Pelvic Pain

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[edit] Pelvic Pain

Sharon K. Knight

Gary H. Lipscomb

Frank W. Ling

Pelvic pain is a common complaint among women seeking medical care. Pain that persists for longer than 6 months' duration is defined as chronic. After a prolonged period, patients often develop characteristics consistent with a chronic pain syndrome, including pain refractory to medical management or out of proportion to identified pathology; impaired physical function, including recreational, work, or sexual activity; signs of depression, such as sleep disturbance; or a change in family role.

The diagnostic and therapeutic approach to a patient with chronic pain is different than that for a patient with acute symptoms. Although rarely life threatening, chronic pelvic pain is potentially debilitating and can be a source of frustration for both patient and physician. A multidisciplinary or integrated approach is most appropriate.

[edit] EPIDEMIOLOGY AND PATHOPHYSIOLOGY

The prevalence of chronic pelvic pain is uncertain because of difficulties in obtaining such information, but an estimated 40% of women seeking primary care and 15% of all reproductive-age women have complaints of chronic pelvic pain. More than 50% of women with pelvic pain report not knowing the etiology of their pain. Pelvic pain is a frequent indication for gynecologic surgery, accounting for 12% of hysterectomies and up to 40% of laparoscopies. Thus this diagnosis may have a significant social and economic impact.

The pathophysiology of chronic pain is not completely understood, and several theories have been proposed. In the traditional somatic model of pain perception, tissue damage at the periphery causes stimulation of pain receptors, resulting in the perception of pain. This model explains acute pain well but is not appropriate for chronic pain. The biopsychosocial model postulates that a complex interaction of somatic symptoms with various psychosocial factors creates an outcome such as chronic pain. Potential contributing factors include the patient's response to pain, psychologic diagnoses and mood states, family patterns of pain response, and personal history of physical or sexual abuse.

Recent research has implicated a neurologic explanation for chronic pain. An afferent stimulus, such as pain, may cause permanent alterations to neurologic pathways at the level of the spinal cord, leading to altered responses to future stimuli that result in hyperalgesia, decreased pain threshold, or altered muscle response. Clinically these changes may be associated with chronic pain, recurrence of pain at previous sites of injury, resistance to therapy, or muscle spasm.

[edit] PATIENT EVALUATION

[edit] History

A complete history is essential for the proper evaluation of chronic pelvic pain. Initial questions should concern the basic qualities of the pain, including location, character, duration, frequency, patterns of radiation, and alleviating or aggravating factors. The physician notes the chronology of pain with changes over time and any relationship to menstrual cycle, sexual activity, bladder or bowel function, and emotional state. An extensive medical, gynecologic, obstetric, surgical, social, and family history includes previous diagnoses such as pelvic inflammatory disease (PID). The pain's effect on the patient's lifestyle and personal interactions should be determined; a pain or symptom diary may be helpful.

Box 37-1 lists the differential diagnoses of chronic pelvic pain using the classic gynecologic approach of dividing the pain into cyclic and noncyclic categories. The two lists are not mutually exclusive because conditions that generally produce cyclic pain may present with noncyclic pain, and vice versa. If the pain is cyclic, the physician obtains a detailed menstrual history, including age at menarche, quantification of amount of bleeding and interval, and regularity and number of days of bleeding. The physician should determine if the pain has been present since menarche or is a new phenomenon. A positive gastrointestinal, urologic, or musculoskeletal review of systems may provide insight into the etiology of pain or help guide the workup or management.

[edit] Physical Examination

A detailed and systematic physical examination should first note the patient's gait and sitting posture on the table. Poor posture, standing with weight mainly on one leg, or sitting primarily on one side may indicate a musculoskeletal cause.

Before the abdominal examination the patient should be asked to indicate the site of the pain with one finger. Gentle abdominal palpation begins at a site distant from the primary location of the pain while checking for masses or areas of tenderness. If an area of tenderness is located, the patient should be questioned about its similarity to the primary pain. Superficial palpation is critical to identifying musculoskeletal pain. During voluntary contraction of the abdominal musculature the patient is asked to place her chin on her chest and lift her legs slightly off the table. Pain that increases is typically musculoskeletal in origin, whereas pain that decreases is usually deep or visceral in origin; no change is equivocal.

