Paediatric gynaecology

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15.1 Paediatric gynaecology

Pamela Rosengarten, Sonia Grover

Prepubescent gynaecology

Vaginal discharge

Introduction

Vaginal discharge in neonates and prepubertal girls can be physiological. In neonates, a white mucoid vaginal discharge is present in most baby girls and is due to the effects of maternal oestrogens; it disappears by about 3 months of age. The second period where physiological discharge may occur is at the time ovarian activity commences with the onset of puberty.

Other conditions that cause vaginal discharge in the prepubertal girl include vulvovaginitis, lichen sclerosis, foreign body, eczema and pinworms.

Vulvovaginitis

This is the most common gynaecological problem in childhood, usually occurring in girls aged between 2 years and prior to the onset of puberty.^1,² Most vulvovaginitis in this age group is non-infectious in origin and results from irritation of the vaginal and vulval skin, particularly where there is contact between the labial surfaces.^2,³ Factors that contribute to genital inflammation include the vaginal and vulval skin of children being thin and atrophic due to low oestrogens and therefore easily irritated. In addition, lack of protective labial hair and fat pads as well as moisture from wet swimming costumes, obesity and poor hygiene may play a role.²^–⁴ Additionally, the presence of bowel flora, which is the normal flora in the atrophic vagina, may contribute to skin irritation and the other related common symptom of offensive smell.

Infectious vulvovaginitis is less common and is due to an overgrowth of one organism, for example Group A Streptococcus, Staphylococcus, enterococci and Escherichia coli. In this instance, profuse discharge is usually present with marked skin inflammation, often beyond the contact surfaces of the labia.³ Isolation of an organism that has strong sexual transmission, such as Neisseria gonorrhoeae or Chlamydia trachomatis, generally indicates sexual abuse or sexual activity and therefore warrants further investigation.^3,⁴

Lichen sclerosis is an uncommon condition of unknown aetiology. It may present in childhood with vulval irritation, pruritus, dysuria or bleeding.^1,² Examination reveals pale atrophic patches on the labia and perineum. The patches can be extensive and coalesce, and with scratching lead to chronic inflammation and purpuric haemorrhage into the skin. The condition usually persists with intermittent exacerbations. Most resolve before puberty although some may continue to have problems into adult life.⁵

Eczema may contribute to the symptoms of vulvovaginitis with the addition of itch. In these cases eczema is usually present elsewhere on the body and can be superimposed on the irritation due to the discharge.

Foreign bodies are a potential cause for a persistent, unresolving, often bloodstained offensive discharge.

Candida is very uncommon in the prepubertal girl unless there has been significant antibiotic use or they are still in nappies.^2,⁴ (Thrush thrives in an oestrogenised environment, not in the atrophic setting.) In this age group, recurrent or unexplained candida requires exclusion of diabetes mellitus or other causes of diminished immune function.

History

The child or parent/caregiver usually describe:

• an offensive vaginal discharge;

• erythema (redness)/irritation of the labia and perineal skin;

• itch, dysuria and urinary frequency may also be present.

These symptoms often fluctuate in severity.

A general medical history is required, with specific history of the symptoms and their duration including nature of discharge as well as any previous treatments. Also important is past history of urinary tract infection, encopresis, constipation, enuresis, the presence of skin disorders, and any other illness, including antibiotic use in the previous 4 weeks. Although a history of perineal hygiene (e.g. wipe front to back, frequency of bathing, type of underwear/clothes, specific irritants, such as bubble baths or use of feminine hygiene sprays in the adolescent population, etc.) should also be established, there is limited evidence to support the role of this in the pathogenesis of vulvovaginitis.³ Where itch is the dominant symptom, pinworms should be considered and questions asked about family symptoms.

Although uncommon, the possibility of sexual abuse should always be considered in a child that presents with genital symptoms, and check for other signs that may be present including alterations in behaviour such as phobias, eating or sleeping disorders.

