Pelvic Pain

PELVIC PAIN History: 1. Pain • • • • •

Characteristics of the pain site, time and nature Relationship of pain to various body functions eg. Veinal bleeding or icrturition Past gynecological or obstetrical events Menstrual Hx (eg.LMP) Symptoms of possible pregnancy (eg.breast changes and woman’s own impression)

2. Shock 3. N/V (NB: Distension: This is common in GIT problems but not gynaecological problems) Examination: 1. Paleness (conjunctiva) 2. Pulse rate 3. Arterial BP Temperature 4. Abdominal examination (helps localize pelvic causes) 5. Observation: Show old scars and degree of distension (site of pain can be elicited from woman at this point) 6. Gentle palpation of abdomen leading to lower pelvic zones may help localize it further 7. Firmer examination: Reveals guarding or rebound tenderness 8. Bimanual vaginal exam: Tenderness in pelvic organ will limit thoroughness of exam as woman will guard ig pain on moving the cervix (called cervical excitation). Moving cervix to side of ovarian or tubal mass will cause intense paoin by a furthr stretch of the overlying peritoneum. Moving the cervix towards the opposite side will decrease pain by releasing tension of peritoneum 9. Rectal exam: May be needed but usually one can assess acute pouch of Douglass problems at vaginal assessment. If structural changes are sought at the back fo the pelvic cavity then rectal examis useful (Eg.endometriotic lesions on the uterosacral ligaments or to differentiate from appendicitis) Investigations: • Hb (chronic bleeding) • Differential WCC • Urine cells and organisms to diagnose urinary infection • hcG levels to check for pregnancy • High vaginal swab and cervical swab to test for genital tract infection • X-rays may be used to check for bowel obstruction •

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Ultrasound is useful to check for pevlci organs (especially using a vaginal probe). It is used to look at: (1) Changes in ovarian morphology and size: Cysts, PCOS, irregular masses (2) Fallopian tube: Swollen tube from pyo or hydrosalpinx and ectopic pregnancy (3) Uterine size detected: thickness of endometrium is shown, presence of pregnancy sac detected as early as 5 weeks, embryonic parts and hetal heart beats by 6 weeks form LMP (4) Fibroids of uterus (5) Pouch of Douglass fluid detected in low as volume 7ml. This can indicate blood loss form ectopic pregnancy

CONDITIONS 1. Vaginal trauma: Intercourse can damage it (after long period of abstinence). Lower end (usually obvious but can be labial or fourchette), upper end (vaginal guarding to prevent easy passage of speculum. So hard ot see), haematoma (paravaginal or paracervical haematoma) Treat: Vaginal repair under anaesthesia 2. Uterine fibroids (leiomyomata): Bengin fibromuscular swellings aririsng in the muscular wall of the uterus. These are oestrogen sensitive. Include submucous (lying immediately below endometrium and enlarging the surface if the uterine cavity leading to menorrhagia. Fibroids can form polypi which extrude though cervix),intramural (commonest fibroid, surrounded by smooth muscle, enlarges uterine wall and distorts venous drainage), subseorus (beneath peritoneum on outer uterine surface-can become pedunculated with risk of torsion or grow into broad ligament).. The fibroids may degenerate and outgrow their blood supply forming : hyaline (aseptic necrosis with loss of muscle cel structure and calcification), cystic (sequel to hyaline change with subsequent breakdown and cyst formation giving honeycomb appearance), fatty (partial necorsis results in development of fatty substances which can undergo calcification that is visible on X ray and ultrasound), red (necrobiasis-particularly encountered in mid-trimester of pregnancy of early puerperium,. Breakdown of blood supply by thrombosis leads to necrosis and suffusion with RBCs), sarcomatous (malignant change reported in small percentage of fibroids). (Submoucosal fibroid: protrude into uterine cavity lined by enodmetrium and increased SA and vascularity cause menorrhagia. Uterus recognized fibroid as abnormal and tires to extrude it though cervix so get secondary dysmenorrheoa. Constant low abdo pain with fiboird degeneration. Symptoms: Asymptomatic (found incidentally on exam), tightness of waisbadn fo clothes, pressure (bladder compression cause frequency, impaired urinary stream. In supporting ligamenets it causes back ache and pelvic heaviness), pain (associated with red degeneration or torsion of sebserous pedicles. Dysmenorrhoea may indicate presence of submucous fibroid), menstrual disturbances (menorrhagia, metrorrhagia-prolonged

