++
Chronic pelvic pain is constant or recurrent pain of at least 6 months’ duration.
++
Incidence 15% in 18–50-year-olds
Endometriosis causes 33%, adhesions 24%
It is the reason for up to 40% of gynaecological laparoscopies
Reason for 15% of hysterectomies
++
The pain can be cyclical (e.g. endometriosis, mittelschmerz) or continuous.
++
The common causes of chronic pain are listed in TABLE 103.3. Chronic pain is more difficult to diagnose and it is often difficult to differentiate between problems such as endometriosis, PID, an ovarian neoplasm and the irritable bowel syndrome. A comparison of the clinical features of endometriosis and PID is presented in TABLE 103.4. Furthermore it is difficult to distinguish clinically between endometriosis of the uterus (adenomyosis) and pelvic congestion syndrome. Both conditions are associated with dysmenorrhoea and a tender normal-sized uterus.
++
++
++
Ectopic pregnancy occurs approximately once in every 100 clinically recognised pregnancies. If ruptured it can be a rapid, fatal condition so we have to be ‘ectopic minded’. It is the commonest cause of intraperitoneal haemorrhage. There is usually a history of a missed period but a normal menstrual history may be obtained in some instances.
+++
Clinical features of a ruptured ectopic pregnancy
++
Average patient in mid-20s
First pregnancy in one-third of patients
Patient at risk
– previous ectopic pregnancy
– previous PID
– previous abdominal or pelvic surgery, especially sterilisation reversal
– IUCD use
– in-vitro fertilisation
Pre-rupture symptoms (many cases):
Rupture:
Pain may radiate to rectum (lavatory sign), vagina or leg
Signs of pregnancy (e.g. enlarged breasts and uterus) usually not present
++
++
DxT amenorrhoea (65–80%) + lower abdominal pain (95 + %) + abnormal vaginal bleeding (65–85%) → ectopic pregnancy
++
Deep tenderness in iliac fossa
Vaginal examination:
Bleeding (prune juice appearance)
Temperature and pulse usually normal early
++
It is possible to diagnose ectopic pregnancy at a very early stage of pregnancy.
++
Urine pregnancy test (positive in most ectopics)
Serum β-hCG assay—may need serial quantitative tests to distinguish an ectopic from a normal intra-uterine pregnancy (IUP). If it is >2000 IU/L an IUP should be visible on vaginal ultrasound. If the uterus is empty, ectopic is more likely. If <2000 IU/L, repeat every second day to see if it is increasing normally as expected in a normal IUP.
Transvaginal ultrasound can diagnose at 5–6 weeks (empty uterus, tubal sac, fluid in cul-de-sac)
Laparoscopy (the definitive diagnostic procedure)
++
Ectopic pregnancy diagnosis
beta-hCG assay
Transvaginal ultrasound
Laparoscopy
++
Possible options are surgery, medical or watchful expectancy. Treatment may be conservative (based on ultrasound and β-hCG assays); medical, by injecting intramuscular methotrexate; laparoscopic removal; or laparotomy for severe cases. Rupture with blood loss (usually about 7% of cases6) demands urgent surgery. Organise blood and contacts, resuscitate as necessary.
++
+++
Ruptured ovarian (Graafian) follicle (mittelschmerz)
++
When the Graafian follicle ruptures a small amount of blood mixed with follicular fluid is usually released into the pouch of Douglas. This may cause peritonism (mittelschmerz), which is different from the unilateral pain experienced just before ovulation due to distension of the ovarian capsule.
++
Onset of pain in mid-cycle
Deep pain in one or other iliac fossa (RIF > LIF)
Often described as a ‘horse kick pain’
Pain tends to move centrally (see FIG. 103.3)
Heavy feeling in pelvis
Relieved by sitting or supporting lower abdomen
Pain lasts from a few minutes to hours (average 5 hours)
Patient otherwise well
++
Note: Sometimes it can mimic acute appendicitis.
