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So we, I think when I was looking to see um your previous lectures were on fibroids and I think they taught you endometriosis. So I just thought we'd take a more symptom based approach for this talk um to look at how we would manage pelvic pain. So this is just the, oh no, this is just the, the first talk of pelvic pain because there's this, this is just the acute presentation and how you would handle a patient that presents with pelvic pain. So any kind of abdominal pain. Um and this comes under the surgical block. I don't think anybody is teaching you the any surgical lectures, but some of this will probably get picked up in and if there's a surgical block that's going to be done later, it could be picked up in that. Um So I was just wondering if um anybody has seen a patient in the um in the emergency room with abdominal or pelvic pain. Has anybody spent any time in E R or the emergency department? Yeah. Sure. Ok. So typically pelvic pain is pain in the abdomen, which is below the umbilicus. So it could include both the right and the left iliac fossa. Okay. So, within the lower abdomen, you would have both the um a sending colon. You'd have the appendix, you'd have the uterus in a woman. You'd have the ovaries, you'd have the tubes and then you'd have the descending colon and you'd have the sigmoid colon. So there are quite a few anatomical structures that are actually present in the lower abdomen. And sometimes this pelvic pain is also um um the patient will localize it to the lumbar area. So then we're talking there of the, you're a Terek um and renal colic presentations. Um And pain can also emanate from both the muscle and the connective tissue. So, pelvic pain is actually quite complex and um it Flomax is a lot of us when a young woman of reproductive age will present with lower abdominal and pelvic pain. And if the pain is more than 3 to 6 months, it's considered chronic. Um So um been can originate in the cervix and the ovaries. Um the fallopian tubes or any of the structures in the abdomen, the urinary tract or even the pelvic floor. Um You can have the muscular skeletal elements of it, irritable bowel and sometimes um previous pelvic inflammatory disease can give rise to adhesions or previous infections. And endometriosis has also give rise to adhesions. And what happens then is that you get entrapping of the nerves. So, um the um the pain can be quite chronic So, can anybody tell me how would you differentiate, for example, pain from pelvic inflammatory disease and adhesions um from pain like coming from a gynecological cause. How, how would you be able to differentiate, say for example, pain from endometriosis to paint from adhesions or musculoskeletal pain, crampy, maybe differentiate that uh like cramps, crampy pain. I'm afraid I don't have any means of communicating with you. Uh I'm sorry, everyone, the doctor can't hear you. So if you could, essentially, what would happen is if you're looking at pain of endometriosis or adenomyosis, then that is cyclical pain. That would be pain that the woman develops with the onset of menstruation. And the pain would last for a week to 10 days after the periods have finished. So you'd get the intensity of the pain and then the pain would abate. Patient's with pelvic inflammatory disease that is currently active. The pain would be there, but then they would be discharged and then there would be a temperature, there would be um evidence of infection. The inflammatory markers would be raised and muscular skeletal pain or nerve entrapment pain is typically linked to um postural alterations and it's constant pain. It's there all the time. One of the um uh red flags in patient's that are presenting with chronic pelvic pain or pain that's been ongoing for a while is pain that does not improve despite taking painkillers. So a patient will come to you and if they say to you, they're having nighttime pain, they're having constant pain and pain that doesn't improve. Despite taking simple painkillers, then that is an indication to investigate them. So if we look at the courses of pelvic pain, um we can see that you have gynecological disorders. So, typically gynecological disorders are cyclic live. So if the pain occurs in the same phase of the menstrual cycle, then you know that that is related to menstruation. And that could be adenomyosis where you've got endometriosis inside the muscle structure of the uterus, or you've got um endometrial lining which is bleeding outside the uterus. Um It's cyclical, it comes on a week or so. Um It comes on with the onset of menstruation and it stays for about week or so afterwards. Um Primary dysmenorrhea as a kind of, of pelvic pain that um and these are young uh women with painful periods and they have consistent pain with every, every menstrual cycle. Um And you've already had a lecturer, endometriosis. So I won't necessarily delve into that. But endometriosis is a condition where you've got the lining of the uterus, which is the endometrium. It comes to lie in all sorts of places. Um uh in the pelvis, it can be remote, it can even be found in the gi tract. Um There are rare cases of endometriosis even happening in