Medical Archive

Definitions

Acute pain

Evaluation of Acute Pelvic Pain

1Hx, pregnancy test, USG, ??? laparo

Reproductive Tract Causes of Acute Pelvic Pain

• Functional cyst: Mittelschmertz (ovulation pain)
  • Rupture of the follicular cyst during ovulation -> release of small amounts of intraperitoneal fluid and subsequent peritoneal irritation.
  • The pain is self-limited and usually subsides within two hours to two days

Ectopic pregnancy

Amenorrhea, bleeding, pain
Tubal dilation ? rupture ? hemoperitonium

Leaking or ruptured ovarian cyst

• Clinical features
  • Sudden-onset, severe, unilateral lower abdominal pain; N/V
  • Unilateral tender adnexal mass on examination
• Ultrasound
  • Thin-walled cyst with pelvic free fluid
• Management
  • Hemodynamically stable with no signs of infection (eg, fever, tachycardia)
    • Observation and reassurance.
  • Hemodynamically unstable patients
    • May have continued bleeding from the ruptured cyst and require surgical intervention

Adnexal torsion

• Risk factors
  • Ovarian mass
  • Reproductive age
  • Infertility treatment with ovulation induction
• Clinical presentation
  • 30? ??? ????.. ??
  • N/V +/- palpable adnexal mass
• Ultrasound
  • Adnexal mass with absent Doppler flow to ovary
• Treatment
  • Laparoscopy with detorsion
  • Ovarian cystectomy
  • Salpingo-oophorectomy if necrosis or malignancy

Acute salpingo-oophoritis & PID

N.gonococcus, Chlamydia
Cervical motion tenderness
Abscess? ??? ??. ??? ??? ?? ??? drain

Tubo-ovarian abscess

Uterine leiomyoma

Pedunculated myoma? torsion ? ischemic necrosis

Treatment
Medical Tx – mens? ??? ???
Surgical Tx – Pain, fertility ??
Perioperative medical Tx – ??? ARF, IVF ???? ? ??.

Gastrointestinal Tract Causes of Acute Pelvic Pain

Urinary Tract Causes of Acute Pelvic Pain

Acute Pelvic Pain: Summary

Cyclic Pain: Primary and Secondary Dysmenorrhea

???
• P ?? ? PGF2? ?? ? Uterine contractility? ???? ischemic pain ??.
• Pain ?? ???? NSAID(80%) or OC(90%) ??. ??? tocolytics, presacral neurectomy
???
• ?????(endometriosis) > adenomyosis, leiomyoma, PID, IUD use
• ??? ???: infertility, urinary Sx or sign (e.g. hydronephros)
• 60~80%? ?????? ??? ????.
• Pelvic congestion
a. Ovarian or uterine venous plexus?? ?? ? transuterine venography
b. ?? manage? hormonal suppression??

Primary dysmenorrhea

Etiology

Excessive PG production

Risk factors

• Age <30
• BMI <20kg/m2
• Tobacco use
• Menarche at age <12
• Heavy/long menstrual periods
• Sexual abuse

Clinical features

• Uterine hypertonicity and ischemia
  • Pain that begins 1-2 days prior to menses
  • Radiates to the lower back and thighs
• PG-induced stimulation of the GI tract
  • N/V, diarrhea
• Normal pelvic examination
• Features that necessitate evaluation for secondary causes of dysmenorrhea:
  • Symptom onset at age >25
  • Unilateral (nonmidline) pelvic pain
  • Pain that does not improve with NSAIDs
  • No systemic symptoms (eg, fatigue, nausea) during menses
  • Abnormal uterine bleeding (eg, intermenstrual bleeding, postcoital spotting)

Management

• NSAIDs
• Combination oral contraceptives

Secondary dysmenorrhea

Adenomyosis

• ????(stroma, gland)? ?? ???? 1LPF < ????? ?.
• Clinical manifestations
  • TRIAD: ???????, ???, ???
  • 40? ????, multiparity, prior uterine surgery (eg, myomectomy)
• Diagnosis
  • ?? ? diffusely enlarged uterine. ??? ?? ? ?? review? ??? ? ??? ??? ?? ??.
  • MRI T2(???): junctional zone? ?? ??.
• Management
  • ??? ?? ?? ??? ??? ??? ??? ????.
  • ??? ?? ??? ???? hysterectomy – 2?? ???? ??? ? ??.
  • ??? ??
    • NSAID, ??? OC, Progestin, GnRH
  • Medical treatment ? ??? ?? ??
    • Mirena

Endometriosis

Management of secondary dysmenorrhea due to endometriosis: pharmacologic

Management of endometriosis: surgical

Chronic Pelvic Pain

Evaluation of chronic pelvic pain

Reproductive tract

Endometriosis

Adhesions

Pelvic congestion

Subacute salpingo-oophoritis

Ovarian remnant and residual ovary syndromes

Gastroenterologic etiology

Urologic etiology

Urethral syndrome

Interstitial cystitis/bladder pain syndrome or painful bladder syndrome

Neurologic and musculoskeletal causes

Nerve entrapment

Myofascial pain

Fibromyalgia

Low-back pain syndrome

Psychological factors

# Genito-pelvic pain/penetration disorder

Pain with vaginal penetration, distress/anxiety over symptoms. No other medical cause
? Desensitization therapy, Kegel exercises

# Localized provoked vulvodynia

=vestibulodynia
Pain to superficial touch on the vestibule.

Management of chronic pelvic pain

Physical therapy