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Pelvic Pain
Acute Pelvic Pain
1. Definition
Acute lower abdominal pain and pelvic pain that is present less than 7 days
2. Pathogenesis
Somatic & Visceral pain
Somatic Stems from nerve afferents of the Somatic Nervous System
Pain Innervation: Parietal peritoneum, Skin, Muscles, Subcutaneous tissues
Typically sharp & localized, often unilateral & focused to a specific corresponding dermatome
Found left or right within dermatomes
Visceral Stems from afferent fibres of the Autonomic Nervous System (Viscera Visceral peritoneum)
Pain Noxious stimuli: Stretching, Distension, Ischemia, Necrosis, Spasm of abdominal organs
Diffuse sensory input Generalized pain, Dull, Achy, Cramping
Visceral pain often localizes to the midline because visceral innervation of abdominal organs is
usually bilateral
Inflammatory or Neuropathic pain
Inflammatory Pain
Tissue injury Inflammation (Prostaglandins & Cytokines)
Body fluids, Inflammatory proteins & cells go to injury site to limit tissue damage
Neuropathic Pain
Sustained noxious stimuli Persistent central sensitization Permanent loss of neuronal inhibition
Decreased threshold to painful stimuli remains despite resolution of the inciting stimuli Persistence
characterizes neuropathic pain
4. Investigations
Laboratory Urine/Serum βhCG (reproductive age without prior hysterectomy)
Testing FBC (Identify haemorrhage)
Urinalysis (evaluate possible Urolithiasis or Cystitis)
Microscopic evaluation & culture of vaginal discharge (if PID suspected)
Radiologic Ultrasound
Imaging TVS Superior resolution of reproductive organs
TAS Uterus/Adnexal structure - Significantly large or lie beyond TVS probe
Colour Doppler Vascular qualities of pelvic structures
Imaging Acute pain Adnexal torsion or Ectopic pregnancy
CT scan
- Evaluate acute abdominal pain in adults
- Potential increased cancer risk in younger patents and women
MRI
- Done when sonography is non-diagnostic
- First line tool often selected for pregnant patients (should limit ionizing radiation exposure)
Laparoscopy Useful if no pathology can be identified by conventional diagnostics
Abdominal Examination
Inspection Prior surgical scars possible BO from post-operative adhesions or incisional hernia
Abdominal distension Bowel obstruction, Perforation, Ascites
Palpation Rebound tenderness or Abdominal rigidity Peritoneal irritation
Auscultation Hyperactive or High-pitched bowel sounds Bowel Obstruction
Pelvic Examination
Purulent Vaginal discharge or Cervicitis PID
Vaginal bleeding Pregnancy complications, Benign/Malignant reproductive tract neoplasia, Acute vaginal trauma
Uterine enlargement Leiomyoma, Pregnancy, Adenomyosis
Cervical motion tenderness Peritoneal irritation, PID, Appendicitis, Colon diverticulum
Tender adnexal mass Abscess of non-gynaecologic origin (e.g. Appendix, Colon diverticulum)
Rectal Examination
Stool guaiac testing for occult blood (Complaints - Rectal bleeding, Painful defecation, Significant bowel changes)
1. Definition
Intermittent or constant pain in the lower abdomen or pelvis for at least 6 months duration, not occurring exclusively
with menstruation (not dysmenorrhea) or intercourse (not dyspareunia) and not associated with pregnancy (not
ectopic pregnancy or miscarriage)
It may be associated with incomplete relief with most treatment, significantly impaired function at home or work, signs
of depression, such as early awakening, LOW and may significantly impact a woman’s QOL
2. Causes
Musculoskeletal Neurologic Miscellaneous
Hernia Neurologic dysfunction Psychiatric disorders
Muscular pain Pudendal neuralgia Physical or Sexual abuse
Faulty posture Piriformis syndrome Shingles
Myofascial pain Abdominal cutaneous nerve
Degenerative Joint Disease entrapment
Levator ani Syndrome Neuralgia of iliohypogastric,
Fibromyositis ilioinguinal, lateral femoral
Spondylosis cutaneous, genitofemoral nerves
Vertebral compression Spinal cord or Sacral nerve
Disc disease tumour
Coccydynia
Peripartum pelvic pain
3. Clinical approach for diagnosis
History Taking
L19 - Pelvic Pain & Endometriosis
Pattern of pain, Clinical measurement of pain level and Main concern about the pain (pain & treatment expectation)
Bladder & bowel symptoms
Results of previous attempts at treatment & amount of medication used
Daily pain diary (2 – 3 menstrual cycle may be helpful in tracking symptoms or activities associated with the pain)