the brain. Um And then you can get um pain from um ovarian masses. So, for example, um if you are getting cyclical pain in the mid cycle, um then that is um the pain of ovulation. And that is quite typical. It will happen anywhere between day 12 to day, 14, 15 of the cycle. And, and these women continue to have that and it's often unilateral pain. So, if you're looking at pain, which is happening at the time of the menstrual cycle, then that is not generalized pain, that is more localized pain. And uh women um will ovulate on alternate ovary. So one time they could have pain on one side, the other time, they could have been on the other side and pain. That is the kind of um discomfort people suffer from Georgian is quite uh dramatic. Um Torsten doesn't happen often in a normal ovary as you might have um testicular torsion, testicular torsion can happen in a normal testes, which is hyper mobile. But a normal ovary to undergo a torsion is usually quite unusual, but the torsion of an ovary will often take place if there is a cyst. So the ovary becomes a bit bulky and it undergoes tor shin. And obviously, that presents as an acute emergency, acute abdominal pain. And whenever there is a torsion of any of the abdominal um structures, the patient presents with vomiting. Um that's quite um characteristic because they get um vagal stimulation with that with pelvic inflammatory disease is uh if you've taken a good decent history. Um and they've had a recent change of their sexual partner. If they've not been tested, they present with lower abdominal pain, vaginal discharge, high fever, high temperature. And uh, that, that, that needs to be treated quite quickly because otherwise, the residual um effect of pelvic inflammatory disease is that you could end up getting um uh tubal scarring, increased risk of ectopic pregnancy. And um um um it would have an adverse effect on her fertility. Now, within this, I've not included ectopic pregnancy because a topic pregnancy is, is very typical. The patient would have a history of um having missed a period. Um You always should be testing for a beta HCG in, in an acute setting because what you don't want to do is to miss an ectopic pregnancy. Fibroids don't cause pain unless you've got adenomyosis with fibroids. Um But the pain that, that you get from you try and fibroids is sort of uh um it's a dull dragging kind of pain very rarely because fibrosarcoma are not that common. Um fibrosarcoma czar less common. Um So most uterine fibroids are benign uh structures. But if a woman presents with chronic pain, then it's really important to be able to scan her quickly and to follow, go up the size of the growth of the uterine fibroid. You have non gynecological courses of pain. So you can have inflammatory bowel disease. You can have diverticular disease. Um infectious processes like rectal abscess is tumor's um intestinal obstruction. They also present with um pelvic pain and cystitis, interstitial cystitis gives rise to chronic pain in women, urinary calculi, especially your it terry colleague. Very, very painful. And then you've got the muscular skeletal conditions like my official pain, abdominal muscle strain. And um most interestingly, you've got not, not. No. I, what I've done is I've taken um, pelvic pain in a younger person, uh separate from pelvic pain in the elderly. Um You can see um patient's who present with lower abdominal pain, which is quite extreme and severe in the older patient. You can, you should consider really whether there's some other abdominal pathology like an aortic aneurysm. Um So how would you evaluate a patient with uh pelvic pain? So obviously, you would go by looking at the history um and do the Socrates, you know, the site onset duration, location, severity, the characteristic of the pain, relation of the pain to the menstrual cycle and whether there's any discharge pain on intercourse, any fever and you should do their basic review of the symptoms. You know, what is their BP? Are they tacky Cardiac? Is there any syncope or presyncope? E and then do just a general review. Um you know, any signs of pregnancy, breast sickness, amenorrhea rule out of pregnancy, whether there's a discharge, any change in bowel habits, rectal bleeding, look for G I disorders and do a good urinary history. So, when you um are taking a history uh, eliciting a previous history of pelvic inflammatory disease and, um, eliciting a history of a previous ectopic is relevant. And the reason for that is that if they've had a previous history of sexually transmitted infection and you're thinking of scarring, there's a high risk of ectopic pregnancy. Um, if you're thinking of, um, recent sexual partner, they've got a discharge, you're thinking of pelvic inflammatory disease. So all of these things have to start, you know, going through your mind and then asking them about a recent change in bowel habits, whether they have an erectile bleeding, any discharge, you start thinking about whether this could be an inflammatory bowel disease. So, in pelvic conditions or in pelvic pain, you have to cast the net very wide. And if they've had any previous abdominal or pelvic surgery, that also needs to be taken note of because even a