Pelvic inflammatory disease (PID) is a common cause of acute pelvic pain, and the incidence is increasing. It is an upper genital tract infection and can include one or more of the following: endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. Prompt treatment and effective contact tracing are important as long-term sequelae include CPP, subfertility, and ectopic pregnancy. Although infection usually ascends from the cervix, cervical swabs can be negative even when pathogenic organisms are isolated from the fallopian tubes. The pain is thought to be due to inflammation, tissue destruction, irritation of peritoneal surfaces, and distortion of anatomy. Right upper quadrant pain and perihepatic adhesions occur in the Fitz-Hugh-Curtis syndrome, which is seen in 10% to 20% of women with PID.^6,7 Clinical features of PID lack sensitivity and specificity but include lower abdominal pain and tenderness, deep dyspareunia, abnormal vaginal/cervical discharge, cervical excitation and adnexal tenderness, and fever.⁸ Evidence of acute infection will not always be seen on diagnostic laparoscopy, and therefore, this investigation should be reserved for cases where alternative pathology needs to be excluded or if a pelvic mass is seen on ultrasound (US).⁹ Where there is a high index of suspicion, it is recommended that empirical antibiotic treatment should be commenced once swabs have been taken without waiting for culture results or performing further investigations.⁹ This is particularly important if other features of sepsis are present, in which instance admission and adherence to local sepsis guidelines is recommended. A number of different organisms are associated with PID, including Chlamydia trachomatis, Neisseria gonorrhoea, Mycoplasma genitalium, and anaerobes.⁸ The most commonly implicated organisms vary geographically, and therefore, local guidelines for appropriate antibiotic treatment regimens should always be consulted. There are now high rates of quinolone-resistant gonorrhoea in the Unites States, and, since April 2007, fluoroquinolone antibiotics have no longer been recommended for the treatment of PID in the United States¹⁰; this is increasingly also the case in the United Kingdom. Antibiotic treatment is usually continued for 14 days (with intravenous doses converted to oral once apyrexial), and therefore, patient compliance can be an issue. The presence of an intrauterine contraceptive device (IUCD) only increases the risk of developing PID in the first few weeks after insertion. Leaving the device in situ while mild PID is being treated does not appear to affect the outcome. In severe cases, however, it is recommended that the IUCD be removed.

When there is definite evidence of a pelvic abscess or severe disease, surgery is recommended (either laparoscopy or laparotomy), to drain the abscess and divide pelvic adhesions, there is no good evidence to recommend division of perihepatic adhesions, however.⁹ Depending on location, it may also be possible to drain pelvic collections under US guidance. This has been shown to be effective with fewer complications than surgery.¹¹

To prevent reinfection, contact tracing and treatment of all sexual partners from 6 months prior to presentation is recommended.⁹ This may be best done through a local genitourinary medicine (GUM) clinic, which will have experience of contact tracing and counseling about the long-term consequences of sexually transmitted infections. If admission is not required and appropriate facilities exist, it may be more effective to refer the woman to a GUM clinic immediately, to be seen the same day, before treatment is started. Sexual intercourse should be avoided until both the patient and her partner have completed a full course of treatment.

The adnexa comprise the fallopian tubes and the ovaries, the overlying peritoneum, and accompanying blood vessels. Common adnexal problems causing pain are discussed here.

Unlike the testes, it is rare for normal adnexa to undergo torsion. However, the ovaries and the distal ends of the fallopian tubes hang free and, if enlarged by an ovarian cyst or hydrosalpinx for example, are able to twist and cause ischemia and thus pain, with necrosis ensuing if the torsion is not resolved. Initially, the pain may be a dull ache that comes and goes; however, once necrosis occurs, the pain becomes constant and severe and may be accompanied by pyrexia, nausea, leucocytosis, and raised inflammatory markers. Clinically, a tender pelvic mass will be found on internal examination, and this can be confirmed with US. Management is surgical, ideally by urgent laparoscopy. If the adnexa appear healthy, then the torsion can be untwisted and the cyst/hydrosalpinx dealt with appropriately. Traditionally, removal of the mass was performed if the tissues appeared gangrenous. However, there is increasing evidence that the appearance of the tissues does not correlate well with residual ovarian function and recovery, and follow-up studies where de-torsion was performed suggest that ovarian function recovers in the majority of cases. It is therefore now recommended that de-torsion be performed and the clinical condition observed with an interval salpingo-oophorectomy performed only if clinically indicated.¹²

A relatively rare cause of acute, or acute-on-chronic, pelvic pain is a hematometra or hematocolpos (literally blood in the uterus or blood in the cervix). This can be primarily from a congenital anomaly or secondary to procedures such as transcervical resection of the endometrium if cervical stenosis occurs. With congenital anomalies where a bifid uterus exists with one blind ending horn, it is possible to have normal menstrual flow from one horn and a gradually increasing hematometra in the other.