Examination

A general examination including sexual development is required. Perineal, vulval and introital examination may be required for the above conditions. Attempts must be made to ensure it is not a traumatic event for the child. The perineum is best examined either with the girl supine with heels together and knees flexed and hips abducted or in the lateral position with knees drawn up to the chest.⁶ Vaginal examination is inappropriate in paediatric patients and usually provides little further information. Specific external examination of the perineum usually reveals mucoid discharge and reddened introitus, particularly on the contact surfaces between the labia.

The presence of a profuse discharge or marked skin inflammation, especially if it extends beyond the contact surfaces of the labia, suggests an infectious cause. An offensive discharge can occur with vulvovaginitis or foreign body. A bloody discharge can occur with vulvovaginitis (particularly with Shigella or Group A streptococci).⁶ The presence of perianal excoriation suggests pinworm.

Investigations

Swabs are generally not required. If taken in mild cases, they usually reveal a growth of mixed coliforms.³ If discharge is visible or profuse or marked erythema is present, introital swabs should be taken for culture. Vaginal swabs are painful and distressing and are not required.

If urinary symptoms are present, the urine (midstream urine; MSU) should be checked to exclude urinary tract infection. A pinworm test should be taken if itch is a prominent symptom. This requires briefly placing clear sticky tape on the perianal skin in the morning and viewing under a microscope for eggs. Otherwise worms may be seen in the perianal region at night.

Ultrasound may provide further information, especially if there is a possibility of foreign body, or if necessary an EUA may be more appropriate.

Management

Vulvovaginitis

Management consists of:

Explanation and reassurance.

Toileting/hygiene advice:

• avoidance of potential irritants such as soaps and bubble baths and other causal factors, such as tight/synthetic clothing and wet bathers;

• vinegar (add one cup white vinegar in a shallow bath and soak) or the use of a simple barrier cream to the labial area (e.g. zinc-castor oil or nappy rash cream) or both.

Rarely, if the problem persists, further action may be required. The natural history of vulvovaginitis is for recurrences to occur up until the age when oestrogenisation begins. If a primary bacterial cause is suspected, cultures should be taken and treatment commenced with the appropriate antibiotics, e.g. initial amoxicillin, and adjusted when culture results are available.

Where itch is a dominant symptom consider:

• Pinworms, especially if perianal excoriation is present, and treat the child and their family with pyrantel 10 mg kg^-1 (maximum 500 mg) orally or mebendazole 50 mg (<10 kg), 100 mg(> 10 kg) orally (contraindicated in pregnancy and <6 months of age) as a stat. dose and repeat 2 weeks later.⁷

• Lichen sclerosis in the asymptomatic patient does not require treatment other than

• reassurance. In symptomatic patients, avoidance of irritants, improved hygiene, reduced trauma and barrier ointments, e.g. nappy rash creams. In more severe cases, a brief course of topical steroid (1% hydrocortisone) and referral to a dermatologist or paediatric gynaecologist is required.

• Eczema, especially if skin disease is present elsewhere. Combined treatment of the vulvovaginitis (as above) and hydrocortisone or Diprosone may be indicated.

Foreign body

If foreign body is suspected then an examination under anaesthesia with vaginoscopy is usually required. If the presence of a foreign body is questionable then an ultrasound may be beneficial to visualise the object. The most common foreign bodies are tiny pieces of tissue paper. The possibility of sexual abuse should be borne in mind.

Vaginal bleeding

Introduction

Vaginal bleeding in the prepubertal child is abnormal after 3–4 weeks of age.⁶

Causes of vaginal bleeding in the prepubertal girl can be classed as hormonal and non-hormonal.

Hormonal causes

Neonates

A withdrawal bleed from maternal oestrogens is common and does not require investigation or treatment. This will cease after approximately 4 weeks of age.

Onset of menstruation

Consider as premature (precocious puberty) if this occurs at less than 8 years of age.⁷

Non-hormonal causes

Vulvovaginitis

In prepubescent girls, vaginal bleeding in this age group is most commonly due to more severe vulvovaginitis (the most common pathogens are Shigella or Group A β-haemolytic streptococci).⁶ The discharge is brown and often offensive (see above under vaginal discharge, vulvovaginitis).