++
++
Explanation and reassurance
Simple analgesics: aspirin or paracetamol
‘Hot water bottle’ comfort if pain severe
++
Benign ovarian tumours, particularly ovarian cysts, may be asymptomatic but will cause pain if complicated. They are common in women under 50 years of age. Ovarian cysts are best defined by vaginal ultrasound, which can identify whether haemorrhage has occurred inside or outside the cyst.
++
+++
Ruptured ovarian cyst
++
The cysts tend to rupture just prior to ovulation or following coitus.
++
Patient usually 15–25 years
Sudden onset of pain in one or other iliac fossa
May be nausea and vomiting
No systemic signs
Pain usually settles within a few hours
++
++
++
+++
Acute torsion of ovarian cyst
++
Torsions are mainly from dermoid cysts and, when right-sided, may be difficult to distinguish from acute pelvic appendicitis.
++
Severe cramping lower abdominal pain (see FIG. 103.4)
Diffuse pain
Pain may radiate to the flank, back or thigh
Repeated vomiting
Exquisite pelvic tenderness
Patient looks ill
++
++
Smooth, rounded, mobile mass palpable in abdomen
May be tenderness and guarding over the mass, especially if leakage
++
++
+++
Malignant ovarian tumours
++
Ovarian cancer has an incidence of 10 cases per 10 000 women per year and accounts for 5% of all cancers in women and 20% of all gynaecological cancers. It is responsible for more gynaecological cancer deaths because the tumour is often well advanced at the time of clinical presentation. Earlier discovery may sometimes be made on routine examination or because of investigation of non-specific pelvic symptoms.
++
Ovarian cancer tends to remain asymptomatic for a long period. No age group is spared but it becomes progressively more common after 45 years (peak incidence 60–65 years) (see CHAPTER 26).
++
The familial causes and relationship to breast and colorectal cancer are being delineated. Refer to CHAPTER 18.
++
++
++
Constitutional symptoms: fatigue, anorexia
Ache or discomfort in lower abdomen or pelvis
Abdominal bloating and ‘fullness’
Gastrointestinal dysfunction (e.g. epigastric discomfort, diarrhoea, constipation, wind)
Sensation of pelvic heaviness
Genitourinary symptoms (e.g. frequency, urgency, prolapse)
± Abnormal uterine bleeding
Postmenopausal bleeding
Dyspareunia and/or dysmenorrhoea (10–20%)
± Weight loss
A bimanual examination assists diagnosis. Look for mass, ascites, pleural effusion
++
A pelvic mass plus ascites usually indicates ovarian cancer but occasionally may be caused by a benign ovarian fibroma (Meigs’ syndrome—a triad of benign ovarian tumour + ascites + pleural effusion).
++
Note: Any ovary that is easily palpable is usually abnormal (normal ovary rarely >4 cm).
++
Pelvic ultrasound with transvaginal and transabdominal views
Tumour markers such as CA-125, β-hCG (choriocarcinoma), human epididymis protein 4 (HE4) and alpha-fetoprotein should be measured only if the ultrasound raises suspicion of malignancy7
++
Refer urgently to gynaecologist. Treatment is usually laparoscopy ± adjuvant chemotherapy.
++
Dysmenorrhoea (painful periods) may commence with the onset of the menses (menarche) when it is called primary dysmenorrhoea, or later in life when the term secondary dysmenorrhoea is applied.
+++
Primary (functional) dysmenorrhoea
++
This is menstrual pain associated with ovular cycles without any pathologic findings. The pain usually commences within 1–2 years after the menarche and becomes less severe with age. It affects about 50% of menstruating women and up to 95% of adolescents.