menstruation, irregular and intermittent bleeding associate d with polyps and other surface lesions often) Investigations: Ultrasound (define the location, dimension and consistency) Diagnosis: Bimanual palpation reveals hard, rounded, nontedner, bosselted mass moving when cervix displaced. It grows fast in pregnancy and shrinks at menopause or with antigonadotrophic hormone therapy (NB: Fibroids form a pseudocapsule by compressing surrounding uterine muscle) Aetiology: >30yo, common in Afro-Carribean, nulliparous and women with low fertility and often family Hx DDx: Pregnancy, ovarian tumour (unilateral does not move with cervical displacement), adenomyosis (diffuse and tender uteirn enlargement) Treatment: (a) If small and asymptomatic then annual exam and U/S (b) Menstrual or pressure symptoms may dictate surgery (c) Pain-requires analgesia (d) Heavir and longer periods perform surgery (e) Embolization under radiological control (cannula passed from femoral artery to uterine arteries and inject tiny silicon particles causing fibroids to degenerate.Pain relief essential for 48hrs. Larhe and multiple fibroids increased risk of hyserecotmy (means can’t have more children) (f) SurgeryL Abdominal hysterectomy (if family complete and woman>40yo, or uterus is large and distorted by fibroids), Vaginal hysterectomy (when fibroids small and few and associated prolapse of uterus),. Myomectomy(I want more children or if desire to retain uterus), submucous fibroids (need to be resected with laser or diathermy via a hysteroscope) (g) Effects on childbearing: Miscarriagem pain from red degeneration, premature labour, dysfunctional uterine contractions, malpresentation or obstructed labour (as pelvis is obstructed), postpartum haemorrhage and retained placenta, conservative management in pregnancy (Aim is for a vaginal delivery but if caesarean seciot is necessary then incise around the fibroids and remove or incise as severe haemorrhage develops so need for hysterectomy) 3. Uterine adenomyosis This is wehre endometrial glands of stroma found in uterine musculature. If localized to one site called an adenomyoma. (Uterus is enlarged and thick-walled with no pseudocapsule formation, as in fibroids. The endometrial glands sometimes do not all menstruate, as they derive from the basal layer of the endometrium) Found in women 35-40yo with reduced fertility. Symptoms are dysmenorrhoea, menorrhagia, and dysparenunia. Signs: Uniformly enlarged uterus and tender on palpation (particularly premenstrually) DDX: Uterine fibroids, early pregnancy, uterine infection

Treatment: Norethisterone, danazol, gonadotrophin analogues (buserelin or goserelin). Abdominal hysterecotm is the treatment of choce but occasionally can resect affected area. 4. Endometritis Acute condition associated with ascending infection. Disease can result form postabortional infection, criminal abortion, excessive curettage, intrauterine device infection or postpartum (after C-section or rarely from blood-borne TB) Findings: Acute infection: Irregular bleeding, uterine tenderness. Chronic infection (secondary amenorrhoea, infertility due to adhesions developing leadind to partial/complete occlusion of uterine cavity-Asherman’s syndrome) 5. Pyometra Infeciton lead to pus which blocks the Fallopian tubes and cervix. Commoner in older women. It causes pain (Stretch uterus muscle), occasional acute bursts of toxamiea(blous of pus forced into vein), chronic ifnetion (low grade temp and malaise), occasionally pus forced through cerix to produce purulent or bloodstained discharge. Pyometra oten associated with cancer of cervix so of have pyometra have hysteroscopy and D&C under antibitoitc toexlcude malignancy 6. Fallopian tube torsion-assoicated with torsion of ovaries and treat by laparotomy /laparoscopy (if tissues healthy then conserved and secured via suture to side wall of pelvis to prevent retorsion), if tissues devitalized the ovary and tube removed 7. Salpingitis: Asceding infection from vagina through cerix. Associated with intercourse, transcervical surgery (D and C or evacuation), intrauterine foreign body (eg.IUD), retained products of concetion, (Blood-borne infection rare) 8. Acute salpingitis: Fallopian tube gets red, swollen and distorted with obstruction at abdominal end so pyosalpinx forms which becomes a hydrosalpinx. Peritoneal inflammation with adhesions to serosal surface occurs leading to a pelvic abscess and septicaemia. . It is usually bilateral and can cause infertility (destruction of cilia).Chronic hydrosalpinx can become reinfected. Get pyrexia, tachycardia, dehydration. Lower abdo pain with guarding, if parietal peritoneum involved then rebound tenderness and distension. Vaginal exam: Cervical excitation ain (bilateral), tender and normal sized uterus, fullness in fornices and tenderness over tubes, vaignal discharge. Invesitgations: Organsism (form cervical discharge), gonorrhoea, E.coli/haemolytic strep/staph found in puerperium and postaboriton, Clostridium welchii thive on placental products (dead tissue), Chlamydia, leucocytosis, laprasopcy only way of making tru Dx (remember to take serosal swabs). DDXL Appendicitis,ruptured ecotpic pregnancy (faint, shoulder tip pain if intraperitoneal bleeding, unilateral tenderness and pregnancy +ve, no pyrexia), ovarian tumour torsion (localilzed pain, unilateral, pregnancy negative, unltraousnd confirms), pyelonephritis (loin tenderness and pus in urine), intestinal obstruction (colicky pain and abdo distension). X rays show fluid levels). Treatment: Sit paitnet upright, IV infusion, broad spectrum antibiotic