Trauma

Accidental injury usually results from straddle injuries where the girl falls on a narrow object (e.g. bicycle cross bar, jungle gym). Non-accidental injury/sexual abuse should be considered in trauma, especially where there is a hymenal tear without a history of accidental penetrating injury.

Foreign body

Vaginal foreign body may also result in bloodstained discharge and should be considered if no infectious cause is identified or there is failure to respond to appropriate treatment. In bleeding secondary to excoriation from pinworms, lichen sclerosis or eczema, examination should demonstrate eczema and lichen sclerosis. The presence of anal and perineal excoriation suggests pinworms and treatment as previously described under vulvovaginitis.

Tumours

Although rare, the possibility of a genital tumour should be considered when there is chronic genital ulceration, non-traumatic swelling, tissue protruding from the vagina or foul smelling, bloody, vaginal discharge. Vaginal bleeding associated with genital enlargement, premature sexual maturation or virilisation may be associated with hormonally active ovarian or adrenal tumour.

Non-vaginal causes of bleeding

Haematuria may stain the underwear or nappy and be reported as vaginal bleeding. This will become evident upon urinalysis. Urethral prolapse often presents with bleeding thought to be vaginal in origin. The peak age is 5–8 years. Bleeding disorders are an uncommon cause of vaginal bleeding but should be considered when there are other systemic signs of a bleeding tendency, e.g. bruising and petechiae.

History

A general medical history including family and past history should be taken.

The history of vaginal bleeding should focus on the amount and circumstances of bleeding, the times of recurrences and the presence of associated pain. A history regarding any perineal trauma should be elicited as well as the possibility of a foreign body. Other medical disorders and symptoms of blood dyscrasias, such as epistaxis and bruising should also be noted.

Examination

Vital signs and haemodynamic stability should be established. General examination, including sexual development, should be performed. On examination, excessive bruising or petechiae and generalised skin disorders, such as eczema, should be noted.

Specific examination requires abdominal and vulval/perineal examination. Abdominal examination should note abdominal tenderness and the presence of a mass. Perineal examination should note the presence of vulvovaginitis, other skin disorders, such as eczema, or traumatic injury.

The common perineal injuries in trauma are bruising/haematoma of vulva and periclitoral folds and superficial lacerations of the labia minora and periurethral tissue. If a hymenal tear is present, a history of penetrating injury, e.g. broom handle or bed post should be sought. If there is no history of penetrating trauma then sexual abuse needs to be considered.

A foreign body in the vagina may be evident on examination of the perineum.

A urethral prolapse will be evident on examination of the perineum as a friable, red-blue (doughnut-shaped) annular mass.

Investigations

Full blood examination should be performed if the child appears clinically anaemic or bleeding has been prolonged. Coagulation studies may be indicated. Perineal swabs should be taken for microscopy and culture where there is evidence of severe vulvovaginitis.

In trauma, where there is a history of penetrating injury or where it is not possible to perform adequate perineal examination, an examination under anaesthesia is required. Midstream urine for micro and culture should also be performed where haematuria is present.

In the child less than 8 years of age who has signs of puberty evident, referral to a paediatric endocrinologist or gynaecologist is required.

Management

Trauma

A warm bath several times a day to help voiding as well as assist in keeping the perineum clean is all that is required. The girl may find voiding in a bath more comfortable. Antibiotics are rarely required. Examination under anaesthesia is only required if there is persistent bleeding, uncertain origin of bleeding, massive bruising or history of a fall on a potentially penetrating object. Suspected sexual abuse must be referred.

Urethral prolapse

The management is conservative as long as voiding is normal. Warm baths may be of assistance. Topical oestrogen cream assists in the resolution.