Diagnosis is by US or magnetic resonance imaging (MRI), and management is surgical, which may be as simple as cervical dilatation or incising an imperforate hymen. The discovery of a congenital müllerian anomaly should prompt a thorough investigation of the renal and urogenital system as many of these anomalies coexist.¹³

An emergency presentation with acute pelvic pain can be an exacerbation of a much more chronic problem. Often, the patient is known to the department, but for others, the sudden worsening of chronic pain can be the final straw that causes the woman to present for the first time. As well as organizing appropriate analgesia (remaining alert to the possibility of an opioid addiction) and treating any associated symptoms, a careful search for the factor(s) precipitating the exacerbation should be made. This may be disease-related, such as an ovarian cyst accident; treatment-related, such as reactivation of endometriosis by add-back hormone replacement therapy (HRT) or constipation secondary to increased analgesia use; or lifestyle-related, such as increased activity worsening musculoskeletal pain or a bereavement worsening psychological status. If such precipitating factors can be identified, they should be discussed with the patient. Coping strategies can be taught to prevent future emergency presentations, which may also be reduced by easy access to a health care professional who knows the woman well.

If a women presents for the first time to a department but is managed elsewhere for their CPP, it is always advisable to contact the team responsible for her care to ensure that management of the acute exacerbation/presentation does not interfere with the long-term plan. Although certainly not the case for the majority of women, there is a small group of patients who attend a variety of different hospitals with the aim of procuring the treatment (be it surgery, opioids, or other options) they desire. Although these women clearly have the right to seek a second or third opinion, it can be helpful to be fully informed of this behavior and the results of previous investigations/surgeries when forming a management plan and deciding which other clinicians may need to be involved.

An ectopic pregnancy is one in which the conceptus implants outside the uterine cavity. Most commonly, this is within the fallopian tube (98.3%) but more rarely can be in the abdominal cavity, on the ovary, or on the cervix. The incidence is approximately 1 in 100 pregnancies¹⁴; however, this is likely to increase with the increasing incidence of pelvic infection and assisted conception. Rarely, a heterotopic pregnancy can occur, which is effectively a twin pregnancy in two different sites (e.g., one intrauterine and one ectopic pregnancy). These cases can be easily missed with false reassurance given once the intrauterine pregnancy is seen on US. With the rising prevalence of assisted conception techniques, the incidence of heterotopic pregnancies is increasing.¹⁵

Classically, presentation is with a period of amenorrhoea followed by brown vaginal loss and then onset of pelvic pain. Realistically, however, presentation is varied, ranging from asymptomatic (an incidental finding at routine scan), through any combination of pain and/or old or fresh vaginal bleeding, to collapse secondary to hypovolemia. Initial pain is thought to be secondary to stretching of the peritoneum covering the distended fallopian tube; however, with rupture of the tube, peritonitis occurs and tracking of the blood up to the diaphragm can cause shoulder tip pain.

In the collapsed patient with a positive pregnancy test, diagnosis is assumed and resuscitation commenced with surgery performed immediately when she is stable. At the opposite extreme, in a hemodynamically stable woman with minimal symptoms, diagnosis can be difficult. In early pregnancy, an intrauterine gestation may not be visible even with transvaginal ultrasound (TVUS). A combination of serial human chorionic gonadotrophin (hCG) levels and repeated US may be required to determine the location and viability of the pregnancy. If a high index of suspicion is present or the woman is isolated socially, this observation may best be done as an inpatient; however, in the majority of cases, early pregnancy clinics facilitate safe outpatient management.

Appropriate management depends on the severity of presentation. With an unstable patient, urgent laparotomy or laparoscopy should be performed depending on the skills of the available surgeon. With a stable patient, the majority of cases should be able to be managed laparoscopically, reducing postoperative pain, recovery time, and hospital stay. Some units now manage appropriate cases medically using methotrexate; however, this is not without risks and requires careful surveillance and a motivated patient.¹⁶

However, the pregnancy is managed, the risks of an ectopic pregnancy in the future are considerably higher than in the background population, and the woman should be counseled about this prior to discharge and advised to get an early scan in her next pregnancy. It should not be forgotten that a pregnancy has been lost, and many women/couples value the opportunity to talk this through either at the time or at a later date.

