Gynaecology

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CHAPTER 22 Gynaecology

Ectopic pregnancy 482
Ovary 483
Pelvic inflammatory disease 484
Dysmenorrhoea 484
Endometriosis 484
Uterine fibroids 485
Mittelschmerz 486

Between 10% and 20% of patients admitted with acute abdominal pain have a gynaecological cause. It is therefore important for the surgeon to be able to distinguish between surgical causes and gynaecological causes of acute abdominal pain. Gynaecological conditions which may be admitted as surgical emergencies include ectopic pregnancy, ovarian cyst (torsion or rupture), salpingitis, dysmenorrhoea, endometriosis, Mittelschmerz and complications of fibroids. Ruptured ectopic pregnancy is a life-threatening condition and requires urgent gynaecological referral.

Ectopic pregnancy

This occurs when the conceptus implants outside the uterus, e.g. fallopian tube, ovary or abdominal cavity. Over 95% occur in the fallopian tube. Risk factors for ectopic pregnancy include use of IUD, after pelvic inflammatory disease, after pelvic surgery and increasing maternal age.

Symptoms and signs

In the early stages, there may be no symptoms. Vaginal bleeding and iliac fossa pain are the commonest symptoms. Later, a mass may be palpable arising out of the pelvis associated with abdominal pain. Ruptured ectopic pregnancy presents with sudden severe pain gradually spreading across the abdomen. Signs of shock may be present with sweating, tachycardia and hypotension. Shoulder tip pain may be present due to irritation of the diaphragm by intraperitoneal blood.

Investigations

• Hb: may be low or may be normal after sudden bleed
• βhCG elevated
• USS: foetus in fallopian tube, intraperitoneal free fluid
• Laparoscopy.

Treatment

Salpingectomy or salpingostomy by laparoscopy or laparotomy.

Ovary

Ovarian cyst

An ovarian cyst is any collection of fluid within an ovary. The classification of ovarian cyst is beyond the scope of this chapter and the reader is referred to a textbook of gynaecology. Most ovarian cysts are benign.

Symptoms and signs

May be found incidentally during routine abdominal or pelvic examination. Dull ache in the lower back or thighs. Pressure, fullness or pain in the abdomen. Dyspareunia. Painful periods and abnormal bleeding. Severe pain may arise from rupture, torsion or haemorrhage into a cyst. Intraperitoneal bleeding may occasionally mimic ruptured ectopic pregnancy. An abdominal mass is palpable when the cyst becomes large. Pressure effects on the bladder may cause frequency of micturition and, on the colon, constipation. Rarely, there may be hormonal symptoms due to secretion by the tumour of androgens or oestrogens. Rarely, ovarian cysts may become massive and fill the whole abdomen. Examination may reveal a mass arising out of the pelvis which it is impossible to get below. Maybe shifting dullness of ascites (malignancy or Meigs syndrome). Bimanual examination: mobility, consistency, nodules in the pouch of Douglas (with malignancy). Hard, irregular fixed mass likely to be malignant.

Investigations

• Hb: ↓ bleeding, malignancy
• WCC ↑ infarction due to torsion
• CA125: ↑ ovarian carcinoma
• USS: abdominal or transvaginal
• CT/PET: assess extent of condition especially if malignancy suspected.

Treatment

Depends on severity of symptoms, age of patient, risk of malignancy, desire for further children. In the case of acute presentation, treatment involves ultrasound guided cyst aspiration, laparoscopy or laparotomy.

Ovarian cancer

Ovarian cancer often presents late. It frequently causes non-specific symptoms which contribute to diagnostic delay resulting in it presenting at a late stage and therefore having a poor prognosis.

Symptoms and signs

Often asymptomatic in early stages. Abdominal pain, discomfort. Bloating, back pain, urinary frequency, constipation, abnormal vaginal bleeding, weight loss. Examination may reveal an abdominal mass or ascites. Pelvic examination may reveal an ovarian mass or secondaries in the pouch of Douglas.

Investigations

• Hb
• CA125
• USS: abdominal and transvaginal
• CT/PET scan: staging
• Laparoscopy.

Treatment

Depends on stage of disease. Oophorectomy. Bilateral salpingo-oophorectomy. In advanced disease, tumour debulking. Chemotherapy.

Pelvic inflammatory disease

Pelvic inflammatory disease (PID) is a generic term for inflammation of the uterus, fallopian tubes and ovaries. The infection usually spreads from the vagina and cervix. PID is most commonly caused by a sexually transmitted infection, usually chlamydia or gonorrhoea. Childbirth, termination of pregnancy, insertion of an intrauterine contraceptive device and sexual intercourse during menstruation may all increase the risk of bacterial infection spreading from the vagina and causing PID.

