Pelvic Pain in Females



Pelvic Pain in Females


Katy Vincent

Jane Moore



Pelvic pain is common in women, frequently leading to disability, social disruption, and loss of economic productivity. Many women do not seek help, often having lived with the pain since adolescence and accepting it as normal. In New Zealand, only 34% of a community sample of women aged between 18 and 50 years reported no pelvic pain, with 55.2% reporting dysmenorrhea, 25.4% chronic pelvic pain (CPP), and 19.7% dyspareunia.1 In the United States, 14.7% of women of the same age range reported CPP with estimated outpatient medical costs of $881.5 million per year, 15% reporting work absenteeism, and 45% reduced productivity.2 Similarly in the United Kingdom, 24% of 18- to 49-year-olds reported CPP3 and 37 of every 1,000 women consulting their general practitioner presented with CPP4; this was comparable to asthma (37/1,000) and back pain (41/1,000) and higher than migraine (21/1,000).

Pelvic pain is a frustrating symptom for both the patient and the doctor. Presentation can be variable, involving many organ systems, and severity can fluctuate over time. The frequent lack of an obvious initial diagnosis in both acute and CPP means that women frequently undergo large numbers of investigations and often unnecessary surgical procedures with associated morbidity and mortality. There is often a long interval between presentation and diagnosis with 25% remaining without a diagnosis after 3 to 4 years and more than 30% of women having had their pain for more than 5 years.4

The aim of this chapter is to provide an overview of the common causes of pelvic pain as well as to detail some of the less well known but easily treated causes with up-to-date evidence and a clear rationale for investigation and treatment. Because of the complexity of the innervation of the pelvis and the anatomical proximity of pelvic viscera, there is frequently overlap between what has traditionally been considered the domain of gynecology, urology, or gastroenterology. Therefore, some conditions will only be briefly discussed here when they are considered in more detail in other chapters of this book.

We discuss acute pelvic pain and CPP separately as, although there are overlaps, presentation and management are often very different. In addition, we also consider pelvic pain in pregnancy, dysmenorrhea, and mittelschmerz and pain associated with the complications of assisted conception. Finally, we discuss dyspareunia and the vulval pain syndromes which frequently coexist with other pelvic pain and whose etiology and management may be similar.








TABLE 64.1 Nongynecologic Causes of Acute Pelvic Pain









  • Appendicitis



  • IBS



  • Constipation



  • Inflammatory bowel disease



  • Mesenteric adenitis



  • Diverticulitis



  • Strangulation of a hernia



  • Urinary tract infection



  • Renal/bladder calculi



  • Acute muscle spasm


IBS, irritable bowel syndrome.



Acute Pelvic Pain


INTRODUCTION

The maxim that “acute pelvic pain in a woman of reproductive age is an ectopic pregnancy until proven otherwise” needs always to be borne in mind as ruptured ectopic pregnancies are associated with high morbidity and mortality and the consequences of a missed diagnosis are severe.5 However, there are many other causes of acute pain in the lower abdominal/pelvic area that also need to be considered in the differential diagnosis. Many of these are not gynecologic (Table 64.1), although the symptom frequently presents, or is referred, to the gynecologist. Unless the patient is extremely unwell, assessment should begin as always with a detailed history followed by examination and appropriate investigations.


OVERVIEW OF ASSESSMENT

Where at all possible, the history should be taken in private, allowing the woman (whatever her age) to have with her only those people she requests to be present. A detailed history of the pain should be taken and associated bowel and urinary symptoms and vaginal discharge/bleeding should be enquired about directly. It is also important to ascertain with accuracy the date of her last menstrual period (LMP) and whether this was normal as well as a contraceptive history and any recent episodes of unprotected sexual intercourse (UPSI). In all cases, but particularly with adolescents, these areas need to be approached sensitively. The presence of any risk factors for ectopic pregnancy (Table 64.2) should be established and the woman’s obstetric history ascertained. With an acute exacerbation of a chronic pain, it is important to inquire whether any precipitating factors (either physical or psychological) are present. At all times, clinicians should consider safeguarding issues and be alert to the possibility of assault, knowing where to access appropriate help locally if required.

Initial examination should ascertain that she is hemodynamically stable before examining the abdomen. The exact site of the pain should be established and evidence of an acute abdomen or abdominal/pelvic masses looked for. Pelvic pain in a sexually active woman (especially with a positive pregnancy test) should prompt a gentle digital internal examination, looking specifically for adnexal tenderness/masses and cervical excitation. Any discharge should be noted and appropriate swabs taken. If vaginal bleeding is present, a speculum examination should also be performed. Rectal examination may be indicated depending on the history. Again, privacy should be ensured, although a chaperone is recommended.








TABLE 64.2 Risk Factors for an Ectopic Pregnancy









  • Past history of PID



  • Progesterone-only contraceptive pill



  • Previous ectopic pregnancy



  • Previous tubal surgery



  • IVF



  • Endometriosis



  • Uterotubal anomalies



  • Fetal exposure to diethylstilbestrol


IVF, in vitro fertilization; PID, pelvic inflammatory disease.