Miscarriage is defined as pregnancy loss prior to viability (currently considered to be 24 weeks) and occurs in 10% to 20% of clinical pregnancies.¹⁷ Because of connotations of blame, the medical term abortion should no longer be used when pregnancy loss is spontaneous. The different types of miscarriage are shown in Table 64.4. Bleeding is not always the presenting feature. Classically, bleeding precedes pain in a miscarriage as opposed to an ectopic pregnancy where the pain occurs first. As this is not reliable, all pain or bleeding in early pregnancy should be referred to an early pregnancy unit for further assessment and management. Management may be expectant, medical (using prostaglandin analogues ± antiprogesterone) or surgical (traditionally known as evacuation of retained products of conception [ERPC] but now more frequently called a surgical management of miscarriage [SMoM] as this terminology is more acceptable to women and their partners). If the woman is hemodynamically unstable or the bleeding is very heavy, then surgery is recommended; otherwise, the choice of
management should be made by the woman. Nonsurgical options are associated with longer periods of bleeding but avoid the risks of a general anesthetic and may allow the woman to feel more in control. Contrary to previous beliefs, there is no increase in infection rate with expectant management.¹⁸ All nonimmunized, Rhesus-negative women who miscarry after 12 weeks’ gestation should be given prophylaxis with anti-D immunoglobulin. Prior to 12 weeks, anti-D immunoglobulin should be given for medical or surgical evacuation or if the bleeding is very heavy and associated with pain.¹⁷ The negative psychological impact of early pregnancy loss can be enormous, both for the woman and her family, and therefore, counseling and support should be offered. Ideally, this should be at a local level, although national support groups also exist.

Uterine fibroids (leiomyomas) are benign tumors of the uterus, which are found in approximately 20% of women of reproductive age. They are usually asymptomatic and are more common in older women and women of African origin. They possess estrogen receptors and are thus stimulated to grow during pregnancy. As their blood supply is mainly peripheral, central areas can suffer from ischemia if enlargement is rapid, causing pain. This is known as red degeneration. The pain is generally well localized with tenderness over the area of the fibroid only (as opposed to placental abruption where the whole uterus is tender and woody hard) and may be accompanied by a mild pyrexia and leukocytosis. Opioid analgesia is often required and admission may be necessary, if only for observation and fetal monitoring if there is any doubt about the diagnosis.

As in the nonpregnant state, hemorrhage into or rupture or torsion of an ovarian cyst can occur during pregnancy. In general, presentation and management are as for the nonpregnant woman; however, symptoms can be masked and nonspecific during pregnancy. Rupture of a cyst can present with severe pain and shock, and in early pregnancy, laparoscopy may be necessary to exclude ectopic pregnancy. However, if pain is resolving and no other symptoms are present, conservative management is recommended. If surgical management is required beyond early pregnancy, laparotomy may have to be considered because of the risks and technical difficulties of a laparoscopy with an enlarged uterus.

As the uterus enlarges, it moves out of the pelvis and becomes an abdominal organ. During this process, the supporting round ligaments are stretched and cause pain in the late first/early second trimester in 10% to 30% of pregnancies. Management is by simple analgesia and reassurance; however, it is important to ensure that other causes of pain are not missed, such as rupture of a heterotopic pregnancy or acute appendicitis.

Uterine retroversion occurs in up to 15% of pregnancies in the first trimester, but by 15 weeks’ gestation, spontaneous anteversion almost always occurs. It is reported that retroversion persists into the second trimester in 1 in 3,000 pregnancies.¹⁹ Rarely, it may not be noticed until a cesarean section is performed at term; however, it can become impacted and present with urinary frequency, urgency, abdominal pain, and urinary retention. Pelvic adhesions secondary to infection or endometriosis and posterior wall fibroids can predispose to incarceration. Diagnosis can be aided by US or MRI (Fig. 64.1); however, fetal parts may be palpable vaginally and an enlarged bladder abdominally. Gentle manual decompression is usually possible after emptying the bladder with a Foley catheter. Intermittent catheterization is occasionally necessary for a few days subsequently, but an indwelling catheter is not recommended because of the risk of infection.²⁰ If asymptomatic retroversion persists until term, delivery should be by cesarean section and a classical incision is often required.¹⁹

Ovarian hyperstimulation syndrome (OHSS) is a serious and sometimes fatal complication of assisted conception techniques. It is a systemic disease secondary to the release of proinflammatory mediators, including vasoactive products, from the hyperstimulated ovaries. It can be subdivided into early, within 9 days of the ovulatory hCG dose, or late and is classified according to severity (Table 64.5). Mild disease has been reported to complicate up to 33% of in vitro fertilization (IVF) cycles, whereas the severe form occurs in around 1%. OHSS is more likely in women with polycystic ovaries, young women, and in cycles where conception occurs, especially of multiple pregnancies.²¹ Presentation is variable depending on severity (see Table 64.5) but should always be borne in mind in a woman with abdominal/pelvic pain who has recently
undergone assisted conception. Mild and moderate disease can be managed on an outpatient basis, but more severe forms or concerns about a worsening condition require admission. In general, management involves symptom control: analgesia with either acetaminophen (paracetamol) or codeine but avoiding NSAIDs and antiemetics suitable for early pregnancy (e.g., prochlorperazine, metoclopramide), continuing progesterone luteal support but stopping hCG support and avoiding strenuous exercise and sexual intercourse because of the risk of ovarian torsion. In severe cases, multidisciplinary management is advised to deal with issues of fluid balance and thromboembolic risk (0.7% to 10%).²² Paracentesis may be necessary but should always be done under US guidance because of the risk of injury to enlarged, vascular ovaries. Importantly, women should be reassured that pregnancy may continue normally despite OHSS.²¹

