Introduction
As pain arising from the pelvis is a subjective perception rather than an objective sensation, accurately determining the etiology is often difficult.
- Dysmenorrhea (uterine pain associated with menses) is the most common gynecologic pain complaint.
Evaluation strategies
- The history provides a description of the nature, intensity, and distribution of the pain. However, imprecise localization is typical with intra-abdominal processes.
- Physical examination includes a comprehensive gynecologic examination. Specific attention should be paid to trying to reproduce the pain symptoms.
- Chlamydia/gonorrhea cervical cultures and urinalysis with culture are frequently helpful.
- Ultrasonography and other imaging studies may be indicated.
- Specialized diagnostic studies based on the presumptive diagnosis may require consultation with other specialists in anesthesiology, orthopedics, neurology, or gastroenterology.
Acute Pelvic Pain
Potentially catastrophic causes (ruptured appendix) require timely intervention to quickly diagnose and treat.
Gynecologic Causes
Three main categories: rupture, infection, and torsion.
• Ectopic pregnancy –
In all women of reproductive age, the first priority in evaluating acute pelvic pain is to rule out the possibility of a ruptured ectopic pregnancy.
• Acute Pelvic Inflammatory Disease (PID) –
It is an ascending bacterial infection that often presents with high fever, severe pelvic pain, nausea, and evidence of cervical motion tenderness in sexually active women.
• Rupture of an ovarian cyst –
Intra-abdominal rupture of a follicular cyst, corpus luteum, or endometrioma is a common cause of acute pelvic pain. The pain may be severe enough to cause syncope. The condition is usually self-limiting with limited intraperitoneal bleeding.
• Adnexal Torsion –
It is seen most commonly in adolescent or reproductive-age women. By twisting on its vascular pedicle, any adnexal mass (ovarian dermoid, hydatid of Morgagni) can cause severe pain by suddenly compromising its blood supply. The pain will frequently wax and wane with associated nausea and vomiting. Threatened, inevitable, or incomplete miscarriages are generally accompanied by midline pelvic pain, usually of a crampy, intermittent nature.
• Degenerating fibroids or ovarian tumors –
It may cause localized sharp or aching pain.
Non-gynecologic causes –
- Appendicitis is the most common acute surgical condition of the abdomen, occurring in all age groups. Classically, the pain is initially diffuse and centered in the umbilical area but, after several hours, localizes to the right lower quadrant (McBurney point). It is often accompanied by low-grade fever, anorexia, and leukocytosis.
- Diverticulitis occurs most frequently in older women. It is characterized by left-sided pelvic pain, bloody diarrhea, fever, and leukocytosis.
- Urinary tract disorders (cystitis, pyelonephritis, renal calculi) can cause acute or referred suprapubic pain, pressure, and/or dysuria.
- Mesenteric lymphadenitis most often follows an upper respiratory infection in young girls. The pain is usually more diffuse and less severe than in appendicitis.
Chronic Pelvic Pain –
Most women, at some time in their lives, experience pelvic pain. When the condition persists for longer than 3–6 months, it is considered chronic.
- Accounts for 10% of all visits to gynecologists and 20–30% of laparoscopies.
- Frequently there is little correlation between the objective severity of abdominal disease and the amount of perceived pain: a third of women who undergo laparoscopy for chronic pelvic pain will have no identifiable cause.
- Ten to twenty percent of hysterectomies are performed for chronic pelvic pain. Postoperatively, 75% of women will experience significant improvement in their symptoms.
- Patients and physicians may both become frustrated because the condition is difficult to cure or manage adequately.
Gynecologic Causes –
- Dysmenorrhea is the most common etiology. Primary dysmenorrhea is not associated with pelvic pathology and is thought to be due to excessive prostaglandin production by the uterus. Secondary dysmenorrhea is usually due to acquired conditions (such as endometriosis). Oral contraceptives and non-steroidal anti-inflammatory drugs are helpful.
- Endometriosis has a spectrum of pain that ranges from dysmenorrhea to severe, intractable, continuous pain which may be disabling. The severity of pain often does not correlate with the degree of pelvic pathology.
- Adenomyosis is a common condition that is usually only confirmed by hysterectomy. Most frequently, women are asymptomatic and this is an incidental pathology finding. An enlarged, boggy uterus that is mildly tender to bimanual palpation is suggestive of the diagnosis.
- Fibroids are the most frequent (benign) tumors found in the female pelvis. They may cause pain by either putting pressure on adjacent organs or undergoing degeneration.
- Ovarian remnant syndrome is characterized by persistent pelvic pain after removal of both adnexa. In such cases, a cystic portion of the ovary is usually identified as the source.
- Genital prolapse may lead to complaints of heaviness, pressure, a dropping sensation, or pelvic aching.
- Chronic PID is usually as a result of persistent hydrosalpinx, Tubo ovarian cyst, or pelvic adhesions.
Treatment depends on the suspected etiology, but non-surgical options may include a discussion of nutritional supplementation, physical therapy modalities, acupuncture/acupressure, or antidepressants.
Non-gynecologic Causes –
- Gastrointestinal disturbances such as inflammatory bowel disease.
- Musculoskeletal problems such as muscle strain or disc herniation.
- Interstitial cystitis (chronic inflammatory condition of the bladder).
- Somatoform disorders are characterized by physical pain and symptoms that mimic disease but are related to psychological factors (domestic discord, sexual abuse). Patients do not have conscious control over their symptoms and are not intentionally trying to confuse the doctor or complicate the process of diagnosis. Women often have long histories of unsuccessful medical or surgical treatments with multiple different physicians.