Acute pelvic pain

DDx. Acute pelvic pain

Rapid onset of pain is most consistent with perforation of a hollow viscus or ischemia. Colic or severe cramping(경련성) pain is commonly associated with muscular contraction or obstruction of a hollow viscus, such as intestine or uterus, whereas pain perceived over the entire abdomen suggests a generalized reaction to an irritating fluid within the peritoneal cavity such as blood, purulent fluid, or contents of an ovarian cyst.

 

Gynecologic disease or dysfunction

Acute pain

1. Complication of pregnancy

a. Ectopic pregnancy

*Ectopic pregnancy

Implantation of the fetus in the fallopian tube produces pain only with acute dilation of the tube. If tubal rupture occurs, localized abdominal pain tends to be temporarily relieved and is replaced by generalized pelvic and abdominal pain as the hemoperitoneum develops. A period of amenorrhea followed by bleeding and pain compose the classic triad of symptoms. 

b. Abortion, threatened or incomplete

*유산 (Abortion) -   

World Health Organization define abortion as pregnancy termination prior to 20 weeks’ gestation or with a fetus born weighing less than 500 g. Spontaneous abortion can be classified clinically a number of ways. Commonly used subgroups include threatened, inevitable, incomplete,and missed abortion.

*Threatened abortion(절박유산)  

The clinical diagnosis of threatened abortion is presumed when a bloody vaginal discharge or bleeding appears through a closed cervical os during the first half of pregnancy.

임신 1삼분기 중 자궁경부가 닫혀있는 중 피가나는 상황을 절박 유산이라고 한다.

*Inevitable abortion(불가피유산)

Gross rupture of the membranes, evidenced by leaking amnionic fluid in the presence of cervical dilatation, signals almost certain abortion.

*Incomplete abortion(불완전유산)

Bleeding ensues when the placenta, in whole or in part, detaches from the uterus.

태반이 자궁으로부터 완전히 혹은 불완전히 분리되고 나서 피가 나는 경우 불완전유산이라고 한다.

Before 10 weeks, the fetus and placenta are commonly expelled together, but later they are delivered separately.

10주 이전에 유산된 경우 태아와 태반은 보통 함께 배출되는데, 10주가 지난 경우 따로 배출된다.

*Missed Abortion(계류유산)—Early Pregnancy Failure

It was used to describe dead products of conception that were retained for days, weeks, or even months in the uterus with a closed cervical os.

임신이 되고 초음파에서 아기집도 보이나 발달과정에서 태아가 보이지 않는 경우 혹은 임신 초기(일반적으로 20주까지)에 사망한 태아가 유산을 일으키지 않고 자궁 내에 잔류하는 경우

Reference - William's obstetrics

2. Acute infections

a. Endometritis

b. PID or salpingo-oophoritis

c. Tubo-ovarian abscess

*PID

 PID is caused by micro-organisms colonizing the endocervix ascending to the Disease endometrium and fallopian tubes. It is a clinical diagnosis implying that the patient has upper genital tract infection and inflammation. The inflammation may be present at any point along a continuum that includes endometritis, salpingitis, and peritonitis. Pelvic inflammatory disease commonly is caused by the sexually transmitted micro-organisms N. gonorrhoeae and C. trachomatis

*Diagnosis

Traditionally, the diagnosis of PID has been based on a triad of symptoms and signs, including

1)pelvic pain, 2)cervical motion and adnexal tenderness, and 3)the presence of fever(38'C). It is now recognized that there is wide variation in many symptoms and signs among women with this condition, which makes the diagnosis of acute PID difficult.