(until high vaginal swab reveals reports) (Clindamycin, augmentin, cephradoxyl or Flagyl suitable-continue antibiotics until after acute phase fo 2-3 weeks on doxycycline), analgesia and gluids, refer to GU clinic for treatment o partner and contact traciting (for radical treatment if Dx is in doubt then exploratory surgery and minimal interference eg.drainage and antibiotic cover) 9. Chronic salpingiits Sequel to acute slapingitis but lower grader purulent organism (eg.chlamydia) Get persistent recurrent episodes of lower abdo pain, dysparenunia (deep), congestive dysmenorrhoea, heavy periods, subfertility. Invesitgaitons: U/S scan of pelvis and laparoscopy if no recent acute episode dye installation with antibiotic cover. Long term dequelae: Subfertility and ectopic pregnancy 10. Ovarian infection: Ovary not inflamed on tis own but infalmmaed in general pelvic infection (salpingo-parametro-oophoritis better description of pelvic abscess). Mumps can affect the ovary and casue ovarian swelling and upset ovulation (rare but if it occurds is temporary unlike the male) 11. Ovarian tumours: Usually asymptomatic but can cause abdominal distension (increased waist size together with shiny skin due to stretch and peau de orange due to oedema), pressure on rectum/bladder/lymphatic systm (pressure or back symptoms), pain (due to complications suchas torsion, rupture, haemorrhage) (can be peritoneal irritation leading to symptoms of shock and abdominal muscle guarding. Torsion accompanied byvomiting). After resuscitation do a laparscopy(can deal with ovarian cyst) but if doubt on whether tmour is malignant then open the abdomen at laparotomy and perform formal removal. Can also be hormonal secretion (oestrogens secreted by granulosa cell tumours leading to menstrual upset or androgens secreted by arrhenoblastomacausing masculinization). (NB: Palpation ca feel firm ovarian cyst, percussion may show central dullness with resonance at flanks, but if ascites is present then sign is lost and shifting dullness replaces it. Pelvic exam-if benign mass separate from uterine body and mobile and if feixed the infection/endometriosiss/malignancy should be suspected). INvestigatiosn: U/S of abdomen-detect mass and ascites. Tumour markers can be raised (eg.CA125) 12. Ovarian cysts: (a) Follicular cysts: These are normal Graafian follicles that are enlarged and unruptured (normal ovary contains one or more small cysts). They are not neoplastic and disappear by resorption of fluid (difficulty in distinguishing follicular cyst from serous cystadenoma) (b) Corpus luteum cyst:Lined with luteal cells (derived from granulosa layer). This is where the corpus luteu reaches 3cm or more and can appear cystic. Sometimes apart from pregnancy corpus luteum persists becoming cystic and causing amenorrhoea folowe dby bleeding. Haemorrhage into corpus luteum cause pain (can resemble symptomsof ecotpic pregnancy) (c) Haemorrhagic cysts: Bleeding into Graafian follicle or corpus luteumNEed haemostasis of affected area and shell out haematoma (d) Theca luteal cyst: Found in association with reiased hCG levels (hydatidiform mole, choriocacinoma, gonadotrophin therapy). Both ovaries enlarged with multiple cysts lined by luteal cels. Ovaries return to normal when hCG levels reduce