condition like a pelvic appendicitis can cause pelvic scarring. And what that does do that is if it involves the fallopian tubes, it would increase your lifetime risk of getting another ectopic pregnancy. So, um when you do the physical examination, then the first priority obviously is to do the vital signs and, and to look for tachycardia and to look for the uh and to look for the um for look for hemodynamic stability or instability. And then of course, you want to do the abdominal and pelvic examinations. Now, usually in, in primary care. Um this is what I do in primary care, I would do an assessment of the patient. And if you are considering doing a pelvic examination in primary care, then you really need to be conscious of the fact that if you're doing a pelvic examination in a woman who has acute pain, then the chance that you might worsen her pain needs to be taken into consideration. And in modern practice, it certainly this is, this is my practice is that yes, you would have to offer a chaperone. You'd have to have a very good reason to do the pelvic examination. You'd want to do your swabs if you can. But you also need to assess the potential of delay and whether for the sake of the patient, she would be better off in a hospital by that, what I mean is I would end up doing an examination and then the guy knee doctor who would see her in the hospital would end up doing another examination or then the surgeon would end up doing another examination. So, unless you're thinking of um torsion of her a variance cyst or if she's got um real tenderness um in her eyelid fossa, the risk there is of delay and then the risk there is of rupturing and a topic. So really speaking, if the woman is hemodynamically unstable or she's um you know, uh tachycardic and the tachycardia could be because of pain, it could be because of hypertension, you would be looking at rapid transfer to the hospital. So usually what I do is when I do an examination, I rely very much on my abdominal palpation. And if it's tenderness there's guarding, there is rebound and there's signs of puritanism for me, that is an indication to refer this patient, a hospital. Um If somebody complains of rectal bleeding, fair enough, you can do a rectal examination because if there isn't any rectal bleeding at that time, then you are certainly reassured that there isn't any active bleeding. And um sometimes it does help if you do the, the rectal examination because what the rectal examination helps you do is it helps you assess uh the uterosacral um area to see whether there is tenderness over there. And if you're referring to the general surgeons, then the general surgeons would probably ask you to do a rectal examination. Now, if you were to do a pelvic examination, you'd start off with inspection, you'd do a speculum examination. Be ready to take swabs, look at the cervix through their look for discharge. And again, I, I don't know how much you have um been trained in this. Back in the day, we used to examine patients' with their permission under an anesthetic. But now a lot of uh medical schools will have pelvi trainers where they would teach the medical student on, on doing an examination. But here is the thing. If you've not, if you're not experienced in doing a pelvic examination, then doing a pelvic examination in a woman who's already distressed or in pain is probably not necessary. But if an experienced person were to be doing it, then you would be looking for um cervical motion tenderness and the way to elicit that is when you're doing the examination, you would touch the cervix very gently and you would move it very slightly to the side. So you wouldn't dramatically push it around. But if, when you touch the cervix, then you just move it very gently. If it causes spain because you're stretching it, then it means that there is some adding excell tenderness, which means that there is something going on right next to the ovary. Um And if you're quite experienced, then you can um um you can actually feel an at an XL mass. But in modern practice, what I have found over the years is that ultrasound is quite easily available and the patient would get a much quicker diagnosis if they were referred into hospital. The other thing not to do is you don't go pushing and prodding somebody if there's an ad in Excel mass, because you can have sort of like an ectopic that is on the borderline and it's a pre rupture or it's beginning to bleed because the pain in an ectopic pregnancy is from the blood. So two things can cause pain in the abdomen. If you have got infection, if you have got uh blood in the peritoneum, then hemoperitoneum is very, very painful. So, the pain that we get from endometriosis is partially because the endometriosis is actually shedding inside um the pelvis and the abdominal cavity. But it's also from the blood that is being produced and that can be quite in irritant. And then when the blood will congeal, it will cause um healing by a lot of scarring. So, infection and hemoperitoneum are uh cause exquisite pain and my own advice. Um If any of the other doctors ask me is that if I think that we're thinking from the history that this could be a potential ectopic, then please please