++
Low midline abdominal pain
Pain radiates to back or thighs (see FIG. 103.5)
Varies from a dull dragging to a severe cramping pain
Maximum pain at beginning of the period
May commence up to 12 hours before the menses appear
Usually lasts 24 hours but may persist for 2–3 days
May be associated with nausea and vomiting, headache, syncope or flushing
No abnormal findings on examination
++
++
Full explanation and appropriate reassurance
Promote a healthy lifestyle:
Recommend relaxation techniques such as yoga
Avoid exposure to extreme cold
Place a hot water bottle over the painful area and curl the knees onto the chest
++
Options include (trying in order):
++
simple analgesics (e.g. aspirin or paracetamol)
NSAIDs
– naproxen 500 mg (o) initially then 250 mg every 6—8 hours (max 1250 mg/day)
– or ibuprofen 200–400 mg (o) tds (max 1600 mg/day)
– commence at first suggestion of pain in the first 3 days of the period (if simple analgesics ineffective)
combined oral contraceptive pill
progestogen-medicated IUCD
++
If not helped by these treatments, further investigation is required.
++
A Cochrane review found that the most beneficial medication was the NSAIDs, and vitamin B1 and magnesium also proved effective. There is no evidence so far that vitamin B6, vitamin E or herbal remedies are effective. Spinal manipulation is unlikely to be beneficial.8
+++
Secondary dysmenorrhoea
++
Secondary dysmenorrhoea is menstrual pain for which an organic cause can be found. It usually begins after the menarche following years of pain-free menses; the patient is usually over 30 years of age. The pain begins as a dull pelvic ache 3–4 days before the menses and becomes more severe during menstruation.
++
++
++
Investigations include laparoscopy, ultrasound and (less commonly) assessment of the uterine cavity by dilation and curettage, hysteroscopy or hysterosalpingography.
++
Management involves treating the cause.
++
Pelvic adhesions may be the cause of pelvic pain, infertility, dysmenorrhoea and intestinal pain. They can be diagnosed and removed laparoscopically when the adhesions are well visualised and there are no intestinal loops firmly stuck together.
++
Endometriosis is the condition where ectopically located endometrial tissue (usually in dependent parts of the pelvis and in the ovaries) responds to female sex hormone stimulation by proliferation, haemorrhage, adhesions and ultimately dense scar tissue changes. The average time to diagnosis is 10 years. The diagnosis is masked by taking NSAIDs and the COC.
++
Patients experience varying degrees of symptoms and loss of gynaecological function according to the site and severity of the endometriosis deposits. Pregnancy is beneficial but recurrence can follow.
++
5–10% incidence
Puberty to menopause, peak 25–35 years
Secondary dysmenorrhoea
Painful defecation during menses
Urinary symptoms; dysuria, frequency
Pain may radiate to lower back, legs or rectum
Subfertility
Dyspareunia
Non-specific pelvic pain
Menorrhagia
Acute pain with rupture of endometrioma
Premenstrual spotting
++
DxT dysmenorrhoea + menorrhagia + dyspareunia = abdominal/pelvic pain → endometriosis
++
Fixed uterine retroversion
Tenderness and nodularity in the pouch of Douglas/retrovaginal septum
Uterine enlargement and tenderness
++
Adenomyosis: this is endometriosis of the myometrium affecting the endometrial glands and stroma. The symptoms are similar to endometriosis plus an enlarging tender uterus.
+++
Differential diagnosis
++
++
Usually by direct visual inspection at laparoscopy (the gold standard)
Transvaginal ultrasound (usefulness not well established, may identify ovarian endometrioma or rectal endometriosis)
Curettage (not routinely performed) shows small sensory C nerve fibres in the endometrium
++
Careful explanation
NSAIDs (first line), can be supplemented by paracetamol
Treatment can be surgical or medical
Medical:10 To induce amenorrhoea (only two-thirds respond to drugs):
– COC: once daily continuously—long term
– levonorgestrel-releasing IUCD (Mirena) 5-yearly and indefinite
– progestogens (e.g. medroxyprogesterone acetate—Depo-Provera) or orally 10 mg bd for up to 6 months
– GnRH analogues, e.g. goserelin, 3.6 mg SC implant every 28 days for up to 6 months, nafarelin (limited by adverse effects)
++
Surgical: Surgical measures depend on the patient’s age, symptoms and family planning. Laser surgery, diathermy ablation and excision of endometriomata can be performed via laparoscopy. When endometriosis is associated with infertility, laparoscopic surgery is preferred to drug therapy.
