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Flashcards in Pelvic and Ovarian Disorders Deck (62)
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1

What is chronic pelvic pain?
5

1. Pain of at least 6 months' duration that occurs below the umbilicus
2. Significantly impacts a woman’s daily functioning and relationships
3. Episodic-cyclic, recurrent pain that is interspersed with pain-free intervals
4. Continuous non-cyclic pain
5. Many times etiology not found or treatment of presumed etiology fails: pain becomes the illness

2

Six major sources need to be considered for pelvic pain?
6

1. Gynecological
2. Gastrointestinal
3. Urological
4. Psychological
5. Musculoskeletal
6. Neurological

3

Etiologies of Chronic Pelvic Pain
1. episodic? 3
2. Continuous? 5

1. Episodic
-dyspareunia
-midcycle pelvic pain (Mittelschmerz)
-dysmenorrhea

2. Continuous
-Endometriosis (mostly cyclic pain)
-adenomyosis
-chronic salpingitis (PID)
-adhesions
-loss of pelvic support

4

1. What is the most common gynecological cause of CPP?

2. What are other gynecological causes? 6

1. Endometriosis
2.
-PID: 30% of women w/ PID develop CPP
-Dysmenorrhea
-Adenomyosis
-Adhesions
-Ovarian cysts
-Ovarian cancer

5

Risk Factors for
Chronic Pelvic Pain
8

1. History of sexual abuse or trauma
2. Previous pelvic surgery
3. History of PID
4. Endometriosis
5. Personal or family history of depression
6. History of other chronic pain syndromes
7. History of alcohol and drug abuse
8. Sexual dysfunction

6

Chronic Pelvic Pain: History findings
9

1. Pain duration > 6 months

2. Incomplete relief by most previous treatments, including surgery and non-narcotic analgesics

3. Significantly impaired functioning at home or work

4. Signs of depression such as early morning awakening, weight loss, and anorexia

5. Pain out of proportion to pathology

6. History of childhood abuse, rape or other sexual trauma

7. History of substance abuse

8. Current sexual dysfunction

9. Previous consultation with one or more health care providers and dissatisfaction with their management of her condition

7

Chronic Pelvic Pain: Physical Exam
7

1. Systematic PE of abdominal, pelvic, and rectal areas, focusing on the location and intensity of the pain

2. Attempt to reproduce the pain

3. Note general appearance, demeanor, and gait… may suggest the severity of the pain and possible neuromuscular etiology.

4. inspect & note any well healed scars
5. palpate scars for incisional hernias
6. Palpate for femoral and inguinal hernias
7. Palpate for any unsuspected masses

8

Chronic Pelvic Pain: Physical Exam
-Abdominal symptoms of more acute process? 5

1. rebound tenderness (peritoneal irritation)
2. increased abdominal pain on palpation with tension of the rectus muscles
3. straight leg raise
-Decrease…. pelvic origin
-increase …. abdominal wall or myofascial origin
4. Fever?...acute process
5. Vomiting?...acute process.

9

Chronic Pelvic Pain: Physical Exam
1. Speculum exam: What would be the source of parametrial irritation?

2. Bimanual/rectal exam: What may be findings for this? 5

3. If you see these symptoms what should you think? 3

4. Palpate the ________, both internally and externally

1. Cervicitis

2.
-tender pelvic or
-adnexal mass,
-abnormal bleeding,
-tender uterine fundus,
-cervical motion tenderness

3. Think acute process such as
-PID,
-ectopic pregnancy, or
-ruptured ovarian cyst

4. coccyx

10

What would the following findingd on bimanual/rectal exam show:
1. Non-mobility of uterus?
2. Cul-de-sac nodularities?
3. Identify any areas that reproduce what?
4. Cerival motion tenderness also called?

1. presence of pelvic adhesions

2. endometriosis
3. deep dyspareunia

4. Chandelier sign

11

Diagnostic Tests for Chronic Pelvic Pain

8

1. Should be selected discriminately as indicated by the findings of the H & P
2. Avoid unnecessary and repetitive diagnostic testing
3. Serum HCG
4. UA
5. Wet prep/KOH
6. Cervical cultures/GC and chlamydia
7. CBC with diff
8. ESR
9. Stool guaiac…if + do GI w/u
10. Ultrasound to identify pelvic masses

12

CPP: Diagnostic laparascopy may identify?
8

1. acute or chronic salpingitis
2. ectopic pregnancy
3. hydrosalpinx
4. endometriosis
5. ovarian tumors and cysts
6. torsion
7. appendicitis
8. adhesions

13

Treatment of Chronic Pelvic Pain

3

May have a surgical interventions? 2

1. Treat underlying cause
2. Psychosocial interventions
3. Medications

1. diagnostic and therapeutic laparoscopy
2. hysterectomy

14

Medications for CPP? 3

Avoid what? 1

1. NSAIDs
2. antidepressants
3. oral contraceptives

1. Avoid long-term narcotic use

15

CPP: Alternative interventions
8

1. biofeedback
2. stress management techniques
3. self-hypnosis
4. relaxation therapy
5. transcutaneous nerve stimulation (TNS)
6. trigger-point injections
7. spinal anesthesia
8. nerve blocks

16

Pelvic Inflammatory Disease
1. What is it?

2. Comprises a spectrum of inflammatory disorders including any combination of what? 4

1. Clinical syndrome associated with ascending spread of microorganisms from the vagina or cervix to the endometrium, fallopian tubes, ovaries, and contiguous structures.

Comprises a spectrum of inflammatory disorders including any combination of:
1. endometritis,
2. salpingitis,
3. tubo-ovarian abscess, and
4. pelvic peritonitis.

17

PID Risk Factors
9

1. Young age at onset of sexual activity
2. New, multiple, or symptomatic partners
3. Unprotected sexual intercourse
4. History of PID
5. Gonorrhea or chlamydia, or a history of gonorrhea or chlamydia
6. Current vaginal douching
7. Insertion of IUD (within 1st 3 weeks)
8. Bacterial vaginosis
9. Sex during menses

18

PID Microbial Etiology
2


2. Overgrowth of microorganisms that comprise the vaginal flora such as? 6

1.
-N. gonorrhoeae: recovered from cervix in 30%-40% of women with PID
-C. trachomatis: recovered from cervix in 20%-40% of women with PID

2.
-streptococci,
-staphylococci,
-Enterobacteriaceae,
-anerobes,
-gardenella vaginalis,
-strep. agalactiae.

19

PID: Pathway of Ascendant infection?
4

1. Cervicitis
2. Endometritis
3. Salpingitis/ oophoritis/ tubo-ovarian abscess
4. Peritonitis

20

Complications of PID
5

Approximately 10-20% of women with a single episode of PID will experience sequelae, including:
1. ectopic pregnancy
2. Infertility
3. Tubo-ovarian abscess
chronic pelvic pain
4. Fitz-hugh-curtis syndrome (perihepatitis)
5. Tubal infertility occurs in 50% of women after three episodes of PID

21

Minimum Criteria in the Diagnosis of PID
2

1. Uterine/adnexal tenderness or
2. Cervical motion tenderness (positive Chandelier Sign)

22

Additional Criteria to Increase Specificity of Diagnosis
6


More Specific Criteria 4

1. Temperature >38.3°C (101°F)
2. Abnormal cervical or vaginal mucopurulent discharge
3. Presence of WBCs on saline wet prep
4. Elevated erythrocyte sedimentation rate (ESR)
5. Elevated C-reactive protein (CRP)
6. Gonorrhea or chlamydia test positive

1. Transvaginal ultrasound
2. Pelvic CT or MRI
3. Laparoscopy
4. Endometrial biopsy

23

General PID Considerations
1. Treatment should be instituted when?

2. Need to treat sexual partners if what?

3. Educate patient to avoid what?

1. as early as possible to prevent long term sequelae

2. +GC/Chlamydia

3. sexual activity until she and partner complete treatment.
-Need close f/u to ensure cure.

24

PID Treatment
1. Regimens must provide coverage of what? 5

2. Outpatient first line therapy?
(3 combinations) + (may add what?)

1.
-N. gonorrhoeae,
-C. trachomatis,
-anaerobes,
-Gram-negative bacteria, and
-streptococci

2.
-Ceftriaxone 250 mg IM in a single dose, AND azithromycin 1 g PO once weekly x 2 weeks

-Ceftriaxone 250 mg IM in a single dose AND doxycycline 100 mg orally 2 times a day for 14 days

-Cefoxitin 2 g IM in a single dose AND Probenecid 1 g orally in a single dose, AND Doxycycline 100 mg orally 2 times a day for 14 days

-WITH OR WITHOUT
Metronidazole 500 mg orally 2 times a day for 14 days

25

Follow-Up
1. Patients should demonstrate substantial improvement within __ hours.

2. Patients who do not improve usually require what? 3

3. Some experts recommend rescreening for what 4-6 weeks after completion of therapy in women with documented infection with these pathogens? 2

1. 72

2.
-hospitalization,
-additional diagnostic tests, and
-surgical intervention.

3.
-C. trachomatis and
-N. gonorrhoeae

26

PID Criteria for Hospitalization
6

1. Inability to exclude surgical emergencies
2. Pregnancy
3. Non-response to oral therapy
4. Inability to tolerate an outpatient oral regimen
5. Severe illness, looks septic, nausea and vomiting, high fever or tubo-ovarian abscess
6. HIV infection with low CD4 count

27

Parenteral Regimens: PID
CDC-recommended parenteral regimen A? 3

CDC-recommended parenteral regimen B? 2


Continue either of these regimens for at least 24 hours after substantial clinical improvement, then what? 2

CDC-recommended parenteral regimen A
1. Cefotetan 2 g IV every 12 hours, OR
2. Cefoxitin 2 g IV every 6 hours
3. PLUS doxycycline 100 mg orally or IV every 12 hours

CDC-recommended parenteral regimen B
1. Clindamycin 900 mg IV every 8 hours
2. PLUS gentamicin loading dose IV of IM (2 mg/kg), followed by maintenance dose (1.5 mg/kg) every 8 hours. Single daily gentamicin dosing may be used.

Complete a total of 14 days therapy with
1. Doxycycline (100 mg orally twice a day) with regimen A or with
2. Doxycycline or Clindamycin (450 mg orally 4 times a day), if using regimen B

28

Screening
1. To reduce the incidence of PID, screen and treat for _______?

1. chlamydia.

29

PID: Annual chlamydia screening is recommended for:
1. Sexually active women = age?
2. Sexually active women >___ that are high risk?

3. Screen pregnant women in the ___ trimester.

1. 25 and under
2. 25


3. 1st

30

Report cases of PID to the local STI program (RSH) in states where reporting is mandated.
Which STIs are reportable in all states?
2

Gonorrhea and chlamydia