pelvic pain in gyn/obs

1. Gynaecological Causes of
Acute Pelvic Pain
Max Brinsmead MB BS PhD
May 2015

2. In the emergency assessment of women of
reproductive age it is important to exclude:
– Ectopic pregnancy
– Acute PID
– Ovarian cyst
– Endometriosis
And you may be left with a diagnosis of
Primary Dysmenorrhoea
The Short List

3. Requires a high index of suspicion
Typical History
• Pain (90 %)
• Then PV bleeding (85%)
• The patient at risk (prior ectopic, tubal surgery etc)
Excluded by negative UCG
Diagnosed by beta HCG >3000 and empty uterus
on ultrasound
DD includes normal pregnancy & miscarriage
Ectopic Pregnancy

4. Diagnosis requires a patient at risk
• Usually younger patient (15 – 25 years)
• New partner or multiple partners
• Or a partner at risk e.g. one that travels
It is a bilateral disease
Pelvic peritoneal tenderness is a subtle sign
WCC & ESR or C-reactive protein can be useful
Requires careful microbiology
• Test for all STD’s simultaneously
A role for laparoscopy in diagnosis
Acute PID

5. Very common
• But not always the source of pain
Pain can be due to:
• Rapid enlargement
• Rupture
• Haemorrhage - typical of the corpus luteum
• Torsion (rare)
Ultrasound is both a boon and a bane because
• Paraovarian cysts
• Mesenetric cysts & Adhesive collections
• Hydrosalpinx, Bladder or even Ureter
May be imaged but do not cause acute pain
Ovarian Cysts

6. Not uncommon with Mirena
Ignore alarming reports from the radiologist
• If the patient is <50 then it is usually benign
Analgesia, observation and reassurance is best
Repeat scan in 3 – 4 months
Can use COC to suppress the ovaries and prevent
confounding “cysts” appearing
Laparoscopy, drainage and biopsy rarely required
Management of functional cysts

7. Risk of malignancy increases with age
Ultrasound assessment
• Look for septa and SOLID AREAS
• Look for Ascites
• Evaluate Doppler flow
Tumour markers in serum essential
• CA125 (CA19.9, CEA, AFP, beta HCG)
Dermoid cyst (Teratoma) most common ovarian
neoplasm of young women
• And may be bilateral (15%)
Evaluating an ovarian tumour

8. Pelvic clearance i.e. TAH & BSO or resection of all
solid tumour
• Except for the very young patient
• With Ca of low grade malignancy
Omentectomy
Peritoneal washings for cytology
Lymph node biopsies
If you can’t do that then resist the temptation to
operate and send her to someone who can!
A malignant ovary requires...

9. Almost always associated with ovarian pathology
Presents as “reverse renal colic”
May present with acute abdomen
Pulls cervix to the side of the torsion
Usually requires salpingo oophorectomy
Ovarian torsion

10. An enigmatic condition
Common
• As many as 1:4 women if your diagnostic criteria are liberal
The “At Risk” Individual
• Has delayed pregnancies
• Family history common
Cardinal symptoms are:
• Dysmenorrhoea
• Dyspareunia
• Infertility
• Premenstrual staining
• Pain with defaecation during menstruation
Endometriosis

11. Physical examination
• There may be tender nodules in the uterosacral ligaments
Ultrasound
• Of little value unless there are endometriomas
Menstrual phase Ca125 may be used
• But has poor sensitivity
Laparoscopy required for diagnosis
• There is a poor correlation between findings and symptoms
• Debate as to the role of biopsy in diagnosis
Treatment
• Medical for pain but surgery for infertility
Endometriosis cont’d

12. Is not associated with any pelvic pathology
• Also called “spasmodic dysmenorrhoea”
Typically a teenager but can occur in the 40's too
Worse before and on the day of first flow
Accompanied by pallor, prostration & diarrhoea
Relieved by NSAIDs in effective doses
Best managed with combined OC
• Which can be given for up to 3m continuously
But the Mirena IUS and sometimes Depot Provera
has a role
Primary Dysmenorrhoea

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