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Pelvic pain in gynecology

Chronic pelvic pain in Gynecology

Acute pelvic pain in gynecology

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

AN ACUTE ACCIDENT
Bleeding of a corpus luteum
Rupture of an endometriotic cyst
ovarian Torsion
(myoma)
appendicitis, intestinal occlusion

Causes of chronic pelvic pain in gynecology

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 .

gynecology pelvic pain images endometriosis retroversion appendix pelvic congestion syndrome
Pathofysiology of chronic pelvic pain

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

pelvic pain endometriosis

deep endo

pain endometriose

Typical endometriosis causes pain

pain endometrioma

Cystic endometriosis causes pain


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

Filmy adhesions cause more pelvic pain than dense adhesions.
Surgery for adhesions and pelvic pain is 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 i.e. 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 pelvic adhesions causing pelvic pain.

Hydrosalpinx can cause pelvic pain but not all hydrosalpinges are painful.

Hydronephrosis can cause pelvic pain often irradiating to the kidney. Unfortunately however, hydronephrosis can be so insidious that occasionally a kidneys is lost  without symptoms 

Adhaesions over the uterus 
Umbilical adhesions 
gynecology pelvic pain images
After appendectomy
pain adhesions

liver-shoulder pain

gynecology pelvic pain images endometriosis retroversion appendix pelvic congestion syndrome
Hydrosalpinx

Pain hydronefrosis

Hydronefrosis

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

gynecology pelvic pain images endometriosis retroversion appendix pelvic congestion syndrome
Varicose veins cause pelvic pain
gynecology pelvic pain images endometriosis retroversion appendix pelvic congestion syndrome
Dissection of the ureter
gynecology pelvic pain images endometriosis retroversion appendix pelvic congestion syndrome
Suture

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

 

gynecology pelvic pain images endometriosis retroversion appendix pelvic congestion syndrome
Interstitial cystitis cause pelvic pain
gynecology pelvic pain images endometriosis retroversion appendix pelvic congestion syndrome
Interstitial cystitis cause pelvic pain

Uterine Myoma can occasionally cause pelvic pain. They in addition can cause pelvic pain by irritating the bladder or the bowel.
Painful retroversion of the uterus is another difficult diagnosis. Generally a retroverted uterus does not cause pelvic pain and thus should not be operated. If not other causes of pelvic pain are found at laparoscopy , I consider it wise to do a high McCall procedure, i.e. 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 correct it.

Adenomyosis or endometrial tissue in the uterine wall is a frequent cause of pelvic pain in gynecology. 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.

gynecology pelvic pain images
Allen and masters Before surgerygynecology pelvic pain images endometriosis retroversion appendix pelvic congestion syndrome
After excision
Allen and Master syndrome is a rare cause of pelvic pain but can even cause irritation of the obturator nerve.

Bowel pain eg chronic appendicitis and irritable colon

Pelvic pain remains a difficult diagnosis 

.

Management of chronic pelvic pain

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The difficulty in pelvic pain management is that many causes of pelvic 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 start medical therapy to try.

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

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

Adhesion cause pelvic pain

The informed consent should detail 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 etc
  • What will be done with pelvic congestion syndrome ? or a retroverted uterus ?
  •  
.

Pelvic pain remains difficult : the most frequent mistakes are

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

A wrong diagnosis of pelvic pain is not that exceptional since clinically difficult.

Ultrasound is wrong in some 10 to 20%,  both false positives as false negatives. The same is true for MRI and Cat scan .
Pelvic pain that increases during menstruation does not mean that it is endometriosis
Not recognizing deep endometriosis or the many other causes of pelvic pain

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 judgement 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.


Uterine Myoma can occasionally cause pelvic pain. They in addition can cause pelvic pain by irritating the bladder or the bowel.
Painful retroversion of the uterus is another difficult diagnosis. Generally a retroverted uterus does not cause pelvic pain and thus should not be operated. If not other causes of pelvic pain are found at laparoscopy , I consider it wise to do a high McCall procedure, i.e. 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 correct it.

Adenomyosis or endometrial tissue in the uterine wall is a frequent cause of pelvic pain in gynecology.  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 pelvic pain but can even cause irritation of the obturator nerve.
Bowel pain eg chronic appendicitis and  irritable colon

Pain localisations

Symptomatology of Gynaecological pain

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

gynecology pelvic pain images endometriosis retroversion appendix pelvic congestion syndrome
Pelvic pain radiation
gynecology pelvic pain imagesendometriosis retroversion appendix pelvic congestion syndrome
Pelvic pain radiation
gynecology pelvic pain images endometriosis retroversion appendix pelvic congestion syndrome
Pelvic pain radiation
gynecology pelvic pain images endometriosis retroversion appendix pelvic congestion syndrome
Pelvic pain radiation

Pathophysiology of pelvic pain 

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

gynecology pelvic pain images endometriosis retroversion appendix pelvic congestion syndrome
Etiology of pelvic pain
gynecology pelvic pain images endometriosis retroversion appendix pelvic congestion syndrome

gynecology pelvic pain images endometriosis retroversion appendix pelvic congestion syndrome
Etiology of pelvic pain

gynecology pelvic pain images endometriosis retroversion appendix pelvic congestion syndrome

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