Labial adhesions

Labial adhesions are seen in infancy, and usually resolve by about 8 years, although they may occasionally persist through to puberty when they will resolve around the time of menarche. The adhesion is not congenital, but it is acquired from a secondary adherence of the atrophic surfaces of the labia minora, presumably as a result of irritation.^1,²

Labial adhesions are usually asymptomatic in children and do not need to be divided as long as the child is able to void. When symptoms occur they usually relate to difficulty with urination or pooling of urine behind fused labia, which results in irritation.^1,^2,⁵ Urinary tract infections are seldom a complication.⁵ Parents should be reassured that separation of the labia will occur when oestrogenisation commences as the child grows. Although it is possible to divide the adhesions with lateral traction this is frequently distressing for the child and the parents, and unnecessary. There is a considerable recurrence rate after this approach.⁵

The use of topical oestrogen cream is likewise unnecessary, and is associated with significant failure and recurrence rates, but may occasionally be indicated when catheterisation is required for a micturating cystoureterogram.

Associated nappy rash or vulvovaginitis is managed as described above.

Distressing vaginal or perineal pain

Severe perineal or vaginal pain, often described as a vaginal shooting pain that is very distressing, is reported in the prepubertal girl. It predominantly occurs in the evening – waking from sleep. The likely cause for this is pinworms (Enterobius vermicularis). The worms, usually found in the perianal region, can become ‘lost’ within the vagina. When they crawl onto the thin atrophic hymen in the prepubescent girl they cause the distressing pain. Treatment with mebendazole, with repeated treatments (usually ×3 at weekly intervals), is required to ensure clearance.

Adolescent gynaecology

Vaginal discharge

Introduction

Vaginal discharge in an adolescent female may be physiological, a symptom of vaginal or cervical infection or secondary to a vaginal foreign body. Under the influence of oestrogen there is an increase in the glycogen production by the vaginal epithelial cells, which supports the growth of lactobacilli in the vagina, which leads to lowering of the vaginal pH to 3.8–4.5. The acidic environment helps to inhibit the growth of bacteria seen in the prepubertal female. Oestrogen also influences the cervix, resulting in increased mucous production, which is largely responsible for the physiological vaginal discharge.⁸

Vaginal infections include candidiasis, bacterial vaginosis and trichomoniasis, with only the latter being sexually transmitted. Chlamydia and gonorrhoea are sexually transmitted infections of the cervix and/or the upper genital tract, which may also result in a vaginal discharge.

History

Diagnosis can often be suspected from the history and the appearance of the discharge.

• Candida infections typically present as a cheesy white discharge and are associated with vulval and vaginal itching, dysuria or superficial dyspareunia in sexually active girls. They are commonly associated with antibiotic use, stress and diabetes mellitus.

• Bacterial vaginosis generally presents as a homogenous white discharge associated with a fishy odour. Symptoms of vaginal irritation are uncommon.

• Trichomoniasis is a sexually transmitted infection (STI) and typically presents with a frothy, green vaginal discharge.

• Chlamydia and gonorrhoea infections may present as vaginal discharge, intermenstrual or post-coital bleeding, urethritis or pelvic inflammatory disease (PID). Chlamydia and gonorrhoea may also be identified incidentally due to the high incidence of asymptomatic infections. The presence of lower abdominal pain and/or dyspareunia in the history increases the likelihood of PID, with a positive and negative predictive value of 17% and 100% respectively.⁹ STIs may be contracted by oral or digital contact and do not necessarily require penetrative intercourse for transmission.

• The most common vaginal foreign body in adolescent girls is a retained tampon. The presenting symptom is often a malodorous discharge.

Examination

Inspection of the external genitalia should be performed, specifically looking for evidence of warts, herpetic lesions, the nature of the discharge and evidence of excoriation.

Adolescent girls who have never been sexually active and/or who have not used tampons should not be examined internally. If there is a suspicion of a vaginal foreign body, vaginal trauma or PID in a girl who is sexually active or uses tampons, a gentle vaginal examination may be considered. However, even sexually experienced girls may be unable to proceed with the examination and alternative forms of assessment may need to be considered.

Investigations

Microscopy, culture and wet-preparation analysis of a vaginal discharge will help to confirm the diagnosis of candidiasis, bacterial vaginosis and trichomoniasis.

The gold standard for diagnosis of both Chlamydia and gonorrhoea is culture from a cervical sample. However, both infections can readily be detected with a high degree of sensitivity using a molecular replication technique (either PCR or LCR) performed on samples collected from either the cervix or a first-catch urine.

