pelvic pain

BACK TO MEDICAL SCHOOL MAY 2006 THE COMMON CAUSES OF PELVIC PAIN Nicholas Myerson Consultant Obstetrician & Gynaecologist Bradford Royal Infirmary Objectives • Define the anatomy / content of the female pelvis • Identify the common causes of pelvic pain • Review key gynaecological causes • Discuss the diagnosis of common causes • Outline management strategies for 1ry & 2ry care settings Objectives • Define the anatomy / content of the female pelvis • Identify the common causes of pelvic pain • Review key gynaecological causes • Discuss the diagnosis of common causes • Outline management strategies for 1ry & 2ry care settings The Female Pelvis Pain Sensation in the Pelvis • Pain sensation mostly via the lumbar plexus (T12 – L4) • Pudendal nerve to anus, perineum and vulva is from the sacral plexus (L4 – S3) • Pain in pelvic viscera is often poorly defined and poorly localised • However if the peritoneum is involved pain is often much sharper with typical peritonism. Objectives • • • • • Revise the anatomy of the female pelvis Identify the common causes of pelvic pain Review key gynaecological causes Discuss the diagnosis of common causes Identify management strategies for 1ry & 2ry care settings Pelvic Pain • Identifying cause(s) of pain can be difficult • Pain can be multi-factorial • Non-gynaecological causes can co-exist e.g. adhesions affecting bowel endometriosis on bowel/bladder IBS • The initial diagnostic aim should be to identify all contributory elements Causes of Pelvic Pain • Acute or Chronic • Gynaecological or Non-gynaecological Common Causes of Chronic Pain Gastro-Intestinal Constipation Irritable Bowel Syndrome Inflammatory Bowel Disease Diverticulitis Herniae Gynaecological Endometriosis Adhesions Physiological/Pelvic Congestion Masses Ovarian remnant Urinary Interstitial cystitis Urethral syndrome Other Back/Postural Pain Musculoskeletal Hernia Nerve Entrapment Psychological Common Gynaecological Causes • • • • • • • • • ACUTE Physiological Pregnancy related Infection Ovarian Endometriosis Benign neoplasia Malignant neoplasia Appendicitis Cystitis • • • • • • • • • • • CHRONIC Physiological Musculoskeletal Infection Ovarian Endometriosis Benign Neoplasia Malignant Neoplasia Adhesions Interstitial cystitis Nerve entrapment Neuropathic Objectives • • • • • Revise the anatomy of the female pelvis Identify the common causes of pelvic pain Review key gynaecological causes Discuss the diagnosis of common causes Identify management strategies for 1ry & 2ry care settings Endometriosis • • • • Exact aetiology uncertain Symptoms may not correlate with extent Site and nature of pain varies between pts. Ectopic deposits endometroid tissue (inc. adenomyosis) • Symptoms often cyclical & worst before menses • Pain; deep dyspareunia; prolonged heavy menses; subfertility Adhesions • History of surgery/infection/endometriosis • Adhesions are frequently asymptomatic • Most common reason for pain after immediate post-operative period • Pain often assoc. with bowel dysfunction and stretching of viscera • Type/pattern of pain variable but often not (wholly) cyclical Trapped or Residual Ovary • • • • • Part of an ovary left after surgery An ovary buried within adhesions History of previous surgery (often difficult) Past history of pelvic pain/adhesions Typically pelvic pain and deep dyspareunia with a cyclical element • Pain localised to the relevant side Pelvic Infection • PID can be acute or chronic If chronic • Pain due to chronic inflammatory response • OR chronic due to adhesions and hydrosalpinges • Not (wholly) cyclical pattern • Deep dyspareunia often a feature Pelvic Infection •May get acute exacerbations with chronic disease OR acute infection: •Diagnostic criteria for acute PID 2 of pain, cervical excitation, adnexal tenderness and 1of discharge/temperature/↑WCC/↑CRP/+ve USS/ +ve laparoscopy Pelvic Congestion • • • • Overfilling (congestion) of the pelvic veins Dull aching pain, usually bilateral Cyclical element is common Worse at end of day/after prolonged standing • Standard investigations often negative Psychological Factors • Chronic pain causes psychological distress • BUT women with relevant history are at increased risk of pelvic pain • Treatment of depression/sleep disorder can improve function, even if caused by pain • Complex linkage between chronic pelvic pain and history of sexual/physical abuse • Abuse may trigger a cascade of events leading pelvic pain to develop but this is not inevitable Objectives • • • • • Revise the anatomy of the female pelvis Identify the common causes of pelvic pain Review key gynaecological causes Discuss the diagnosis of common causes Identify management strategies for 1ry & 2ry care settings Diagnosis • As always will depend on history + examination + investigation • History often the most informative element • Full chronic pain history can take 30-45 minutes • Examination is always useful but may elicit significant discomfort • Investigations are not always useful or required at early stage Key Gynae Points in the History • Ask about onset of pain duration of symptoms (acute –v- chronic) cyclical element (when in the cycle?) dyspareunia (cyclical/every episode?) dysmenorrhoea (worsening?) menstrual cycle (changed?) fertility plans for future pregnancy past history of