MRCOG PART 2 SBAs and EMQs
| Course PAID | ||
| notes | 336 | |
| EMQ | 1502 | |
| SBA | 2115 | |
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Essay 327: Chronic pelvic pain
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Posted by MR R. |
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| MR A healthy 15 year old school girl attends the gynaecology clinic accompanied by her mother. She gives a 6 months history of pelvic pain and painful periods. (a) Discuss your clinical assessment [9 marks]. I will ask her the nature of thepain,radiation,severity,aggravating or releiving factors.Pain starting on day 1 or 2 and associated with nausea and vomiting can suggest primary dysmenorrhoea.Mid cycle pain can suggest mittelsmersch syndrome.Pain starting premenstrually,with heavy periods and releived by them suggests endometriosis.Pain associated with vaginal discharge and deep dyspareunia can signify underlying pelvic inflammatory disesase(PID).Cyclical pain with mucusy stools and alternating diarrhoea and constipation releived by defaecation can suggest Irritable bowel syndrome.Rectal bleeding with bowel disturbances can suggest Inflammotor bowel disease.Associated features like dysuria,frequency,incomplete emptying can suggest interstital cystitis or Urinary tract infection(UTI).I will ask her age of menarche,length of cycle,duration of bleeding and menorrhagia.I will enquire re sexual history and sometimes young girls might be reluctant to reveal in front of their parents.Therefore it might help especially if the pain is chronic in nature to have a private consultation without the mother.History of sexual abuse shoulld be sought sensitively.Psycological factors or family or social presuure should be identified.I will ask about present contaception and any side effects with them.I will ask about pain releif as this may indicate the severity.I will ask family history of inflammatory of bowel diseses.any significany gynaecological history like treatmeny for PID should be enquired.I will ask about any personal/family history of medical condition like focal migraines,thromboembolism,breast cancer & cardivascular diseases if to start any hormonal treatments.I will ask about smoking, alcohol intake. Genral examination of the patient to identify any anaemia from heavy menstrual blleding.Obvious distress of the patient from pain should be identified.Abdominal examination to elicit any tenderness,mass,gaurding and rigidity.Pelvic examinaton avoided if virgo intacta.However pelvic examination can reveal fixed retroverted uterus with nodules in the uetrosacral ligaments in endometriosis or vaginal endometrisis.Obvious vaginal discharge with adnexal and cervical excitation tenderness in PID.Ovarian cyst/Fibroids their size and location can be picked up.A loaded rectum can signigy constipation.Rectal crohns can be identifies in the parianal region. (b) Discuss and justify your investigations given that clinical examination is normal [5 marks]. A pain diary can be helpful to know th erelation with menstruation.A full blood count can show leucocytosis in PID and anaemia in haevy menstrual loss.CRP and ESR can be elevated in PID.Urine culture can reveal organisms is there is underlying Urinary tract infection.Endocrine profile(LH,FSH,FAI - raised and SHBG - reduced) can suggest anovulatory dysmenorrhoea associated with polycystic ovarian disease.A transabdominal(virgo intacta) or transvaginal ultrasound will he helpful in recognising ovarian cysts,fibroids and endometriomatas.A negative scan can reassure patient.More invasive procedures like laparoscopy and hysterscopy are reserved only for reistant cases not responding to medical therapy in view of the patients age and also the inherent risks with the procedure. (c) Discuss the treatment options given that no underlying cause has been found [6 marks) Longstanding pelvic pain can be difficult to treat.The patient should be approached sensitively.The patient should be given an opputinity to express her concerns.A MDT approach with gynaecologists,pain physician,urologist, surgeons and psycologist should be sought.Simple analgesia like paracetamol and prostacyclin synthase inhibitors taken 24 -48 hours before onset of pain and for the dtration of the pain can help(mefenamic acid 500md tds or ibubrufen 400 md tds)Combined oral contaceptive pillls taken cyclically or continiously for 3 months is said to help 80 % of the patients with primary dysmenorrhoea.Change in dietary habits and lactulose and senna will be helpful for constipation.Psychologist referral for counselling sessions if underlying psycological cause identified.Antispasmodics like mebeverine are very helpful for Irrtable bowel syndrome.Urology and surgical referaal should be sought if there are underlying urological or surgical causes for the pain.Nerve pain can respond to gabapantin and amitrytipilline.Pain clinic referaal should be considered if resistant to medical therapy and no underlying cause has been found.Sometimes when accompanied by mother there could be lot of pressure from the mother to do invasive investigations and these should be restricted unless there is strong clinical suspicion. of any secondary pathology.Investigations like laparoscpy and USS sometimes can be helful for the patients to understand that organic cause for the pain has not been identified.This might help them to come to terms with this.However it should be understood that sometimes they can result inadverent small findings and treatment of these which might not be the primary cause for the pain. |
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Posted by nazia M. |
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| Adequate time for initial assessment of patient to tell her story this is therapuetic also. Good communication between clinician and patient and her mother is important. First ask about pattern of pain: site any pelvic trigger point to exclude nerve entrapment ,severity, continuous or intemittent, any aggravating and relieving factors, radiating to any site, associated to bowel or bladder symptoms to exclude irritable bowel syndrome and interstitial cystitis, any cyclity with menstruation, effect of movement and posture on pain to exclude musculo skeletal pain. Ask about at which day of menstrual cycle pain occur or before menses,duration of cycle,regular or not, amount of bood loss,any vaginal discharge,if sexually active sexual history ask about pain during coitus,condom use,multiple partners or not to exclude PID,endometriosis.Any pelvic surgery to exclude adhesions.whether she has taken any treatment.psychological problems like child or sexual abuse can cause chronic pelvic pain this can be discuss sensitively.any ovulation trigger point for pelvic congestion syndrome.If cyclity of pain related to menses then daily pain dairy for 2 or 3 menstrual cycle. clinical examinations include general physical examination to check any postural problem,neurological examination,abdominal exam to check any pelvic mass,pelvic trigger point or ovulation point.if patient sexually active vaginal exam to check any adnexal mass and tenderness,any nodules in pouch of douglus or in uterosacral ligament.uterus fixed,retroverted,tender any visible nodule in vagina if examination has done during periods,any vaginal discharge.Proper counselling of patient and her mother is done before starting examination. b)Screening for genital infection is done if<25 yr for chylamadia infection from endocervical swab.Transvaginal scan to exclude any adenexal mass (endometrioma or tubovarian)which may not be pick during vaginal examination or patient may not be sexually active to do vaginal examination,dilated pelvic vein due to pelvic congestion can also be excluded.MRI is not routinely done.If patient is suspected of endometriosis,PID or adhesion then laparoscopy should be done treatment can also be done sametime after taking informed consent.although scoring system dont correlate with severity of pain. C)1)Hormonal treatment with cocs,Gnrh analogue.danazole ,progestogens if pain cyclical before doing diagnostic laparoscopy,efficasy of all drugs same but different side effect profiles.2)appropriate anlgesia likeNSAID,can be used if failed then refer to specialist pelvic pain clinic or pain management team.3)complementries therapies,acupunture,diet modification can be tried.4)ihelp from other colleagues like urologist,gastroentrologist,psychotherapist,pschologist sought. c) |
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Posted by L S. |
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| LS: (a) Discuss your clinical assessment [9 marks]. Her history should be explored on timing of pain in relation to menses, defaecation, micturition or movement. The site of pain and its radiation asked. The nature of her pain if it is colicky or constant and if there is associated symptoms like nausea or vomiting when pain occurs enquired. The duration of her pain and its effect on her functional ability enquired. Associated bladder symptoms (frequency, dysuria) or bowel symptoms (alternating constipation and diarrhea) should be explored. The effect of posture and movements on her pain asked. Past abdominal surgical history enquired. Enquire if she has had any previous investigation and treatments, if so what the outcomes were. Symptoms suggestive of life-threatening disease should be excluded like unexplained rectal or vaginal bleeding, sudden severe weight loss or sudden change in her bowel habits. Ask on her sleep and appetite disturbances and if she is feeling tearful to detect psychosocial co-morbid. Her sexual history should be sensitively explored and if there is risk of sexual assault assessed. Her general examination should be carried out, especially her abdomen to detect any abdominal mass and if the abdomen is tender with rebound tenderness and guarding. Pelvic examination need not be carried out if she is not sexually active as any mass in the adnexa can be picked up be an ultrasound of the pelvis. Rectal examination may be indicated in some situations. (b) Discuss and justify your investigations given that clinical examination is normal [5 marks]. Daily pain dairy can be carried out for two to three menstrual cycles. This will help identify provoking factors and understand the cause of her pain. Infection screen via urethral and endocervical swabs can be carried out especially for gonorrhea and Chlamydia if pelvic inflammatory disease is suspected or as an opportunistic screening for Chlamydia in women aged less than 25 who are sexually active. This will help to refer those detected with the infection to the genitourinary medicine (GUM) clinic for optimal care, up to date advice and contact tracing. Mid stream urine for blood, microscopy and culture to rule out urinary cause of her pain should be carried out. Imaging like pelvic ultrasound is used to screen and assess for presence of adnexal masses especially endometrioma but it has little value in other causes of pelvic pain. Magnetic resonance imaging (MRI) can be useful to diagnose adenomyosis or endometriosis, to assess palpable nodules felt on clinical examination or rectovaginal disease and to detect any rare pathology. Diagnostic laparoscopy is considered gold standard but is associated with operative morbidity and could lead to inappropriate management of the cause of her pain. It should only be carried out as a second line intervention when initial therapeutic approaches have failed. (c) Discuss the treatment options given that no underlying cause has been found [6 marks]. An integral approach combining physical and psychological techniques should be used. She should be informed on the multifactorial nature of chronic pelvic pain from the beginning and aim to gain a partnership in the management plan and her progress. Non gynaecologic components which were obtained from her history should be referred to the relevant healthcare member like gastroenterologist, urologist, GUM physician, psychologist, physiotherapist or psychosexual counselor to help her further. Normal imaging finding may reassure her and may be able to manage her pain with simple analgesia. For cyclical pain hormonal therapy with either combined oral contraceptive, progestogens, danazol or gonadotrophin releasing hormone analogues can be used. Each is restricted to their range of side effects but a trial period of three to six months can be attempted before the option of a diagnostic laparoscopy is carried out. If no abnormality is found and all empirical treatment has failed referral to pelvic pain clinic should be considered. |