Management

• Candida albicans is the most common cause of vaginal thrush. One treatment option is clotrimazole 10% cream inserted vaginally as a single dose at night. An alternative, if the patient, is intolerant of topical therapy and not pregnant, is fluconazole 150 mg orally as a single dose.¹⁰

• Bacterial vaginosis should be treated in symptomatic patients and in those at high risk of acquiring other STIs. Oral metronidazole 400 mg bd for 5 days is recommended in non-pregnant patients.¹⁰

• Trichomoniasis can be treated with oral metronidazole 2 g orally as a single dose.¹⁰

• Chlamydia treatment is with either a 7-day course of doxycycline (100 mg bd) or a single oral dose of 1 g azithromycin.¹⁰

• Gonorrhoea has developed resistance to a number of antibiotics and therefore treatment should be based on local sensitivities. In urban Australia a single dose of 250 mg ceftriaxone intramuscularly in combination with cover for Chlamydia is currently recommended.¹⁰

• A retained tampon can generally be removed in the ED. However, occasionally the swollen tampon cannot be extracted due to a hymenal ring and removal under general anaesthesia is required. If the tampon is removed in the ED it should be immediately placed into a container of water to limit exposure to the often offensive odour.

Disposition

Adolescents with a sexually transmitted infection should have a follow-up communicable disease consultation to discuss prevention of further STIs. Ongoing contraception and contact tracing should also be addressed.

Gonorrhoea and Chlamydia are notifiable diseases in some Australian states.

Abnormal vaginal bleeding

Introduction

Abnormal vaginal bleeding may be caused by a complication of pregnancy, trauma, infection or it may be secondary to contraceptive use. The most common causes of heavy vaginal bleeding are anovulatory bleeding or an underlying haematological condition.¹¹

Menstrual cycles in adolescents are often anovulatory due to the gradual maturation of the hypothalamic–pituitary–ovarian axis, which can take up to 5 years after the menarche.¹¹^–¹⁴ Anovulatory or dysfunctional uterine bleeding generally presents as irregular, often heavy, blood loss. Anovulatory bleeding may result from a relative deficiency of either oestrogen or progesterone. Relative oestrogen deficiency is more common in thin young women who have just commenced their menstrual cycles. The relative oestrogen deficiency results in a thin, atrophic endometrium, which can bleed profusely.

In girls with higher endogenous oestrogen levels, anovulatory menstrual cycles are more likely to result in a relative progesterone deficiency due to failure of the luteal phase. In this case the unopposed oestrogen results in thickening of the endometrial lining, which can bleed erratically.

Menorrhagia, whether associated with ovulatory or anovulatory cycles, may be a marker of systemic illness. Up to 20% of patients admitted with menorrhagia have been found to have an underlying haematological disease, the most common of which is a coagulopathy, half of which are von Willebrand’s disease and the other half due to platelet problems or dysfunction – other factor deficiencies are very rare.^11,¹⁴

Chronic untreated menorrhagia may also present with signs and symptoms of anaemia.

Examination

The haemodynamic status of the patient and the severity of the bleeding should be assessed. A general examination should be performed, particularly noting evidence of a haematological disorder or anaemia.

Investigations

A full blood count, iron studies and coagulation screen will assist in identifying anaemia, an underlying coagulopathy or haematological cause for the bleeding( although caution needs to be taken in interpreting these results as stress may result in apparent ‘normalising’ of the test results, particularly in von Willebrand’s disease ¹¹). A pregnancy test should also be performed.

Ultrasound may be helpful when ovarian pathology is suspected and can sometimes be used to assess the thickness of the endometrium, although transabdominal views may be limited. An STI screen should be obtained if clinically indicated, as Chlamydia in particular can cause intermenstrual or heavy bleeding.

Dilation and curettage is very rarely indicated for a diagnosis and is not a recognised treatment for dysfunctional uterine bleeding.¹⁵

Management

Heavy bleeding, either acute or chronic, should be treated with fluid and blood products as clinically indicated.

