Gynaecological Causes of Acute Pelvic Pain

Max Brinsmead MB BS PhD

May 2015

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

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

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

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

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

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

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...

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

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

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

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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