Prof Khaled M Khaled FRCOG, PhD

Consultant Obstetrician and Gynaecologist

Director of Education

Colchester University Hospital
Essex
Pelvic pain - Is it a
Gynaecological problem?
What is chronic pelvic pain ?
Pain confined to pelvis > 6 months duration


Not exclusively with menstruation/intercourse


Not associated with pregnancy

Incidence up to 1 in 5 women

Clues in the history
Cyclical variation in pain
midcycle / dyschezia / sec dysmen
Irregular pv bleeding
anovulation / exclude pregnancy / Ca
PV discharge / fever
Infection
Swelling / abdo mass. cyst / pregnancy / fibroid
Examination clues
Cervical excitation

Nodules / masses / fixed / part mobile

Examination during menstruation
Investigations
Swabs
WCC, ? Ca125
TVS mapping scan
MRI T2 weighting / fat suppression
Laparoscopy
Chronic pelvic pain - Causes
1-3% Trapped nerve/
residual ovary
1% Pelvic varicosities
1% Fibroid
4% Ovarian cyst
7% Chronic PID
23% Adhesions
31% Endometriosis
40% No gynae cause
50% - Interstitial cystitis
Improvement 30-50%

25-50% - Psychological /
psychosexual
Improvement 80%
75% - Musculoskeletal
Improvement 53%

50% - Irritable bowel
Improvement 36%
No Gynae cause for CPP 40% CASES
Endometriosis
History secondary dysmen, dyschezia
ca125 (25-50% sensitivity)
Scans Pelvic pain mapping during menses (if
normal 80% chance lap normal)
Adenomyosis seen more effectively with power doppler
Endometriosis
30% placebo
NO BETTER
THAN EXCISION
80%
70% mild
90% sev
70% mild
80% mild
60% sev
Success rate
1 year
Diagnostic laparoscopy
LUNA
Presacral neurectomy
Laparoscopic excision
Laparoscopic ablation
65% mild
25% sev
OCP/PROVERA/GnRH
Success rate
5years
Treatment
Endometriosis - new drug therapies
Aromatase inhibitors (letrozole/arimidex)
95% success when routine medical therapy failed
Alpha E2 Antagonists
Selective Prog receptor modulators (due
licence 2007)
Mifegyne
new contraceptive / stops periods
Adhesions
Only dense vascular adhesions really relevant
Good data on success rates lacking (20-80%)
? Anti-adhesion forming agents useful
Chronic PID
Especially < 25 yrs
Stat azithromycin maybe beneficial if non
compliant
Ovarian cyst
Pain usually persistent
Conservative follow-up if < 5cm + simple

Residual ovary / Trapped ovary /
trapped nerve post Pfannenstiel
GnRH relieves pain , then oophorectomy
Pain blocks for ilioinguinal nerve

Deep dyspareunia (positional) with
retroverted uterus
Advise change in position
Can perform laparoscopic ventrosuspension
(90% success, but in those finished family
ideally)
Fibroid
When large and degenerating constant pain
? SPRMs 30% size reduction
Lap myomectomy with embolisation
Lap myolysis
Or hysterectomy

Pelvic varicosities
Aching pain after standing / bending forward
Aching pain for next day after intercourse
Periovarian vessels > 5mm size
Provera 30-50mg for 6/12, has 50% success
Embolisation for resistant cases 65% success
Hysterectomy last resort

Conventional treatment failures
Pentoxiphylline
Mirena
Letrozole / micronor
Diet modification
Psych / sex / nonpenetration
Avoid multiple laparoscopies
Specialised Pain clinics
Summary
Treatment success Incidence Cause of pelvic pain
1%
1%
1-3%
4%
7%
23%
31%
40%
50-100% Trapped nerve/ residual
ovary /
ventrosuspension
50-65% Pelvic varicosities
50-90% Fibroid
90% Ovarian cyst
80% Chronic PID
? 30-80% Adhesions
30-90% Endometriosis
25-50% No gynae cause
What to do when all else fails ?