It is one of the common presenting complaints accounting for about 10% of referrals to the gynaecology outpatient clinic. Majority of the times no obvious pathology is detected. It is important to manage these patients with sensitivity to ensure that the resulting psychological damage is limited. At the same time the clinician should avoid getting forced into undertaking investigations that are not clinically indicated.
• Pelvic infection
Recurrent infections with resulting adhesion formation could become a difficult clinical problem to treat.
Is one of the commonest reasons for ongoing pelvic pain. It affects approximately 10% of women in reproductive age. Unfortunately, the pathophysiology is still poorly understood and it is not easy to clinically correlate the presenting symptoms with the severity of the disease as seen at laparoscopy. There is a range of symptoms and most commonly women present with pelvic pain, dysmenorrhoea, infertility, or a pelvic mass. Direct visualization and biopsy during laparoscopy or laparotomy is the gold standard diagnostic test for this condition and enables the gynaecologist to identify the location, extent, and severity of the disease.
Pelvic tumours, benign and malignant, could lead to long-standing unresolved pain. Ovarian cysts and fibroids are the commonest tumours responsible for such pain.
• Other causes
Ovulatory pain (mittelschmerz) and premenstrual pain are the physiological causes for chronic pain. Pelvic congestion syndrome is being accepted as another possible cause.
This could be a cause for chronic pain and also an effect of long-standing pain for which no cause can be found. It is a diagnosis by exclusion.
• Childhood sexual abuse
Childhood trauma can present with chronic pain.
• Urinary tract infection
Recurrent UTIs could lead to chronic cystitis and unresolving pain.
• Irritable bowel disease
This is a very common cause and is diagnosed by exclusion.
• Inflammatory bowel disease
Crohn's disease or ulcerative colitis can both lead to chronic pain.
This is not uncommon and can be treated effectively if detected.
A detailed history about the onset duration and progress of the pain is essential. This will provide significant information to help arrive at the diagnosis.
These include dyspareunia, vaginal discharge, bladder, and bowel symptoms. Dyspareunia could be caused by endometriosis or pelvic infection. Offensive vaginal discharge is suggestive of pelvic infection.
Other relevant history
• Detailed menstrual history, contraceptive history, and smear history is essential.
• History about any previous pregnancies. Any traumatic deliveries and postnatal depression could be the underlying reason for chronic pelvic pain.
• Previous medical and surgical history to note any bowel and bladder related problems in the past.
• History of medications such as analgesics used in the past provides information about the severity of pain.
• Social history—unemployment and drug abuse could be important social problems leading to depression and symptoms such as chronic pelvic pain.
• Effect of the symptoms on the patient's lifestyle—absence from work and disturbance in family life may reflect the severity of pain.
• General examination
While obtaining history and performing general examination it is important to observe the patient for expressions of being in obvious pain and discomfort.
• Abdominal examination
This is done to look for previous scars indicating multiple surgeries to remove vestigial organs. Loaded sigmoid may suggest constipation. Any tender areas in the abdomen may suggest intra-abdominal pathology.
• Pelvic examination
• Vulval inspection
This is performed to look for any obvious discharge.
• Speculum examination
This would reveal any offensive vaginal discharge suggesting pelvic infection or presence of local lesions on the cervix or the vagina.
• Bimanual examination
To look for forniceal thickening and tenderness. Nodules and tenderness in the uterosacral ligaments may indicate endometriosis. Any obvious palpable masses may be due to tumours or fibroids. Rectal examination may reveal a loaded rectum suggesting constipation.
• Full blood count
It is important to look for raised white cell count suggesting presence of infection.
• Raised C-reactive protein
This is seen in the presence of pelvic infections and inflammatory bowel disease.
• Urine culture and sensitivity
To look for evidence of urinary tract infection.
• Endocrine profile
This could help to detect raised LH/FSH ratio and serum testosterone levels suggesting polycystic ovarian disease.
• Transvaginal ultrasound examination
It is very useful to detect any obvious pelvic pathology such as uterine fibroid, ovarian cyst, endometriotic cyst, and polycystic ovaries. A normal scan is also very reassuring and leads to symptom relief in the anxious patients.
• Diagnostic laparoscopy
Depending on the severity of the symptoms and the findings of the preliminary investigations one may have to perform a laparoscopy to evaluate the abdomen and pelvis further. It is an invasive test associated with anaesthetic and surgical risks, but provides valuable information to understand the cause of the chronic pain. A negative laparoscopy also becomes very reassuring and can help the anxious patient psychologically.
• A systematic approach and extreme sensitivity is necessary throughout the management of these patients.
• One must think of non-gynaecological causes, which are likely to cause chronic pelvic pain.
• Psychological disturbances are common and counselling could benefit these patients significantly.
• Dietary alterations to increase the dietary fibre content along with increased daily fluid intake should be considered.
• Stool softeners and other laxatives such as Senokot Hi-Fibre can cure pelvic pain caused by constipation.
• If clinically indicated, referral should be considered for the opinion of a bowel surgeon at an early stage.
• If a gynaecological cause is found, then appropriate medical or surgical treatment is initiated.