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Posted by H H. |
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| hhh A sensitive approach in dealing with this teenager is adopted to get a rapport with her. Every chance is taken to obtain history from her in absence of her mother.Will ask her regarding her pain,site,nature and radiation and its relation to her menstrual cycle, occurring mostly in first day of her period(spasmodic dysmenorrhea), all through her period( endometriosis though rare at such age) ,after her period or unrelated to her period(other pathology gynecological or surgical). Will ask of her menstrual cycle, age at menarche, LMP(may be pregnancy related), regularity, amount of bleeding(clots-number of pads). Will ask of her sexual history,frequency, pain during intercourse, number of partners, sexually transmitted infections STI, use of contraception and type, wether she had treatment for STI or she thinks she has STI that need treatment as she noticed offensive vaginal discharge. Will ask if she had any medications to relieve her pain. Will ask of her bowel habits and if there are changes in frequency or consistency of motions (irritable bowel syndrome IBS), bloody stools, loss of weight which might denote inflammatory bowel disease IBD. Will ask of urinary symptoms,urgency,dysuria(interstitial cystitis). Will ask of surgical history (adhesions). Will ask sensitively regarding sexuall abuse. Will do general examination, pulse,BP and temp(pyrexia)and look for bruises, BMI for wt loss. Will do abdominal examination for lower abdominal tenderness(acute PID or cystitis), abdominal mass (fibroid,ovarian cyst,pregnancy), will take consent for local examination (taking fraser criteria in consideration) if sexually active ,will detect presence of vaginal discharge , cervical tenderness,tenderness in both fornices in Acute PID, mobility of uterus,fixity, nodules in douglas pouch (endometriosis), ovarian cyst. Rectal examination if not sexually active. If amenorrhoeic will do a pregnancy test to exclude pregnancy related cause of pelvic pain(ectopic) . FBC and CRP to exclude an inflammatory process. Despite absence of discharge(clinical exam normal) will do Tripple swab,high vaginal,endocervical for Chlamydia and gonorrhea as these might not show symptoms or signs. Urine dipstix for nitrites,and blood to exclude infection (if +ve do culture sensitivity), glucose and ketones . If suspected of having IBS or IBD will need gastroenterology investigations ,proctoscopy or colonoscopy. As clinical exam is normal, ultrasound is not indicated, but if still has pain despite treatment a laparoscopy performed by a consultant might be indicated after proper counseling of risks and benfits. As no underlying cause has been found and the pain is related to her periods ,the patient is explained that this is most likely pain due to menstruation ,what we call spasmodic dysmenorrheal and is due to fact that she started ovulation. Assurance is given to her and her mother and this pain is usually responds to simple analgesics as NSAID like mefenemic acid. If patient does not respond to treatment ,will try to give her COCP after counseling regarding side effects as headache,wt gain and bloatdness, however it will make her menses regular,less painfull and lighter . Psychosexual counseling is needed if suspect sexual abuse and this should be reported to responsible authorities. Follow up appointments needed to see regarding response of treatment and compliance.Written information given and support groups from the net might be helpful. In resistant patients ,acupuncture may help, homeopathy(power of self healing) . Surgery is of no benfit (LUNA laparoscopic uterine nerve ablation or presacral neurectomy, despite the later may have benfit , it associated with much complications) |
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Posted by Ir A. |
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| I will enquire about her age at menarche and the regularity and length of her cycles, any history of heavy menses or intermenstrual bleeding. I will also ask her whether the pain is only during her periods or constantly present. I will enquire about any associated urinary or bowel symptoms. I will take a sexual history in a sensitive manner after asssuring her of confidentiality. If she is sexually active, I will enquire about symptoms of deep dyspareunia, unhealthy vaginal discharge and fever. I will also ask her about contraception. I will take history of any previous surgery. I will ask about the impact of the pain on her quality of life. I will examine her and look for localised tenderness, gaurding or palpable abdominal mass. If she is sexaully active, i will do speculum and vaginal examination and look for cervical excitation, uterine size, mobility, nodularity of uterosacral ligaments and any adnexal mass or tenderness. I would like to take an endocervical swab for chlamydia and gonorrhoea as pelvic inflammatory disease may present with chronic pelvic pain. I will do a urine microscopy and culture as urinary infection may cause similar symptoms. I will order a pelvic ultrasound to rule out any ovarian cyst/endometrioma or tubo-ovarian mass or and submucosal fibroid or polyp. If the symptoms are severe or persistent and o not respond to initial management, diagnostic laparoscopy may be considered to establish the cause of pain. Opinion from gastroenterologist should be sought to rule out other nongynaecological causes of pain like irritable bowel syndrome. If no underlying cause is found, I will reassure her that there is no underlying pathology. The treatment will depend on the impact of pain on her quality of life. I will prescribe NSAIDS like mefanemic acid initially. Combined oral contraceptive pills may be considered with the additional benefits of cycle control and contraception. Psychotherapy and counselling may also benefit the patient. A multidisciplinary team including a pain physician, specialist pain nurse and physiotherapist may benefit the patient. |
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Posted by sonu P. |
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| a) A symptom of chronic pelvic pain in a young girl should should be dealt with sensitively. Atleast a part of consultation should be carried out in absence of the mother with a chaperone present. A history of socio-economic status, age of menarche, regularity of menstrual cycles, severity of dysmenorrhea, heavy periods,smoking,alcohol and drug abuse, whether sexually active or not and presence of vaginal discharge is obtained. I will also enquire about any previous treatment and its response and performance at school. Eliciting a history of psychosocial problems can be challenging and should be done tactfully. There may be an associated history of similar symptom in the mother. A history of sexual abuse takes time and patience. Any symptoms of bowel and bladder involvement like frequency, dysuria, alternating diarrhoea and constipation will help to rule out recurrent UTI, IBS respectively. On examination, any abdominopelvic masses are ruled out. Palpable tender caecum may suggest IBS. If patient is virgo intacta, speculum examination can be omitted but a local perineal examination must be done to look for warts and ulcers. If she is sexually active, a thorough pelvic examination is performed to look for vaginal discharge and swabs are taken for gonorrhoea and Chlamydia; and fornecial mass and tenderness are identified. b) In view of normal clinical examination, an abdominopelvic ultrasound is requested to look for pelvic masses, being aware that it does not pick up endometriosis and mild to moderate PID well. Urine can be sent for gonorrhoea and Chlamydia (NAAT) if she is virgo intacta. If she is sexually active,a triple swab is sent to diagnose STIs. In absence of a clear cause of CPP, a diagnostic laparoscopy may be considered.A standard questionnaire should used to assess psychological well being and quality of life. c) Chronic pelvic pain is difficult condition to diagnose and treat. If no cause is found, sometimes only reassurance may be needed.A trial of NSAIDs initially followed by combined oral contraceptive pill is appropriate. General advice about healthy life style is given including stopping smoking if indicated and regular exercise.If psycho-social problems are elicited,appropriate referral for counseling is done.If sexual or physical abuse is suspected, a multidisciplinary approach including social services and child protection team should be involved.A paediatric referral may be considered as they have more experience in eliciting and dealing with abuse issues. Few complimentary therapy methods for CPP like acupuncture,yoga and meditation should be mentioned in the consultation.Written information and contact details of self-help groups could be invaluable. |
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Posted by Peanut C. |
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| a)Menstrual history is taken which should include age of menarche, cycle length, duration and severity of flow. and last menstrual period. Enquiry is made about the relation of pain to menstrual cycle, its intensity and its effect on her quality of life. History should include gastrointestinal symptoms such as if pain is relieved by defaecation, any change in the frequency, form or appearance of stool to exclude irritable bowel syndrome. Information is obtained about bloody diarrhea and passage of mucus which indicate inflammatory bowel disease as non gynaecological conditions also can present in cyclical manner. History is taken if she has dysuria , frequency and urgency of mictiurition After providing adequate privacy, she should be asked in a sensitive manner if she is sexually active. Possibility of psychosexual abuse is excluded. She should be probed gently about any pressures in the family or at school as social pressures may contribute to the perception of pain. Information obtained regarding the treatments she had received and quality of relief obtained from those treatments. Abdominal examination is performed to exclude palpable abdominal and pelvic masses. Pelvic examination is distressing to the girl and rarely helpful in reaching the diagnosis so should be avoided. b) Investigations include FBC, CRP and ESR which help in the diagnosis of inflammatory bowel disease. Suspicion of inflammatory bowel disease should prompt referral to a gastroenterologist Pelvic ultrasound is helpful in that if normal, it is reassuring and rarely endometriomas can be found in this age group. A diagnosis of primary dysmenorrhoea can be made if ultrasound is normal and after exclusion of gastrointestinal pathology. c) A supportive and ernpalhetic approach to women with dysmenorrhoea makes an important contribution to management Explanation about the etiology of pain like production of prostaglandins along with the provision of simple analgesics such as NSAIDS like mefanamic acid is helpful in relieving the pain. Their intake is associated with GI side-effects . If no contraindications such as migraine or history of venous thromboembolism, COCP may be more appropriate if she is likely to become sexually active in the near future. Diagnostic laparoscopy is indicated only if symptoms are resistant to empirical treatment. Know that this is associated with operative risks and may lead to erroneous diagnosis / treatment for instance symptoms being attributed to minimal endometriosis |