Impact of pain on the patient’s QOL (e.g. effect of pain on daily activities, work, relationships, sleep, sexual function)
Psychological assessment (e.g. Symptoms such as sleep or appetite disturbance & tearfulness, Current stress in life)
Abuse history (Past/Present assault, Particularly intimate partner violence)
Gynaecological factors (Worsened by stress and menstruation)
Pregnancy & Delivery
Prior abdominal surgery
Psychologic risk factors
Physical Examination (Allodynia = pain from innocuous stimulus, Hyperalgesia = Extreme response to painful stimulus)
General Examination
Demeanour (facial expression)
Mobility
Posture (e.g. abnormal gait, guarding, careful positioning)
Back Scoliosis, Sacroiliac tenderness, Trigger points, Pelvic asymmetry
Abdomen Head-raise test (for diastasis partial/complete separation of Rectus Abdominis muscle or hernias)
Vulva Cotton swab to perform sensory examination & Identify area of tenderness
Speculum Examination
Cervical lesions, Infections & Endometriosis implants can be identified
Palpate vaginal vault with long cotton swab Post hysterectomy dyspareunia(Nerve entrapment/Localised lesions)
Pelvic Examination
Tone & muscle control
Presence of vaginismus (painful spasmodic contraction of vagina)
Cervical motion tenderness
Uterine mobility
Uterine & adnexal tenderness and masses
Rectovaginal Examination
Assess for any rectovaginal nodules, scarring or tethering & to determine its extent
7. Management
Positive Diagnosis on Laparoscopy Negative Diagnosis on Laparoscopy
Adhesions - Adhesiolysis Presacral neurectomy
Ovarian Remnant Syndrome Laparoscopic Uterosacral Nerve Ablation (LUNA)
- Unintentional, incomplete dissection & removal of the Sacral Nerve Stimulation
ovary during a difficult or emergency oophorectomy Injection of the Trigger points of Abdominal wall,
Pelvic Congestion Syndrome (Dilated pelvic veins) Vagina & Sacrum with LA
- Ovarian vein ligations & Percutaneous embolization Antidepressants
- Progestogens daily in high doses Hysterectomy (effective for CPP + Reproductive
Residual Ovary Syndrome symptoms)
- Recurrent pelvic pain
- Persistent pelvic mass after hysterectomy
Endometriosis
1. Definition
Presence of endometrial glands and stroma outside of the uterus
2. Causes/Pathogenesis
Retrograde Retrograde menstruation through fallopian tubes
menstruation Refluxed endometrial fragments invade the peritoneal mesothelium and develop a blood
supply for implant survival and growth
Women with outflow tract obstruction have a high incidence of endometriosis
Immunologic & angiogenic factors aid implant persistence
Stem cell theory Undifferentiated endometrial cells (from endometrium basalis layer) differentiate into
epithelial, stromal & vascular cells as endometrium is routinely regenerated each cycle
If displaced to an ectopic location (e.g. retrograde menstruation) Endometriosis
Aberrant Lymphatic Lymphatic spread to Pelvic Sentinel Lymph nodes
or Vascular spread of Findings of endometriosis in unusual location such as the groin
endometrial tissue
Colemic metaplasia Parietal peritoneum is pluripotent (metaplastic transformation to normal endometrium)
Ovary & Müllerian ducts are derived from colemic mesothelium
May explain cases of endometriosis without menstruation
- Premenarchal girls & males treated with estrogen & orchidectomy for prostate cancer
3. Ovarian endometriomas
a) Morphology
Smooth-walled
Dark-brown ovarian cysts (filled with a chocolate-appearing fluid)
Unilateral or Multilocular (Large)
b) Theories
Invagination of ovarian cortex implants
Colemic metaplasia
Secondary involvement of functional ovarian cysts by endometrial implants located on the ovarian surface
4. Anatomical sites
Endometriosis may develop anywhere within the pelvis & extra-pelvic peritoneal surfaces
Implants – Superficial/Deep Infiltrating Endometriosis (DIE) (infiltrate vital structures like bowel, bladder, ureters)
L19 - Pelvic Pain & Endometriosis
Most commonly in dependent areas of the pelvis
Commonly Rarely
Anterior/Posterior cul-de-sacs Rectovaginal septum Surgical scars
Oher pelvic peritoneum Ureter Pleura
Ovary Bladder
Uterosacral ligaments Pericardium
5. Classification
6. Differential diagnosis
Primary dysmenorrhea Congenital anomalies of Reproductive tract
Adenomyosis Interstitial cystitis or Recurrent UTI
Uterine Fibroid IBS or other bowel pathology
PID Cancer (e.g. Cervix, Uterus, Ovary, Rectum,
Adhesions Bladder)
Musculoskeletal disorders
7. Diagnostic evaluation