13. New growths (a) Serous cystadenoma: Benign tumour contains protein rich fluid resemble serum) and contains papillary growths. Bilateral tumours seen and can change to malignant growth. (b) Mucinous cystadenoma (commonest): Benign growths that contains viscus mucin and cyst grows slowly and reaches large size. IT is mutlilocular (each loculus lined by columnar epithelium ciliated and proliferate for form papillary folds.) Can change to malignant form (c) Pseudomyoxoma peritonei: Occurs if contents of cyst leak (spilled into peritoneal cavity) (epithelial cells lining cyst proliferate eand produce mucinous scites which fulls whole peritoneal cavity filled with mucoinous material) (can alo arise form mucocele of appendic and found n males/females) (d) Fibroadenoma: Benign tumour (arise form CT as a solid non-encapsulated tumour which can be bilateral and grow to 20cm. Normal ovary compressed but not invaded. Benign tumour composed of whorls of fibrous CT resembling ovarian stroma. Assoicated with ascites, hydrothorax, hydropericardium. This association is known as Meig’s syndrome (found in Brenner tumour, granulosa cell ro theca cell tumour). (e) Brenner tumour: Found in postmeopusal women (small and symptomsless tumour). Solid tumour with nests of epithelial cells enclosed in fibroud issue (cavities arise in epithelial nests contain mucin like mucinous cystadenoma). Meig’s syndrome. (f) Germ cell tumours: Arise form undifferentiated sex cells. Seen in ovary (dysgerminoma-seen in infantile genitlaia, undescended testes,normal peoplesecretes gonadotrophins os positive pregnancy test obtianed) and testes (seminoma). Consists of epithelieal cells (round cells like spermatocytes)arranged in alveoli separaed by septa of fibroud tissue infiltrated with round cells, (resemblelymphocytes). Occurs in young patientsand can become malignnt. (Note: Endodermal sinus tumour or embryonal carcinoma can occur with dysgerminoma) (g) Dermoid or benign teratoma. Occurs in 15-30yo, arises from unfertilized ovum and occurs in reproductive period, multiple and bilateral. A dermoid is a thickwalled cyst with solid parts. Torsion is common. The cysts if lined by squamous epithelium and contains teeth, cartilage, GIT epitheliu, nervous tissue, thyroid tissue, sebaceous glands, hairs, fatty sebaceous secretion resembling sebum. Malignant change can follow(to sqaumous epithelioma or embryonal carcinoma and hyperthyroidism can follow a being teratoma) (h) Solid teraotma: (cotnians primitive tissues of ectoderm, kesoderm, and endoderm so tumour contains all variety of bizarre hsiotlogical pattern. Very malignant) (i) Gonadoblatoma: Occurs in abnormal gonads and in individuals with sex chromatin negtative. Consists of large germ cells like those of a dysgerminoma and small cells like a granulosa cells. Can show hormonal activiy and become malignant (j) Grandulosa cell tumourL Resemble granulosa cells (polygonal with deeply staining nuclei). Arranged in rosettes (clear space between them and strands of CT

run between granulosa cells). Malignant change can occur and they secrete oestrogens.Occur at any age and in infants cause precocious puberty with uterine bleeding. In adult woman can cause profuse irregular uterine bleeding (hyperopestroenized endometrium). In postmenopausal women irregular utrine bleeding is caused, with oestrogenizaion of uterus, vulva and vaigna.Therre can be carcinoma o uterus with hyperoestrogenized endometrium. (k) Thecoma: Solid tumour and Meig’s syndrome can occur. Yellow fatty areas show up sections stained for fat are scattered among the fibrous tissue cells. These are theca lutein cells. A mixed granulosa cell tumour and theocma also occurs. It occurs in women>30yo.Can present with a pelvic mass or with uterine harmorrhage or both (ascites and pleural effusions can be seen). High incidence of endometrial carincoma associated with thecoma (l) Sertoli-Leydig cell tumour: Called androbalsotma or arrhenoblastoa this tumour causes virilism from its testosterone metabolism, but is rare. Tumour can be cystic/solid and potentially can be malignant. Cells consist of undifferentiated mesenchyme and can be arranged in tubules as in the testicle (Exmaple: 2yo F presents with unlilateral abdo pain, cvomiting, abdo rebound and guading. She is apyrexial and her LMP was one week ago. Likely to be a torted/twisted demroid cyst(not PID as PID is bilateral, not bleeding into rupture of a cyst which causes peritonism but not vomiting, and torted ovarian cyst commonly associated with vomiting) Dysmenorrhoea This is pain associated with menstruation occurs in two main forms: • Primary, spasmodic • Secondary, congestive or acquired (1) Spasmodic dysmenorrhoea: Very common and most normal women have some discomfort with onset of menstruation. Pain is severe during first hours-days of period. It can be continuous or spasmodic like colic, accompanied by vomiting or faintig, felt in pelvis and lower back, radiating into legs, diarrhea. (Pain is caused by excessive PG producing contractions of uterine muscles in first days of menstruation. Associated with adenomyosis). Management: Simmple analgesics (aspirin, paracetamol, codeine. Mefenamic acid gives good relief of pain), hormone therapy (OCP-inhibit ovulation and causes painless bleeding) (2) Secondary, congestive or acquired dysmenorrhoea: Occurs>30yo. Pain beigns before menstruation and relieved when bleeding starts. Felt in pelvis and back and made worse with exertion.Other symptoms such as menorrhagia and dysparenunia. This type of dysmenorrhoea occurs with a physical cause (chronic pelvic sepsis, endometriosis, acquired fixed retroversion of uterus, fibroids) Endometriosis Presence of endometrium outside of uterusThe tissue responds to hormones like normal endometrium, and occurs in second half of a woman’s reproductive life between the ages fo 30-45yo and regresses at menopausse. Occurs in women who are childless or have few