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Posted by Aruna R. |
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| Aruna A healthy 15 year old school girl attends the gynaecology clinic accompanied by her mother. She gives a 6 months history of pelvic pain and painful periods. (a) Discuss your clinical assessment [9 marks]. (b) Discuss and justify your investigations given that clinical examination is normal [5 marks]. (c) Discuss the treatment options given that no underlying cause has been found [6 marks]. Clinical assessment: History: I will elicit the nature, severity of pain and its relationship to menstrual cycle. Pain in the luteal phase and during menstruation associated with heaviness and back pain is suggestive of secondary dysmenorrhoea whereas Primary dysmenorrhoea is with constant pain starting on the day of menstruation and subsides at the end of it. It is associated with nausea, vomiting, diarrhoea and syncope. Bowel symptoms like blood, mucus in the stool with pain suggestive of irritable bowel disease(IBD). Urinary frequency, urgency, loin pain may be due to urinary tract infection. If possible she should be enquired separately about sexual history. Whether she is sexually active, does she have dysperunia or any vaginal discharge. Sexual abuse should be enquired about very sensitively. I will enquire about past pelvic infections and any psyco-sexual problems. I will enquire about contraceptive history including IUCD. Examination: I will rule out abdomino-pelvic mass by abdominal examination. if sexually active I will perform speculum examination to check any abnormal discharge and do bimanual examination to assess the size of the uterus and cervical motion tenderness. If any associated bowel problems surgical opinion is very helpful. Fistula and ulcers in the perineum may be suggestive of inflammatory bowel disorders. Investigations: Full blood count (FBC), CRP may reveal leucocytosis and high CRP . This may be due to pelvic infections. High vaginal swab, endocervical swabs for chlamydia and gonorrhia. Pelvic ultrasound to rule out ovarian cysts, and fibroids. Psycologist or psycosexual specialist assessment in case of psyco-sexual problems.Colonoscopy with surgeons to rule out IBD. Urine analysis and urine culture to rule out urinary infections. Primary dysmennorea is a diagnosis of exclusion. If all this are negative than this could be due to Primary dysmennorea. Treatment options: Simple analgesics like paracetamol and codeine are helpful .If not Non-steroidal anti-inflammatory drugs (NSAIDS) are used to ease the pain. Combined oral contraceptives used 3 monthly may relieve the pain. Depot medroxy progesterone injections may cause amenorrhoea and helps to ease of the pain. Complementary therapies like ( TENS) Transcutaneous nerve stimulation, acupuncture , relaxation therapy can also be tried. Psycologist referral and good counselling will also be beneficial. |
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Posted by S V. |
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| SV A healthy 15 year old school girl attends the gynaecology clinic accompanied by her mother. She gives a 6 months history of pelvic pain and painful periods. (a) Discuss your clinical assessment [9 marks]. Clinical assessment should include a history of duration of pelvic pain ,its nature and radiation. Age of menarche, menstrual regularity and severity of dysmennorhoea (days off school)should be established.Enquiry about factors like relation of pain to menstrual periods with deep dyspareunia(if sexually active),dysmennorhoea indicates endometriosis.Pelvic pain associated with vaginal discharge wuld indicate PID.Association with bowel problems like constipation alternating with diarrhoea and passing mucus would indicate inflammatory bowel disease .Urinary frequency with dysuria and nocturia and suprapubic pain would point to interstitial cystitis. If sexually active, take a sexual history to exclude risk of STIs .There might be hidden agendas like stress at home or school pressures which should be ruled out if possible without mother at the consultation. Sensitive enquiry of sexual abuse as it is associated with chronic pelvic pain . (b) Discuss and justify your investigations given that clinical examination is normal [5 marks]. Bloods for FBC and CRP to rule out an inflammatory processes.A urine dipstick to check for blood, nitarates, MSU to exclude UTI and investigate for chlamydia and gonorrhoea by NAAT if the patient is a virgin.If the patient is sexually active, endocervical and vaginal swabs to rule out STIs as most are asymptomatic. A pain diary would help in charting symptoms in association with other factors and to monitor improvement Pelvic ultrasound is not sensitive for peritoneal endometriosis but is helpful in ruling out ovarian endometriomas.MRI is useful for investigating for endometriosis / adenomyosis. (c) Discuss the treatment options given that no underlying cause has been found [6 marks]. Management for dysmennorhoea should start with an explanation of cause of pain symptoms i.e prostaglandins.Suppression of prostaglandins with NSAIDs or antiprostaglandins like mefenamic acid is effective. Side effects like gastric symptoms should be mentioned.The combined oral contraceptive pill is also effective in reducing dysmennorhoea and for endometriosis. Laparoscopy only in resistant cases and should be second line treatment as it is associate with increased operative morbidity.Ablation of endometriotic lesions will improve symptoms in mild to moderate endometriosis. Psychosexual counselling and support group information if history of sexual abuse helps patients. UTIs should be treated and if IBS/Crohns, refer to the gastroenterologist. Reassurance to patient and mom should in majority of cases improve symptoms.In very extreme cases, where pain persists with all investigations being normal, the patient may benefit from a pain clinic. |
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Posted by VINITA N. |
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| VN A healthy 15 year old school girl attends the gynaecology clinic accompanied by her mother. She gives a 6 months history of pelvic pain and painful periods. (a) Discuss your clinical assessment [9 marks]. (b) Discuss and justify your investigations given that clinical examination is normal [5 marks]. (c) Discuss the treatment options given that no underlying cause has been found [6 marks]. A) chronic pelvic pain in a 15 year old can cause significant morbidity and affect her social and personal development. She should be approached in a sensitive manner giving enough time to tell her story. She should be asked about her periods in depth i.e, when did she attain menarche, what is the duration, are they heavy, has she noticed any change in the pattern of her periods. Next she should be asked to ellaborate about painful periods, whether the pain starts before her periods and stops in a day or 2 with onset of periods signifying primary dysmenorrhoea,this could be ovulatory cycles. does the pain start after the onset of period and lasts till her periods which is secondary.She should be asked if she has any pain midcycle again signifying ovulatory cycles. Next other causes for pain should be sought for like bowel related, she should be asked for colicky nature of pain being relieved by opening bowels, any alteration in pattern of defecation and type of stools which could point towards irritable bowel syndrome. urinary symptoms like dysuria, suprapubic pain could be related to interstitial cystitis. She unlikely would have had any surgery to cause neuropathic pain as she is a healthy 15 year old, however important to rule out any neuropathic or muscular cause for the chronic pain. She should be sensitively and in private asked about sexual history, previous history of pelvic inflammatory disease in her or partner and also regarding contraception if sexually active.She should also be enquired about sexual or emotional abuse in a sensitive manner. Examination includeschecking for pallor which could be due to heavy periods. abdominal examination to note site of pain and ask about radiation of pain with relieving and aggravating factors. If sexually active, vaginal examination looking for size of uterus as fibroids can cause dysmenorrhoea, adnexal tenderness and pain during cervical excitation could suggest PID. B)Blood test like full blood count and crp to check for inflammatory markers could point towards PID, low haemoglobin could be related to heavy periods. Urine dipstick could show urinary infection and blood and casts in urine could point towards interstitial cystitis. If sexually active endocervical swabs for chlamydia and gonorrhoea should be obtained. Ultrasound may be useful to show any structural abnormality but more importantly will reassure her if normal. Laparoscopy should only be used in after first line treatment fails and she should be counselled about the risks of the procedure and also possibility of negative laparoscopy. C)REassurance that nothing is wrong is in itself therapeutic and she might be happy not go ahead with any other treatment. If she does want some treatment, simple analgesics like paracetamol, mefenamic acid can be taken during painful periods. If pain does not settle, contraceptive pills after ruling out any contraindication for them, may be considered which help by causing anovulatory cycles. It is possible to have multiple cause for the pain and sometimes may need the help of the pain clinic and also psychologist and therefore in refractory cases should be managed by a multidisciplinary team. |
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Posted by A A. |
