PELVIC PAINAssociate Professor Dr Hanifullah Khan
Objectives1. Understand the definition & terminology2. Identify the causes & form a differential diagnosis3. Clinically evaluate a patient with this problem
Introduction• Pelvic pain is discomfort in the lower abdomen – Below the umbilicus• may originate in – reproductive organs (cervix, uterus, uterine adnexa) – or other organs ● Urological ● Gastrointestinal ● Musculoskeletal ● Neuropathic ● Other• Sometimes the cause is unknown
Causes Pelvic pain Gynae Non-gynae cause cause OtherCyclical Discrete organs
Definition• Ectopic endometrial tissue within the myometrium• Older age group than endometriosis patients• Associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium
Symptoms• Similar to endometriosis and other pelvic pathology – Pain more likely to be suprapubic – More likely to have abnormal bleeding• Usually older patient• Less likely to be infertile• May have secondary infertility• Previous pregnancies or procedures to uterus• Mimic fibroids – frequently coexist
Symptoms• Heavy menstrual bleeding – Usually cyclical – Prolonged menstrual periods — seven days or more of menstrual bleeding – More likely to be associated with anaemia• Pelvic pressure or pain• Frequent urination• Constipation• Backache or leg pains
Pain• Rarely, a fibroid can cause acute pain – when it outgrows its blood supply• Deprived of nutrients, the fibroid degenerates• Causing pain and fever• Pedunculated fibroids can trigger pain by twisting on its stalk and cutting off its blood supply
Definition• Pelvic inflammatory disease (PID) - infection of the female reproductive organs• Occurs when sexually transmitted bacteria spread from the vagina to the uterus and upper genital tract• Important to avoid because it can result in infertility or ectopic pregnancy• Prompt treatment of a sexually transmitted disease can help prevent PID.
Causes• Unsafe sexual practices• IUDs may increase risk of PID• Barrier method, such as a condom, reduces the risk• Bacteria may also enter the reproductive tract as a result of an IUD insertion, childbirth, miscarriage, abortion or endometrial biopsy• Most common – Chlamydia – Gut organisms – Fungal
Symptoms• Pain in the lower abdomen and pelvis• Heavy vaginal discharge with an unpleasant odor• Irregular menstrual bleeding• Dyspareunia• Low back pain• Fever, fatigue, diarrhea or vomiting• Painful or difficult urination
HOCI• Rule out pregnancy• Gynecologic history – onset, duration, location, and character of pain – gravity, parity, menstrual history, history of STI – Severity of pain & its relationship to the menstrual cycle• Important associated symptoms – include vaginal bleeding – vaginal discharge – symptoms of hemodynamic instability (eg, dizziness, light- headedness, syncope or near-syncope)
Types of pain• Visceral pain• Referred Pain• Somatic Pain• Myalgia• Hyperalgesia• Neuroinflammation
System review• Seek symptoms suggesting possible causes – morning sickness, breast swelling or tenderness, or missed menses (pregnancy) – fever and chills (infection) – abdominal pain, nausea, vomiting, or change in stool habits (GI disorders) – urinary frequency, urgency, or dysuria (urinary disorders)
Past history• Note history of – Infertility – ectopic pregnancy – pelvic inflammatory disease – Urolithiasis – Diverticulitis/GI prolems• Any previous abdominal or pelvic surgery should be noted
Physical examination• Begins with review of vital signs for signs of instability – eg, fever, hypotension• Focus on abdominal and pelvic examinations• Begin with inspection
Thrombosis of the Inferior Vena Cava and Dilated Veins of the TrunkRoncato C, Lefant PY. N Engl J Med 2011;364:2535-2535.
Abdominal examination• Palpation for – Tenderness – Masses – peritoneal signs• Location of pain and any associated findings may provide clues to the cause• Rectal examination is done to check for tenderness, mass, and occult blood.
Pelvic examination• Inspection of external genitals, speculum examination, and bimanual examination• Cervix - inspected for discharge, uterine prolapse, and cervical stenosis or lesions• Bimanual examination - assess cervical motion tenderness, adnexal masses or tenderness, and uterine enlargement or tenderness
Key points1. Pelvic pain is common and may have a gynecologic or nongynecologic cause.2. Pregnancy should be ruled out in women of childbearing age.3. Quality, severity, and location of pain and its relationship to the menstrual cycle can suggest the most likely causes.4. Dysmenorrhea is a common cause of pelvic pain but is a diagnosis of exclusion
References• The Merck Manual – Pelvic Pain• Mayo Clinic - mayoclinic.com/health/chronic-pelvic- pain/DS0