Acute Pelvic Pain

1. Acute Pelvic Pain Christopher R. Graber, MD Salina Women’s Clinic 15 April 2011

2. Overview • Definitions and Symptoms • Acute OB/Gyn Pain • Complication of pregnancy • Acute infection • Adnexal disorders • Other • GI, GU, Musculoskeletal, other

3. Definitions • Acute pain • Sudden onset, sharp rise, short course • Cyclic pain • Definite association with mestrual cycle • Dysmenorrhea – painful menstruation • Primary or secondary • Chronic pelvie pain • Greater than 6 months duration

4. Pelvic Pain – Symptoms • Rapid onset • Perforation of hollow viscus or ischemia • Colic or severe cramps • Muscular contraction, obstruction of hollow viscus such as uterus or intestines • Entire abdomen • Generalized reaction to irritating fluid within the peritoneal cavity

5. Acute Pelvic Pain • Complications of pregnancy • Ectopic, abortion, leiomyoma degeneration • Acute infections • Endometritis, PID, TOA • Adnexal disorders • Hemorrhagic functional cyst, ovarian torsion, torsion of paratubal cyst • Ruptured cyst – functional or neoplastic

6. Pregnancy ComplicationsEctopic • Ectopic pregnancy – implantation in a site other than the uterus (95% in tube) • Acute pain due to tubal dilation • If rupture  localized changes to generalized peritonitis (due to hemoperitoneum) • hCG less than expected or abnormal rise • Use ultrasound to locate pregnancy • Heterotopic pregnancy rare (both uterine and ectopic)

7. Pregnancy ComplicationsEctopic • Treatment • Methotrexate • 50 mg/m2 IM x1 • Multiple-dose regimen an alternative • Surgery • Linear salpingostomy • Partial salpingectomy • Follow quant hCG if no fetal tissue recovered • MTX: quant on days 4 and 7, expect 15% drop

8. Methotrexate for Ectopic • Absolute contraindications • Breastfeeding, immunodeficiency • Chronic liver disease, active pulmonary disease • Leukopenia, thrombocytopenia, anemia • Peptic ulcer disease, renal dysfunction • Known sensitivity to methotrexate • Relative contraindications • Gestational sac >3.5 cm, embryo cardiac motion • Elevated hCG quant

9. Pregnancy Complications • Abortion (loss of pregnancy <20w) • Threatened – any vaginal bleeding • Inevitable – bleeding plus dilation • Complete – spontaneous expulsion • Incomplete – passage of some tissue • Missed – no expulsion of tissue for 8w • Induced – medical or surgical

10. Pregnancy Complications • Degeneration of leiomyoma • Rapid growth during pregnancy, outgrowing blood supply • If pedunculated, can cause torsion • Increased progesterone • Degeneration sometimes seen on imaging • Supportive care unless torsion or not pregnant

11. Acute Pelvic Pain • Complications of pregnancy • Ectopic, abortion, leiomyoma degeneration • Acute infections • Endometritis, PID, TOA • Adnexal disorders • Hemorrhagic functional cyst, ovarian torsion, torsion of paratubal cyst • Ruptured cyst – functional or neoplastic

12. Acute Infections • Endometritis (postpartum uterine infection) • Fever, abdominal pain, leukocytosis • Vaginal delivery • Overall risk 1%, increased after prolonged labor or rupture of membranes • 13 % risk if chorioamnionitis during labor • Cesarean delivery • Decreased by single-dose pre-op abx • Increased risk with manual extraction of placenta • Treatment – Abx: amp, gent, clinda

13. Acute Infections • Pelvic inflammatory disease • Acute salpingo-oophoritis • Pain, fever, purulent vaginal/cervical discharge • Cervical motion tenderness, adnexal tenderness • Outpatient vs. inpatient mgmt • Inpatient if: acute abdomen, pregnancy, vomiting, no response to PO abx, TOA • http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf

14. Acute Infections • Tuboovarian abscess (TOA) • Sequela to PID • May be palpated on exam, seen on imaging • Treatment with IV abx • Exploratory surgery may be needed, especially if rupture occurs

15. Acute Pelvic Pain • Complications of pregnancy • Ectopic, abortion, leiomyoma degeneration • Acute infections • Endometritis, PID, TOA • Adnexal disorders • Hemorrhagic functional cyst, ovarian torsion, torsion of paratubal cyst • Ruptured cyst – functional or neoplastic

16. Adnexal Disorders An ovarian cyst that is not torsing, rapidly expanding, infected, or leaking does not cuase acute pain

17. Adnexal Disorders • Ovarian cysts – leaking, hemorrhagic • May be mittleschmertz • Similar symptoms as a ruptured ectopic • Increasing abd pain, dizziness if hemoperitoneum • May be a surgical abdomen • Diagnosis: hCG, CBC, ultrasound • Treatment: supportive or surgical

18. Adnexal Disorders • Adnexal torsion • Ischemia from twisting of the vascular pedicle of an ovary, tube, or paratubal cyst • May be constant or intermittent pain • Onset may coincide with physical activity • Diagnosis – sono: rapidly increasing mass • Treatment – surgery, with possible removal • Benign cystic teratoma is most common neoplasm to undergo torsion

20. Non-OB/GYN Acute Pain • GI • Gastroenteritis, appendicitis (can be similar to PID), bowel obstruction, diverticulitis, IBS • GU • Cystitis, pylonephritis, ureterallithiasis • Musculoskeletal • Abdominal wall hematoma, hernia • Other • Acute porphyria, pelvic thrombophlebitis, aneurysm, abdominal angina

21. Sources Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR 2010;59. Comprehensive Gynecology. Stenchever MA editor. Mosby Inc., St. Louis, MO. 2001. Novak’s Gynecology – 13th edition. Berek JS editor. Lippincott, Williams, and Wilkins, Philadelphia, PA. 2002. Williams Obstetrics – 22nd edition. Cunningham FG editor. McGraw-Hill, New York, NY. 2005.