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Pelvic Pain

INTRODUCTION

Pelvic pain implies pain originating from the viscera and soft-tissue structures within the pelvic cavity and from its enclosing bony structure. It also includes referred pain and pain extending into the suprapubic area of the lower abdomen and the groin.

CHRONIC/PERSISTENT PELVIC PAIN (PPP) IN WOMEN

Features

  • Incidence 15–25% of women

  • Endometriosis causes 33%, adhesions 24%

  • Reason for up to 40% of gynaecological laparoscopies

  • Reason for 5% of hysterectomies

  • Can be cyclical (e.g. endometriosis, mittelschmerz) or continuous

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Table P4 Pelvic pain: diagnostic strategy model

Probability diagnosis

Gynaecological disorders, e.g.

  • endometriosis

  • pelvic adhesions

Musculoskeletal disorders

Irritable bowel syndrome

Referred spinal pain

Serious disorders not to be missed

Neoplasia/cancer

  • lower bowel

  • cervix and uterus

  • ovary

Vascular

  • internal iliac artery—claudication

Severe infection

  • osteomyelitis

  • pelvic inflammatory disease

  • pelvic abscess

Ectopic pregnancy

Pitfalls (often missed)

Endometriosis

Constipation/faecal impaction

Paget disease

Stress fractures, incl. SCFE

Prostatitis/prostatodynia

Misplaced IUCD

Hernia in evolution (e.g. inguinal)

Pudendal neuralgia

Masquerades

Depression

Spinal dysfunction

Urinary tract disorders, incl.

infection

Functional disorders

Psychosexual dysfunction

Investigations for pelvic pain

Select from:

  • endocervical swabs

  • MSU ± Chlamydia PCR

  • plain X-ray

  • transvaginal US ± lower abdominal US

  • colour Doppler US imaging

  • colonoscopy/flexible sigmoidoscopy

  • cutaneous pain mapping

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