PELVIC PAIN
most commonly ACUTE - due to appendicitis, misscarriage, ectopic
causes of acute pelvic pain
GI: appendicitis, constipation, diverticular disease, IBS
urinary tract: UT, calculus
gynaecological - ectopic pregnancy, miscariage, acute pelvic infection, ovarian cysts
other causes: MSK
ddx for CPP
skeletal - degenerative joint disease, scoliosis, spondylolisthesis, osteitis pubis
myofascial - fascitis, nerve entrapment syndrome, hernia
urinary tract - UTI, calculus, interstitial cystitis
psych - somatization, psychosexual dysfunction, depression
GI - adhesions, appendicitis, constipation, diverticular disease, IBS
neuropathic - pudendal nerve entrapment, spinal cord neuropathies
Gynae - endometriosis, adhesions (chronic pelvic infection), adenomyosis, leiomyoma, pelvic congestion syndrome, ovarian cysts
comparison of acute and chronic pelvic pain
ACUTE
CHRONIC
rest often helpful
variable intensity
short duration
anxiety common
well-defined onset
disease symptom
rest usually not helpful
persistent
unpredictable duration
depression common
ill-defined onset
may not be possible to identify an underlying disease process
diagnostic laparoscopy - additional tests depend on symptoms (cystoscopy, bladder biopsy, dye test, hysteroscopy)
adhesions (dense, vascular) likely to cause pain
no visible pathology
suspected endometriosis at laparscopy
other pathology eg PID, ovarian cysts
input of appropriate specialist
letter of reassurance about absence of gynaecological pathology to the pt
input of GI surgeons if appropriate
chronic pain management or laparscopic adhesiolysis using adhesion barriers
take biopsies and stage
severe or extensive or deep or rectovaginal endometriosis +/- dense adhesions
moderate or superficial endometriosis overlying ureters +/- dense adhesions
bowel or bladder or ureter involvement with endometriosis
minimal/mild superficial endometriosis not overlying ureters +/- filmy adhesions
input of appropriate specialist eg urogynaecology, lower GI surgeons
hormonal and/or surgical treatment: laparascopic ablation or excision of all visible disease [+/- neuroablation]
click to edit
hormonal and/or surg treatment: laparscopy or laparotomy to excise all visible disease
click to edit
click to edit
follow up at 6-12 mths at nurse clinic either in person or by postal questionnaires
click to edit
click to edit
response - discharge from gynae clinic
admission with acute pain: exclude acute abdo, do not rush into surgery, pain management service, ix
click to edit
non response = review by consultant team - refer to chronic pain management team +/-
- dont rush into repeat surgery
- ix other causes
- suspect persistent endometriosis
suspect adenomyosis - MRI
consider hysterectomy +/- BSO
important to take detailed mens hx - freq, character of vag bleed
take sexual hx - sup or deep dyspareunia, contraception, STI
there may be fam hx of gynae disorders- endometriosis
ask how pain is affecting their life
click to edit
ACUTE PELVIC PAIN
bimanual exam may reveal uterine or adnexal enlargement = suggest pelvic mass, fibroids or an ovarian cyst
cervical excitation - pain associated with digital displacement of the cervix - is associated with ectopic preg and pelvic infection
tenderness or pain elicited by bimanual palpation of the pelvic organs = suggest inflam = infective eg chlamydia or noninfective eg endometriosis
a fixed immobile uterus suggests multiple adhesions and nodularity within the uterosacral ligaments (sometimes palpable only by combined rectovaginal exam) can be a feature of endometriosis
most important gynae conditions are ectopic preg, miscarriage, PID and torsion or rupture of ovarian cysts
if urine preg test neg - a high vaginal swab, endocervical swab and FBC should be performed for evidence of infection
all sexually active <25 yrs offered chlamydia screening
US helpful in identifying ovarian cysts
dont forget non gynae causes
important to continue monitoring vital signs and to provide analgesia
if diagnosis unclear and pain not resolving, diagnostic laparoscopy may be warranted
an innocent cause of pain is exp mid cycle with ovulation, the so called mittelschmerz - pain is usually sudden in onset, can be quite severe and if persistent in each cycle = will respond to ovulation suppression with COC
CHRONIC PELVIC PAIN
intermittent or constant pain in lower abdo or pelvis of at least 6mths duration, not occurring exclusively with menstruation or intercourse and not associated with preg
an association with dysmenorrhoea, dyspareunia, irregular menstruation, abnormal vaginal discharge, an underlying gynaecological problem
altered bowel habit, excess flatulence or flatus, constipation or diarrhoea point to GI problem, particularly IBS
PREDISPOSITIONS: phys and sexual abuse, pelvic pathology - endometriosis, adhesions and pelvic varices
40% of women with CPP dont have identifiable biological cause, despite extensive ix - often involves a diagnostic laparoscopy
chronic pelvic infection assoc with high incidence of tubal damage and consequently an increased incidence of ectopic pregnancy, infertility or CPP
may be due to relapse of infection because of inadequate treatment, reinfection from untreated partner, post-infection tubal damage or further acquisition of STIs
OVARIAN CYSTS -majority benign - particularly those of acute pain
pain - torsio, cyst rupture or bleeding occurring into a cyst
torsion needs surgical removal
OTHER CAUSES
If ix are neg and remains sig diag doubt about whether a pain is gynae or not = consider 3mth trial of ovarian suppression with a GnRH analogue - if symptoms reduce = true gynae cause - possibility of adenomyosis - hysterectomy = long term improvement
NO IDENTIFIABLE CAUSE FOR PAIN
get pt to accept chronic pelvic pain syndrome as a disease involve partner in decision making
manage - psychosocial therapy, analgesia - anticonvulsant - gabapentin, hormonal treatments, antidepressants - amytrptyline, surg excision of nerves (uterine nerve ablation) and pelvic clearance
complementary therapies - reflexology, homeopathy, acupuncture