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| AA a: Pelvic pain should be seen as symptom with number of contributory factors rather than as diagnosis Pelvic pain can be due to gynecological, nongyncological, or psychiatric disorder. I will give adequate time for initial assessment and ask her ideas about her symptoms and to elicit the impact of her symptoms on her quality of life. Pattern of pain whether continuous or intermittent, colicky in nature, location of pain and its radiation, duration and in relation to menses give clue for cause of pain. Pain associated with nausea vomiting constipation alternating with diarrhea due to irritable bowel syndrome. Dysuria frequency and urgency due to urological cause. I will find effect of movement and posture on pain. I will ask about menstrual cycle regularity, duration and amount of bleeding. Enquire about painful period since menarche or new onset. Any history of vaginal discharge, treatment taken for pelvic infection .history of any abdominal surgery can be cause of adhesions causing pain. When situation allows me by maintaining confidentiality and in sensitive way ask about sexual history, use of contraption and her wishes to use. History of sexual abuse. Ask about social life or any stressful events. Symptoms suggestive of life threatening should be identified like rectal bleeding weight loss, suicidal ideation. Clinical examination for pallor general wellbeing. Per abdomen for abdominal tenderness rebound tenderness, abdominal distention or any scar marks. Pelvic examination only in sexual active otherwise not recommended. b: Daily pain diary for 2 to 3 menstrual cycle will identify pain provoking factors. Full blood count ,c reactive protein elevated in IBD and may identify in inflammatory process. Urine dipsticks for blood and culture should send .abdominal ultrasound can identify fibroid and endometriomas and normal scan may reassure the patient. MRI is useful in identifying deeply infiltrating endometriosis and avoids surgical complication of laparoscopy. Diagnostic laparoscopy only if empirical treatment failed and symptoms persist, but risk of laparoscopy and anesthesia explained. C: If investigations are normal and her symptoms mild no treatment required only reassure her. Non-gynecological causes need referral to relevant specialist such as gastroenterologist, urologist, physiotherapist and psychologist. NSAIDS like mefenamic acid and COCP are effective and first line therapies for primary dysmenorrhoea. Danazole, gestrinone and GnRH analogues are equally effective in relieving pain but of limited use due to side effects. Persistence pain can be managed in multidisciplinary approach and in pain clinic. |
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Posted by Bee N. |
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| A healthy 15 year old school girl attends the gynaecology clinic accompanied by her mother. She gives a 6 months history of pelvic pain and painful periods. (a) Discuss your clinical assessment [9 marks]. (b) Discuss and justify your investigations given that clinical examination is normal [5 marks]. (c) Discuss the treatment options given that no underlying cause has been found [6 marks]. (BEE) A) Due to her age and the possibility of sexual abuse, I will rather take a History with the patient alone. I will take a history of (exactr location, severity,frequency and duration of pain when it occurs and ask about nature (constant or colicky type) to have an idea if it is bowel or reproductive organ related. I will ash about associated sypmtoms. If relieved with defeacation, may be irritable bowel syndrome. If associated with intercourse, may be due to endometriosis. Iwill enquire about presence of urinary symptoms such as suprapubis dyscomfort while urinating, urgency and frequency( interstitial cystitis). I will ask if the pain is worse on movement which may suggest a musculoskeletal origin. I will ask for previous history of pelvic inflammatory disease or past abdominalor pelvis surgery which may suggest adhesions. i will then enquire if sensitively if she has had any form of sexual abuse which may be a cause of her pain. I will take a menstrual history as amennorrheoa could lead to suspicion of pregnancy of even uterine synechiae. I will ask about menorrhagia and frequency of periods to find out if she has polycystic ovarian syndrome..I will ask her what medications she has used so far for treatment and if she has seen any other doctor for this problem to know what has been done for her so far. I will then examine her generally to find any signs of physical abuse such as bruises. I will examine her abdomen for tenderness or masses. I will inspect her vagina with consent of her parent or guardian but avoid an internal examination if she is virgo intacta. If she is not a virgin and internal pelvic examination allowed, a fixed uterus or palpaple nodules at the uterosacra ligaments will suggest endometriosis. I will feel the adnexa for masses (endometrioma) and do cervicakl excitation as well observe for any vaginal discharge. I will take endocervical swabs for chlamydia and gonococcus and a high vaginal swab. I will advice the patient that a pain dairy to map occurence and relationship of pain to activities will be useful.I will take urine for culture to rule out infection (UTI). I will take bloods for FBS, CRP which may show evedence of infection and LFT, E&U to rule out kidney or liver pathology. Pelvic USS (transabdominal if a virgin) will be useful to find out presence of masses in the pelvis. Laparoscopy will be done only as a second line of investigation and is gold standard for investigation. B) Patient usually should be managed in a multidisciplinary setting consisting of gynaecologist, urologist, gastroenterologist, pain specialists, general practitioner. I will listen carefully to what she thinks is the cause of her pain and take it on board while counselling. Discussion should be sensitive knowing that I need patient to be able to confide in me. I will reassure her with all negative results. I will start her on an emperical treatment with combined oral contraceptive pills since it may still be related to her periods despite nothing being found. I will consider trying her on simple analgsia like non steriodal antiinflammatory drugs bearing in mind that it has limited value in management of chronicpelvic pain. I will also refer her to the pain team for further management of her pain. I will write to her GP to inform about managementand follow up. |
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Posted by Chitra.s M. |
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| A.History of the nature of pain,any radiation ,relation to menstrual cycle-whether constant ,menstrual exacerbation is enquired.Effect on quality of life(loss of school days) is asked about.Any history of associated bowel/bladder symptoms like constipation/diarrhoea, frequency and bladder pain noted.Effect of movement and posture on pain is asked.Menstrual history is asked to note the age of menarche, regularity, menstrual loss,cycle length and LMP.Ensuring privacy, history of sexual activity, number of partners ,contraceptive use and any vaginal discharge is enquired about.Possible history of sexual abuse is enquired sensitively.Details of any previous investigations and treatment taken is noted. She is examined to note her BMI,pulse , BP and temperature.Abdominal examination is done to look for any mass and tenderness.Vaginal/rectal examination is not done if she is not sexually active. Vaginal examination is considered if she is sexually active and consents for the examination.Presence of discharge,cervical motion tenderness, uterine tenderness,adnexal mass and tenderness are looked for. B. Full blood count and CRP/ESR is done for evidence of infection(pelvic inflammatory diseases, inflammatory bowel disease).MSU sample is tested for evidence of urinary tract infection.Pelvic Ultrasound , if normal ,is reassuring as finding of pathology like endometioma is rare in the girl\'s age group. If she is sexually active ,vaginal and endocervical swabs are taken to detect chlamydia and gonococcal infection.She is asked to keep a pain dairy for 2-3 months to help identify any provoking factors.Diagnostic laparoscopy is considered only if no cause is found and inadequate/ no response to treatment ,after counselling about the serious risks associated with laparoscopy and that the findings may be negative. C. The girl is informed that the most probable diagnosis is dysmenorrhea since no underlying cause has been found.Her views regarding pain management are taken into consideration while forming a management plan.Analgesics like NSAIDs(mefanamic acid,ibuprofen) may help relieve the pain.They are associated with side effects like nausea.Combined oral contaceptive pills or progestogens are effective and can be used if there are no contraindications .COCPs are also useful if contraception is required(gillick competence is assessed).Non pharmacological methods like transcutaneous nerve stimulation,acupuncture and other complementary therapies can be tried to relieve pain.Psychological support and support groups may be of value.Referral to pain management team is considered if pain is not adequtely controlled with the above measures. |
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Posted by millionaire2004 A. |
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| AG. A healthy 15 year old school girl attends the gynaecology clinic accompanied by her mother. She gives a 6 months history of pelvic pain and painful periods. (a) Discuss your clinical assessment [9 marks]. This girl has chronic pelvic pain (CPP). CPP is multifactorial in origin and this should be explored from the initial consultation. Make effort to see the girl alone (with chaperone) without presence of her mother. Establish from the girl herself whether there is actually a problem. History is essential and her thoughts and believes of her pain need to be addressed. Ask about nature of pain (colicky,burning,stabbing). Organic pain are usually colicky whereas neuropathic pain can be highly localised,stabbing or shooting in nature. Ask about pain radiation as dysmenorrhea can radiates to the thigh. ask about site of pain. Suprapubic pain in gynaecological or urological pain while periumbilical pain may be refferred pain from terminal ileum/colon. Relationship of pain to her menstrual cycle is important. Pain that increased during menstruation may suggest endometriosis or gynaecological cause of pain.Pain aggravated by movements may indicate musculoskeletal in origin. Pain relieeved by defecation may suggest irritable bowel syndrome (IBS). Ask about associated symptoms. Nausea and vomiting can occur in severe dysmenorrhea. Change in bowel habits and consistency of stool, passage of mucuos per rectal,abdominal bloating may suggest IBS. Ask about urinary frequency,urgency,nocturia,dysuria, which may suggest urological cause of pain. If she is sexually active, a history of per vaginal discharge may suggest pelvic inflammatory disease. Sensitively ask about history of sexual abuse or current intimate partner sexual violance. Enquire about school performance, her relationship with others and her daily living activities in order to identify any stress factors leading to pain. Look out for any life threatening signs such as suicidal ideation which need attention. Perform a general examination. Measure body mass index and examine for development of secondary sexual characteristics. Look for signs of physical abuse. Perform abdominal examination looking for abdominal distention/mass (suggest pelvic pathology). If appropriate, perform speculum examination looking for vaginal discharge and presence of vaginal septum. Urethral and endocervical swabs may be taken for chlamydia. Do Pelvic examination assessing uterine size,shape,mobility,tenderness and presence of any adnexal mass. Enlarged uterus with presence of vaginal septum suggest haematometra/haematocolpus. If vaginal examination is inappropriate, do a per rectal examination instead. (b) Discuss and justify your investigations given that clinical examination is normal [5 marks]. Do urine