a) Physical Examination
Speculum Blue or Red powder-burn lesions seen on the Cervix or Posterior Vaginal Fornix
Examination These lesions can be tender or bleed with contact
Bimanual Uterosacral ligament nodularity & tenderness Active disease or Scarring along the ligament
Examination Enlarged, Cystic adnexal mass, Mobile or Adhered to pelvic structures Ovarian Endometrioma
Retroverted, Fixed, Tender Uterus and Firm, Fixed posterior cul-de-sac
DURING MENSES Pelvic nodularities secondary to endometriosis (easily detected)
Rectal Rectovaginal septum nodularity or tenderness
Examination
b) Symptoms from Specific Sites
Pain Common types of pain Rare types of pain
Endometriosis-associated CPP Dyschezia (Pain with defecation)
L19 - Pelvic Pain & Endometriosis
Dysmenorrhea Dysuria
Dyspareunia Abdominal pain
Non-cyclic pain
Endometriosis-associated Dysmenorrhea
- Typically precedes by 24 – 48 hours
- Pain more severe & less responsive to NSAIDs & COC than Primary dysmenorrhea
- Presence of DIE positively correlates with severity of dysmenorrhea
Endometriosis-associated Dyspareunia
- Often related to Rectovaginal septum, Uterosacral ligament or Posterior cul-de-sac
- Tension on diseased uterosacral ligament during intercourse pain
- Suspected if pain develops after years of pain-free intercourse
Non-cyclic CPP
- If Rectovaginal septum or Uterosacral ligament Pain may radiate to rectum or lower back
- Sciatic nerve involvement Pain radiating down the leg & causes cyclic sciatica
Infertility Adhesions Impair normal oocyte pick-up & transport by the fallopian tube
Moderate to severe (Stage III to IV) Tubal & Ovarian architecture are often distorted
Severe > Mild undergoing IVF Poorer implantation and pregnancy rates
Rectovaginal Defecatory pain develops Dyschezia (Chronic or Cyclic) associated with constipation,
lesions diarrhea or cyclic haematochezia
Origin of symptoms Fixation of rectum to adjacent structures or Rectal wall inflammation
Symptoms may also stem from DIE to the GIT
Bowel DIE – rectosigmoid colon (predominant), less common small bowel, cecum, appendix
Lesions are usually confined to Subserosa & Muscularis propria
- Thus, Colonoscopy offers poor diagnosis sensitivity
- More severe cases Transmural IO or Clinical picture suggesting malignancy
TVS Rectal DIE
MRI Clarify anatomy & Degree of invasion
Laparoscopy Definitive diagnosis
Management
- No Obstructive symptoms Conservative management with Hormonal therapy
- Treatment often surgical Colorectal Segment resection
- Variables Anatomic site, DIE depth, Lesion size, Number of foci
Urinary Tract Endometriosis considered if UT symptoms persist despite negative urine culture results
lesions Bladder disease (Symptoms) Dysuria, Suprapubic pain, Frequency, Urgency, Hematuria
Costovertebral angle pain Urethral endometriosis with obstruction & hydronephrosis
- Can progress eventually to kidney function loss
TVS Suitable accuracy for bladder DIE, less for urethral disease
Cystoscopy with Biopsy Help clarify the diagnosis
Treatment Medical or Surgical
- Surgery for bladder Partial cystectomy
- Surgeries for urethral involvement
1) Freeing the tethered ureter by Uretolysis
2) Segmental resection & Anastomosis
3) Ureter reimplantation into the bladder (Ureteroneocystotomy)
Anterior Can be an endometrioma of the anterior abdominal wall
Abdominal Wall - Develop in the abdominal scar (e.g. Uterine surgery, C-section, Prior operations)
Implants are usually found within the subcutaneous layer, are palpable & may involve the
adjacent fascia. Less often rectus abdominis muscle is infiltrated
- Surgically excised for pain relief & diagnosis18
Diagnostic tools Abdominal sonography, CT, MRI, FNAC
Thoracic lesions Catamenial – Pneumothorax occurring in conjunction with menstrual periods
Cyclic chest or Shoulder pain, Haemoptysis, Pneumothorax
Preferred imaging Chest CT
Treatment
Pneumothora Minimally invasive thorascopic surgery
x
Haemoptysis Hormonal or Surgical treatment
8. Investigations
L19 - Pelvic Pain & Endometriosis
Laboratory To exclude infections & pregnancy complications
Testing FBC
Serum/Urinary βhCG
Urinalysis & Culture
High Vaginal & Endocervical swabs
CA125 – elevated levels with endometriosis severity (poor for mild, better for stage III or IV)
Diagnostic TVS Initial diagnostic tool
Imaging Accurate in detecting & aids in exclusion of other causes of pelvic pain
Endometrioma
- Cystic with homogenous, low-level internal echoes (Ground glass echogenicity)
