • Pelvic inflammatory disease
      • Rupture/torsion of an ovarian cyst
      • Ovarian torsion
      • Tubo-ovarian abscess
      • Degenerative fibroids
      • Endometritis
      • Pelvic tumours/Gynaecological malignancy
      • Pelvic vein thrombosis/Pelvic congestion syndrome
      • In young (adolescent) women with primary amenorrhoea and pelvic pain, consider imperforate hymen/transverse vaginal septum
    • Other systems
      • UTI, bladder malignancy, kidney stones
      • Appendicitis
      • Irritable bowel syndrome, Coeliac, colon cancer, IBD
      • Adhesions
      • Strangulated hernias
      • Functional pain

pelk

oiu

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: