Pelvic Pain and Dysmenorrhea

Novak’s Gynecology

Samsung Medical Center

Obstetrics and Gynecology

1st year Choi, Suk Joo



Chapter 14 Pelvic Pain and Dysmenorrhea



I. Introduction



   A. Acute vs Cyclic vs Chronic

      1. Acute : intense, sudden onset, sharp rise, short course

      2. Cyclic : associated with menstrual cycle

      3. Chronic : more than 6 months



II. Acute Pain



   A. The character of pain

      1. Rapid onset : perforation of a hollow viscus or ischemia

      2. Colic or severe cramping pain : muscular contraction or obstruction of a hollow viscus

      3. Entire abdominal pain : irritating fluid within the peritoneal cavity



   B. History

      1. Early diagnosis of acute pelvic pain is critical because delay can increase morbidity and mortality

      2. Presence of abnormal bleeding or discharge

      3. Menstrual, sexual, and contraceptive component

      4. Previous STD and gynecologic conditions

      5. Medical and surgical history

      6. How and when the pain started

      7. The presence of GI symptoms or urinary symptoms and signs of infection



   C. Pathology

      1. Abnormal Pregnancy

         1) Symptoms

            a. Abdominal pain – acute dilation of the tube

            b. Generalized pain after temporarily relief – rupture, hemoperitoneum

            c. Amenorrhea for 6-8 weeks

            d. Irregular bleeding or spotting – fluctuation of hCG and low progesterone

            e. Referred pain to the right shoulder – diaphragm irritation

            f. Dizziness and syncope – significant blood loss

         2) Signs

            a. Orthostatic vital signs

            b. Tenderness and guarding

            c. Generalized abdominal distension and RT

            d. Cervical motion tenderness

            e. A palpable mass

         3) Diagnosis

            a. A serum or urine hCG

            b. Ultrasonography



      2. Leaking or Ruptured Ovarian Cyst

         1) Symptoms

            a. Acute pain – torsion, rapid expanding, infection, leaking

            b. Sudden and associated with generalized abdominal pain

         2) Signs

            a. Hypovolemia – hemoperitoneum

            b. Abdominal T/RT – peritoneal irritation

            c. Hematocrit decrease – active bleeding

         3) Diagnosis

            a. Pregnancy test, CBC, USG, culdocentesis

            b. A hematocrit >16% of fluid obtained from PCDS - hemoperitoneum

         4) Management

            a. Hemoperitoneum – surgical treatment

            b. Culdocentesis – determining the cause of peritonitis

               i) Fresh blood – corpus luteum

               ii) Chocolate old blood – endometrioma

               iii) Oily sebaceous fluid – benign teratoma

               iv) Purulent fluid – PID or tubo-ovarian abscess

         5) Mittelschmerz : the pain associated with rupture of the ovarian follicle at the time of ovulation



      3. Torsion of Adnexa

         1) Benign cystic teratoma – most common neoplasm that undergo torsion

         2) Symptoms

            a. Severe and constant pain

            b. Autonomic reflex response (e.g., nausea, emesis, apprehension)

         3) Signs

            a. Tenderness and localized RT in the lower quadrants

            b. Presence of large pelvic mass

            c. Mild fever and leukocytosis – infarction

         4) Diagnosis

            a. Palpable by physical examination

            b. Ultrasonography

         5) Management

            a. Must be treated surgically – cystectomy or oophorectomy



      4. Acute Salphingo-oophoritis

         1) Symptoms

            a. Gonococcal PID – acute pain increased with movement, fever, purulent vaginal discharge, nausea, vomiting, associated menstrual period

            b. Chlamydial PID – more insidious symptoms

         2) Signs

            a. Abdominal T/RT(+/+)

            b. Cervical motion tenderness and bilateral adnexal tenderness

            c. Leukocytosis, elevation of ESR

         3) Diagnosis

            a. Signs of PID

            b. Culdocentesis – WBC or bacteria on Gram stain

            c. G(-) intracellular diplococci of the cervical smear

            d. Chlamydia antigen test (+) of the cervix

            e. Appendicitis oftem is mistaken

         4) Management

            a. Outpatient – broad spectrum and oral antibiotics for uncomplicated PID, reassess within 48 hrs

            b. Inpatient – IV antibiotics

            c. Hospitalization criteria – suspected or undiagnosed tubo-ovarian abscess, pregnancy, presence of an IUD, uncertain diagnosis, nausea and vomiting precluding oral medication, upper peritoneal signs, and failure to respond to oral antibiotics within 48 hrs

                      

      5. Tubo-ovarian Abscess

         1) Sequela of acute salpingitis, usually bilateral

         2) Symptoms and signs are similar to acute salpingitis although pain and fever for more than 1 weeks

         3) Rupture – life threatening surgical emergency d/t G(-) endotoxin shock

         4) Diagnosis

            a. Palpated on bimanual examination as very firm, exquisitely tender bilateral fixed mass

            b. Ultrasonography

         5) Management

            a. Unruptured – IV antibiotics

            b. Ruptured – Exploratory laparascopy



      6. Uterine Leiomyomas

         1) Symptoms

            a. Discomfort – when myoma encroach on adjacent structure

            b. Pain – degeration or torsion    

         2) Signs

            a. Irregular solid mass arising from the uterus

            b. Degeneration - abdominal T/RT, fever, leukocytosis

            c. Ultrasonography

         3) Management

            a. Observation and pain medication

            b. Surgical treatment for torsion



      7. Endometriosis

         1) Symptoms

            a. Dysmenorrhea, dyspareunia, dyschezia, luteal phase bleeding, infertility

            b. Rupture – chemical peritonitis, hemoperitoneum is rare

         2) Diagnosis

            a. Culdocentesis – identify the contents of ruptured endometrioma

            b. Ultrasonography

         3) Management

            a. Laparoscopy or laparotomy (definite diagnosis)

               Cystectomy and Oophorectomy

            b. Ovarian hormonal suppression (pseudomenopause) after surgery



      8. Gastrointestinal Tract

         1) Appendicitis is the most common intestinal source of acute pelvic pain

         2) Symptoms

            a. Diffuse abdominal pain, esp epigastric pain

            b. Nausea and vomiting

            c. Within a matter of hours, the pain shifts to RLQ

            d. Fever, chill, emesis, obstipation

         3) Signs

            a. McBurney’s point tenderness

            b. Generalized muscle guarding, abdominal rigidity, RT

            c. A right sided mass or tenderness on rectal exam

            d. Psoas sign, obturator sign

            e. Cervical motion tenderness - absent

         4) Diagnosis

            a. Ultrasonography

            b. Gastrograffin or barium enema

            c. Diagnostic laparoscopy

         5) Management

            a. Laparotomy, with false-positive rate of 20% is preferable



      9. Acute Diverticulitis

         1) Symptoms

            a. Severe LLQ pain following a long history of irritable bowel symptoms

            b. Fever, chill and constipation usually present

            c. Anorexia and vomiting usually absent

         2) Signs

            a. Distension with LLQ tenderness and localized rebound tenderness

            b. Bowel sound decreased or absent if peritonitis is present

            c. Leukocytosis

         3) Diagnosis and Management

            a. History and physical exam

            b. CT

            c. Barium enemais contraindicated

            d. Broad spectrum antibiotics IV



     10. Intestinal Obstruction

         1) Most common cause : postsurgical adhesions, hernia formation, inflammatory bowel disease, carcinoma of the bowel or ovary

         2) Symptoms

            a. Colicky abdominal pain, abdominal distension

            b. Vomiting, constipation

         3) Signs

            a. Marked abdominal distension

            b. Bowel sounds are high pitched and maximal during colicky pain

            c. Bowel sounds decrease(progression) and absent(ischemic bowel)

         4) Diagnosis and Management

            a. Abdominal X-ray

            b. Surgical management for complete obstruction

            c. IV fluid and NG tube suction for partial obstruction



     11. Urinary Tract

         1) Symptoms

            a. Lithiasis - Severe and crampin pain, radiating to costovertebral angle to the groin, hematuria

            b. Cystitis – dull suprapubic pain, frequency, urgency, dysuria, hematuria

            c. Pyelonephritis – flank and CVA pain

         2) Signs

            a. Lithiasis and pyelonephritis – CVAT

            b. Cystitis – suprapubic tenderness

         3) Diagnosis

            a. U/A and urine culture

            b. Ultrasonography, IVP

         4) Management

            a. Medical and surgical management are both options



D. Diagnostic Tests



      1. All female of reproductive age with acute pelvic pain

         1) CBC with differential count

         2) ESR

         3) Urinanalysis

         4) Sensitive qualitative urine or serum pregnancy test



      2. Other studies

         1) Culdocentesis

         2) Pelvic ultrasonography

         3) Abdominal X-ray

         4) CT



III. Cyclic Pain : Primary and Secondary Dysmenorrhea



   A. Dysmenorrhea is a common gynecologic disorder that affects approximately 50% of menstruating women. Primary dysmenorrhea is menstrual pain without pelvic pathology, whereas secondary dysmenorrhea is painful menses with underlying pathology.



   B. Primary Dysmenorrhea

      1. The cause is increased endometrial PG production

      2. Symptoms

         1) The pain usually begins a few hours prior to or just after the onset of a menstrual period and may last as long as 48-72 hours

         2) Labor-like suprapubic cramping, lumbosacral back pain, radiating to anterior thigh

         3) Nausea, vomiting, diarrhea, syncope

      3. Signs

         1) Suprapubic region tenderness

         2) No other specific signs,

      4. Diagnosis

         1) Rule out underlying pelvic pathology and confirm the cyclic nature of pain.

         2) Pelvic exam

         3) Cervical studies for gonorrhea and chlamydia

         4) If no abnormalities are found, primary dysmenorrhea can be diagnosed.

      5. Treatment

         1) PG synthetase inhibitor (effective in 80% of patients)

            a. Prior to or at the onset of pain and continuously every 6-8 hours

            b. The medication should be taken for the first few days of menses

            c. A 4-6 months course of therapy with changes in dosages and types of inhibitors

            d. Contraindication – GI ulcer, bronchospastic hypersensitivity to aspirin

            e. Side effect – nausea, dyspepsia, fatigue

         2) Oral contraceptives

            a. Decrease endometrial proliferation and create an endocrine millieu  similar to the early proliferative phase when PG is lowest.

            b. More than 90% will have relief.]

         3) Hydrocodone, Codeine added for 2-3 days per months



   C. Secondary Dysmenorrhea

      1. Usually occurs years after the onset of menarche

      2. The pain often begins 1-2weeks prior to menses and persists until a few days after the cessation of bleeding.

      3. The most common cause – Endometriosis, adenomyosis, IUD

      4. Adenomyosis

         1) Ingrowth of endometrium into the uterine musculature

         2) Symptoms

            a. Often asymptomatic

            b. Dyspareunia, dyschezia, metrorrhagia

            c. Excessively heavy or prolonged menstrual bleeding

         3) Signs

            a. Uterus is diffusely enlarged, (usually <14cm), soft and tender

            b. Mobility is not restricted, no association with adnexal pathology

         4) Diagnosis

            a. A clinical diagnosis and imaging studies are not definitive

         5) Management

            a. Hysterectomy

            b. NSAIDs

            c. Oral contraceptives