TABLE 64.3 Investigation of Acute Pelvic Pain









  • Urinary/serum hCG



  • MSU



  • Vaginal swabs (including appropriate culture to detect Chlamydia)



  • Urethral swab



  • FBC, G&S (cross-match if ectopic suspected)



  • CRP



  • Pelvic US-TA or TV as appropriate



  • Abdominal radiograph (+/- contrast)



  • Pelvic MRI



  • Diagnostic laparoscopy


CRP, C-reactive protein; FBC, full blood count; G&S, group and save; hCG, human chorionic gonadotrophin; MRI, magnetic resonance imaging; MSU, midstream urine; TA, transabdominal; TV, transvaginal; US, ultrasound.


All women should have a urinary pregnancy test, but otherwise, investigations should be prompted by the history and examination findings rather than routinely ordered. Initially, investigations should be kept to a minimum in the case of an acute exacerbation of CPP. Investigations that might be considered are listed in Table 64.3.


GYNECOLOGIC FACTORS


Pelvic Inflammatory Disease

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.


Adnexal Pathology

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


Adnexal Torsion

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


Other Ovarian Cyst Accident

As well as undergoing torsion, an ovarian cyst (either functional or pathologic) can also cause pain by rupturing or by hemorrhaging into itself. Ruptured cysts usually cause acute pain followed by a generalized dull ache; however, if enough fluid/blood is released into the pelvis to irritate the diaphragm, then shoulder pain may also be present. Diagnosis is usually clinical, although, a US may show fluid in the pelvis and the absence of a previously noted ovarian cyst. Pregnancy must always be excluded (usually with a urinary pregnancy test), but if the pain is resolving and the woman is hemodynamically stable, then management is conservative, providing symptom relief. However, if she is unstable or a significant amount of fluid is present in the pelvis, laparoscopy may be required. In this instance, it is obviously important to be sure the diagnosis is correct and that an ectopic pregnancy, for example, has not been missed.

Hemorrhage into a cyst may be self-limiting or require surgery. Again, this decision should be based on the clinical picture.

In all these cases, if there is any doubt as to the nature of the cyst, then surgery should be performed so that tissue for histology can be obtained.



Hematometra/Hematocolpos

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


Acute Exacerbation of Chronic Pelvic Pain

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.


COMPLICATIONS SPECIFIC TO PREGNANCY

A number of complications specific to pregnancy can present with pelvic pain and need always to be borne in mind in a woman of reproductive age. It is also worth noting, however, that the physiologic and anatomical adaptations of pregnancy can alter the presenting features of many non-pregnancy-related conditions such as appendicitis. When treating pain in a possibly ongoing pregnancy, nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated because of effects on implantation, fetal renal function, and premature closure of the ductus arteriosus. Acetaminophen (paracetamol) and opioids, however, are safe. Reassurance and explanation are perhaps more important than ever in these cases to avoid anxiety about the pregnancy further clouding the clinical picture.


Ectopic Pregnancy

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

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.








TABLE 64.4 Types of Miscarriage17,157





















Threatened


May be continuing to bleed


Viable pregnancy


Inevitable


Bleeding


Cervical os open


Complete


Bleeding settled


All products of conception passed


Incomplete


May be continuing to bleed


Products still present


Delayed


No/minimal bleeding


Fetal demise, all products still present


Anembryonic pregnancy


May have bleeding


Gestational sac present but no yolk sac or embryo



Fibroid Degeneration

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.


Ovarian Cyst Accident

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.


Ligamentous Stretch

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.






FIGURE 64.1 Magnetic resonance imaging of persistent retroversion of the uterus at 20 weeks’ gestation. The uterine fundus containing the breech (curved arrow) can be seen in the pouch of Douglas. The placenta (asterisk) is attached to the posterior uterine wall with a large intramural fibroid (arrowheads) superiorly on the lower portion of the anterior wall, and the cervix (arrows) just below, above the level of the symphysis pubis (P). (From Hamoda H, Chamberlain PF, Moore NR, et al. Conservative treatment of an incarcerated gravid uterus. BJOG 2002;109:1074-1075, with permission.)


Urinary Retention and Uterine Incarceration

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


COMPLICATIONS OF ASSISTED CONCEPTION


Ovarian Hyperstimulation Syndrome

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








TABLE 64.5 Symptoms and Signs of Ovarian Hyperstimulation Syndrome

















Mild OHSS


Abdominal bloating


Mild abdominal pain


Ovarian size usually <8 cm


Moderate OHSS


Moderate abdominal pain


Nausea ± vomiting


US evidence of ascites


Ovarian size usually 8-12 cm


Severe OHSS


Clinical ascites (occasionally hydrothorax)


Oliguria (<300 mL/d)


Hematocrit >45%


Hyponatremia (sodium <135 mmol/L)


Hypo-osmolality (osmolality <282 mOsm/kg)


Hyperkalemia (potassium >5 mmol/L)


Hypoproteinemia


Ovarian size usually >12 cm


Critical OHSS


Tense ascites or large hydrothorax


Hematocrit >55%


White cell count >25,000/mL


Oligo/anuria


Thromboembolism


Acute respiratory distress syndrome


OHSS, ovarian hyperstimulation syndrome; US, ultrasound.


