Pelvic Pain

Introduction

Pelvic pain is a common presentation in gynecology and a crucial topic for MCCQE1 preparation. This comprehensive guide will cover the essential aspects of pelvic pain, focusing on Canadian healthcare practices and MCCQE1 exam objectives.

Classification of Pelvic Pain

Pelvic pain is typically classified based on duration:

1. Acute pelvic pain: Lasting less than 3 months
2. Chronic pelvic pain: Persisting for 3 months or longer

Etiology

Understanding the various causes of pelvic pain is crucial for MCCQE1 success. Here's a comprehensive list organized by system:

1. Gynecological

   • Dysmenorrhea
   • Endometriosis
   • Adenomyosis
   • Pelvic inflammatory disease (PID)
   • Ovarian cysts or tumors
   • Ectopic pregnancy

2. Urological

   • Urinary tract infection (UTI)
   • Interstitial cystitis
   • Urolithiasis

3. Gastrointestinal

   • Irritable bowel syndrome (IBS)
   • Inflammatory bowel disease (IBD)
   • Diverticulitis
   • Appendicitis

4. Musculoskeletal

   • Pelvic floor muscle spasm
   • Fibromyalgia
   • Hernias

5. Psychological

   • Depression
   • Anxiety
   • Somatization disorder

Clinical Presentation

When assessing a patient with pelvic pain, consider the following:

1. Characteristics of pain (onset, duration, location, quality, severity)
2. Associated symptoms (fever, vaginal discharge, urinary symptoms)
3. Menstrual history
4. Sexual history
5. Obstetric history
6. Past medical and surgical history

Investigations

Investigations for pelvic pain may include:

1. Laboratory tests

   • Complete blood count (CBC)
   • Urinalysis and urine culture
   • Pregnancy test (β-hCG)
   • Sexually transmitted infection (STI) screening

2. Imaging studies

   • Transvaginal ultrasound
   • Pelvic MRI (for complex cases)

3. Diagnostic procedures

   • Laparoscopy (gold standard for diagnosing endometriosis)
   • Hysteroscopy

Management

Management of pelvic pain depends on the underlying cause. Here are some general approaches:

1. Pharmacological

   • NSAIDs for pain relief
   • Hormonal therapies (e.g., combined oral contraceptives)
   • Antibiotics for infectious causes

2. Non-pharmacological

   • Physiotherapy
   • Cognitive behavioral therapy
   • Dietary modifications

3. Surgical

   • Laparoscopic treatment of endometriosis
   • Hysterectomy (for severe cases unresponsive to other treatments)

Canadian Guidelines

The Society of Obstetricians and Gynaecologists of Canada (SOGC) provides guidelines for the management of pelvic pain. Key points include:

1. Chronic pelvic pain should be approached as a diagnosis, not just a symptom.
2. A multidisciplinary approach is recommended for complex cases.
3. First-line treatment for endometriosis-associated pain is hormonal therapy.

Key Points to Remember for MCCQE1

• Always consider pregnancy in women of reproductive age presenting with pelvic pain.
• Ectopic pregnancy is a life-threatening emergency that requires immediate intervention.
• Endometriosis is a common cause of chronic pelvic pain and may be asymptomatic.
• Pelvic inflammatory disease can lead to long-term complications if not treated promptly.
• A multidisciplinary approach is often necessary for managing chronic pelvic pain.

Sample Question

A 28-year-old woman presents to the emergency department with acute onset of severe right lower quadrant pain. She reports that her last menstrual period was 6 weeks ago. On examination, she is pale and diaphoretic with a blood pressure of 90/60 mmHg and a heart rate of 110 bpm. Abdominal examination reveals right lower quadrant tenderness with guarding. Which one of the following is the most appropriate next step in management?

• A. Perform a transvaginal ultrasound
• B. Administer intravenous antibiotics
• C. Order a CT scan of the abdomen and pelvis
• D. Perform an immediate laparoscopy
• E. Administer intravenous fluids and order a quantitative β-hCG test

Explanation

The correct answer is:

• E. Administer intravenous fluids and order a quantitative β-hCG test

This patient presents with signs and symptoms suggestive of a ruptured ectopic pregnancy, which is a life-threatening emergency. The history of missed menstrual period, acute onset of severe unilateral pelvic pain, and signs of hemodynamic instability (hypotension, tachycardia) are classic for this condition.

The most appropriate next step is to stabilize the patient with intravenous fluids to address the potential hypovolemia and to confirm the diagnosis with a quantitative β-hCG test. This approach allows for rapid assessment and management while preparing for potential emergency surgery if needed.

While transvaginal ultrasound (option A) is useful in diagnosing ectopic pregnancy, stabilizing the patient and confirming pregnancy should take precedence. Antibiotics (option B) are not indicated as the primary management for suspected ectopic pregnancy. A CT scan (option C) is not the imaging modality of choice for suspected ectopic pregnancy and may delay necessary treatment. Immediate laparoscopy (option D) may be necessary but should not be performed before confirming the diagnosis and stabilizing the patient.

References

1. Society of Obstetricians and Gynaecologists of Canada. (2018). Guideline No. 164-Management of Chronic Pelvic Pain. Journal of Obstetrics and Gynaecology Canada, 40(6), e747-e787.

2. Jarrell, J. F., Vilos, G. A., Allaire, C., Burgess, S., Fortin, C., Gerwin, R., ... & Yong, P. J. (2018). No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain. Journal of Obstetrics and Gynaecology Canada, 40(11), e747-e787.

3. Bhutta, H. Y., Devchand, R., Srivastava, A., Primrose, J. N., & Fox, R. (2016). A contemporary approach to the diagnosis and management of pelvic inflammatory disease. The Obstetrician & Gynaecologist, 18(1), 30-38.

4. CanMEDS Framework. Royal College of Physicians and Surgeons of Canada. http://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e (opens in a new tab)

5. Medical Council of Canada. Objectives for the Qualifying Examination. https://mcc.ca/objectives/ (opens in a new tab)