dipstick and urine for culture and sensitivity to rule out urinary tract infection. Urethral and endocervical swabs to detect chlamydia or gonorrhea. however, presence of chlamydia is not diagnostic of PID and the absence does not rule out PID. Cystoscopy may be considered to rule out interstitial cystitis. Full blood count and CRP done to look for evidence of inflammatory process. Pelvic ultrasound may not be so useful when clinical examination is normal. However, clinical examination and ultrasound can not detect endometriosis and adenomyosis reliably. MRI may be considered. Diagnostic laparascopy is gold standard but better reserved as a second line investigation if initial treatments fails. It is associated with anaesthesia and operative morbidity. Colonoscopy may be considered if history is suggestive of GIT cause. However, IBS can be diagnosed with high accuracy with clinical criteria. Laparascopic pain mapping is new, and it\'s acceptability, reproducibility is of concern. (c) Discuss the treatment options given that no underlying cause has been found [6 marks]. Treatments starts with explaining to the patient and her mother regarding multifactorial origin of CPP. Any concerns and her belief regarding her pain need to be listened to. Reassurance is all that is sometimes needed. Oral analgesia is appropriate. Prostaglandin synthetase inhibitors such as ibuprofen may be effective. if her mentrual cycles are irregular, progestogens (norethisterone) 5mg daily can be given from day 15-25 of her menstrual cycle. It can help to regulate her menses and relieve pain. Combined oral contraceptive pills can be considered. It helps to relieve pain and regulate menstrual cycle.However, it may not be so acceptable in a young girl. It may be more appropriate if the patient is sexually active as it can also provide contraception. Antidepressant may also be helpful but liase with psychiatrist. Diagnostic laparascopy alone without adhesiolysis has been shown to improve pain score in patients. it helps by changing patients believe about her pain. Refer her for councelling if appropriate ( to psyco-sexual councellor in sexually abused patient). Consider involving child protector if current sexual abuse is suspected of life threatening signs present. Refer for stress management. Arrange follow up visits to assess her pain and progress in treatment. |
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Posted by zara A. |
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| a]A sympathetic approach should be taken toher and her mother considering their anxiety,develop good rapport ,some issues like sexual abuse and social problems should be discussed in isolation.Primary dysmenorrhoea is most likely diagnosis,but need to exclude underlying physical and pshycosexual causes of pain.History of pain should be taken,ask patient to tell her story and beliefs about pain,directed questions asked about site, nature of pain [stabbing,colicky],intermitent or continuous,radiation,aggravating and relieving factors.Menstrual | ||
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Posted by zara A. |
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| menstrual history should betaken age of menarche, LMP ,REGULARITY of cycle ,length of cycle,amount of bleeding,[menorrhagia indicate fibroid],relation of pain with menstrual cycle should be established,the pain starting before menstrual cycle and relieved with menstruation indicate primary dysmenorrhoea,PAIN which worsens on menstruation indicate endometriosis.Effect on quality of life should be assesed like abstinence from school and pain affecting social functioning.Bowel symptoms should be asked ,wt loss ,bloody diarrohea with passsage of mucous indicate inflammatory bowel disease,change in frequency and form of stools ,and pain relieved on daefecation indicate irri table bowel syndrome.Bladder symptoms like frequency,urgency,and burning micturation should be asked.Ask about of previous surgery[adhesions can cause pain].Ask about sleep and appetite[to exclude pshycological problems].She should be asked about association of pain with move ment[musculoskeltel].She should inquired about previous treatment taken,what was effect of treatment ,any sideeffect.Ask senstively in isolation about sexual activity and whether consensual ,no of parteners, or sexual abuse ,she should asssured of confiedentiality if consensual but not in case of sexual abuse.Assess her need for contraception and her competency to give consent [GILLICKS COMPETENT].Rule out any contraindication to contraception like migrane.HISTORYof vaginal discharge and dyspareunia should be noted .Social history should betaken smoking ,any pressure from family,social problems ,any fears.Examination should bedone ,note her attitude,posture.PALLOR should looked[indicate menorrhagia].abdominal examination for scars ,distension,any mass,gaurding.Perineal examination done to look for scars fistula[inflammatory bowel disease.Sign of sexual abuse noted .SPECULUM examination and bimanual examination should be done if sexually active,other wise not indicated,to look for discharge,on bimanual uterine size ,any adenexal tenderness or mass,cervical motion tenderness,fixed retroverted uterus and nodules indicate [endometriosis].b]The investigations are indicated if atypical symptoms or previous treatment failure,with typical primary dysmenorrhoea not indicated.PATIENT asked to mantain pain diary for 2 to3 months to look pattren of pain.ESR ,FBC ,AND CRP done ,if raised indicate underlying inflammatory disorder.CA125 if raised indicate patient which can get benefit from early laproscopy.TRANSABDOMINAL PELVIC or tvs done depending if sexually active ,noninvasive,can detect pathology like fibroid,uterine anamoly ,endometrioma.Even if negative then reassure pt.BUt cannot detect peritoneal endometriosis.MRI noninvasivecan detect pelvic pathology but expensive can miss peritoneal disease.Laproscopy indicated if atypical symptoms and in resistent cases if treatment failure,as second line of investigation,can be therapeutic if endometriosis ,and helps to develop patient beliefes about pain.Patient should be counselled about complications of laproscopy and possibility of negative laproscopy.Irritable bowel disease and even some endometriosis can be missed on laproscopy.c]Explanation and reasssurance that no sinister pathology and normal physiology ofmenstrualcycle should be explained .Supportive attitude adopted.patient should be managed in specialist pain clinic with integrated approach.NSAID LIKE mefenamic acid or ibuprofen can be prescribed ,will be effective if started 1t0 2 days before mestruation and taken during menstruation.associated with GIT side effects.COX 1 AND COX 2 can also be given asssociated with less side effects.Alternative therapies like TENS and acupuncture can be considered.OCPS are effective can be give monthly or tri cycling can be done ,will be suitable if contraception needed ,but before assess gillicks competency.Arrange follow up.Provide information leaflets and support group addresses.inform GP. | ||
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Posted by NIRMALA M. |
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| (a) I will approach her with sympathy and elicit history regarding her pelvic pain about onset, location which gives a clue about origin of pain, character (dull aching represents visceral and non norceceptive pain presents as intense, sharp), severity, radiation, aggravating, relieving factors and whether it is related to menstrual cycle or not as non cyclical pain is unrelated to gynae pathologies and how does it affect her quality of life. Detailed menstrual history whether pain starts with the start of menstruation as in primary dysmenorrhoea or pain starts before menstruation and becomes better after onset of menstruation as in secondary dysmenorrhoea for example in endometriosis, pelvic inflamatory disease. I will also ask whether her periods are regular to know whether ovulatory or anovulatory cycles, any history of menorrhagia (as in DUB, endometriosis, PID), inter menstrual bleeding (as in chlamydia and polyps), any post coital bleeding if sexually active (any cervical pathology), dyspareunia (as in endometriosis and chronic PID). I will ask about presence of foul smelling or abnormal vaginal discharge in between periods, whether any urinary symptoms like burning micturition, increased frequency and rule out any bowel problems. If sexually active, I will deal in a sensitive way regarding her relationship whether stable, number of partners in previous six months, whether using any contraceptive methods especially along with barrier methods. I will rule out any past history of pelvic inflammatory disease, termination of pregnancies, STIs. I will exclude any previous abdominal surgeries like appendicectomy or ovarian cystectomy to rule out adhesions. I will ask her whether she is a smoker, alcoholic and use illicit drugs. I will also make sure that any psychological issues like depression, sexual abuse and domestic violence not been missed. I will proceed with abdominal examination to elicit site of tenderness, guarding, rigidity and to exclude any abdomino-pelvic masses. I will do a speculum examination with consent and chaperone to exclude any cervical lesions. I will finally do vaginal examination to exclude any uterine mass like fibroid and adenomyosis and to exclude any adnexal mass like endometriotic cysts, pyosalpinx and rule out any fornicael tenderness and cervical excitation as occurs in endometriosis and PID. (b) I will do oppurtunistic screening for chlamydia and gonorrhoea after getting consent and explaining her in case of positive result, her partner should be treated as well. I will do urine analysis if positive for leukocytes and nitrites, I will send for MSU. If urine positive for haematuria, I will arrange for cysto urethroscopy to rule out interstitial cystitis, Kidney function tests, IVU. I will do bloods like FBC and CRP |
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Posted by NIRMALA M. |
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| (a) I will approach her with sympathy and elicit history regarding her pelvic pain about onset, location which gives a clue about origin of pain, character (dull aching represents visceral and non norceceptive pain presents as intense, sharp), severity, radiation, aggravating, relieving factors and whether it is related to menstrual cycle or not as non cyclical pain is unrelated to gynae pathologies and how does it affect her quality of life. Detailed menstrual history whether pain starts with the start of menstruation as in primary dysmenorrhoea or pain starts before menstruation and becomes better after onset of menstruation as in secondary dysmenorrhoea for example in endometriosis, pelvic inflamatory disease. I will also ask whether her periods are regular to know whether ovulatory or anovulatory cycles, any history of menorrhagia (as in DUB, endometriosis, PID), inter menstrual bleeding (as in chlamydia and polyps), any post coital bleeding if sexually active (any cervical pathology), dyspareunia (as in endometriosis and chronic PID). I will ask about presence of foul smelling or abnormal vaginal discharge in between periods, whether any urinary symptoms like burning micturition, increased frequency and rule out any bowel problems. If sexually active, I will deal in a sensitive way regarding her relationship whether stable, number of partners in previous six months, whether using any contraceptive methods especially along with barrier methods. I will rule out any past history of pelvic inflammatory disease, termination of pregnancies, STIs. I will exclude any previous abdominal surgeries like appendicectomy or ovarian cystectomy to rule out adhesions. I will ask her whether she is a smoker, alcoholic and use illicit drugs. I will also make sure that any psychological issues like depression, sexual abuse and domestic violence not been missed. I will proceed with abdominal examination to elicit site of tenderness, guarding, rigidity and to exclude any abdomino-pelvic masses. I will do a speculum examination with consent and chaperone to exclude any cervical lesions. I will finally do vaginal examination to exclude any uterine mass like fibroid and adenomyosis and to exclude any adnexal mass like endometriotic cysts, pyosalpinx and rule out any fornicael tenderness and cervical excitation as occurs in endometriosis and PID. (b) I will do oppurtunistic screening for chlamydia and gonorrhoea after getting consent and explaining her in case of positive result, her partner should be treated as well. I will do urine analysis if positive for leukocytes and nitrites, I will send for MSU. If urine positive for haematuria, I will arrange for cysto urethroscopy to rule out interstitial cystitis, Kidney function tests, IVU. I will do bloods like FBC and CRP |