Symptoms and signs

Lower abdominal or pelvic pain ranging from mild to severe. Abnormal vaginal discharge. Abnormal vaginal bleeding. Dyspareunia. Low back pain. Fever. Lower abdominal tenderness. Rarely a palpable mass if tubal abscess. Bimanual examination – cervical motion tenderness (cervical excitation) with or without and adnexal tenderness.

Investigations

• Hb
• FBC: WCC ↑
• High vaginal swab: trichomonas vaginalis (bacterial vaginosis)
• Endocervical swabs: chlamydia, neisseria gonorrhoeae
• Laparoscopy.

Treatment

Ambulant patients with mild symptoms

Treat to cover Chlamydia, gonorrhoea and anaerobes. Treatment is with doxycycline 100 mg b.d. 14 days plus 5 days metronidazole 400 mg b.d. If gonorrhoea is suspected add ciprofloxacin 500 mg as a single dose.

Patient systemically unwell

Admit. Intravenous antibiotics. Laparoscopy. Drainage of tubal abscess.

Dysmenorrhoea

Dysmenorrhoea is painful menstruation. It may be primary or secondary. It is an extremely common complaint experienced by up to 95% of women of reproductive age. It typically consists of cramping suprapubic pain which starts at the onset of the menstrual flow and lasts for up to 72 h. It may be so severe that it mimics a lower abdominal emergency. Primary dysmenorrhoea has no associated organic pathology. Secondary dysmenorrhoea is associated with identifiable pathology, e.g. endometriosis, pelvic inflammatory disease, adenomyosis.

Endometriosis

Endometriosis is the presence of endometrium outside the lining of the uterine cavity. Of the women presenting with gynaecological symptoms, 10–15% have this condition. The condition may also be seen in asymptomatic women at laparoscopy or laparotomy.

Symptoms and signs

Symptoms are extremely variable. They include dysmenorrhoea, lower abdominal and pelvic pain. Dyspareunia. Low back pain. Infertility. Abdominal tenderness. PV – tenderness, thickening and nodularity in the Pouch of Douglas, ovarian mass, fixed retroverted uterus. Endometriosis may affect the urinary tract giving rise to haematuria, dysuria or ureteric obstruction. It may also affect the gastrointestinal tract causing cyclical rectal bleeding or obstruction. Rarely, it can affect the lungs causing haemoptysis. It may also occur in surgical scars and umbilicus causing cyclical pain and bleeding.

Investigations

• Laparoscopy: Gold Standard
• Transvaginal ultrasound: useful in diagnosis of ovarian endometrioma
• MRI: subperitoneal deposits
• CA125: limited value as screening test or diagnostic test.

Treatment

Analgesics. Combined oral contraceptive agents. Progestogens. Gonadotrophin-releasing hormone agonists. Surgery – conservative surgery to eradicate lesions with diathermy or laser. Radical surgery – hysterectomy, bilateral salpingo-oophorectomy.

Complications

Adhesion formation. Sub-fertility.

Uterine fibroids

A fibroid is a benign tumour of uterine smooth muscle termed a leiomyoma. They are the most common benign neoplasm in females. There are four types named according to where they are found.

1. Intramural fibroids are found in the wall of the uterus and are the most common type.
2. Subserosal fibroids are found growing outside the wall of the uterus and can become very large. The latter may become pedunculated and therefore subject to torsion.
3. Submucosal fibroids are found in the muscle beneath the epithelium of the womb.
4. Cervical fibroids are found in the wall of the cervix.

Symptoms and signs

Often asymptomatic. Menorrhagia leading to anaemia. Abdominal discomfort. Pressure on bladder, causing frequency. Pressure on rectum, causing constipation. Severe pain, torsion or degeneration. Palpable abdominal mass. Palpable mass on bimanual examination. Severe abdominal pain due to torsion of a pedunculated fibroid or degeneration of a fibroid following disruption of blood supply.

Investigations

• Hb: anaemia
• USS: abdominal and transvaginal
• MRI.

Treatment

Surgery

Myomectomy (hysteroscopic), laparoscopic, laparotomy. Hysterectomy (vaginal or transabdominal).

Uterine artery embolization

Mittelschmerz

This is a term for ovulation pain or mid-cycle pain. It is experienced by about 20% of women either in every cycle or intermittently.

Symptoms and signs

Lower abdominal and pelvic pain occurring midway through the menstrual cycle. It usually appears suddenly and subsides within hours, although sometimes it may last up to 72 h. The patient may be able to localize it to a particular ovary.

Investigations

USS: to exclude other causes of abdominal pain.

Treatment

Pain relief. Contraceptive pill to prevent ovulation.

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