Dr.

Hanaa
Acute pelvic pain Alheidery
5th class
Acute pelvic pain in a woman of reproductive age with a +ve pregnancy test is an
ectopic pregnancy until proven otherwise.
History
• Pain: site, nature, radiation, aggravating/relieving factors.
• LMP.
• Contraception.
• Recent unprotected sexual intercourse (UPSI).
• Risk factors for an ectopic pregnancy
• Vaginal discharge or bleeding.
• Bowel symptoms.
• Urinary symptoms.
• Precipitating factors (physical and psychological).
Examination
• Is she haemodynamically stable? Risk of bleeding from ectopic.
• Abdomen: does she have an acute abdomen? masses?
• Pelvic: are discharge, cervical excitation, adnexal tenderness, masses present?
Investigations
• Urinary/serum hCG.
• MSU.
• Triple swabs (high vaginal, cervical, and endocervical Chlamydia).
• FBC, Group and Save (cross-match if ectopic suspected), CRP.
• Pelvic USS—transvaginal or abdominal as appropriate.
• Abdominal X-ray (+/– contrast), CT, MRI as appropriate.
• Diagnostic laparoscopy.
Treatment
• Resuscitate if necessary.
• Analgesia.
• Specific treatment will depend on cause of pain.

ACUTE PELVIC PAIN

Gynaecological causes of acute pelvic pain
• Early pregnancy complications:
• ectopic pregnancy
• miscarriage
• ovarian hyperstimulation syndrome
• PID
• Ovarian cyst accident:
• torsion
• haemorrhage
• rupture.
• Adnexal pathology:
• torsion of fallopian tube/parafi mbrial cyst
• salpingo-ovarian abscess.
• Mittelschmerz mid cycle pain of ovulation (German: Mittel = middle, Schmerz = pain).
• Pregnancy complications pregnancy
related (<24wks)
• fibroid degeneration
• ovarian cyst
• accident ligament stretch.
• Primary dysmenorrhoea,
• Haematometra/haematocolpos.
• Non-gynaecological causes.
• Acute exacerbation of chronic pelvic pain.
Non-gynaecological causes of acute pelvic pain
Gastrointestinal
• Appendicitis.
• Irritable bowel syndrome (IBS).
• IBD.
• Mesenteric adenitis.
• Diverticulitis.
• Strangulation of a hernia.
Urological
• UTI.
• Renal/bladder calculi.

Chronic pelvic pain: gynaecological cause

Definition Intermittent or constant pelvic pain in the lower abdomen or pelvis of
at least 6mths’ duration, not occurring exclusively with menstruation or
intercourse and not associated with pregnancy.
Chronic pelvic pain (CPP) is a symptom, not a diagnosis.
Prevalence
• Annual prevalence in women aged 15–73 is 38/1000 (asthma: 37/1000, back pain:
41/1000).
• Many women do not receive a diagnosis even after many years and multiple
investigations.
Causes Endometriosis Adenomyosis
• Characterized by the presence of ectopic endometrial tissue in the
myometrium.
• Often occurs after pregnancy, particularly after CS or TOP (breaches the
integrity of the endometrial/myometrial junction).
• Initially causes cyclical pelvic pain and menorrhagia, but can worsen until pain
is present daily.
Adhesions
Trapped ovary syndrome
After hysterectomy the ovary becomes trapped within dense adhesions at the
pelvic side wall.
Pelvic venous congestion
• Dilated pelvic veins, believed to cause a cyclical dragging pain.
• Worst premenstrually and after prolonged periods of standing and walking.
• Dyspareunia is also often present.

Chronic pelvic pain: non-gynaecological causes

Gastrointestinal causes
• Irritable bowel syndrome (IBS): common, occurring in ~20% of women of
reproductive age.
• Constipation: common cause of pelvic pain that is easily treated. Opiate
analgesics should not be prescribed for CPP without a laxative.
• Hernia: abdominal or pelvic hernias may cause pain.
Urological causes
Interstitial cystitis (IC)
• Inflammatory disorder causing pain and urinary frequency.
• Diagnosed on cystoscopy.
• Pain is often relieved by voiding.
Urethral syndrome
• Associated with frequency/dysuria in absence of infective cystitis.
• Aetiology is not known, possibly due to a chronic low grade infection of the
paraurethral glands (‘female prostatitis’).
Calculi
• May occasionally trigger a chronic pain cycle.
Musculoskeletal causes
Fibromyalgia
• Widespread pain especially in the shoulders, neck, and pelvic girdle.
• Characterized by tender points and a reduced pain threshold.
• Often shows cyclical exacerbations.
Neurological causes
Nerve entrapments
• Trapped in fascia or narrow foramen or in scar tissue after surgery.
• Classically results in pain and/or dysfunction in nerve distribution.
Neuropathic pain
• Results from actual damage to the nerve (surgery, infection, or
inflammation).
• Classically described as shooting, stabbing, or burning.
Psychological associations with CPP
• Anumber of studies have shown that women with CPP have increased number
of –ve cognitive and emotional traits, although it is not known whether these are
cause or consequence of pain.
• History of abuse (physical, sexual, and psychological) also associated with CPP,
but may not be revealed at the first consultation.

Chronic pelvic pain

Diagnosis and treatment History
As for acute pelvic pain, but also including:
• A detailed history of the pain, including events surrounding its onset, site,
nature, radiation, time course, exacerbating and relieving factors,
and any cyclicity.
• A sexual history and future fertility wishes should be explored (it may be
possible to discuss abuse at this point).
Examination
• As for acute pelvic pain.
• Speculum may not be appropriate if history of vaginismus or pain secondary to
difficult smear or abuse.
Investigations Be careful not to overinvestigate initially.

Therapeutic trial of GnRH analogues

With clearly cyclical pain, a trial of a GnRH analogue (GnRHa) can be a useful
diagnostic tool:
• Women requesting hysterectomy with bilateral salpingooopherectomy
can be reassured that it may be a successful treatment if their pain is relieved with a
GnRHa.
• If their pain persists on GnRHa treatment, they should be counselled that
hysterectomy is unlikely to remove their pain and other causes
for it should be explored.
Treatment
Analgesia
• Pre-emptive analgesia may prevent emergency admissions.
• Opiates may be required for severe, acute exacerbations, but if needed
regularly, referral to a dedicated pain clinic should be made.
• Neuropathic treatments such as amitriptyline, gabapentin, and pregabalin
can be useful.
Hormonal treatments
The COCP, progestagens, and GnRH analogues can be effective. If pain is improved
with a GnRHa then this can be combined safely with low-dose HRT for at least 2yrs.
Complementary therapy
A variety of complementary therapies can produce good results and should be
encouraged if the woman suggests them. Support groups can also give
reassurance.
Surgery
This has a limited role to play, but hysterectomy can be helpful, as above.