Pelvic Pain

Dysmenorrhea

Painful menses either due to the absence of other pathology (primary) or attributable to pelvic pathology (secondary)

Dyspareunia

Pain with intercourse

Dyschezia

Pain with bowel movements

Dysuria

Pain with urination

Vulvodynia

Pain of the vulva

Allodynia

Pain with non-noxious stimuli

Hyperalgesia

increased response to noxious stimuli

Acute

Which type of pain last under 3 months, signifies an acute disturbance from normal, and by removing the stimuli, the pain reduces

Chronic

Which type of pain last more than 6 months, may not be associated with a clear injury, and may have a social/sexual/emotional consequence?

Somatic (peritoneum, fascia, muscles, skin, bones - things with lots of nerves)

Which type of pain is often sharp, lateralized and maps to dermatomes?

Visceral (think bladder, bowel, uterus, ovaries)

Which type of pain is often dull/vague and the perceived location often corresponds to embryologic origin (midgut vs. hindgut)?

Dysuria, frequency, hematuria, incomplete voiding, incontinence, constipation/diarrhea (cyclic or chronic), Dyschezia, hematochezia, vaginal dryness, discharge, vulvar rash, dyspareunia, joint pain, rash, bruising, depression, anxiety, hx of abuse

Common associated symptoms of pelvic pain

herpes, yeast infection, syphilis trauma (straddle, hematoma, lac, assault), skene’s glands, bartholin’s cyst, abscess, vulvar disorders

Vulvar causes of acute pelvic pain

Trauma (penetrating (most common), pelvic fracture, hydraulic), vaginitis, foreign body, candida (burning/irritation), bacterial vaginosis

Vaginal causes of acute pelvic pain

cervicitis

Cervix causes of acute pelvic pain

PID, threatened/incomplete abortion, prolapsing myoma, degenerating myoma

Uterine causes of acute pelvic pain

ectopic pregnancy, PID, salpingitis, paratubal cyst

Fallopian tube causes of acute pelvic pain

PID, cyst/torsin, tuboovarian abscess, mittelschmerz, ectopic pregnancy

Ovarian causes of acute pelvic pain

Gastroenteritis, colitis, appendicitis, diverticulitis, constipation, IBS, IBD, SBO, mesenteric ischemia, malignancy, cystitis, pyelonephritis, nephrolithiasis, perinephric abscess, hernia, abdominal wall trauma, peritonitis, herpes zoster, opiate withdrawal, vasculitis, sickle cell crisis, AAA

Non-Gyn causes of acute pelvic pain

Abdominal exam (scars, distention, sounds, etc), Pelvic exam (speculum and bimanual)

Important tips for Physical Exam for Pelvic Pain

Qual Hcg (unless menopause, hysterectomy), UA/Urine culture (if urinary symptoms present), STI screening (based on risk factors), CBC (infection/anemia), CMP (associated N/V), Type and Screen if preg with vaginal bleeding (Rh status)

Lab evals for pelvic pain

U/S 🥇 (structural masses of the uterus, infected tubes, adnexal masses, free fluid), CT abdomen/pelvis (if it’s not giving gyn), MRI (safe for preggos - indicated for distorted pelvic anatomy, mullerian anomaly evaluation, large/poorly delineated masses)

Imaging studies for Pelvic pain

PID with unclear diagnosis, ovarian torsion, ruptured ectopic, persistent adnexal masses

What are the indications for a diagnostic laparoscopy for acute pain?

Pelvic Inflammatory Disease (PID)

An ascending infection of the upper female reproductive tract (uterus/adnexa)

Cervical motion tenderness (chandelier’s sign), uterine tenderness, adnexal tender

Physical Exam findings in PID

Fever (over 101.6), mucopurulent discharge, abundant WBCs on saline microscopy, ESR/CRP elevation, N.gonorrhoeae or C.trachomatis

What are some findings that enhance specificity of physical exam findings of PID?

CBC, NAAT (for STIs), pelvic U/S (check for the presence of tuboovarian abscess)

Workup for PID

Abx (Inpatient: cefotetan/Cefoxitin + doxy OR Clinda + gentamicin OR ampicillin/sulbactam + doxy; Outpatient: ceftriaxone/Cefoxitin and probenecid OR 3rd CPH + doxy with or w/o metro; Levofloxacin/ofloxacin with or w/o metro), antiemetics, pain control (NSAIDs)

Management of PID

Ectopic pregnancy

An Extrauterine pregnancy that occurs OUTSIDE the normal endometrium (95% are tubal)

location, size, patient preference, rupture risk

Medical vs. surgical treatment of ectopic pregnancy depends on

Adnexal torsion

A twisting of the adnexa (fallopian tubes/ovary) on a vascular pedicle resulting in ischemia - more common on the right side (increased mobility)