Neurologic examination of the lower extremities may reveal abnormal reflexes, muscle weakness, or sensory findings. These may indicate a herniated disk or other neurologic cause, and more extensive neurologic evaluation may be necessary.

The pelvic examination should begin with visual inspection of the external genitalia. Gentle palpation with a moistened cotton-tip swab at the introitus and hymenal region may aid in identifying vulvar vestibulitis, a variant of pelvic pain that often presents as new-onset dyspareunia. A systematic one-handed (monomanual) pelvic examination should precede the traditional bimanual examination to help differentiate pelvic pain from abdominal wall pain. Initially the anterior vaginal wall should be palpated to assess for tenderness at the bladder base or urethra. The physician should also attempt to express discharge from the urethra. The examining fingers should then be turned posteriorly to palpate the levator ani muscles at approximately the 5 and 7 o'clock positions. Further palpation lateral and anterior to this area as well as cephalad and slightly lateral to the ischial spine aids in evaluation of the obturator internus and piriformis muscles, respectively. Systematic examination of these muscle groups aids in the diagnosis of pelvic floor muscle spasm, which may be a primary source of pain or a contributing factor to pain caused by other etiologies. The patient's ability to perform a voluntary pelvic floor contraction should be evaluated.

Pain caused by palpation of the cervix and adnexal regions or the presence of cervical motion tenderness should be assessed monomanually, followed by the traditional bimanual examination. Uterine size, mobility, and tenderness and the reproducibility of the primary complaint by uterine palpation provide important information if hysterectomy is subsequently considered. Similar information should be obtained regarding both adnexa. Rectovaginal examination is necessary to assess the uterosacral ligaments adequately and may delineate findings not obtained from vaginal examination alone. Visual inspection with a speculum should be done at the end so that other aspects are not altered by potential discomfort.

[edit] CYCLIC PAIN

An estimated 30% to 50% of reproductive-age women have cyclic pelvic pain, 10% to 15% of whom have symptoms severe enough to interfere with normal activities. Although the cyclic nature of pain implies a causal relationship with the female reproductive system, care must be taken to differentiate true menstrual-related symptoms from symptoms aggravated by body changes occurring during the menstrual cycle. The physician must also differentiate cyclic pain unrelated to the menstrual cycle from true dysmenorrhea.

Dysmenorrhea is broadly divided into two categories: primary and secondary. Secondary dysmenorrhea has a readily identifiable cause (e.g., fibroids, endometriosis), whereas primary dysmenorrhea has no identifiable cause.

[edit] Primary Dysmenorrhea

Most menstrual women experience some degree of primary dysmenorrhea at some time in their lives. The pain is characteristically sharp or cramplike and generally occurs in the first 3 days of menstruation. Pain is generally suprapubic but may radiate to the back, inner thighs, or deep pelvis. Nausea, with or without vomiting, and diarrhea may also occur. Dyspareunia, even during menstruation, is uncommon and should suggest other pathology. The diagnosis of primary dysmenorrhea is one of exclusion (i.e., no other abnormalities should suggest the cause of dysmenorrhea).

Patients with secondary dysmenorrhea often have other symptoms in addition to cyclic pain that suggest the underlying etiology. Heavy menstrual flow with dysmenorrhea suggests a diagnosis of uterine leiomyoma, adenomyosis, or endometrial polyps. Likewise, cyclic pain in a patient with primary amenorrhea suggests outflow obstruction. Gastrointestinal, urinary, or musculoskeletal complaints should raise the possibility of a nongynecologic process (see later discussions).

Laboratory studies are of limited use in the evaluation of patients with dysmenorrhea. Blood counts to assess blood loss in patients with excessive bleeding and sedimentation rates to identify a chronic inflammatory process are occasionally helpful. Ultrasound and other radiologic modalities rarely provide additional helpful information except when the physical examination is inadequate or is suspicious but not conclusive of a particular condition. Imaging techniques may even further confuse the diagnosis by identifying a small physiologic ovarian cyst or other benign process, which may result in additional unnecessary tests and, occasionally, unnecessary surgery.

