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Fifth stage
Gynecology
Lec-4
د.سراب
2/3/2015
Chronic pelvic pain
Pain in the lower abdomen with or without valvar pain and more than 6 month duration.
Usually (not always) associated with dysmenorrhea or dyspareunia.
Evidence of this disease like that of asthma, headache, migraine, backache.
Also it occur in post-menopausal women.
Causes:
According to anatomical origin of pain:
1- Abdominal wall (muscles, bone, nerves).
2- Peritoneal (by stretching).
3- Viscera (urinary system, bowel, reproductive system).
4- Pain due to vessels (congestion, varicose veins).
According to nature of cause:
1- Inflammatory: infection (salpingitis), no infection (endometriosis).
2- Mechanical: genital prolapse, retroverted uterus, adhesions, ovarian cyst, torsion,
compression.
3- Functional: chronic cystitis, irritable bowel syndrome.
4- Neuropathic pain: post-surgery, nerve compression (in disc prolapse and nerve root
compression).
5- Musculoskeletal: muscle spasm, myalgia.
Type of pain:
Visceral pain
Referred Pain
Somatic Pain
Myalgia
Hyperalgesia
Neuroinflammation
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Sources of chronic pelvic pain:
Gynecological
Urological
Gastrointestinal
Musculoskeletal
Neuropathic
Other
Incidence:
14 – 24% of women b/w 18 and 50 years.
1/3 do not consult doctor.
60% who consult are not referred to tertiary centre.
Population studies: GI (37%), Urinary (31%), Gynae (20%).
Laparoscopic findings: No pathology (35%), Endometriosis (33%), Adhesions (24%).
Differential Diagnosis for Chronic Pelvic Pain:
Gynecologic
Endometriosis syndrome
Adhesions (chronic pelvic inflammatory disease)
Leiomyomata
Adenomyosis
Pelvic congestion syndrome
Irritable bowel
Chronic Appendicitis
Inflammatory bowel disease
Diverticulosis
Diverticulitis
Meckel’s diverticulum
Urologic
Abnormal bladder function (detrusor instability)
Urethral syndrome (chronic urethritis)
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Interstitial cystitis
Psychosexual dysfunction/abuse
Psychological
Depression
Somatization
Personality disorder
Musculoskeletal
Nerve entrapment (neuritis)
Fasciitis
Scoliosis
Disc disease
Spondylolisthesis
Osteitis pubis
Surgical
Chronic appendicitis
Hernia
Bowel disease
Adhesive disease
Assessment:
1- History:
Site: localized or generalized.
Onset and duration.
Aggravating factors: by intercourse.
Relieving factors: by analgesia or drugs or certain position.
Severity of pain: by interfering with quality of life.
Nature of pain.
Radiation of pain.
Associated with menstrual cycle:
o Primary (spasmodic) dysmenorrhea no underlying cause, started at
menarche, start at the beginning of menstrual cycle.
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o Secondary (congested) dysmenorrhea there is underlying cause, start later in
life, start 7-10 days before menstruation.
o Dyspareunia:
Superficial (occur at vulva) or deep (occur at abdomen).
Do daily chart of pain.
Mood sometimes psychological cause of pain (so give antidepressant).
Quality of life (work, posture).
Physical and sexual abuse.
Review of other system:
o GIT IBS (bloating, frequency of stool, pain relieved by defecation).
o Renal chronic interstitial cystitis (hematuria, frequency, urgency).
Physical examination:
Gait or walking of patient could be referred pain form other area.
Neurological examination.
Abdominal examination:
o Inspection: scars.
o Tenderness due to nerve entrapment: Target point ((2 cm medial to iliac crest,
ovarian point which is 2cm above and lateral to symphysis pubis)).
Pelvic examination:
o Inspection: erythema (valvulitis), varicose veins in vulva.
o Digital examination: myalgia of pelvic muscles during insertion of finger.
o Palpation: Tenderness (infection), anteverted or retroverted uterus, mobility of
uterus, adhesions (tube or ovary), mass (pelvic abscess or endometriosis).
Investigations:
High vaginal endocervical swab (most common cause is chlamydia).
Radiology US (size of uterus and adnexa), MRI, Doppler.
Contrast radiology (diagnostic and therapeutic by doing embolization of vessels).
Diagnostic laparoscopy.
Cystoscopy (chronic interstitial cystitis).
Bowel endoscopy (sigmoidoscopy).
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Treatment:
Multi discrepancy: gynecologist, general surgeon, radiologist, psychologist.
Medical treatment:
Infection: antibiotics, anti-TB.
Endometriosis: progesterone.
Depression: antidepressant (amitriptyline, SSRI), gabapentin.
Nerve entrapment: local anesthetics (long acting).
Analgesics: paracetamol.
Surgical treatment:
Adhesion: adhenolysis.
Ovarian cyst: removal.
Endometriosis: early (ablation), later (endometrectomy).
Nerve surgery.
Hysterectomy and oophorectomy give GnRH agonist, if respond do hysterectomy.
Other:
Magnetic.
Phototherapy.
Writing therapy.
Radiological therapy (embolization of vessels).
Psychological therapy.