please, you want to refer this patient to hospital if possible by ambulance 999, this is not somebody who you would want to uh cause an excessive delay or leave uh them in, in the, in the uh in a in a dilemma because there are delays also in hospital. So the sooner you get this patient to the right person, the better for everybody. Um There are obviously uh red flags. Um So the red flags are obviously hemodynamic instability, tachycardia, hypertension, pre syncope, syncope that tells you that there's some hemodynamic compromised. We're looking at bleeding, we're looking at peritoneal rigidity, rebound, guarding with hemodynamic instability. That is a medical emergency. Uh postmenopausal bleeding is obviously a different pathway. Anybody who has fever or chills or sudden nausea, pain or vomiting, that is more in favor of a torsion. Um Obviously, everybody should have a pregnancy test and a urine analysis. Um And we get such um good results now by ultrasonography because a um ultrasounds are easily available. The expertise is they're both in the community um uh as well as in the hospital that um you would be able to um see a uh bless. Okay. Um Thank you. Thank you. Sorry, that's my birthday. Somebody just sent me a message. Um So, um yeah, so, so what I was trying to say over here is um the, the um easy availability of ultrasonography makes the diagnosis of a pregnancy or an ectopic um rapidly available. Now, can somebody tell me? And I wish I thank you all. Thank you. Happy birthday. Yes, thank you, everybody. Um Can somebody tell me what's the value of doing an ultrasound in somebody who you think has got an ectopic pregnancy? Anybody know it's a very simple answer. I'm not trying to trick you out, you think about it. So suppose you have somebody who comes to you with acute lower abdominal pain and the uh okay. So MS Patel, he says it sounds a clear tubal pregnancy position of implantation. Okay. No, but that's actually not the answer I'm looking for. So see somebody at six weeks comes to you in the um if somebody comes to you in the uh in your um in your surgery um with lower abdominal pain and they are say six weeks by the dates pregnant. Um, and they've already gone to any and this is, this is actually a real life case. This has happened with me in my career. They've, they've come to you and they've said I went to a any, uh, they did an ultrasound and, uh, they said I'm pregnant. So, um, uh Sharon has said to see where the a topic pregnancy is then if it is ruptured. So, uh Mr Assad is saying growth of size and inflammation. So okay, all of those are correct. But from a logical perspective, why do you think I'm asking about the, the uh the the ultrasound? Because the reason is no, no, it's noninvasive. Yes, you're right. But here, here is the deal. If you see a, you try and pregnancy and ectopic is highly unlikely, it's not that it cannot occur at the same time. So there is a condition called a heterotopic pregnancy where you can have, you try and pregnancy and you can have an ectopic pregnancy at the same time, but they're rare as hen's teeth. It's something like one in 40,000 or something that is a very, very rare condition. And I've actually seen two of them in my career when I used to work in arms and janie. But the issue is the reason we do the ultrasound is we want to see if there's a pregnancy in the uterus. We're actually not looking to see for the adnexa the adding excell mass is um it's an additional benefit when you're doing the ultrasound. The first primary reason for doing the ultrasound is to ensure that we can localize you try and pregnancy. That's the first thing we do. So when we're doing an ultrasound, we go and scan the adnexa, secondarily, what we do is we look at the uterus first because if we can see, um, yeah, thinking of horses before zebras. Yes, thank you. Thinking of horses before zebras. What you want to do when you do the ultrasound is the first thing I would ask my house officer is, have you done a scan? Is there, are you trying pregnancy? So if you can see a sac, if you can see a fetal heart, even if you can see a miscarriage happening. If there is a you train pregnancy, then the chance of an adnexa pregnancy is a tubal pregnancy is it's there. It's possible. I've seen it happen twice in 30 years. It's possible but it's unlikely. The first thing is do an ultrasound. If there's a, you train pregnancy, you can take a deep breath because then here's the other problem. If your B to hate C G is high, then you don't know which pregnancy it's coming from. And then you'd really be looking at somebody who is uh experienced ultrastenographer, really experienced ultrastenographer to look into the adnexa to see if there's an Adnexa mass or not. But having a, you train pregnancy is you can take a nice deep breath and say that's fine. That's you tryin pregnancy. But I still don't know why this woman is having pain, then you can start looking for other things. But you've ruled out an ectopic if you've got uh you train pregnancy. So the primary reason is not to look for the you train uh ectopic pregnancy. You can see if there's a at Nexon mask, but if there's a, you train pregnancy with the fetal heart, you're pretty safe. Um Obviously, you