Because the underlying pathophysiology in patients with primary dysmenorrhea is related to prostaglandin synthesis, the mainstay of treatment is nonsteroidal antiinflammatory drugs (NSAIDs). Although the chemical structures of the NSAIDs are similar, patients who have poor or partial response to one NSAID may respond well to a different agent.

Hormonal agents are frequently prescribed for dysmenorrhea. Oral contraceptives (OCs) are widely used for relief of primary dysmenorrhea in patients not desiring pregnancy. Since none appears to be superior to the others, physicians should use the OCs with which they are most familiar. Although OCs are generally prescribed on a 28-day cycle (21 days of hormone followed by 7 hormone-free days), they can be used continuously (no hormone-free days) in an attempt to produce amenorrhea if patients still have dysmenorrhea during withdrawal bleeding. Unfortunately, breakthrough bleeding is common and often limits the use of this regimen. Depo-Provera may also be used to induce hypomenorrhea or amenorrhea in these patients, but only 50% can be expected to become totally amenorrheic in the first year of use. Likewise, gonadotropin-releasing hormone (GnRH) agonists have been used to obtain amenorrhea, but their use is limited by the high cost of therapy and associated bone loss with long-term use. GnRH agonists for dysmenorrhea should probably be reserved for therapy of symptomatic endometriosis.

Although all these treatment modalities for primary dysmenorrhea may also be used for secondary dysmenorrhea, results are less satisfactory. Only specific therapy for the cause of secondary dysmenorrhea provides satisfactory results.

[edit] Secondary Dysmenorrhea

Endometriosis is one of the most common diagnoses for women with complaints of chronic pelvic pain. The classic symptoms associated with this condition include a longstanding history of dysmenorrhea, deep dyspareunia, and infertility. The dysmenorrhea often becomes progressively worse, lasts throughout menses, and begins premenstrually. Many women with endometriosis are asymptomatic. In women undergoing laparoscopic sterilization, one study found an equal incidence of endometriosis among those with and those without chronic pain.^[1] Also, severity of pain correlates inconsistently with degree of endometriosis and may have an inverse relationship. Physical findings that suggest endometriosis include a fixed, poorly mobile uterus and tenderness, induration, or nodularity of uterosacral ligaments.

Adenomyosis is diagnosed histologically by the finding of endometrial glands and stroma infiltrating myometrial tissue. When symptomatic, adenomyosis typically presents as dysmenorrhea, menorrhagia, and central deep dyspareunia; it is a common incidental finding after hysterectomy. Pelvic examination may reveal a mildly enlarged, tender, globular, symmetric uterus. Similar symptoms may be associated with uterine leiomyoma; however, examination may differ with a greatly enlarged or asymmetrically enlarged uterus.

Pelvic congestion is another proposed etiology of chronic pain, with overdistention of pelvic vasculature causing pelvic discomfort. Clinical presentation includes secondary dysmenorrhea, which may worsen as the day progresses and with prolonged standing, menorrhagia, dyspareunia, and back pain. Varicosities may be visualized at surgery. Ultrasound and venography are suggested diagnostic tools.

[edit] Ovarian Remnant Syndrome

Ovarian remnant syndrome^[2][3] has been described in young women who have underdone surgical removal of both ovaries. This syndrome may occur when residual ovary is unintentionally left at the time of surgery, typically when the procedure required extensive or difficult dissection such as with endometriosis or pelvic inflammatory disease. The primary symptom is cyclic or constant chronic pelvic pain with or without a pelvic mass. Dyspareunia, urinary symptoms secondary to urethral obstruction, and dyschezia have been described. The patient may also report lack of menopausal symptoms. Examination may aid in the identification of a mass. FSH and LH levels are typically in a premenopausal range. Surgical excision of all functional ovarian tissue is the treatment of choice.

[edit] NONCYCLIC PAIN

[edit] Gynecologic Etiologies

In patients with a history of PID or pelvic surgery, adhesions are a potential source of chronic pain. Their role, however, is controversial; patients with chronic pelvic pain and pain-free controls have a comparable incidence of adhesions. Adhesions may be suspected with decreased mobility of pelvic organs or a sense of thickening, but adequate evaluation of adhesive disease severity by physical examination is difficult.