children, and full-term preganancy leads to regression. Common in Europeans. .Endometriosis consist of endometrial glands and stroma and tissue bleeds in reposnse to hormone cyclical changes but no escape of blood which gets encysted. Infiltration of surrounding structures like bowel occurs with fibrosis. These enometriotic areas vary from pinhead size to large cyst with tarry material (chocolate cyst). Endometriosis commonest in pelvis and occasionally found in sites like pleura and umbilicus. It can affect the: • ovaries which take the form of endometrial cysts continaing blood or chocolate cysts adherent to surrounding tissues(typical endometrial glands not always seen as destroyed by large cysts). • Pelvic peritoneum is often affected(eg.over back of utrus, gfallopian tubes, pouch of Douglass-present as black odules with scarrign and puckering of peritoneal surface and adhesions can form between these and back of uterus casing fixed retroversion). • Uterine ligaments(uterosacral and rectovaginal ligaments, roud ligament, inguinal ligaement involved-can present as tumour in groin) • Bowel: Intestines and rectum infiltrated and causes bowel obstruction • Urinary tract: Haematuria and painful micturition • Abdominal wall: If isolated lesion in umbilicus (cyclincial bleeding) and occurs in scar sfollowing operation (eg.Caesarean ) • Perineum and vaigna: Seen in perineal scars and vaginal wall Clinical features: • Pain-three types: congestive dysmenorrheoa (begins with mensturaiton), ovulation pain (midcycle), dyspareunia (felt in deep pelvis due to pressing on uterosacral ligaments and rectovaignal septum in coitus) • Infertility (damage to tubes) • Disturbance of menstruation: Menorrhagia (if deposits in mometrium) and shorter cycles and prolonged bleeding can occur (adenomyosis) • Other symptoms: haematuria, dysuria, intestinal obstruction, pain on defaecation, occasionally chocolate cyst can rupture Physical signs:Msot common present with fixed retroversion of uterus with enlarged, tender ovaries adherent behind it. Deposits in uterosacal ligaments palpable as tender nodules. La[aroscopy needed to establish diagnosis. Treatment (Cnservative-as occurs in reproductive period, doesn’t become malignant and regresses at menopause) • Hormone therapy: Should occur after making diagnosis via laparoscope and if chocolate cysts they are drained and if local areas of endometriosis can be coagulated with laser/diathermy through laparoscope.Danazol inhibits megonadotrophin secretion and sppresses menstruation (ensure women is not pregnant and danazol is not a contraceptive), progesterone (norethisterone or medroxyprogesterone suppresses menstruation), GnRH agonists (inhibit ovarian function)

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Surgery: Laparoscopy: Diathrmy or laser (if pelvic mass >5cm, acute rupture of cyst or intestinal obstruction then surgey needed-usually try conservative approach aiming to leave uterus and ovaries, t if woman doesn’t want children and intractable then hysterctom with bilateral salpingo-oophorecotm)