*Treatment

Therapy regimens for PID must provide empirical, broad-spectrum coverage of likely pathogens, including N. gonorrhoeae, C. trachomatis, gram-negative facultative bacteria, anaerobes, and streptococci. An outpatient regimen of cefoxitin and doxycycline is as effective as an inpatient parenteral regimen of the same antimicrobials. Therefore, hospitalization is recommended only when the diagnosis is uncertain, pelvic abscess is suspected, clinical disease is severe, or compliance with an outpatient regimen is in question. Hospitalized patients can be considered for discharge when their fever has lysed, the white blood cell count has become normal, rebound tenderness is absent, and repeat examination shows marked amelioration of pelvic organ tenderness

The most important signs of acute salpingo-oophoritis are cervical motion tenderness and bilateral adnexal tenderness. Other origins of pelvic pain such as appendicitis can be mistaken for PID. Laparoscopy can be used to diagnose salpingitis and rule out other causes of pelvic pain; however, it cannot be used for the diagnosis of endometritis, which is usually based on clinical findings.

3. Adnexal disorder

a. Hemorrhagic functional ovarian cyst

b. Torsion of adnexa

*Diagnosis

-The process of torsion occludes the lymphatic and venous drainage of the involved adnexa; therefore, the mass rapidly increases in size and can be palpated on examination or visualized by ultrasound. Ultrasound confirms the presence of a mass.

*Management

-Adnexal torsion must be treated surgically. If the tissue has not infarcted, the adnexa may be untwisted and a cystectomy performed if appropriate. If necrosis has occurred, an oophorectomy was indicated previously. Now, even with a necrotic-appearing ovary, there is evidence that sparing the adnexa can preserve the ovarian hormonal and reproductive function

c. Rupture of functional, neoplastic, or inflammatory ovarian cyst

*Leaking or Ruptured Ovarian Cyst

Functional cysts (e.g., follicle, corpus luteum) are the most common ovarian cysts and rupture more readily than do benign or malignant neoplasms. The pain associated with rupture of the ovarian follicle at the time of ovulation is called mittelschmerz. The small amount of blood leaking into the peritoneal cavity and high concentration of follicular fluid prostaglandins could cause this midcycle pelvic pain. However, the pain is mild or moderate and self-limited, and with an intact coagulation system, hemoperitoneum is unlikely. A hemorrhagic corpus luteum cyst can develop in the luteal phase of the menstrual cycle. Rupture of this cyst can produce either a small amount of intraperitoneal bleeding or frank hemorrhage resulting in significant blood loss and hemoperitoneum.

Recurrent pelvic pain

1. Mittelschmerz (midcycle pain-생식주기 중간의 배란통, 배란 시 여포의 파열로 발생한 통증)

*Mittelschmerz - The pain associated with rupture of the ovarian follicle at the time of ovulation; blood, follicle fluid prostaglandins 

2. Primary dysmenorrhea

3. Secondary dysmenorrhea

 

Gastrointestinal

1. Gastroenteritis

2. Appendicitis

3. Bowel obstruction

4. Diverticulitis

5. Inflammatory bowel disease

6. Irritable bowel syndrome

 

Genitourinary

1. Cystitis

2. Pyelonephritis

3. Urethral lithiasis

 

Musculoskeletal

1. Abcominal wall hematoma

2. Hernia

 

Other

1. Acute porphyria

2. Pelvic thrombophlebitis

3. Aortic aneurysm

4. Abdominal angina

Pain history Mneumonic

<OLD CAARTS>

Onset - When and how did pain start? Did it change over time?

Location - Localize specifically? Can you put a finger on it?

Duration - How long does it last?

Characteristics - Cramping, aching, stabbing, burning, lightening, tingling, itching?

Alleviating/Aggravating factors - What makes it better or worse? (medication, stress reduction, heat/ice, position change, specific activity, stress, mestrual cycle?)

Associated symptoms -   Gyn(dyspareunia, dysmenorrhea, abnormal bleeding, discharge, infertility)

GI(constipation, diarrhea, bloating, gas, rectal bleeding)

GU(frequency, dysuria, urgency, incontinence)

NEURO(specific nerve distrubution)

Radiation - Does it move to other areas(dermatomal distribution)?

Temporal - What time of day(elation to menstrual cycle and activities of daily living)?

Severity - Scale of 0 ~ 10

Reference -From Rapkin AJ, Howe CN. Chronic pelvic pain: a review. In: Family practice recertification. Monroe Township, New Jersey: Medical World Communications, 2006;28:5967.