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Posted by NIRMALA M. |
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| a) I will approach her with sympathy and elicit history regarding her pelvic pain about onset, location which gives a clue about origin of pain, character (dull aching represents visceral and non norceceptive pain presents as intense, sharp), severity, radiation, aggravating, relieving factors and whether it is related to menstrual cycle or not as non cyclical pain is unrelated to gynae pathologies and how does it affect her quality of life. Detailed menstrual history whether pain starts with the start of menstruation as in primary dysmenorrhoea or pain starts before menstruation and becomes better after onset of menstruation as in secondary dysmenorrhoea for example in endometriosis, pelvic inflamatory disease. I will also ask whether her periods are regular to know whether ovulatory or anovulatory cycles, any history of menorrhagia (as in DUB, endometriosis, PID), inter menstrual bleeding (as in chlamydia and polyps), any post coital bleeding if sexually active (any cervical pathology), dyspareunia (as in endometriosis and chronic PID). I will ask about presence of foul smelling or abnormal vaginal discharge in between periods, whether any urinary symptoms like burning micturition, increased frequency and rule out any bowel problems. If sexually active, I will deal in a sensitive way regarding her relationship whether stable, number of partners in previous six months, whether using any contraceptive methods especially along with barrier methods. I will rule out any past history of pelvic inflammatory disease, termination of pregnancies, STIs. I will exclude any previous abdominal surgeries like appendicectomy or ovarian cystectomy to rule out adhesions. I will ask her whether she is a smoker, alcoholic and use illicit drugs. I will also make sure that any psychological issues like depression, sexual abuse and domestic violence not been missed. I will proceed with abdominal examination to elicit site of tenderness, guarding, rigidity and to exclude any abdomino-pelvic masses. I will do a speculum examination with consent and chaperone to exclude any cervical lesions. I will finally do vaginal examination to exclude any uterine mass like fibroid and adenomyosis and to exclude any adnexal mass like endometriotic cysts, pyosalpinx and rule out any fornicael tenderness and cervical excitation as occurs in endometriosis and PID. (b) I will do oppurtunistic screening for chlamydia and gonorrhoea after getting consent and explaining her in case of positive result, her partner should be treated as well. I will do urine analysis if positive for leukocytes and nitrites, I will send for MSU. If urine positive for haematuria, I will arrange for cysto urethroscopy to rule out interstitial cystitis, Kidney function tests, IVU. I will do bloods like FBC and CRP to know any ongoing infection and to keep it as baseline. I will request for an USS abdomen and pelvis to rule out any impalpable mass lesions of the uterus and adnexae. Pelvic venography can be done if highly suspicious of venous congestion. Pain mapping of ilioinguinal and iliofemoral nerve can be considered if facilities are available. If all the above investigations are normal, diagnostic laparoscopy can be done after detailed discussion with the patient and her mother regarding the risks and inability to find out a cause if they are anxious to know the cause and the benefits of treating adhesions and endometriosis if present. (c) Treatment options should be made in partnership with the patient after exploring her concerns and expectations about her pain. All her doubts and false beliefs should be addressed. The aim of treatment is to relieve the pain and to improve the quality of the life. From her history and investigations, its more likely that she has primary dysmenorrhoea, however it could not be the cause for chronic pelvic pain. The treatment options are pharmacologic and non pharmacologic methods like physiotherapy, psychotherapy and alternative methods. Pharmacologic methods include NSAIDs with or without opiods as combination of these have additive effect. Slowly step up the analgesics as dictated by the pain. COC pills can be started. The pain should be dealt with multi disciplinary team like psychologists, pain specialists, physiotherapists, if uncontrolled with analgesics. Exercises, cognitive behavioural therapy, dietary modifications including well nourished diet, TENS, avoidance of alcohol, stopping smoking helps in symptomatic improvement. Explore whether her family is supportive any offer social services help if needed. Offer her information leaflets about pelvic pain, dysmenorrhea which helps her understand her problem well. Give her information about support group network like THE SHE TRUST. |
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Posted by A- N. |
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| Clinical assessment; I would take a detailed history of pain such as location, type of pain, aggravating and releaving factors, radiation of pain in relation to menustral cycle. If the pain starts with the menustral cycle and subsides once bleeding stops the disgnosis of primary dysmenorrhea is probable. If pain preceeds menustration and relieved by start of bleeding, could be due to pelvic pathology such as endometriosis this may be associated with factors as dyspaerunea, pelvic inflamatory disease which may also have associated factors as discharge per vaginum. history of previous surgery and pelvic infections may suggest the pain is due to adhesions, this is non cyclical and dull with no localising factors. Bowel symptoms such as alternating constipation and diahorrea, releaved by defecation may suggest irritable bowel disease. urinary symptoms as pain and burning during micturation, urgency, frequency, reccurrent UTI like symptoms may be due to urinary tractr infections or interstiatial cystitis. Past history of sexual abuse may point towards the psycho sexual cause being the cause of chronic pelvic pain. heavy periods with pain that is more during the periods may suggest fibroids being cause of pelvic pain. examination including checking for anaemia which may beassociated with heavy bleeding and may be seen in fibroids. abdominal examination for surgical scars suggesting previous surgeries and hence adhesions as a cause of pelvic pain. to check for pelvic masses which may be due to large fibroids or endometriomas. pelvic examination done when there is suspicion of pelvic pathaology as endometriosis, PID in endometriosis, the examination may be painful, with palpable nodularity over the uterosacral ligaments, tenderness in adnexia or when moving the cervix, these signs may also be seen in chronic pelvic inflamation but may be associated with vaginal discharge. she should be given good explaination regarding the possible causes and also to explain what she thinks being the cause of pelvic pain. good communication, listining, explaining in detail that there is a possibality that no cause may be found after full investigations are important. complete psychological assessment is essentialwhich may be the precipitating cause. b) investigations: I would do a full blood count to rule out anaemia which may suggest there is heavy periods thus may be seen in fibroids. the raised white cell count may suggest infection as pelvic inflamatory disease being cause of pelvic pain. high vaginal swab to check for trichomoniosis, endo cervical, uretheral swabs it identify gonoccoal and chlamydial; infections causing PID and thus pelvic pain. trans abdominal or transvaginal ultrasound examination to identify pelvic pathology as fibroids, oraviran cysts endometrioma in particular, which may nbot be detectable clinically. diagnostic laparoscopy will help in the detection of ebndometriosis, adhesions or sometimes chronic pelvic infection being cause of pelvic pain. it will also help in diagnosis of ovarian cysts such as endometrioms causing the pelvic pain. even if the laparoscopy is negative will go a long way in reassuring the women that no organin pathology is present. however it is associated with risks including anaesthetic risks, bowel, bladder and vascular injury. urine microscopy and culture and sensitivity will help in diagnosisn the urinary tract infections. Cystoscopy will help in diagnosis of interstitial cystitis. c) the management approach should include multidisiplinary team including gynaecologist, physiotherapist, gastro enterologist/colorectal team, pain management team and if required a psycho sexual counseller. Intially non steriodial anti inflamatory drugs may be used to control pain following which analgesics may be used in WHO ladder pattern. simple paracetamol may suffice in some patients, in some non opiodes may be required, in others opiodes may be required. oral contraceptive pills for 3-6 months may be help ful especially in endometreiosis where this may lead to good pain control additional advantage may be in decreasing blood loss thus helping in anaemea and in regulating cycles. mefanamic acid 500mgs tds during periods will relive pain in 30-40% of cases other mode of treatment are physiotheraphy, vitamin B1, herbal remedies,there is no roboust evidence that these helps. surgical options including cervical dialation, sacral neuronectomy have minimal effect in releaving pain. |
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Posted by Bgk H. |