Premenstrual tension BEhaviorual symptoms and physical signs in second half of menstrual cycle and abolishes after menstruation. Symptoms include: Irritability, depression, lassitude, insomnia, lack opf concentration, oedema due to fluid retention, abdo swelling, swollen fingers/ankles, weight gain and migraine. Occurs in luteal phase and can have endogenous depression and suicide during this time. Thought caused by renninangiotensiin, changes in monoamine HT, reduction in endogeous opioids) Treatment: Replace progestogens (if deficient in second half), oestroge to suppress ovulation, oral contraceptive, danazol (stops ovulation), primrose oil, pyridoxine VitB6) (can affect dopamine and serotonin metabolism), antidepressant during premenstrual phae can help)(eg.fluoxetine) Abdominal organs 1. Pyelonephritis:Abdo pain (loin apin and costovertebral angle tenderness), pyrexia, shivering. Examine urine for pus cells and organism. Treatment: Bedrest, fluids, antibiotics(for ureteric stone pehtidine as analgesic and antispasmodic) 2. Appendicitis: Due o enlarging uterus appendix pushed up from RIF to right paracolic gutter. Surgery. (higher mortalityof appendicits in pregnancy as mother’s scaredof operating so leave it off, so must emember appendicits cause higher mortality formother and fetus for not operating than operitn on it which cures it) 3. Rectus haematoma:Deep epigastric arteries and veins stretched by growing uterus and after severe attack fo coughing one fo these veins ruptures (haematoma). Pain localized under one segment of rectus muscle but after a few hours this sign spreads. If late can be anaemia due to loss of blood into haematoma. Laparotomy diagnoses it and as it’s usually too late to ligate veins surgery not needed 4. Bowel problems: Refer to surgical colleague

Condition

History

Examination

Ectopic pregnancy

-Pain-sudden onset, constant, shoulder tip -Other: Sudden collapse, period of amenorrhoea, minivaginal bleeding Pain-gradual onset, constant, generalized, , bilateral -Other-vaignal dischargem irregular menses Pain-gradual onset, constant, generalized Otheremnorrhagia

Rebound guarding, decreased BP, increased pulse, temp<37, vaginal exam-unilateral cervical excitation, uterus small for dates, so closed

Pain-sudden onset, constant, maybe getting

Acute salpingitis

Fibroid degeneration

Ovarian cyst accident: Torsion

Investigation

Ultrasound scan Hb Empty uterys. normal/decreased Free fluid in WBC normal pouch of hcG+ Douglass ?Adenexal mass

Guarding?rebound T>37.5, BPnormal, pulse raised. Vaginal exam –bilateral cervvcal excitation

Hb normal, increased WCC, hc-ve, +ve high vaginal swab

No abnormlity detected

Tender over fibroids T 37-37.5 Vaginal exam-no cervical excitation, enlarged uterus

Hb equal, WBC qual or increased, hcG negatuve

Fibroid seenin uterine wall with cystic areas

Rebound tenderness T 37-37.5 BP equal, pulse

Hb normal, WBC normal or increased, hCG negatuve

Echogenic mass seen separate from uterus? Free

less Othervomiting Rupture

Haemorrhage

Pain –sudden onset, constant , getting less Otherirregular menses Pain-sudden onset, constant, becoming less

Appendicitis

Pain-gradual osnet, right sided Otheranorecia, no bowel sounds, N/V

Pyelonephritis

Pain-in loin, colicky Other-N/V, rigors, dysuria

Obstruction

Painintermittent, generalized colicky Other-N/V, anorexia, bowels not open

raised Vaginal examunilateral cervical excitation, adnexal mass Rebound, guarding, T 37, pulse, B normal Vaginal examgenerlized tenderness only

fluid

Hb normal, WBC normal, hCG negatuve

Free fluid in pouch of Douglass. No cyst seen

Renound, guarding T37, BP normal, pulse raised, vaignal exam-unilateral cervical excitation, adenxal mass Rebound guarding, right sided tenderness, T=37-37.5, BP normal, raised pule, vaignal exam-no abnormality detected, PRempty rectum, right sided tnderness Loin tenderness, T>37.5, vaginal exam-no abnormality detected

Hb normal or increased, WBC normal, hCG-ve

Echogenic cyst, free fluid if ruptured

Hb normal, increased WBC, hCG negative

No abnormality detected

Hb normal, raised WBC, hcG-ve, MSU+ve

Reound, guarding, distension No bowel sounds. Temperature 37 Vaignal exam-no abnormality detected PR-empty rectum

Hb normal WBC normal or raised hcG-ve

Renal pelvicalyceal dilatation Palvis-no abnormality detected Pelvis-no abnormality detected, AXR-dilated loops with fluid levels