+++
Pelvic inflammatory disease
++
There are great medical problems in the serious consequences of PID, namely tubal obstruction, infertility and ectopic pregnancy. PID may be either acute, which causes sudden severe symptoms, or chronic, which can gradually produce milder symptoms or follow an acute episode. Acute PID is a major public health problem and is the most important complication of STIs among young women. The majority are young (less than 25 years), sexually active women who are also nulliparous. PID is usually polymicrobial, caused by sexually acquired pathogens and/or vaginal flora.11
++
Some patients may experience no symptoms but others may have symptoms that vary from mild to very severe. The clinical diagnosis can be difficult as signs and symptoms can be nonspecific and correlate poorly with the extent of the inflammation.
++
++
+++
Both acute and chronic
++
Dyspareunia
Menstrual problems (e.g. painful, heavy or irregular periods)
Intermenstrual bleeding
Abnormal, perhaps offensive, purulent vaginal discharge
Painful or frequent urination
++
The diagnostic criteria for acute PID are presented in TABLE 103.5.
++
++
In acute PID there may be lower abdominal tenderness ± rigidity.
Pelvic examination: in acute PID there is unusual vaginal warmth, cervical motion tenderness and adnexal tenderness. Speculum examination usually reveals a red inflamed cervix and a purulent discharge.
++
These can be subdivided into three broad groups:
++
Exogenous organisms: those which are community acquired and initiated by sexual activity. They include the classic STIs, Chlamydia trachomatis (the most common causative organism) and Neisseria gonorrhoeae. This usually leads to salpingitis.
Endogenous infections: these are normal commensals of the lower genital tract, especially Escherichia coli and Bacteroides fragilis. They become pathogenic under conditions that interrupt the normal cervical barrier, such as recent genital tract manipulation or trauma (e.g. abortion, presence of an IUCD, recent pregnancy or a dilatation and curettage). The commonest portals of entry are cervical lacerations and the placental site. These organisms cause an ascending infection and can spread direct or via lymphatics to the broad ligament, causing pelvic cellulitis (see FIG. 103.6).
Actinomycosis: very rare cause of a chronic polymicrobial inflammatory mass that can mimic pelvic malignancy. Due to prolonged IUCD use. Look for Actinomyces israelii on culture if suspected and seek expert advice.
++
++
Diagnosis is clinical. A definitive diagnosis is difficult since routine specimen collection has limitations in assessing the organisms. Definitive diagnosis is by laparoscopy but this is not practical in all cases of suspected PID.
++
Endocervical swabs for NAAT (e.g. PCR) N. gonorrhoeae, C. trachomatis and M. genitalium
Endocervical swab for culture
Blood culture if febrile
Pelvic ultrasound to detect alternative causes of pain
++
Note: Any IUCD should be removed if there is no response to treatment in 48 to 72 hours. A new IUCD can be inserted once the infection has resolved. Current sexual partners should be treated with agents effective against C. trachomatis (and N. gonorrhoeae if likely), irrespective of test results.
+++
Sexually acquired infection11
++
Mild to moderate infection (treated as an outpatient):
++
ceftriaxone 500 mg (in 2 ml 1% lignocaine) IM or 500 mg IV, as a single dose (for gonorrhoea)
plus
metronidazole 400 mg (o) 12 hourly for 14 days
plus
doxycycline 100 mg (o) 12 hourly for 14 days
++
Severe infection (treated in hospital):
++
ceftriaxone 2 g IV daily or cefotaxime 2g IV tds
plus
azithromycin 500 mg IV daily
plus
metronidazole 500 mg IV 12 hourly until there is substantial clinical improvement, when the oral regimen above can be used for the remainder of the 14 days
+++
Infection non-sexually acquired (related to genital manipulation)
++
Mild to moderate infection:
++
++
Severe infection (including septicaemia):
++
amoxy/ampicillin 2 g IV 6 hourly
plus
gentamicin 4–6 mg/kg IV for 1 dose, then 1 or 2 further doses based on renal function
plus
metronidazole 500 mg IV 12 hourly