Acute Pelvic Pain

Acute Pelvic Pain

Q. 1

The severity of pelvic pain in endometriosis correlates best with :

 A

Number of implants

 B

Depth of invasion

 C

Stage of disease

 D

Ca 125 levels

Q. 1

The severity of pelvic pain in endometriosis correlates best with :

 A

Number of implants

 B

Depth of invasion

 C

Stage of disease

 D

Ca 125 levels

Ans. B

Explanation:

Depth of invasion


Q. 2

21-year-old woman presents to the emergency department complaining of pelvic pain, a yellow-green vaginal discharge, and fever, all of which have been worsening over the last 24 hours. She has no frequency or dysuria. She has no medical problems. Her past surgical history is significant for a cesarean delivery 2 years ago performed for a nonreassuring fetal heart rate tracing. She takes no medications and is allergic to sulfa drugs. She is sexually active with multiple male partners who sometimes use condoms. She works as a medical assistant. Her temperature is 38.2 Deg C (100.7 F), blood pressure is 100/60 mm Hg, pulse is 110/minute, and respirations are 12/minute. Her abdominal examination is significant for diffuse tenderness, rebound, and guarding. Speculum examination demonstrates a copious greenish vaginal discharge that appears to be coming from the cervix. Pelvic examination is significant for cervical motion tenderness and adnexal tenderness. Laboratory evaluation shows:
 
Urine hCG: negative
Urinalysis: negative
Leukocytes: 15,000/mm3
Hematocrit: 39%
Platelets: 200,000/mm3
 
Which of the following is the most likely diagnosis?
 A

Ectopic pregnancy

 B

Gonococcal cervicitis

 C

Pelvic inflammatory disease (PID)

 D

Spontaneous abortion

Q. 2

21-year-old woman presents to the emergency department complaining of pelvic pain, a yellow-green vaginal discharge, and fever, all of which have been worsening over the last 24 hours. She has no frequency or dysuria. She has no medical problems. Her past surgical history is significant for a cesarean delivery 2 years ago performed for a nonreassuring fetal heart rate tracing. She takes no medications and is allergic to sulfa drugs. She is sexually active with multiple male partners who sometimes use condoms. She works as a medical assistant. Her temperature is 38.2 Deg C (100.7 F), blood pressure is 100/60 mm Hg, pulse is 110/minute, and respirations are 12/minute. Her abdominal examination is significant for diffuse tenderness, rebound, and guarding. Speculum examination demonstrates a copious greenish vaginal discharge that appears to be coming from the cervix. Pelvic examination is significant for cervical motion tenderness and adnexal tenderness. Laboratory evaluation shows:
 
Urine hCG: negative
Urinalysis: negative
Leukocytes: 15,000/mm3
Hematocrit: 39%
Platelets: 200,000/mm3
 
Which of the following is the most likely diagnosis?
 A

Ectopic pregnancy

 B

Gonococcal cervicitis

 C

Pelvic inflammatory disease (PID)

 D

Spontaneous abortion

Ans. C

Explanation:

Pelvic inflammatory disease (PID) is a significant cause of morbidity among sexually active menstruating women. PID refers to an upper genital tract infection, especially of the endosalpingeal cells that line the fallopian tubes. When the infection involves the fallopian tubes only, it is referred to as a salpingitis. When it involves the ovaries as well, it is then referred to as a salpingo-oophoritis. The endometrium is also often involved (endometritis).

The peak incidence of the disease is in the 15- to 24-year-old-group. This patient presents with the typical symptoms of PID, particularly abdominal/pelvic pain. Fever and vaginal discharge are often present in gonococcal PID, but may be absent in other forms of PID. The diagnosis of PID is made when the patient has abdominal tenderness, cervical motion tenderness, and adnexal tenderness plus a temperature > 38 C (100.4 F), or leukocytosis (>10,000/mm3), or laboratory documentation of chlamydial or gonorrheal infection. Treatment is with antibiotics.

Ectopic pregnancy is ruled out with the negative urine pregnancy test. An ectopic pregnancy is a pregnancy that is implanted abnormally, most often in the fallopian tubes. As a pregnancy, it secretes human chorionic gonadotropin (hCG), which can be found in the blood or urine. When this is not present, ectopic pregnancy is ruled out.
 
Gonococcal cervicitis presents with findings localized to the cervix. This patient has findings that go beyond a cervicitis. Given her abdominal tenderness with rebound, cervical motion tenderness, and adnexal tenderness, she is manifesting involvement of the fallopian tubes and peritoneum. While the gonococcus may be the offending organism in this case, this patient has more than a gonococcal cervicitis.
 
A patient with a spontaneous abortion can present in a variety of ways, but most commonly she will present with complaints of vaginal bleeding or the passage of tissue from the vagina. A spontaneous abortion represents a failed pregnancy and this patient has no evidence of a failed pregnancy, and an abundance of evidence for PID.