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| bgk a. I will approach in sensitive and non-judgemental manner. I will give opportunity for the patient to be alone during consultation. The aim is to identify the cause that may be gynaecological and non-gynaecological in origin. I will start by asking about the nature of the pain. Relation of the pain to menstruation as pain start just before menses and ends after completion of menses may suggest endometriosis. I will also ask about vaginal discharge that may suggest pelvic infection. Intermittent, colicky type of pain at the loin and groin area may suggest urinary tract in origin. Association with bowel symptoms such as constipation, diarrhoea, change of stool consistency may suggest irritable bowel symptoms. The severity of the pain should be asked and effect on her quality of life need to be determined. I will enquire sensitively about her sexual history. Any history of sexual assault may also present with chronic pelvic pain. If she is sexually active, method of contraception need to be asked. I will ask the number of parner she has. Her partner status should be asked whether he has multiple partner and any sexual transmitted disease. Her menstrual history need to be asked. Regularity of her menstruation and amount of menstrual loss need to be asked to rule out any menorrhagia. Her previous medication taken for the pain need to be asked. On clinical examination, general wellbeing of the patient needs to be assessed. I will perform abdominal examination to detect any palpable mass. I will also perform speculum examination if she is sexually active and take high vaginal swab if there is any discharge seen. Vaginal examination can also elicit any adnexal tenderness and cervical excitation and if present may suggest pelvic inflammatory disease. Fixed retroverted uterus may suggest endometriosis. b. I will send her urine for culture and sensitivity and full examination to rule out any urinary infection. I will send swab from vagina, to detect an organism. I will the perform ultrasound to detect any abdominal mass. If clinical index of suspicion of endometriosis is high, non-invasive imaging such as MRI pelvis can be considered. And I will consider diagnostic laparoscopy if she agreeable. c. I will explain to her and reassure that there is no identified pathology contributing the pain. Patient perception of the cause of the pain need to be considered and listened. If it is not ffecting her lifestyle then, reassurance can be given. I will give her adequate analgesia for pain relief. I will advise to modify her lifestyle like diet and exercise. Referral to cognitive behavioural therapy also can be considered. |
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Posted by Arun D. |
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| A healthy 15 year old school girl attends the gynaecology clinic accompanied by her mother. She gives a 6 months history of pelvic pain and painful periods. (a) Discuss your clinical assessment [9 marks]. (b) Discuss and justify your investigations given that clinical examination is normal [5 marks]. (c) Discuss the treatment options given that no underlying cause has been found [6 marks]. a) 1. I will ask about details of menstrual history, number of days she bleed,interval between periods,any intermenstrual bleeding,amount of bleeding,associated with clots or not,number of tampons she use for bleeding. 2. i will ask about details of period pain including onset,temporal relationship with periods, severity,referred or not,severity, needs to take analgesia or not. 3. I will ask her about nature of the pelvic pain including site, onset, severity, referred or not, nature of pain ,cyclicity present or not, relationship with bowel or bladder functions. 4. are there any alteration of bowel function in last 6 months, alternate constipation with diarrhoea present or not. 5. any history suggestive of UTI present or not. 6. i will enquire about her sexual history including duration of sexual activity, number of partners, contraception used, any unhealthy vaginal discharge present or not. 7. i will also enquire her about any previous pregnancy/ terminations, mode of termination if yes. 8. i will also enquire her about any previous significant medical history or surgical history. 9. any allergic history should also be recorded. 10. any previous treatment history for her pain or for any other illness should also be documented. 11. eneral survey should be done to exclude any grosss systemic disease. 12.abdominal examination to be performed to rule out any abdominal mass or any free fluid, guarding/ rigidity. 13. under chaperone and verbal consent, pelvic examination should be performed including inspection of vulva and vagina. If she is sexually active, speculum examination should be done and high vaginal swab and chlanydial swabs to be taken. Bimanual examination should also be performed to diagnose any pelvic mass. b) Urine pregnancy test to rule out any pregnancy related events. Urine dipstics examination to rule out any cystitis or UTI. Mid stream urine examination to rule out any UTI. Trans vaginal ultrasound to investigate pelvic anatomy, rule out any ovarian cyst,fibroid uterus or adenomyosis or endometrioma. MRI can also be done to exclude endometriotic deposits which can be missed by TVS. Diagnostic laparoscopy can be performed if all preceeding investigations are neggative and pain in very severe. Efore undertaking laparoscopy, implications of negative finding should also be discussed and documented clearly. c) If no underlying cause has been fould, initial trial with analgesics like paracetamol and NSAID should be started. If still uncomfortable, codydramol can be tried for a short term basis. GnRH analogue monthly for 6 months may also be prescribed and reassessed after 6 months. If irritable bowel syndrome is suspected, proper gastr-enterology referral should be made. Antidepressant s trial can also be given.a |
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Posted by KWASI RICHARD A. |
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| a. Considering her age, approach her sensetively with sympathy and empathy. Allow her to tell her own story as much as possible and also involve the mother. A detailed history abouth the pain should be sough. This should include the onset, nature and type of pain. Pain occurring with the onset of menstruation is indicative of primary dysmenorrhoea. Pain proceeding periods and relieved by menstruation is likely to be caused by secondary dysmenorrhoea. Non-cyclical pain is suggestive of non-gynaecological pathology. A detailed menstrual history should be taken, her age of menarche, regularity of cycle, cycle length and her last menstrual period. Exclude bowel and bladder pathology symptoms. Sensetively explore sexual history and consider the possibilty of sexual abuse. Also enquire about previous pelvic infection or surgery and assess risk of adhesion formation. A psychological assessment of pain should be carried out; impact of the pain on her education and school work, daily activities, emotional state, peer group and her relatioship with family and friends. Abdominal examination to exclude pelvic masses and illicit any tenderness. Pelvic examination to exclude pelvic masses and adenexal masses, also looking for tell-tale signs of sexual abuse on vulva inspection. Rectal examination should also be considered if there is a positive history of altered bowel habits. b. Swabs will be taken to screen for infections, particularly chlamydia and gonorrhoea, if the is any suspicion of pelvic infection. Ultrasonography is useful to assess adenexal masses if clinical examination suggests this. Diagnostic laparoscopy may be required in the diagnosis of endometriosis or pelvic adhesions. c. Conservative - do nothig. Reassure her that nothing pathological was found on assessment. For medical treatment, a non-hormonal option includes using non-steroidal anti-inflammatory analgesics (NSAIDs), eg ibuprofenor mefenamic acid. These medications limit the production of prostoglandins and reduce myometrial contractility. Medical hormonal treatment involves the use of combined oral contraceptive pill if NSAIDs are ineffective or contraindicated. There is significant reduction in pain within 3 months of commencing COCP. Alternative therapies like accupuncture exist, however, there is no evidence for their efficacy. Psychological therapy may also be considered. |
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Posted by Dr Dyslexia V. |
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| X a) A careful history should be obtained in regards to the nature of the pain as to burning nature, colicky in nature and it’s relation to menses, such as prior to onset of menstruation or during menstruation or after menstruation as it could point to organic gynaecological pathology such as endometriosis or adenomyosis. Pain during onset of menses and relieved after the first two days of menses could indicate primary spasmodic dysmenorrhea and reassurance and a course of NSAIDs could be given. History of sexual intercourse and history of any sexually diseases should be illicited preferably without the preference of the accompanying mother as patient could be reluctant to reveal the information. During the private history taking, history of any current sexual abuse of childhood sexual abuse should be taken as it could be contributing to her current symptoms. History of vaginal discharge which is foul smelling could suggest STD and urinary retention due to painful vulval ulcers could indicate herpes. None gynaecological symptoms such as dysuria, frequency should be taken to suggest urinary tract infection. Bowel symptoms such as bloatedness and difficulty in diffication could indicate irritable bowel syndrome and presence of bloody diarrhea and mucous in feces could indicate inflammatory bowel syndrome. History of any previous surgeries such as appenticectomy or any laparotomy could indicate pain due to adhesion. Examination should include general condition such as emanciated and thin teenager which could indicate underlying causes such as neglect and abuse. Abdominal investigation should be done to illicit any sign of tenderness and presence of any mass such as ovarian or uterine mass. A pelvic examination should be done with the consent of patient and mother if she is sexually active to illicit any adnexal tenderness, or any presence of ulcers which could indicate pelvic inflammatory disease. While bimanual palpation of a retroverted uterus with nodules could indicate endometriosis. b) Investigation should include a use of pain diary to document the onset of pain the relieving of pain and it’s relation to the menstrual cycle as it can identify mid cycle pain such as mittel-schmertz. Urine for microscopy and midstream urine culture should be performed to rule out urinary tract infection. During pelvic examination if performed opportunistic for Chlamydia and gonorrhea could be done using endocervical swabs and rectal swabs which could indicate pelvic inflammatory disease. Pelvic Ultrasound could be done to image for any presence of ovarian mass of pouch of Douglas mass as endometriama or uterine fibroid. Ultimately a diagnostic laparoscopy could be done to look for any endometriosis or presence of adhesion as in PID could be seen. MRI could be done to detect any presence of endometriosis if invasive procedure such as laparoscopy wished to be avoided. c) Cyclical pain could be contributed by ovarian cause and ovarian suppression with trial of oral contraceptive pills could be used to alleviate symptoms or a course of gonadotropin antagonist could be used as well. Referral to psychologist and psychotherapist could be done in cases of sexual abuse or history of sexual abuse or psychosomatic pain is suspected. Counseling could be of benefit in this as well. If bowel symptoms predominates a course of anti spasmodic such as mebeverine could be tried. If required referral to gastroenterologist. Use of empirical analgesia such as NSAIDs could also be used for symptomatic relief. Referral to pain clinic could be done if ultimately no course has been found and all investigations have been exhausted. |