Pelvic infection can occur after investigation of tubal patency with a hysterosalpingogram (HSG) or laparoscopy and dye test or after oocyte retrieval. Prior to such investigations being arranged, all women should have cervical swabs performed, and any infection should be treated with an appropriate antibiotic regimen. Oocyte retrieval is usually performed transvaginally under US guidance. Rates of pelvic infection secondary to this procedure vary between units and published series but are generally low, between 0% and 1%.²³ Initial management is with antibiotics and US to exclude a pelvic abscess. Progressive worsening of symptoms or failure to improve should prompt a further search for a pelvic collection and consideration of the possibility of bowel damage, for which laparoscopy or laparotomy would be required.

CPP is seen in women of all social classes with no variation in prevalence depending on marital or employment status.⁴⁸ However, social support can be an important factor in how a woman deals with her pain and social isolation can make the situation very difficult. It is easy to see how a vicious circle is set up with pain leading to the loss of the woman’s social role and thus her self-esteem, causing isolation and contributing to further pain.

Although frequently alluded to, the relationship between physical or sexual abuse and CPP is still not clear. The majority of studies is retrospective and only target women who have already developed the symptom. It appears that women in secondary care with any chronic pain condition are more likely to report a history of childhood abuse than pain-free women. When CPP is considered, sexual abuse is more commonly reported than in other pain conditions. It could be, however, that childhood sexual abuse is a predisposing factor for the development of depression, anxiety, and somatization which may then lead to the development of CPP.²⁴ In a rare prospective study,⁴⁹ children who had been abused were followed until their 20s and were not found to have an increase in medically unexplained symptoms when compared to a population who were not known to have been abused. However, those with unexplained symptoms were more likely to report their abuse. Thus, a revealed abuse history should not be assumed to be the cause of the pain, but failure to respond to treatments should perhaps prompt an exploration of these areas if a good therapeutic relationship already exists.

A recent study assessed whether a history of abuse is associated with the development of gynecologic disorders associated with CPP. In a cohort of 473 women undergoing laparoscopy, they found no increased risk of endometriosis, fibroids, or ovarian cysts in those with an abuse history but did find that a history of physical abuse was associated with a higher likelihood of pelvic adhesions.⁵⁰

Women with CPP display an increased incidence of “negative” psychological features, such as depression, anxiety, and catastrophization.⁵¹ This is common with other chronic pain conditions, such as fibromyalgia and irritable bowel syndrome (IBS). However, it is not possible to know whether these factors predispose a woman to develop CPP, contribute to a perpetuation of the pain, or are a consequence of years of living with pain and attempts to justify its severity or even existence to friends, family, and health care professionals. What is known is that psychological state can alter the experience of pain, and this is the area that should be emphasized to the woman when a
referral to a psychologist is suggested. Improving sleep patterns alone can both improve mood and have a significant effect on ability to function.

Similarly, whether personality types predispose to the development of chronic pain conditions or merely alter the way in which they are dealt with is not known. Some personality traits can make recovery more difficult. “Driven types,” for example, are unable to pace themselves and do too much on a “good day” so that on the following day, symptoms are worse again. On the other hand, those who take easily to the “sick role” can be hard to persuade to engage in therapeutic options and may also fail to respond. Women with diagnosed personality disorders should be managed in conjunction with a psychiatrist.

A detailed history of the pain should be taken including when and how it began; its associations, such as bowel, bladder, and psychological symptoms; and the effects of posture and movement. The circumstances surrounding the start of the pain and whether they recently changed should be discussed, as should the reasons why she has presented now. Cyclicity of symptoms or exacerbation with intercourse need to be established as does her current and future fertility aspirations. Relevant information may well be gleaned from her obstetric history, and a contraceptive and smear history should also be taken. It should be ascertained that no “red flag” symptoms, such as rectal bleeding or weight loss, exist. Although a history of past or present abuse (verbal, physical, or sexual) may also be present, it may not be appropriate to discuss this at the first consultation. If abuse is revealed, these experiences need to be accepted as stated, and it is important to know where to access specialist help locally should this be required.²⁴