Sharp lower pelvic pain, adnexal pain/tenderness on exam, adnexal mass on U/S

Diagnostics for Adnexal torsion

Surgical Emergency (laparoscopy preferred)

Management of Adnexal Torsion

Vaginitis, vaginal atrophy, cervicitis, adenomyosis, leiomyoma, salpingitis, hydrosalpinx, cysts, endometriosis, adhesive disease, pelvic organ prolapse, Pelvic congestion syndrome, malignancy

GYN causes of Chronic Pelvic Pain

Constipation, IBD, IBS, diverticulitis, stones, painful bladder syndrome, interstitial cystitis, pelvic floor dysfunction, fibromyalgia, arthritis, depression, medication dependency, PTSD, abuse

Non-GYN causes of chronic pelvic pain

Adenomyosis

An extension of the endometrial glands and stroma into the uterine musculature that occurs in 20-40% of hysterectomy specimens

heavy and painful periods, uterus symmetrically enlarged/tender/boggy on exam, Heterogenous appearance of the myometrium (TVUS), Hysterectomy 🏆

Findings in Adenomyosis

Uterine Leiomyomas

A benign smooth muscle neoplasms (most common uterine neoplasms) of the uterine musculature that is experienced by 70-80% of patients by their late 40s

pelvic pain, bulk symptoms (pressure), urinary symptoms (pressure on bladder), back pain, heavy/prolonged menstrual bleeding

Symptoms of uterine Leiomyomas (2/3s are asymptomatic)

Hormones (combined or progesterone only), GNRH agonist 🩹 (temporary), myomectomy (hysteroscopic/abdominal), uterine fibroid embolization, radiofrequency fibroid ablation, hystectomy

Treatment plan for Leiomyomas

Diameters of 3cm+, mobile, simple, not associated with ascites

Characteristics of a Functional Ovarian Cysts

U/S, palpable adnexal mass on exam

Diagnostics for Functional Ovarian Cysts

Observation (those under 10cm will likely regress), surgical management if persistent/symptomatic, OCPs (prevent future cyst - data doesn’t really prove this but oh well)

Treatment for Functional Ovarian Cysts

Mature cystic Teratoma (dermoid cysts)

The most common ovarian neoplasms that is composed of ectodermal tissues (sweat/sebaceous glands, hair follicles, teeth)

Cystectomy/oophorectomy (examine the other side during surgery as well), laparotomy/laparoscopic procedure (depends on the size of the cyst)

Management of teratomas

Endometriosis

The presence of endometrial glands and stroma outside the endometrial cavity or uterine musculature that is present in up to 80% of women with pelvic pain

Frequent/prolonged menses, white, family hx, early menarche, nulliparity, urine anomalies

Risk factors for Endometriosis

Dysmenorrhea, dyspareunia, dyschezia, pelvic pain (70%), cyclic bowel/bladder symptoms, decreased fertlity

Symptoms of Endometriosis

stage, site, morphologic characteristics, severity of symptoms

When it comes to Endometriosis there is NO relationship between

Fixed uterus/adnexa, adnexal mass (endometrioma), uterosacral nodularity, retroverted uterus

Physical exam findings of Endometriosis

Laparoscopy (superficial powder burn lesions - black, blue, red, clear OR endometriomas (chocolate cysts))

Definitive diagnostics for Endometriosis 🏆

Hormonal management (continuous OCP or progesterone only, DMPA, hormonal IUD, Depo-lupron (GNRH agonist), Elagolix (GNRH antagonist)), Surgical excision/ablation, Hysterectomy with maybe bilateral salpingo-oophorecomy 🏆

Treatment plan for Endometriosis

Related to defection, associated with change in stool frequency/appearence

ROME IV Criteria for IBS

Education/lifestyle changes (mild), Loperamide (if moderate IBS-D); polyethylene glycol/pelvic floor therapy (if moderate IBS-C); Refer to GI or antidepressant if severe

Treatment for IBS

Bladder pain syndrome

An unpleasant sensation perceived to be related to the urinary bladder, associated with LUTS for longer than 6 weeks without infection or other identifiable cause

Worsened by bladder filling, certain foods/drinks, improved by voiding, urinary urgency/frequency, pain in the lower abdomen, perineum, urethra, low back pain

Symptoms of Bladder pain syndrome

Pain management (amitriptyline, cimetidine, PPS), patient education, stress management, self-care modification, PT, Intravesical DMSO/heparin/lidocaine, elimination diet challenge

Treatment plan for Bladder pain syndrome

Myofascial Pain Syndrome

A hyperirritable area within a muscle promotes persistent fiber contraction - “trigger points” can be identified with palpation of different pelvic floor muscle groups

Pelvic floor PT

Treatment for Myofascial Pain Syndrome