Pelvic organ prolapse may be associated with chronic pain. Patients with prolapse often report a sensation of pelvic pressure or heaviness ("something falling out") that increases as the day progresses and with standing. Discomfort may limit the patient's ability to perform normal daily activities and is often relieved by the supine position. Pelvic examination should include an assessment of the position of the cervix or vaginal vault as well as the anterior and posterior vagina during Valsalva's maneuver. Placement of a pessary may be a therapeutic as well as a diagnostic measure to determine if the pain improves when the prolapse is reduced. Surgical therapy may also be corrective.

[edit] Nongynecologic Etiologies

[edit] Musculoskeletal Causes.

The musculoskeletal system is the most common source of nongynecologic chronic pelvic pain. Unfortunately, the musculoskeletal evaluation is also the most frequently overlooked component in the patient evaluation. Factors that suggest a musculoskeletal source of chronic pelvic pain include poor posture, scoliosis, unilateral standing habits, marked lumbar lordosis, leg length discrepancy, abnormal gait, abdominal wall trigger points or tenderness, history of low back trauma, and a previous, normal laparoscopy. A thorough examination is especially important in diagnosing a potential musculoskeletal cause.

Slocumb^[4] suggested that hypersensitive areas of the abdominal wall (trigger points) are the most common cause of pelvic pain. These trigger points are hyperirritable areas that are tender when compressed and may generate referred pain and tenderness. Trigger points typically develop after some muscle strain and can often be found within a taut band of skeletal muscle. Trigger points can respond dramatically to specific therapy. In his classic study, Slocumb^[4] used trigger point injections of local anesthetic agents to treat 122 patients with chronic pelvic pain. More than 50% of patients became pain free, only 13 had surgery, and all those with only abdominal wall injections had a successful response. Those with vaginal trigger points had an 84.6% response rate to injections.

In the patient with demonstrable trigger points, injection with local anesthetic may be a useful therapeutic and diagnostic aid. A 1-inch to 1½-inch, 22-gauge needle is recommended for superficial musculature. Although smaller needles cause less discomfort on skin penetration, they are less able to disrupt a trigger point mechanically. Smaller needles may also be too flexible, sliding around taut muscle bands and masking tactile clues. Trigger points are injected using aseptic technique. The patient may feel a muscle twitch or flash of referred pain during insertion. The palpating finger should maintain tension on the skin as various injection tracts are made. If a trigger point is not identified directly, the injection may be less effective but still useful diagnostically. Successful injection results in loss of tenderness and, if originally present, relaxation of the tight muscle band.

Although any local anesthetic may be used for trigger point injections, bupivacaine 0.25% is our agent of choice. Volumes of 10 ml or less are usually adequate to produce a clear diagnostic test. Interestingly, pain relief often extends far beyond the drug's normal duration of action and is frequently longer with subsequent injections, which may indicate recovery of normal muscle and nerve function. Relief of pain after trigger point injection shows the patient her pain is at least partially musculoskeletal and not necessarily from gynecologic causes. Trigger point injections can be diagnostic and also therapeutic, either alone or as a series of injections.^[4] Trigger point injections should be viewed as helpful adjuncts in an overall management plan.

Levator ani and pelvic floor muscle spasms are other frequently overlooked causes of pelvic pain. Careful monomanual examination may reveal evidence of this syndrome. Patients with other sources of pelvic pain in turn may develop spasm of pelvic floor musculature as an additional source of pain.

Physical therapy, when included in a multidisciplinary approach, has been very successful in managing patients with chronic pelvic pain due to musculoskeletal causes. Referral to a physical therapist for further evaluation or more intensive physical therapy instruction is frequently helpful. If referral is unavailable or not practical, NSAIDs, muscle relaxants, and heat application may be effective. Initial use of these agents on a scheduled rather than an as-needed basis for the first 1 to 2 weeks of treatment is recommended. These medications may also be used in conjunction with physical therapy. Newer nerve stimulation therapies have shown promise as potential therapeutic options.

[edit] Gastrointestinal Causes.