Oestrogens and progestins are generally used in the management of anovulatory bleeding. Suggested regimens vary with respect to the route of administration, the dose and the type of hormone used. Currently there is no convincing evidence in favour of any particular regimen.¹⁶

For both the acute and non acute bleed tranexamic acid should be used. This can be used in combination with hormonal approaches. If using progestogens first line, regimens include oral norethisterone 5–10 mg every 2 hours for four doses, followed by 5 mg two to three times a day for 14 days.⁸ Commencing the oral contraceptive pill once the bleeding has ceased may be sensible, as cessation of the progestogens will almost invariably result in bleeding recommencing.

Alternatively, treatment may include oral conjugated oestrogens 0.625–1.25 mg every 4–6 hours or oral oestradiol 1–2 mg every 4–6 hours until the bleeding stops, which is usually about 24 hours. The dose is then reduced to once or twice daily. Intravenous conjugated oestrogens are no longer available in Australia and have been associated with thromboembolic complications, consequently oral regimens are generally preferred.¹⁷ This approach is worth taking when progestogens have already been used and failed, but can be used first line. Again, the oral contraceptive pill should be commenced for ongoing control, particularly if there is a need to allow some time before further menses in the context of a low haemoglobin. Supplement with iron therapy.

Menorrhagia, in the absence of a coagulation disorder or other underlying pathology, can be treated with non-steroidal anti-inflammatory agents or tranexamic acid, which reduce the menstrual loss by 33% and 50% respectively,^11,¹⁸ or, alternatively, low-dose oral contraceptive therapy.¹²

Disposition

The identification of a coagulation disorder will necessitate review by a haematologist. Pregnancy-related bleeding should be reviewed by an obstetrician/gynaecologist. Anovulatory bleeding and simple menorrhagia can be managed by either a primary care physician or a gynaecologist.

Pelvic pain

Introduction

The differential diagnosis of acute pelvic pain in an adolescent includes both gynaecological and non-gynaecological causes. Common gynaecological causes include pregnancy-related pain, dysmenorrhoea, ovulation pain (Mittelschmertz), ovarian cysts and their complications, torsion of the ovary, pelvic inflammatory disease (PID), endometriosis and congenital uterine abnormalities, such as imperforate hymen.

History

A general gynaecological history should be taken, with particular note made of the relationship of the pain to the menstrual cycle. History should also include the nature of onset of the pain and a history of similar episodes. The pain of dysmenorrhoea, Mittelschmertz, endometriosis and imperforate hymen may be cyclical. However, they may also present during the first episode or as an unusually severe exacerbation. An ectopic pregnancy is not excluded by the history of a recent menstrual period.

• Primary dysmenorrhoea is common in the adolescent population; it refers to pain associated with menstruation in the absence of underlying pathology. The pain is generally described as crampy, occurring in the lower abdomen, often with radiation to the back or to the inner thighs. Associated features may include nausea, vomiting, diarrhoea, headache and syncope. The symptoms have been attributed, in part, to an increased release of, or increased sensitivity to, prostaglandins. The diagnosis is generally made on the basis of history and limited physical examination findings.

• Mittelschmertz is pelvic pain related to ovulation. The pain is generally dull in nature and located in either of the iliac fossae. The pain may last from a few hours to 2–3 days. The pathological basis of the pain is unclear but may be due either to distension of the capsule of the ovary prior to ovulation or to spillage of a small amount of follicular fluid at the time of ovulation.^8,¹⁹

• Simple ovarian cysts are a normal physiological consequence of ovulation. They can be up to 6 cm in diameter. The pain may be from irritation of surrounding structures or stretching of the wall of the cyst. Corpus luteal cysts can reach up to 10 cm in size and may present as acute pain secondary to haemorrhage into the cyst. Both simple and corpus-luteal cysts can present as acute pain they rupture. Although uncommon, a ruptured corpus-luteal cyst may continue to bleed and be associated with significant haemoperitoneum.⁸ Bleeding disorders need to be considered if recurrent haemorrhagic cysts occur or a significant haemoperitoneum.

• Complex ovarian cysts include dermoid cysts, which are often asymptomatic but may cause local pressure symptoms.

