Gynaecologic pain

Pain is a frequent complaint in gynaecology. Many causes exist besides endometriosis

Causes of Acute pelvic pain

Acute pelvic pain means that something suddenly happened such as

a bleeding in a corpus luteum : occurs generally at midcyle during ovulation ; it mimics a cystic endometriosis on ultrasound. Most important, this should NOT be operated
torsion of the ovary : is more likely to occur when an ovarian cyst exists, diagnosis is made by ultrasound demonstrating absence of blood flow in the ovary.
bleeding from a corpus luteum is relatively rare gives all symptoms of an acute abdominal bleeding
a rupture of an extra uterine pregnancy
PID : pelvic infection
intestinal causes as appendicitis, volvulus, peridivertivulitis

Causes of chronic pelvic pain

At the right a list the main causes of pelvic pain . The relationship between the severity of the pain and the lesions however is variable . The same lesion may cause a lot of pain whereas other women are pain free. It is important to understand the pathophysiology of pelvic pain : visceral pain is more sensitive to distension (like a full bladder) than to lesion .

Endometriosis is an important cause of pain. Deep endometriosis causes a lot of pain but 5-7% of women are pain free, cystic endometriosis also causes severe pain but not in 25 %, typical endometriosis is a cause of pain but 50% is pain free. Important is to realize that pain is not always cycle dependent. Subtle endometriosis and stromatosis or endosalpingiosis are not a cause of pain. Pain in adenomyosis is variable

Adhesions can cause pain but the relationship between adhesions and pain is very variable.

Filmy adhesions can cause more pain than dense adhesions.
Surgery for adhesions and pain is still debated. We consider a CO2 laser an important advantage because surgery is fast with minimal tissue damage. In addition quality of surgery and the experience of the surgeon is important ie minimal manipulation and damage and no bleeding.
Adhesions between liver and wall or Fitch Hugh Curtis can occur following a pelvic infection and cause pain in the liver region during movement. Generally this is associated with either an hydrosalpinx and or pelvic adhesions

Hydrosalpinx can cause pain but not all hydrosalpinges are painfull.

Hydronephrosis can cause pain often irradiating to the kidney. Unfortunately however, hydronephrosis can be so insidious that occasionally a kidney is lost almost without symptoms : another reason that pain should be taken serious and investigated thoroughly.

Pelvic varicose veins or pelvic congestion syndrome : this probably is much more frequent than generally thought, but the diagnosis is diffcult to make. In addition during laparoscopy this goes unnoticed if the laparoscopy is not started in anti-trendelenburg (head up) position. A ligature of the vein is sufficient, although generally these women end with an hysterectomy (which also cures the pelvic varices )

Interstitial cystitis is increasingly recognised as a cause of pelvic pain. The diagnosis can only be made by cystoscopy and confirmed by biopsy.

Uterine Myoma can occasionally cause pain. They in addtion can cause pain by irritating the bladder or the bowel.
Painful retroversion of the uterus is another difficult diagnosis. Generally a retroverted uterus does not cause pain and thus should not be operated. If not other causes of pain are found at laparoscopy , I consider it wise to do a high McCall procedure, ie shortening of the utero sacrals, which redresses the uterus. The procedure for those who are used to suture is so simple rapid and without risks, that it is a pity not to correst it.

Adenomyosis or endometrial tissue in the uterine wall.  Adenomyosis has been defined as an infiltration of more than 7 mm. This however is not useful clinically to make the diagnosis since pathology is only available after hysterectomy. The clinical diagnosis today is made by ultrasound and/or by NMR : Two types exist : thickening of the junctional zone and focal adenomyosis.

Allen and Master syndrome is a rare cause of pain but can even cause irritation of the obturator nerve.

Bowel pain eg chronic appendicitis and  irritable colon

Pain remains a difficult diagnosis Factsheet of the ASRM concerning pain and endometriosis

Management of pelvic pain

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The difficulty in pain management is that many causes of pain cannot be diagnosed without a laparoscopy.   Those  who do not feel confident to be able to treat surgically all causes of pelvic pain have a tendency to start medical therapy to try.

Decision 1 : is a laparoscopy necessary or can we start conservative therapy ?

This is the most difficult decision which is based upon symptoms, clinical exam and ultrasound. Eventually additional exams will be asked. Fundamentally a distinction should be made between gynaecological pain, bowel pain and other causes .

Then the decision will be made that either the diagnosis can be made with sufficient confidence and a therapy can eventually be started. In most cases however the diagnosis will not be clear without a laparoscopy, the abdomen being after all a ‘black box’.

Decision 2 : after a laparoscopy has been decided , which additional exams and preparation should be made i.e. what is the differential diagnosis

Deep endometriosis should be suspected when pain is very severe, in women with perineal radiation of pain or after a clinical exam during menstruation. If suspected, a contrast enema, an IVP and a bowel preparation are mandatory.

It is wise to explain in the informed consent form what will be done during surgery

Only diagnosis or an operative laparoscopy if indicated : since most gynaecologists cannot handle all pathology is wise to discuss what will be done specifically e.g. :

will superficial endometriosis be vaporized, will cystic ovarian endometriosis be excised, and if deep endometriosis is found, will it be excised or will the patient be referred.

What will be done when very severe adhesions are found , or when varicose veins are found, or adenomyosis et

Pelvic pain remains a difficult management : the most frequent mistakes are

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A wrong diagnosis : thus either a (necessary) laparoscopy will not be performed , either a laparoscopy without sufficient preparation will be performed

A wrong diagnosis is not that exceptional since clinically difficult.

Ultrasound is wrong in some 10 to 20% Both false positives as false negatives : this emphasizes the importance of an ultrasonografist with experience. The same is true for MRI and Cat scan .
A pain that increases during menstruation does not mean that it is endometriosis
Not recognizing deep endometriosis

Incomplete surgery – or incomplete preparation.

Incomplete excision of deep endometriosis because of lack of experience – or avoidable bowel resections.
Destruction of the ovary by lack of experience or unnecessary ovariectomy
Deep endometriosis is often not recognized, especially at the level of the sigmoid
Varicose veins are often not recognized since the patient is in Trendelenburg.

Inadequate judgment during laparoscopy

Superficial endometriosis does not exclude that other causes of pain may exist.
Chronic pain without obvious pathology, does not mean adenomyosis and a hysterectomy.

Symptomatology of Gynaecological pain

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Pelvic pain has specific localizations and radiations : see slides below.

Pathophysiology of Pelvic pain

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Pathophysiology of pelvic pain is specific and different of other somatic pain : different nociceptors , different activation. See slides of a presentation on pathophysiology.