Up to 60% of patients referred for chronic pelvic pain may have gastrointestinal (GI) symptoms, particularly irritable bowel syndrome. Because of the visceral innervation of the bowel, it is often difficult to differentiate lower abdominal pain of gynecologic origin from that of GI origin. A careful history, especially bowel habits, may reveal details that suggest a GI etiology. Abdominal pain associated with irritable bowel syndrome characteristically improves after a bowel movement and is often worse with eating. Other common symptoms include a sense of rectal fullness or incomplete rectal evacuation, passage of pelletlike stools, and exacerbation of pain during stress. Although dyspareunia is frequently gynecologic in origin, many women with an irritable bowel also have dyspareunia.

The physical examination should always include a rectal examination and testing for occult blood. Tenderness localized over the sigmoid colon in the absence of inflammatory signs is frequently present in patients with irritable bowel syndrome, whereas a tender mass in the left lower quadrant in a febrile patient suggests diverticulitis. No known detectable structural or biochemical abnormality is associated with irritable bowel syndrome, but activation of hypersensitive receptors in the bowel wall due to physiologic distention or contraction may be responsible for the pain. The conscious threshold for perception of visceral sensation in the form of pain may be altered in patients with irritable bowel syndrome. Many women have coexisting psychopathology, such as somatization disorders, anxiety disorders, depression, and other psychologic syndromes.

Current medical treatment for irritable bowel syndrome is generally unsatisfactory; 30% to 70% of patients have continued symptoms even after long-term treatment. Treatment consists primarily of reassurance, education, stress reduction, bulk-forming agents, anxiolytics, and low-dose tricyclic antidepressants; bulk formers are the most effective therapy. Anticholinergics are generally ineffective. Multidisciplinary pain management is often appropriate for these patients, as for any patient with chronic pelvic pain.

[edit] Urinary Tract Causes.

Because the urinary and gynecologic tracts share a complex neurologic system, pain originating from the urinary tract may be difficult to differentiate from gynecologic pain. Thus questions regarding urinary frequency, urgency, nocturia, dysuria, hematuria, incontinence, voiding difficulty, and previous urologic workup are important, particularly if the gynecologic evaluation is inconclusive. Potential urinary tract causes of chronic pelvic pain include interstitial cystitis, urethral syndrome, urethral diverticulum, urolithiasis of the bladder or lower ureter, radiation cystitis, urethral caruncle, and neoplasm. Initial tests should include a urinalysis with culture and sensitivity to rule out microbiologic sources. A 24-hour voiding diary may provide more accurate assessment of the patient's symptoms.

Generally, cystourethroscopy should be performed in patients with irritative voiding symptoms (urgency, frequency) or hematuria. This procedure allows evaluation of the urethra and the bladder mucosa for evidence of chronic infection, bladder stones, tumors, or diverticula. These diagnoses must be ruled out before the chronic pain syndromes, interstitial cystitis and urethral syndrome, are considered.

Interstitial cystitis is a chronic idiopathic bladder syndrome characterized by irritative voiding symptoms, no objective evidence for another disease process (diagnosis of exclusion), and a characteristic cystoscopic appearance. Significant findings at the time of cystoscopy include the classic Hunner's ulcer (velvety red patch, present in only 6% to 8% of cases), linear submucosal hemorrhages (glomerulations), and a reduced bladder capacity under anesthesia. Prevalence estimates range from 10 to 500/100,000. The majority of patients are Caucasian females between the ages of 40 and 48 years. Examination may reveal tenderness at the bladder base, urethra, or suprapubic region. However, no findings are pathognomonic. When this diagnosis is suspected by history and office evaluation, a double fill cystoscopy may be helpful. This involves passive hydrodistention of the bladder under anesthesia. After 2 to 5 minutes, the bladder is drained and once again hydrodistention is performed to maximum capacity. The bladder is then inspected for the characteristic findings previously discussed. Hydrodistention may be therapeutic in up to 60% of patients. Proposed etiologies and attempted therapies are numerous. Therapies targeted at the level of the glycosaminoglycan layer have been used most frequently. This layer forms a protective "blood-urine" barrier at the bladder mucosa, which prevents adherence of bacteria and crystals, as well as transfer of solutes into the urine. Dimethylsulfoxide (DMSO) is an intravesical therapy targeted at this level, with success rates ranging from 34% to 40%. Pentosanpolysulfate (elmiron) is an oral heparin analog also targeted to this level. Initial success with elmiron was promising; however, long-term success has been disappointing, ranging from 6% to 19%. Currently neuromodulation-based therapies are under study and may represent the direction of future therapy.