want to do a urine analysis. Look for any blood, look for any protein, any cause of urinary tract infection. That's not to say that you can't get dual pathology. So you can have somebody with a normal pregnancy or an ectopic with a urinary infection and they can be numerous other other pathologies. So, um pelvic ultrasonography is obviously key and then what do you do if the pain becomes really severe? If it's persistent, it's unidentifiable or there's hemodynamic instability, you will have no choice but to proceed to a laproscopy or a laparotomy. Um And as I said, you know, um you can usually see um a fetal uh pole by about 4 to 5 weeks, but the fetal heart round about 5 to 6 weeks, you should be able to see. Um and um it makes the diagnosis of an ectopic pregnancy unlikely. So the first step would be history taking clinical examination, ultrasonography, et cetera. And then if you are at a loss in an acute instances, you'd call in the surgeons. If you don't think this is gynecological. Definitely. Of course, you'd have to call in the surgeons. You could proceed to a laproscopy and sometimes the patient's hemodynamically unstable, you just have to go to a laparotomy. Um You have to treat the cause, obviously, pelvic pain, non pregnant women, you can give them anti inflammatories. Um You can give them opioids. Um And then uh if you're getting primary dysmenorrhea or secondary dysmenorrhea, endometriosis, you can use hormonal manipulation, muscular skeletal pain is a difficult one. Uh The reason it's a difficult one is that you have to rule everything else out before you say to somebody, okay. I think that this is muscular skeletal pain. Um And you would get your physiotherapy colleagues. Um You would do MRI S uh you would do some um provocation testing with your um physiotherapist and, and then you would arrive at that diagnosis, but it would be a diagnosis of exclusion. Um I have seen in patient's back in the day, we used to resort to hysterectomy as a last option, especially if they have what is called a frozen pelvis. And a frozen pelvis is somebody who, when you do a laproscopy, literally, everything is uh solid. So there's so much scarring that there is uh very little room for manoeuvre and it's not something that we do anymore because the, the results are not that great if you resort to such, um, um, uh, if you resort to something as dramatic as a hysterectomy, um, I just wanted to talk about pelvic pain in the elderly and pelvic pain in the elderly. The only reason I'm talking about pelvic pain in the elderly is we tend to focus a lot on pelvic pain in younger people. But pelvic pain does happen in elder women and they do present with it. We see a lot of it in, in general practice, there can be quite a lot of, uh, reasons for it. So obviously, we're not talking of uh any menstrual causes. Usually it is related to the bladder constipation or prolapse. And one of the things to remember in the elderly is, um, ovarian cancer. Um, and anybody that presents with symptoms of lower abdominal pain, weight loss, dyspepsia bloating or even a change of bowel habits, you need to do a thorough clinical examination. So be aware of an elderly woman who presents to you with the novo pelvic pain. It's either bowel bladder uterus or ovaries. So these are sort of high risk people. You don't want to just discount what they're saying. And personally, from in my own clinical practice, I go to ultrasound very, very quickly. I would definitely take um, a full history. I would ask them about their bowels if they have any tenderness or anything. I would do an ultrasound. I would look to investigating them sooner rather than later because in these stations, um, you don't want to miss a cancer. Um, prolapse is very easy. If you examine them, then you can, you can, um, you can, um, tell that if there is a prolapse, but an ultrasound is something that I would definitely go for very quickly in the elderly. So, just to, uh, recap that, you know, it's common, um, rule out pregnancy, we've just talked about elderly people don't miss an ectopic or an acute abdominal pathology pathology. And if you're in doubt, then certainly, you know, refer your patient, do your safety netting and do your documentation. So that brings us to the end of this talk. Any questions? Hello? Any questions? Oh, thank you. Thank you, Sarah. Yes, it was my birthday and I, I guess I, when I first took up the dates, I didn't realize that it was my birthday. So um thank you all for your kind wishes. Any questions or anything. Thank you, Mr uh Thank you very much. Now, um on the cardiology lecture, we'll have to take on the last bit of the cardiology lecture. Um at the next cardiology lecture I'm told that um there isn't much time now for taking up the, the rest of the cardiology lecture, but I was keen on doing that. So we'll take it up in the next cardiology block, which I believe might be next week. Yeah, it would be next week is that. Ok, great stuff, Hannah. Any anything for me? Any instructions for me? You're welcome. Thank you. So shall I just close this session everybody? Are you happy? No questions? Thank you. Thank you very much. That's brilliant. Thank you very much. Bye bye everyone. Bye bye.