Pelvic Pain

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An approach to acute and chronic pelvic pain

 Despite of many similarities in the etiology of pelvic pain , there are some crucial differences in the approach and the management. It needs careful observation.

Causes

Gynecological

1 Uterine

• Dysmenorrhea
• Fibroid with degeneration
• Adenomyosis
• Bicornuate uterus
• Haematocolpos

2 Ovarian

• Mittleschmertz
• Rupture of follicular cyst
• Salpingo-oopheritis
• Endometriosis

3 Tubal

• Pelvic inflammatory disease (PID)
• Ectopic pregnancy
• Salpingitis
• Torsion of hydrosalpinx

4 Others

• Pelvic congestion syndrome

Non gynaecological causes

1 GIT(Gastrointestinal)

• Amoebiasis
• Appendicitis
• Irritable bowel syndrome
• Obstruction
• Tuberculosis

2 Urinary

• Cystitis
• Stone in ureter

3 Muscular

• Trauma
• Abdominal wall haematoma
• Femoral and inguinal hernia

4 Psychological

• Sexual abuse
• Depression

Acute pelvic pain

Causes are usually

• Appendicitis
• Ectopic pregnancy
• Twisted ovarian cyst
• Trauma
• Acute gastroenteritis
• Intestinal obstruction

Chronic pelvic pain

CPP

American college of obstetrics and gynecologists describes it as a
non cyclical pain of 3 months duration or cyclical pain of 6 months duration, either of which interfere with normal routine activities.

or

1.  Pain which is refractory to the medical treatment.
2.  When there is significant impairement of physical and sexual function.
3.  Depression

Diagnosis is based on

HIstory

• Nature of pain
• Severity
• Duration
• Relation to menstrual cycles
• Aggravating and relieving factors
• Bowel movement
• Urinary history
• Menstrual history

Clincal examination

• Gait of the patient
• Color and general appearance is noted.
• Alteration in the posture
• facial expressions of the patient
• Tender points on the abdomen

Per vaginal examination

• Hymen whether ruptured or not (haematocolpos can also cause pain )
• Urethra , any discharge or lesion
• Discharge from vagina
• Cervical erosion on per speculum examination
• Tenderness in the fornices or adenexal masses
• Uterine size
• P/S
• Smear is taken for gonorrhoea and chlamydia infection.

Differential diagnosis (D/D)

1 Functional cysts

A haemorrhagic corpus luteum cyst can develop in the luteal phase and its rupture can produce intraperitoneal leak and haemoperitoneum can cause pain.

2 Inflammatory tubo ovarian masses , endometriomas can also rupture.

Onset of pain is sudden and sometimes dizziness and syncope if more blood is lost in the peritoneum.If loss is minmal then signs of shock will not be there.
CBC , USG , culdocentesis , diagnostic laparoscopy confirm the diagnosis.

3 Ectopic pregnancy

• Acute pain
• Usually history of amenorrhoea with spotting or bleeding per vaginum
• Pregnancy test is positive.
• USG confirms the diagnosis.
• Laparoscopy
• Laparotomy
• or methotrexate are the line of treatment.

4 Twisted ovarian cyst

If there is ischaemia due to twist it will cause unbearable pain.A benign cystic teratoma is the most common to undergo torsion.

Diagnosis

• Acute pain
• Vomiting
• Large tender adenexal mass
• Leukocytosis
• Mild rise in temperature

Treatment is surgical

• Laparoscopic or laparotomy
• If necrosed then oopherectomy is required.
• If not infarcted then just untwist the cyst.

5 Haematocolpos

Hymen is persistent and there is accumulation of blood in vagina.
on usg , solid mass in vagina is found.Hymen is bluish in colour.
give a cruciate incision in the hymen and drain out the blood.

6 Acute salpingo-oopheritis

Caused by gonorrhoea and chlamydia. PV and D&C can cause the transmission of the disease.
there is fever, purulent discharge , nausea, vomiting , bilateral fornices tendreness.
ESR is raised and there is leukocytosis.
Cervical smear will show gram negative intracellular diplococci.
for chlamydia there will be positive chlamydia Ag test.

Treatment of salpingo-oopheritis

• Broad spectrum antibiotics
• Hospitalization if TO abscess is there.

7 IUCD can also cause pelvic discharge with pain.

Give antibiotics , if doesn’t subside then remove it.

Mittleschmertz

When ovarian follicle ruptures there is small amount of blood leakege in the peritoneal cavity causing mid cyclic pain.

Primary dysmenorrhoea

Usually seen after 1 or 2 years of menarche , with ovulatory cycles.there is fall in progesterone levels  and breakdown of lysosomes which releases enzymes acting on phospholipids and there is increased synthesis of prostaglandins which cause excessive uterine contractions resulting in menstrual pain.

Treatment

• NSAIDs
• Low dose OCPs

Secondary dysmenorrhoea

Can occur with anovulatory cycles also.seen usually after 30 years of age.

Causes are

• Endometriosis
• IUCD
• Ovarian cyst
• Neoplasm

Treat the underlying cause.

Recurrent pelvic pain

• Mid cyclical
• Mild spotting is usually mittleschmertz.

Treatment

• Prostaglandin inhibitors

Primary dysmenorrhoea

• Is diagnosed with history
• Usg  is normal
• Subsides with prostaglandins and low dose ओच्प्स

If does not subside,then it can be secondary dysmenorrhoea

Diagnosis

• Usg
• laparoscopy
• Adhesions, TO masses , endometriomas or bicornuate uterus are the findings.

If Endometriosis :
Surgical fulgration and excision of the lesion
and biopsy is done.
If adhesions are found (they are usually post operative) , then perform adhesiolysis.

Pelvic congestion syndrome

• Ovarian and Internal iliac varices cause this syndrome.
• History is significant
• Premenstrual exacerbation of the pain which is unilateral and increases in standing posture and is relieved in supine position.
• Laparoscopy / imaging / selective ovarian and internal iliac venography are done to diagnose it.
• Embolization is the treatment.
• Sucess rate is 50 to 80 %.
• GnRh agonists like goserlin acetate and medroxyprogesterone acetate are also given.

References

1. Mini sood, pubertal menstrual anomalies;Jaypee Publication;125-135;20033
2. Joseph S, adolescent pelvic pain, best practice and research clinic obs and gyne,vol 7;93-101;2003
3. AOGD october 2008 ,Dr Chandra Mansukhani.

Related articles

• Common Causes of Vaginal Pain (everydayhealth.com)
• MCQs-Gynaec-2 (bhagia.wordpress.com)
• Can my pelvic pain be endometriosis? (zocdoc.com)
• I have had pelvic pain for 3 months now, I am not sure what it is! (zocdoc.com)
• How can I lessen the frequency of chronic pelvic pain? (zocdoc.com)