Chronic pelvic pain

Published on 09/03/2015 by admin

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Last modified 09/03/2015

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Chapter 16 Chronic pelvic pain

Michael Flynn

Pelvic pain is the commonest indication for laparoscopy. This is pain present for at least 6 months severe enough to interfere with normal daily activities.

Physiology and innervation

Pain

• Somatic innervation from the vulva, perineum and lower vagina is via the pudendal nerve (S2–S4).
• Visceral innervation from the uterus, tubes, ovaries and visceral peritoneum is via the autonomic nervous system (T10–L1).
• The assessment of pelvic pain requires a detailed pain history and system review.

Origin

• gynaecological
• gastrointestinal
• urological
• musculoskeletal
• neurological

Viscera

• Viscera are not sensitive to thermal and tactile sensation.
• Pain is poorly localised.
• Pain is referred from the overlying peritoneum via dermatomes of the same nerve root.

Stimuli that produce pain

• distension/contraction of an organ
• stretching of organ capsule
• irritation of the parietal peritoneum
• ischaemic tissues
• inflammation, neoplasia or fibrosis stimulating nerves

Examination

• General examination: look for signs of malignancy, lymphadenopathy, oedema.
• Abdominal palpation: feel for masses, ascites, organomegaly.
• Vaginal speculum examination:

• check for discharge
• cervical pathology
• bimanual examination: check uterine size and position, adnexal pathology, cervical motion pain, pouch of Douglas
• uterosacral ligament nodularity, thickening or tenderness
• rectal examination for masses
• lumbosacral and hip joints

• Assess anatomical locations of tenderness and correlate these with areas of pain.

Gynaecological causes of pelvic pain

• cyclical: dysmenorrhoea, ovulation pain, endometriosis, adenomyosis (some aetiologies of pelvic pain can be exacerbated during menses (irritable bowel syndrome and interstitial cystitis))
• chronic pelvic inflammatory disease
• polycystic ovarian syndrome
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