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Case 18.3 – Acute Pelvic Pain (Benign Ovarian Disease)

Category: Endocrine & Reproductive Symptoms | Discipline: Obstetrics & Gynaecology | Setting: Emergency Department

Case

Bella Cheng is19 year's old, she presents with sudden onset of severe pelvic pain. On arrival in the ED she appears pale. Her boyfriend Dale informs you that they had just finished dinner and were watching a movie, when Bella grabbed her stomach and doubled over with pain. He has never seen her in so much pain before.

She has not been unwell.

Observation. Distressed due to the pain, Pale.

Afebrile, BP 120/70, PR 90 bpm. RR 20/min.

Questions

1. What are the key features of your history and examination of Bella?

Important factors in the assessment of abdominal pain

  • Duration
  • Site and radiation
  • Severity
  • Precipitating and relieving factors (food, drugs, alcohol, posture, movement, defaecation)
  • Nature (colicky, constant, sharp or dull, wakes patient at night)
  • Pattern (intermittent or continuous)
  • Associated features (vomiting, dyspepsia, altered bowel habit)

Important parts of the gynaecological history

  • Menses: Current cycle, LMP, abnormal bleeding
  • Pain: dysmenorrhoea, dyspareunia, pelvic pain
  • Pregnancies: number, outcome, complications
  • Contraception
  • Sexual History: Current partner, change in partner is last 6 months, vaginal discharge, STI

Key features in examination

  • Symptoms and signs of peritonitis
  • Abdominal examination: Inspection, palpation, percussion, auscultation
  • Pelvic examination: tenderness, appearance of vaginal discharge
2. What are the important gynaecological and non-gynaecological causes to consider with Bella's presentation?

Inflammation

  • Pelvic Inflammatory Disease
  • Appendicitis
  • Diverticulitis
  • Cholecystitis
  • Pancreatitis
  • Pyelonephritis
  • Intra-abdominal abscess

Perforation/rupture

  • Ectopic pregnancy
  • Ovarian cyst (rupture or leaking, torsion, infection, haemorrhage into a physiological luteal cyst)
  • Peptic ulcer
  • Diverticular disease
  • Aortic aneurysm

Obstruction

  • Intestinal obstruction
  • Biliary colic
  • Ureteric colic

Retroperitoneal

  • Aortic aneurysm
  • Malignancy
  • Lymphadenopathy
  • Abscess

Psychogenic

  • Depression
  • Anxiety
  • Hypochondriasis
  • Somatisation

Locomotor

  • Vertebral compression with referred pain
  • Abdominal muscle strain

Metabolic/endocrine

  • Diabetes mellitus
  • Addison's disease
  • Acute intermittent porphyria
  • Hypercalcaemia

Drugs/toxins

  • Corticosteroids
  • Azathioprine
  • Lead
  • Alcohol

Haematological

  • Sickle-cell disease
  • Haemolytic disorders

Neurological

  • Spinal cord lesions
  • Tabes dorsalis
  • Radiculopathy
  • Gastroenterology
  • Irritable Bowel Syndrome
  • Constipation
3. What investigations would you undertake in the assessment of Bella? How would the results influence your differential diagnosis and management?
Blood tests FBC (raised WCC, low Hb)
LFT
EUC
Amylase
Urine MCS
Quantitative Bhcg
Swabs High vaginal: MCS, Chlamydia PCR, Gonorrhoea PCR
Imaging Ultrasound will identify most ovarian cysts
CT/MRI scanning may be useful if the nature of the lesions remains unclear
(Consider erect CXR, abdominal X-ray, RUQ Ultrasound if other features)
Laparoscopy Severe symptoms or clinical signs of shock is indicative of intraperitoneal pathology, such as bleeding and necessitates emergency laparoscopy or laparotomy
4. Pelvis ultrasound demonstrates a simple cyst in Bella's right ovary with evidence of fluid in the pouch of Douglas. What are physiological ovarian cysts? How do they differ from other cysts or benign tumours of the ovary?

Physiological cysts are a common occurrence of the normal cyclical function of the ovary. They may be follicular, theca lutein or corpus luteum in origin. Prior to ovulation the ovarian follicle measures up to 3cm in diameter; a physiological cyst is by definition a unilocular cyst >3cm in diameter. Such cysts rarely become larger than 10cm. They are usually singular (unless following ovarian stimulating drugs or in the presence of trophoblastic disease)

Physiological cysts are more common in users of progesterone-only contraceptives and around the time of menarche and perimenopause.

5. Bella's pain has now settled with analgesia and she is feeling much better. Outline your management plan for her, including writing a discharge letter for her GP.

Uncomplicated physiological cysts resolve spontaneously within 8-12 weeks.

Management plan

Ensure adequate analgesia for discharge

Repeat Ultrasound in 2- 3 cycles to ensure resolution

Instructions for action if pain returns or becomes worse

Consider opportunistic screening: cervical screening test, STI screen, ensure HPV vaccination complete

GP letter should include:

Summary of presentation

Results of all investigations

Plans for follow up and any further investigation