• Ovarian torsion is an uncommon condition and is almost exclusively seen in association with ovarian pathology. The history is typically an acute onset of colicky iliac fossa pain, with the right being affected more than the left. There may be associated nausea, vomiting and a leucocytosis. Ultrasound has a high degree of sensitivity and specificity in making the diagnosis of an enlarged ovary – however, doppler studies are not necessarily conclusive and presence of flow does not exclude torsion.^20,²¹

• Pelvic inflammatory disease can have a range of clinical presentations, depending on the location and the severity of the infection. The pain can range from mild to severe; systemic features of infection are not always present. Due to the significant complications associated with untreated PID, the isolated findings of adnexal, uterine or cervical motion tenderness in the young woman who is sexually active, for which no other cause can be found, have been suggested as a basis for the diagnosis and treatment of PID.²²

• Endometriosis is reputed to cause a range of menstrual disorders and pain syndromes. However, the symptoms do not appear to correlate well with the degree of disease identified at laparoscopy. The diagnosis should be made with caution due to the risk of labelling a patient with what may be seen as a sentence for chronic pain and infertility.

• Congenital obstructive abnormalities include an imperforate hymen or obstruction of one side of a double uterine, cervical or vaginal system. An imperforate hymen may present as cyclical or irregular lower abdominal pain in a girl with well-developed secondary sexual characteristics and the absence of menstruation. Unilateral obstruction in a double system more typically presents with dysmenorrhoea that commences several days after the onset of menses and persists beyond the end of the menstrual period.

Examination

Examination should include vital signs and abdominal examination. Pelvic examination can give additional information regarding the location of the pain and its relationship to pelvic organs. Uterine, adnexal or cervical motion tenderness should be sought if pelvic examination is performed. The identification of an adnexal mass is clinically imprecise. However, it should prompt consideration of such conditions as ovarian torsion, tubo-ovarian abscess or ectopic pregnancy.

Investigations

A pregnancy test and a pelvic ultrasound are the most valuable tests for excluding pregnancy-related conditions. Ultrasound is the investigation of choice for the definition of masses and in the identification of ovarian cysts.²³ If a congenital anomaly is suspected, information regarding the kidneys at the time of the ultrasound can be helpful.

Laparoscopy is reserved for pain that cannot be adequately explained or has failed to respond to appropriate treatments. Laparoscopy may be required to exclude torsion where a cyst is present combined with a suspicious history.²¹ It may also have a role in the investigation of chronic pelvic pain.

Management

• Dysmenorrhoea will generally respond to antiprostaglandin agents, such as mefenamic acid 500 mg orally 8-hourly or ibuprofen 400 mg orally 8-hourly. The response is improved by commencing treatment prior to the onset of symptoms.²⁴ Lifestyle issues, such as increasing physical exercise and decreasing stress, may also improve symptoms.²⁵ For patients who fail to respond to treatment, combined oral contraceptive therapy is considered second-line therapy and further investigation, such as ultrasound and laparoscopy, may be considered to identify other pathology, for example significant endometriosis.²⁴

• Mittelschmertz and simple ovarian cysts can often be treated by reassurance. However, if this is not adequate, simple analgesia and non-steroidal anti-inflammatory drugs may be required. If the pain is recurrent then consideration should be given to the use of the combined oral contraceptive pill in an attempt to suppress ovulation. Failure of resolution of a cyst after 2 months or a simple cyst greater than 8 cm diameter may require surgical exploration.⁸

• Complex ovarian cysts, including dermoids and endometriomas, are generally treated surgically.

• Ovarian torsion requires urgent operative intervention with the aim to preserve ovarian tissue. ²¹

• PID can be treated with either oral or parenteral antibiotics. However, there should be a low threshold for admission in adolescents.²⁶

Disposition

Most forms of pelvic pain will require further management or investigation and should be referred accordingly.

The management of anovulatory vaginal bleeding.

The diagnosis and management of ovarian torsion.

The diagnostic criteria and optimal management of PID.

Acknowledgement

The contribution of Sheila Bryan as author in the first edition is hereby acknowledged.

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