Urethral syndrome is also a diagnosis of exclusion. Although good epidemiologic data are lacking, it is thought primarily to affect reproductive-age females. Dysuria, voiding dysfunction, and particularly, postcoital voiding dysfunction are common complaints in addition to irritative voiding symptoms. Multiple etiologies have been proposed, including chronic urethritis with inflammation of the urethral glands, hypoestrogenism, and urethral spasm. Cystourethroscopy and urodynamic testing may contribute to the diagnosis. Therapies are aimed at these proposed causes and include suppressive antibiotic therapy, urethral dilation, local estrogen therapy, skeletal muscle relaxants, α-blockers, biofeedback, and nerve stimulation therapy.

Because these patients with interstitial cystitis or urethral syndrome present a confusing or changing clinical picture, consultation with a urologist or urogynecologist may be extremely helpful.

[edit] History of Abuse.

Multiple studies have attempted to evaluate the relationship between chronic pelvic pain and sexual or physical abuse. It is difficult to compare these results because of differences in study design and definition of abuse. Most studies, however, show an overall increased rate of abuse among women with chronic pelvic pain compared with pain-free controls. One study reported that women with chronic pelvic pain had significantly higher rates of previous sexual abuse compared with pain-free subjects or women with chronic pain at other sites.^[5] In general, abuse prevalence rates are approximately 50% in chronic pelvic pain patients vs. 20% in control groups.

Evaluation of a patient with chronic pelvic pain should include a physical and sexual abuse history. Even if the patient is unable to discuss such issues at the first interview, disclosure may take place in the future. Knowledge of an abuse history enables the physician to guide the patient to appropriate counseling or support services.

[edit] Psychiatric Issues.

Depression coexists with chronic pain in up to 50% of patients. The cause-and-effect relationship of these conditions has been debated; some even suggest that these diagnoses should be considered a single entity. Regardless, it is important to recognize and treat depression when present. Such therapy, although not curative, is an important adjunct to other therapies. After treatment for depression, the patient may feel better overall and respond better to other attempted therapies.

Multiple pharmacologic choices for therapy are available. Selective serotonin reuptake inhibitors (SSRIs) have gained popularity because of their favorable side effect profile. Antidepressants such as imipramine (a tricyclic antidepressant) and amitriptyline (a MAO inhibitor), however, have the added effect of pain relief through a neurologic mechanism. One common side effect of many antidepressant medications is sexual dysfunction, which may already be an issue for many women with chronic pelvic pain.

Psychiatric consultation should be considered if the patient has a history of inadequately treated depression, other psychiatric conditions, suicidal ideation, or failure of single-drug treatment regimens. A common psychiatric manifestation in patients with chronic pelvic pain is somatization, in which emotional problems are expressed as physical symptoms^[6] (see Chapter 50 ). These symptoms may cause significant distress but are not fully explained by clinical findings. Principles of management of somatizing patients are based on their ongoing needs for sanctioned caregiving and include the following:

• Schedule set amounts of time and intervals for physician visits. Do not vary time of visits or make contact contingent on symptoms.
  
• Accept the patient's need to be considered ill, realizing that some patients may be threatened by the prospect of complete cure or relief.
  
• Ask open-ended questions to allow the patient to structure the discussion.
  
• Minimize secondary gain (e.g., time off work, disability pay).
  
• Recognize and control personal reactions (frustration, anger) toward patients.
  
• Remain alert for intercurrent illness.
  

[edit] MANAGEMENT

Nonsurgical treatments for potential etiologies of chronic pelvic pain are discussed earlier (Box 37-2); this section focuses on surgical options. Surgery is often a logical extension of a thorough diagnostic and therapeutic management scheme in patients who have chronic pelvic pain. For the nonsurgically trained physician, this requires referral to a specialist.