Adapted from Mathur RS, Drakeley AJ, Raine-Fenning NJ, et al. The Management of Ovarian Hyperstimulation Syndrome. London: Royal College of Obstetricians and Gynaecologists; 2016.



Pelvic Infection

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.


Dysmenorrhea

Dysmenorrhea is defined as pain with menstruation and was excluded from older definitions of CPP.24 However, there is increasing evidence of psychological distress, reduced quality of life, and long-term alterations in central nervous system structure and function in women with dysmenorrhea25,26,27,28 such that the most recent International Association for the Study of Pain (IASP) Taxonomy does include it as a subcategory of CPP.29 Estimates of prevalence range from 20% to 90%, and it has a major social and economic impact, being the leading cause of school and work absenteeism in young women.30 Traditionally, dysmenorrhea has been subdivided into primary and secondary. Primary (functional) dysmenorrhea is not associated with other pathology; is thought to be due to overproduction of prostaglandins and leukotrienes in the myometrium causing strong, painful contractions of the uterus; and is common in adolescents.31 It is frequently considered to be a “normal” part of development and assumed to improve with age or after pregnancy, although this has not been shown to be true in longitudinal studies. Secondary dysmenorrhea is associated with other pathology (Table 64.6) and therefore often occurs with other symptoms such as dyspareunia and menorrhagia. It is traditionally considered to affect women in their 30s and over, but it is worth remembering that children as young as 8 years old have been shown to have biopsy-proven endometriosis,32 and congenital uterine anomalies probably occur in around 4% of the population, increasing to 10% in adolescents with pelvic pain.31 Clinically, therefore, we find this distinction to be unhelpful and consider dysmenorrhea as a symptom which deserves to be treated and investigated as appropriate, no matter what age the patient.








TABLE 64.6 Causes of Dysmenorrhea









  • Endometriosis



  • Adenomyosis



  • Müllerian anomalies



  • PID



  • Fibroids



  • Cervical stenosis



  • Pelvic venous congestion



  • Intrauterine device


PID, pelvic inflammatory disease.


Initial assessment should include a detailed history, including risk factors for pathology associated with dysmenorrhea and other symptoms. In young girls who are not sexually active and without associated symptoms, a pelvic examination is not necessary before commencing empirical treatment. If there are concerns about structural anomalies, an abdominal US can offer reassurance but cannot diagnose or exclude endometriosis.






Mittelschmerz

Mittelschmerz (literally “middle pain” in German) is one-sided, lower abdominal pain that occurs at or around ovulation. It can last from minutes to 48 hours and requires no treatment other than simple analgesics. It is thought to occur in approximately 50% of women at some point. What causes the pain is not known, but possible suggestions include tubal, uterine, or cecal spasm; increased tension in the ovary or Graafian follicle; or peritoneal irritation due to leak of blood or fluid from the follicle. However, the latter is probably unlikely as in one study, 33 out of 34 women experienced the pain prior to follicular rupture (as confirmed with US),46 and pain is on the same side as follicular rupture in only 86% of women.47 Mittelschmerz probably causes most concern when a woman recommences ovulation after a long period of treatment with an ovulation inhibitor. Because it is not expected, the sudden, acute pain can then lead to investigation for other conditions such as appendicitis or an ovarian cyst accident. Similar, but more severe, pain can occur with trapped ovary syndrome and endometriosis, as discussed in the following text.


Chronic Pelvic Pain


INTRODUCTION

CPP is a symptom, not a diagnosis. As is seen, the causes are diverse, often multifactorial, and not always evident on routine examinations or even laparoscopy. As well as the economic impact already alluded to, CPP has major psychological, social, and cultural consequences not only for the woman but also for her partner, family, and society as a whole. It is acknowledged that it is frequently poorly managed; yet, it is as common as migraine and back pain and affects all races and social classes.


FACTORS ASSOCIATED WITH CHRONIC PELVIC PAIN

A number of factors are thought to be associated with CPP and should be explored during the consultation at an appropriate point.


Social

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.


Abuse

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


Psychological

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.


Personality

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.


OVERVIEW OF ASSESSMENT

The initial assessment of a woman with CPP is very important. Complete recovery at follow-up is associated with a favorable patient rating of the quality of the initial consultation.52 The woman needs to be given time to tell her story, without interruptions, but with the support of whomever she would like to be present (which may be no one but the doctor). The extra time taken to listen to the history in the patient’s own words may well give valuable information about the context of the pain, its effects on her life, and her beliefs about its cause and prognosis. In fact, an explanation for the pain has been shown to be one of things women with CPP most want out of their consultation (Table 64.7).53 The process of telling her story and of the examination can, in itself, be therapeutic. Once a cycle of chronic pain has been set up, it is unlikely that a single cause for the pain will be identified, and the clinician should be alert for any contributing factors that may be revealed.


History

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