pain/infection etc Key Other Points in the History • If no clear Gynae features specifically ask previous history of pain past investigation/treatment (inc Surgery) associated GI symptoms associated Urinary symptoms effect of pain on quality of life symptoms depression consider possibility of abuse does pain vary with movement/exertion History Taking • Taking a full history of chronic pelvic pain is very time consuming • A pain diary is a very useful diagnostic aid • A menstrual diary can be kept concurrently • Symptoms alone may be diagnostic • There are certain ‘red flag’ symptoms which should be sort and if present need prompt referral ‘Red Flag’ Symptoms • • • • • • • • PR bleeding New bowel symptoms if >50 yrs New pain after menopause Pelvic mass Excessive (unplanned) weight loss Irregular bleeding PV if >40 years Post-coital bleeding Severe depressive symptoms Source: RCOG Guideline No.41 (April 2005) The Examination • Generally a full abdominal and vaginal assessment • Remember the limits of the pelvis and location of the uterus & ovaries • Particular attention to: scars site and degree of tenderness presence, location & size of masses Vaginal Examination • Inspection for; trauma, inflammation, blood, discharge • Speculum; discharge or blood, cervical appearances • Bimanual palpation; cervical excitation size, axis, mobility of uterus adnexal masses or adnexal tenderness • Examination will often be unremarkable or find only general tenderness Key Examination Findings • Atypical discharge - infection • Cervical excitation - pelvic inflammation • Uterus on the ‘citrus scale’ if very large – fibroids/neoplasia/pregnancy if bulky – adenomyosis/infection/pregnancy • Unilateral tenderness is not a specific sign • Generalised tenderness can reflect several processes including IBS • Severe pain on examination – inflammation/necrosis/psychological Investigations • Triple swabs for infection • FBC/CRP for suspected infection • USS; TVS is best for adnexal views scans often negative if no physical changes: masses and uterine pathology will be seen ovarian change; endometrioma/masses; hydrosalpinges • USS will therefore often be negative Objectives • • • • • Revise the anatomy of the female pelvis Identify the common causes of pelvic pain Review key gynaecological causes Discuss the diagnosis of common causes Identify management strategies for 1ry & 2ry care settings Management • • • • • • Will depend on the cause/suspected cause Referral may or may not be required Referral not always to a Gynaecologist Management in 1ry setting is often possible Co-morbidities are common Treatment of physical symptoms can reveal psychological element to causation Management (2) • Generally, treat the most prominent symptom complex first • Even if no other therapeutic manoeuvres are to be tried, try to achieve adequate analgesia NSAIDs e.g. Mefanamic Acid, Ibuprofen Paracetamol/compound analgesia Gabapentin / amitryptiline may work Non-Gynaecological Causes (1) • IBS can be diagnosed on symptoms alone treat with dietary modification antispasmodics • Backache and dyspareunia caused by IBS may also be relieved • IBS and chronic pelvic pain are associated with pain which has a psychological component which may need referral Non-Gynaecological Causes (2) • Pain related to movement/position may be musculo-skeletal try analgesia +/- physiotherapy or other • History of depression or other disorder should be treated along usual pathways • History of old or ongoing abuse will need action with/before trying to treat pain with usual strategies Treating Gynaecological Symptoms • Symptoms of possible infection/PID triple swabs antibiotics (chlamydia & broad spectrum) • Markedly cyclical pain +/- dysmenorrhoea consider OCP (can bi- or tri-cycle) other ovarian suppression • Endometriosis often recurs trial OCP/progestogens (days 6-25 cycle) possible GnRH analogues Refer the ‘Red Flag’ Symptoms • • • • • • • • PR bleeding New bowel symptoms if >50 yrs New pain after menopause Pelvic mass Excessive (unplanned) weight loss Irregular bleeding PV if >40 years Post-coital bleeding Severe depressive symptoms Non-Gynaecological Referral • Suspected adhesions may be referred to general surgery • Non-resolving predominantly GI symptoms may need Gastroenterology • Urological symptoms revealed or predominating need Urology (or Urogynae.) • Psychiatric symptoms as required When to Refer to Gynaecology • When the cause or nature of pain cannot be defined • When first-line gynaecological management has been unsuccessful • Where management of other systems (GI/Urological etc.) has been unsuccessful • When specific features are present in history/examination or investigation When to Refer to Gynaecology (2) • Fertility problems/issues occurring concurrently with pain • Very severe or recurrent symptoms • Abnormal findings on investigations e.g. USS evidence of ovarian cysts hydrosalpinx • No apparent pathology Summary Points • Pelvic pain is common in women between menarche and menopause • It may be acute or chronic • Pain is often not gynaecological in origin • More than one cause may be present including psychological/abuse factors • Initial treatment of non- ‘red flag’ symptoms in general practice will often succeed • Ovarian suppression/hormonal manipulation underlies much Gynae management