[edit] Diagnostic Laparoscopy

The traditional gynecologic approach to chronic pelvic pain has included diagnostic laparoscopy for all patients. The need for this procedure is debated. A prospective randomized study showed no benefit of laparoscopy in diagnosis or success of therapy compared with a multidisciplinary approach that did not include laparoscopy.^[7] Several studies have shown similar rates of pathology (e.g., adhesive disease, endometriosis) in patients with chronic pelvic pain and pain-free patients undergoing laparoscopy for other indications. Therefore the decision to proceed with diagnostic laparoscopy is the physician's choice. Since approximately 30% of patients with chronic pelvic pain will have normal findings at laparoscopy, a plan for further management of these patients must be developed.

[edit] Adhesiolysis

Surgical lysis of adhesions either through the laparoscope or by laparotomy appears to be the logical therapy for patients with documented adhesive disease from PID. Unfortunately, no evidence indicates that adhesions are always a cause of such pelvic pain. Only a small percentage of patients with chronic pelvic pain have documented adhesive disease, and as noted, studies show a comparable incidence of adhesions in patients and controls. Success rates range from almost no success (except in subsets of patients with significant bowel involvement) to 65% complete or partial improvement. Patients considering adhesiolysis should be informed that (1) adhesions are present but may not be the cause of pain; (2) they may not obtain relief with the procedure, or the pain may become worse; and (3) adhesions may re-form and result in further pain. The patient should also know the risks associated with the surgery.

[edit] Nerve Ablation Procedures

Uterosacral nerve ablation has a limited role in the treatment of chronic pelvic pain and is only indicated as a second line of therapy for dysmenorrhea. The purpose is transection of afferent fibers within the uterosacral ligaments. Assessment of pain relief with injection of local anesthetic at the uterosacral ligaments should be performed before ablation. The procedure can potentially be performed at laparoscopy if no other pathology is found. Long-term complications are not defined.

Presacral neurectomy has been proposed as a potential therapy for dysmenorrhea, dyspareunia, chronic central pelvic pain, and sacral backache. The primary indication is unsuccessful medical management of primary dysmenorrhea; success rates are 70% to 80%.

[edit] Uterine Suspension

Uterine retrodisplacement may be associated with pelvic pain. Since up to one third of all women may have a retroverted uterus, this finding in itself is not an indication for uterine suspension. Typical symptoms include pelvic pressure, low back pain, and deep dyspareunia. If pain related to retrodisplacement is suspected, a trial of therapy with a Smith-Hodge pessary to antevert the uterus should be undertaken. If pain is relieved, a uterine suspension is a potential therapeutic option. In a patient who no longer desires fertility, vaginal hysterectomy is another option.

[edit] Ovarian Remnant Removal

After surgical removal of the uterus and ovaries, cyclic pain from an ovarian remnant may develop (ovarian remnant syndrome). This typically occurs after oophorectomy during difficult surgeries for endometriosis or adhesive disease. In younger patients this diagnosis may be suspected if follicle-stimulating hormone levels are not elevated. Radiologic procedures (e.g., computed tomography scan, ultrasound) may be helpful in making the diagnosis. Patients may obtain relief with surgical removal of the remnant, but the procedure may be technically challenging.

[edit] Hysterectomy

Chronic pelvic pain is the third most common indication for hysterectomy and accounts for approximately 15% of all hysterectomies performed. Hysterectomy should be reserved for patients who have failed conservative therapy. Although no randomized prospective studies have assessed success rates of hysterectomy for chronic pelvic pain, one study^[8] reported a 75% cure rate at 6 months in women who had a hysterectomy for central pelvic pain.

[edit] Integrated Approach

A multidisciplinary approach that includes gynecology, gastroenterology, urology/urogynecology, anesthesiology, psychiatry, and physiotherapy in a single geographic site, such as a pain clinic, is ideal for management of patients with chronic pelvic pain. Multiple studies have noted increased success rates with such an approach. If these resources are not available, an integrated approach using appropriate consultants is acceptable. Certain aspects of an integrated approach, such as psychiatric consultation, are more likely to be accepted by patients when introduced at an early time and as a routine part of management.^[9][10]

[edit] REFERENCES