Q. 3

A 25-year-old female states that she and her husband have been trying to have a baby for the last two years. The patients medical history included cyclical pelvic pain, dysmenorrhea, dyspareunia, and, not uncommonly, infertility. The physical exam reveals the following: diffuse abdominal or pelvic pain of variable location, nodular thickening and tenderness along the uterosacral ligaments, on the posterior surface of the uterus, and in the posterior cul-de-sac, scarring and narrowing of the posterior vaginal fornix, and adnexal enlargement and tenderness. What is your diagnosis?

 A

Endometriosis

 B

Ectopic pregnancy

 C

Adnexal mass

 D

Pelvic relaxation

Q. 3

A 25-year-old female states that she and her husband have been trying to have a baby for the last two years. The patients medical history included cyclical pelvic pain, dysmenorrhea, dyspareunia, and, not uncommonly, infertility. The physical exam reveals the following: diffuse abdominal or pelvic pain of variable location, nodular thickening and tenderness along the uterosacral ligaments, on the posterior surface of the uterus, and in the posterior cul-de-sac, scarring and narrowing of the posterior vaginal fornix, and adnexal enlargement and tenderness. What is your diagnosis?

 A

Endometriosis

 B

Ectopic pregnancy

 C

Adnexal mass

 D

Pelvic relaxation

Ans. A

Explanation:

Endometriosis is the growth of tissue outside the uterus.
The ectopic endometrial tissue can proliferate, and infiltrate, and spread to remote sites elsewhere in the body.
Sites that endometriosis is most often found are, ovarian, pelvic peritoneum, anterior and posterior cul-de-sac, uterosacral, round, and broad ligaments, and fallopian tubes. 
 
An ectopic pregnancy is one that develops at any site other than the endometrium.
Symptoms of an ectopic pregnancy are abdominal pain possible a missed period, abnormal bleeding at the time of presentation is not uncommon.
Physical characteristics of an adnexal mass that may give a presumptive diagnosis: consistency (cystic, solid or both), size (in centimeters) morphology and surface contour (smooth, nodular, vague or sharp borders), location around the uterus, mobility (free or fixed to adjacent structures) tenderness, unilateral or bilateral.
 
Ref: Cunningham F.G., Leveno K.J., Bloom S.L., Hauth J.C., Rouse D.J., Spong C.Y. (2010). Chapter 40. Reproductive Tract Abnormalities. In F.G. Cunningham, K.J. Leveno, S.L. Bloom, J.C. Hauth, D.J. Rouse, C.Y. Spong (Eds), Williams Obstetrics, 23e. 

Q. 4

A 35 year old female presents to the clinic with complaints of pelvic pain, dysmenorrhea and dyspareunia. Transvaginal ultrasound revealed presence of endometrial tissue outside the uterus. All the following drugs are indicated in the treatment of her condition, except

 A

Oestrogen

 B

Progestins

 C

GnRH agonists

 D

Danazol

Q. 4

A 35 year old female presents to the clinic with complaints of pelvic pain, dysmenorrhea and dyspareunia. Transvaginal ultrasound revealed presence of endometrial tissue outside the uterus. All the following drugs are indicated in the treatment of her condition, except

 A

Oestrogen

 B

Progestins

 C

GnRH agonists

 D

Danazol

Ans. A

Explanation:

Oestrogen alone is not given in endometriosis.

It is given as combined OCP and creates a pseudo pregnancy state.

Other drugs useful in its management includes danazol, gestrinone, medroxyprogesterone acetate and GnRH agonists.


Q. 5

Pelvic pain is mediated by ‑

 A

Pudendal nerve

 B

Sciatic nerve

 C

Autonomic nerves 

 D

None of the above

Q. 5

Pelvic pain is mediated by ‑

 A

Pudendal nerve

 B

Sciatic nerve

 C

Autonomic nerves 

 D

None of the above

Ans. C

Explanation:

Ans. is ‘c’ i.e., Autonomic nerves

  • Visceral afferent fibers of pelvis travel with autonomic nerve fibers.
  • Visceral afferent fibers conducting reflexive sensations (information that does not reach consciousness) travel with parasympathetic fibers to spinal sensory ganglia of S2– S4.
  • The route taken by visceral afferent fibers conducting pain sensation differs in relation to an imaginary line, the pelvic pain line, that corresponds to the inferior limit of peritoneum, except in case of large intestine, where pain line occurs midway along length of sigmoid colon.
  • Visceral afferent fibers that transmit pain sensations from the viscera inferior to pelvic pain line travel in parasympathetic fibers of the spinal ganglia S, – S4 (via pelvic splanchnic nerve or nerve erigentes).
  • Visceral afferent fiber conducting pain from the viscera superior to pelvic pain line follow the sympatheitc fibers reterogradely to inferior thoracic and superior lumbar (Ti – Li 0,2 )spinal ganglia.


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