• If regular analgesics do not work and the routine investigations have failed to detect a specific cause, a referral to the pain clinic should be considered.
• Laparoscopy should be considered only if necessary. Surgical therapy can be performed concurrently with diagnostic surgery and may include excision or ablation of endometriotic tissue, division of adhesions, and removal of endometriotic cysts. Laparoscopic excision or ablation of endometriosis has been shown to be effective in the management of pain in mild-to-moderate endometriosis. Adjunctive medical treatment pre- or postoperatively may prolong the symptom-free interval. There is insufficient evidence from the studies identified to conclude that hormonal suppression in association with surgery for endometriosis is associated with a significant benefit with regard to any of the outcomes identified. There is little or no difference in the effectiveness of GnRHas in comparison with other medical treatments for endometriosis. Side effects of GnRHas can be controlled by the addition of addback therapy.
Pain that is rapid in onset (<24 hr) usually associated with signs of peritonism (guarding, rebound, rigidity).
• Common: ectopic pregnancy, miscarriage, ovarian cyst, pelvic inflammatory disease.
• Less common: Ovarian/adnexal torsion/tubovarian abscess.
LMP, site of pain and nature ?colicky or persistent ?vaginal discharge ?fever ?previous past gynaecology history.
Abdomen soft or rigid, ?rebound, ?peritonism when coughs, ?requiring regular analgesia, ?mass palpated.
Pregnancy test, MSU for microscopy and culture, high vaginal swab for culture (HVS), endocervical swabs, FBC, serum human chorionic gonadotrophin (HCG), G&S, pelvic ultrasound (US) examination.
• Ectopic: serum HCG >1500 U empty uterus on ultrasound with small amount of per vaginal bleeding and adnexal pain. Transvaginal scan (TVS) can diagnose 80% cases and laparoscopy almost 100% cases.
• Miscarriage: colicky pelvic pain with per vaginal bleeding moderate/large amount, positive pregnancy test and US suggests miscarriage.
• Ovarian cyst: usually constant pain and cyst is seen on US. May be a simple cyst, or have mixed echos of haemorrhage (spider web appearance)—haemorrhagic cysts classically luteal phase cycle and after intercourse. Ground glass appearance on US suggests endometrioma and mixed bright echos suggest a dermoid.
• Ovarian cyst/fibroid torsion: pain constant or colicky may radiate to leg, associated with vomiting and raised white cell count (WCC) or interleukin 6 (IL62), cyst seen on US. Doppler ultrasound maybe useful.
• Pelvic inflammatory disease (PID): acute PID associated with pyrexia (>38°C), cervical excitation/dyspareunia, vaginal discharge, and raised WCC/C-reactive proteins (CRP). Gold standard diagnosis is at laparoscopy, but usually not required and is first treated medically. If non responsive to IV treatment consider tubovarian abscess and drainage.
• Non-gynaecological causes should be considered and computerized tomography (CT) is a useful tool3.
• Ectopic: laparoscopic salpingectomy if contralateral tube healthy and patient is haemodynamically stable. Conservative approaches can be considered in specific situations.
• Ovarian cyst: when <5 cm and not requiring regular analgesia, it can be managed conservatively. If patient requires parenteral analgesia and/or there are signs of acute abdomen then laparoscopy and ovarian cystectomy may be advisable.
• Haemorrhagic ovarian cysts: haemorrhage into a cyst is usually managed conservatively provided it is not causing a lot of pain and the patient is haemodynamically stable. If pain is not controlled, signs of peritonism or haemodynamic disturbance, laparoscopic lavage is performed and a cystectomy or haemostatic manoeuvre employed4.
• Ovarian cyst torsion: torsion can be managed conservatively by laparoscopically untwisting the torsion if employed within 36 hr of the torsion, thus avoiding adnexectomy5.
• PID: oral treatment: ofloxacin 400 mg twice a day plus oral metronidazole 400 mg twice a day for 14 days. IV treatment: ofloxacin 400 mg bd plus metronidazole 500 mg tds for 14 days. Oral therapy can be started 24 hr after clinical improvement. Surgical drainage may be rarely required.
1. Burnett LS (1988). Gynecologic causes of the acute abdomen. Surgical Clinics of North America, 68(2), 385–98.
2. Cohen SB, Wattiez A, Stockheim D, et al. (2001). The accuracy of serum interleukin-6 and tumour necrosis factor as markers for ovarian torsion. Human Reproduction, 16(10), 2195–7.
3. Taourel P, Pradel J, Fabre JM. et al. (1995). Role of CT in the acute nontraumatic abdomen. Seminars in Ultrasound, CT & MR, 16(2), 151–64.
4. Larue L, Barau C, Rigonnot L. et al. (1991). Rupture of hemorrhagic ovarian cysts. Value of celioscopic surgery. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction, 20(7), 928–32.
5. Rody A, Jackisch C, Klockenbusch W. et al. (2002). The conservative management of adnexal torsion—a case-report and review of the literature. European Journal of Obstetrics, Gynecology, & Reproductive Biology, 101(1), 83–6.