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Posted by leelavathi C. |
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| young girl with chronic pelvic pain need a sensitive approch to assessment. i will take a detail history of pain - location, radiation, nature of pain ( constant or colicky). enquire about timing of pain associated with menstruation, defecation, micturition or movements. i will take detail menstrual history - age of manarche, regularity of periods, menstrual flow. take a sexual history - age of first sexual activity, about partnar, any sexual abuse (in a sensitive approch). enquire about any previous investigations , treatments for pain. Enquire about gastrointistinal symptoms like diarrhoea, constipation and its relation to pain. on abdominal examinaton check for tenderness, any pelivic masses.once patient sexually active then perform vaginal examination, check for uterine size, shape, mobility, tenderness,any adenexal masses,tederness. B) urethral and endocervical swabs for chlamedia should be taken once patient sexually active or any history suggestive of PID. however negetive swab can not exclude PID. pelvic ultrasound should perform to look for any pelvic mass, endometriomas. trans vaginal ultrasound should perform once patient sexually active.MRI is a sensitive to diagnose endometriosis. diagnostic laproscopy is gold standered test for chronic pelvic pain. but this is last sort of investigation after emperical treatment failed, and any additional treatment needed like endothermic ablation of endometriatic deposits. it need fully informed consent. FBS, CRP should be done to rule out inflammatory causes. C)Multidisciplinary treatment involving gynecologist, GUM specilist, psychiatrist, pain therapist.the possible diagnosis in this patient is dysmenorrhoea so simple analgesics should recomended .if condition not improved, advice OCPS after councelling with mother.if history suggestive of IBS-anti spasmodics, dietary manipulations should recomended. once no abnormolity found and emperical treatment has failed pain should be managed in conjuction with the pain clinic. B) B) |
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Posted by Kiran J. |
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| A healthy 15 year old school girl attends the gynaecology clinic accompanied by her mother. She gives a 6 months history of pelvic pain and painful periods. (a) Discuss your clinical assessment [9 marks]. (b) Discuss and justify your investigations given that clinical examination is normal [5 marks]. (c) Discuss the treatment options given that no underlying cause has been found [6 marks]. I would enquire regarding her pelvic pain i.e onset of pain ,aggaravating facotrs, relieving factors,duration the pain lasts for ,character of pain radiation ,if the pain commences at the start of periods then it could be primary dysmennorhea.If before onset of periods and relived after periods begin may be associated with pathology like endometrioses.Associated symptoms are of nausea vomiting and diarrhea alternating with constipation may be due to irritable bowel syndrome.I would enquire regarding dysuria, frequency, urgency and sensation of incomplete evacuation as it may be due to UTI,Interestitial cystitis.If the pain increases on physical activity or in certain posstions may be due to musculoskeletal reasons.I would sensitively enquire her regarding her sexual history and if she is sexually active if she has dysparuenia ,offensive/discoloured vaginal discharge of recent onset with history of fever ,general malaise as it could be due to PID. I would ask regarding type of contraception and if she is currantly with someone who has been screened/or investigated for STI.Her menstrual history includes age of menaeche and if periods have always been painful or heavy fom menarche.her cycle whether regular,intermenstrual spottig, period flow heavy or light and lenght of cycle.I would enquire if she is sexually active if she has ever been pregnant or had a miscarriage/TOP.I would enquire regarding abdominal /pelvic surgeries although adhesions may ort not result in pelvic pain.Lastly I will ask regarding smoking ,alcohol and drugs as it would give me an insight into her social circumstances.Perinat to know what social support she has at home any safegarding issues pretaining to domestic violence Examination includes her BMI,general physical examination(Pulse, BP ,Temperature) to see the general state of health of the young adult.Abdominal examination to find out regarding tenderness on deep palpation, massess or organomegaly.Pelvic examination can be done if sexually active and STI screening can be offered if not done recently.cervical examination to see if any swellings or growths ,tenderness on palpation,Bimanual uterine examination to assess size of uterus and mobility ,adenexal swellings or tenderness to assess possible organi c cause for her pain i.e PID,endomertrioses B.Investigations consist of FBC,CRP to see inflammatory markers which can be raised in PID.Ultrasound examination can be done as it may reassure the patient but they should be made aware that it may only be able to visualize gross abnormality like ovarian cysts/masses or fibroroid uterus and that given the pelvic examination was normal there may be no positive finding on scan.If empirical treatment does not bring about any improvement in her pain than Laparoscopy can be cosidered as it can dtect abnormalities such as endometrioses which may not be visible on scan and can be therapeutic as well(diathermy/resection of endometrioses) C. Treatment options include simple reassurance if symptoms are mild and not effecting quality of life.I can enquire regarding any preliminary treatment given in primary care and if she has been compliant with it.She can be offered mefenamic acid 500mg thrice aday during periods and NSAIDS for pain.She can be offered combined oral contraceptive pill or progesterone only pill if there is a contraindication to OCP.OCP can be beneficial in reducing pain ,regulating cycle if irregular ,decerease period blood flow and give contraception as well. I compliance is an issue she can be offered depot provera as its once ever 3 months, can be effective in reducing pelvic pain but may be associated with menstrual irregularity ans long term use can result in loss of bone mineral density. If she has associated bowel symptoms she can be given antispasmodics and stool softners if she has constipatioin. If there are safe gaurding issues or psycosexual problems appropriate help is given accordingly. |
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Posted by Bobey B. |
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| I would like to take a detailed clinical history of onset of pain , timing in relation to menses , defecation , micturition and other associated symptoms as nausea and vomiting with the details of menstrual history. The chance should be taken to explore her family and social background and the effect of her symptoms on her quality of life. Detailed gastrointestinal history should be taken . Symptom-based diagnostic criteria can be used to make the diagnosis of irritable bowel syndrome as Rome criteria .Symptoms such as abdominal bloating and passage of mucus are suggestive of IBS. Genitourinary symptoms as frequency and dysuria should be asked. History of sexual abuse , if suspected is asked subtly and sensitively in absence of her mother. History of previous treatment , any benefits had been gained and side effects should be obtained. A thorough clinical abdominal examination is necessary to rule out palpable pathology. Distended and tender caecum and sigmoid is sometimes found in irritable bowel syndrome. Pelvic examination( including rectal examination ) is unnecessary , rarely useful and associated with significant discomfort. The clinical assessment may reveal normal finding . The diagnosis is most likely a primary dysmenorrhoea ,however gastrointestinal disorders such as IBS or inflammatory bowel disease are possible diagnosis. b) Non-surgical relevant investigations such as full blood count ( FBC ) and erythrocyte sedimentation rate ( ESR ) are important in the assessment of the inflammatory bowel disease. Urine microscopy and culture is important in the assessment of urological causes. Pelvic ultrasound scan is useful as a normal result would provide reassurance . Sometimes ,ultrasound scan may reveal pathology not noted on clinical examination as endometrioma. c)Detailed explanation of the cause of the pain , as the diagnosis in the majority of cases is a primary dysmenorrhoea . Explanation of its physiological basis given sympathetically is reassuring to the most girls. Simple analgesia can be tried as acetyl-salicylic acid and codeine. NSAIDs such as mefenamic acid reduce prostaglandin production, or priopionic acid derivatives ( flurbiprofen ) are very effective for symptomatic relief in 80% of patients. COCP inhibit ovulation , relieve dysmenorrhoea and are the first line treatment if the girl wishes contraception. Laparoscopy is indicated only ,if symptoms are resistant to the previous mentioned treatment as disorders such as endometriosis and pelvic inflammatory disease need to be ruled out. If all the previous measures failed ,pain should be managed in conjunction with specialist pelvic pain clinic. |
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Posted by Atashi S. |
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| (A) I will take history about severity of pain and its effects on quality of life. Site and side of pain , radiation is to be asked. Nature of pain continuous ,colicky or intermittent is to be asked for. pain associated with nausea , vomiting,fever is to be asked. Any aggravating or relieving factor need to be noted. Pain persist throughout the cycle or not, aggravates during menstruation or relieves with the onset of menstruation is to be looked for. Menstrual history including LMP, cycle, duration, flow, irregularity is to be asked. She is sexually active or not,H/O termination of any unwanted pregnancy need to be explore. Bladder and bowel habit , presence of dysuria is to be noted. Examination includes degree of anemia, pulse, temperature and blood pressure. Abdominal examination to detect any lower abdominal mass and presence of rt illiac fossa or suprapubic tenderness.If she is sexually active per vaginal and bimanual examination is to be done to dectect any uterine or adenaxal mass,tenderness in the pouch of doglus, nodule in the pouch of doglus, fornices are free or not. (B)Complete blood count including ESR and C-reactive protein. Pelvic ultrasonography to detect any uterine and ovarian mass or any other pelvic pathology.Urine for routine and microscopic examination.Culture and sensitivity test if needed.Plain X-ray KUB to dect any urinary calculi or any other pathology.High vaginal and endocervical swab for C/S if she is sexually active. (C)Psychological support and assurance to the patient and to the mother. She will maintain personal hygiene. Bladder and bowel is to be emptied regularly. She will intake adequate fluid and green leafy vegetable to avoid constipation .In case primary dysmenorrhoea NASID like Mefenamic acid is to be given for 3 to 5 days.Oral contraceptive pill can be given cyclically for 3 to 6 months. |
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