- Normal surrounding ovarian tissue
- Unilocular, 1 – 4 septations can be found
- Cysts can display thick septations or walls (Rarely)
Colour Pericystic
Dopple Not intracystic flow
r
Diagnostic Is the primary method used diagnosing endometriosis
Laparoscopy Surgical findings Discrete endometriotic lesions, Endometrioma (easily identified), Adhesions
Implants Pelvic organ serosa & Pelvic peritoneum
Variably Coloured of Endometriotic lesions***
Red Red, Red-Pink, Clear Frequently vascularized
Whit White, Yellow-Brown Fibrosis & Few vessels
e
Black Black, Black-Blue Pigmented by hemosiderin deposition from trapped menstrual debris
Morphological difference of Endometriotic lesions
- Smooth blebs on peritoneal surfaces
- Holes/Defects within the peritoneum
- Flat stellate(start shape) lesions (Points are formed by surrounding scar tissue)
Pathologic DO NOT require biopsy & histologic evaluation for diagnosis
Analysis Rely solely on laparoscopic findings in the absence of histologic confirmation (often overdiagnosis)
Histologic diagnosis Endometrial glands & Stroma found outside the uterine cavity
***Water/Serous/Mucin secretion Red (heme) Black (hemosiderin) White (bilirubin
10. Management
Medical Analgesics NSAIDs – very effective for endometriosis, SE: Gastric ulceration
Paracetamol
Codeine (add to PCM & NSAIDs when in adequate pain relief)
Hormonal COCs (1st line) – taken conventionally, continuously or in a tricycle regimen
treatment Progestogen – When COC is contraindicated
- Medroxyprogesterone acetate (MPA), Norethisterone (NET), POP, LNG-IUS,
Norplant (Subcutaneous contraceptive with levonorgestrel)
- Symptom relief not obtained after 3 – 6 months, consider switching
LNG-IUS – Reduces pain with symptom control maintained over 3 years
Androgens
Indications HMB, Endometriosis, Fibrocystic Breast disease, Breast pain
(mastodynia), Hereditary angioedema
Dose 100 – 200mg orally twice a day (BD)
Side Effects Androgenic – Hirsutism, Acne, Oily skin, Deepening of voice
Contraindication Pregnancy Can masculinize a female fetus
GnRH agonists
With add-back theory
- Low-dose estrogen & progestin, Danazol, Calcium-regulating agents (Calcitonin)
- Tibolone (Synthetic steroid Mimics Estrogen & Progesterone)
L19 - Pelvic Pain & Endometriosis
Surgical Conservative (minimally invasive – Fertility) Radical (fertility not required)
Aim to remove (excise) or destroy(ablate) areas of Total Abdominal Hysterectomy +
endometriosis to improve symptoms Bilateral Salpingo-Oophorectomy
Mild to Ablation &/ Excision of endometriotic HRT after BSO
Moderate lesions reduce pain compared with Unopposed estrogen, combined-
diagnostic laparoscopy alone continuous regimen or tibolone
Severe & Excisional surgery - Note there is an increased risk in
DIE Laparoscopic Uterosacral Nerve developing breast cancer associated
Ablation (LUNA) with combined estrogen &
Laparoscopic Helium Plasma progestogen HRT & Tibolone
Coagulation
Complementary Nutritional & Complementary Therapies
- Homeopathy, Reflexology, TCM, Herbal treatments
Follow up Relapse is common after surgical procedures
Managing Relapse
- Explain the commonness of relapse, Exclude other conditions &/ medical treatment (e.g. COCs)
- Options: NSAIDs, &/ Medical treatment (e.g. COCs), Consider repeat surgery
Endometriosis Expectant Mild – Moderate
& Infertility Couple conceive spontaneously
Expectant approach is appropriate in these couples for up to 2 years
Severe
Probability of spontaneous pregnancy is significantly low
Medical Suppression of ovarian function to improve fertility in minimal-mild/severe
endometriosis is not effective
More harm than good may result from treatment because of adverse effects
& loss of opportunity to conceive
Surgical Minimal-Mild Moderate-Severe
Laparoscopic ablation + adhesiolysis Excision/Ablation of all visible
- May improve chance of endometriosis & adhesions to
pregnancy correct pelvic anatomy
Ovarian Drainage
Endometrioma Ablation
Excision of the endometrioma is preferable to drainage & ablation in regard to
recurrence of symptoms, endometrioma and spontaneous pregnancy rate
b) GnRH agonist
Induce a reversible postmenopausal state and regression of endometriotic deposits
- As effective as other medication in relieving the pain
- Limited use due to loss of Bone Mineral Density (BMD) in the first 6 months
***If treatment is to be used for >6 months, then use HRT ‘add-back’ therapy