Pelvic pain, endometriosis and minimal-access surgery

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6 Pelvic pain, endometriosis and minimal-access surgery

Pelvic pain

Pelvic pain is a common reason for referral to a gynaecologist. The origin of the pain may be gynaecological, but non-gynaecological causes such as irritable bowel syndrome (IBS) and constipation can have similar clinical features, including exacerbations in the premenstrual period or during menses. Diagnosis depends on a detailed genitourinary and gastrointestinal as well as gynaecological history. Often no specific cause is identified.

Clinical features

Ectopic pregnancy is suggested by pain associated with dizziness, fainting, shoulder pain or collapse.

Ovarian cyst torsion presents with sudden onset of unilateral pain, which is colic-like or twisting and severe. Vomiting is usual and tachycardia, hypotension and pyrexia are found on examination. The pain may be intermittent if torsion is incomplete.

Ovarian cyst rupture presents with constant pain and signs of peritonism, but systemic features are less common.

A full gynaecological and obstetric history is important to make an accurate diagnosis. The diagnosis will often be made by paying particular attention to the nature, timing and associated features of the pain:

• What is the nature, site, type and onset of the pain? Is it constant or intermittent? Is it colic-like?

• What are the exacerbating and relieving factors?

• How does it relate to periods? A 3-month symptom diary is helpful in relating the pain to the hormonal cycle.

• How does the pain vary with defecation or micturition? Are there associated factors such as nausea, vomiting, bloating or malaise?

• A thorough urinary and bowel history is always necessary.

• Is there any significant previous surgical history?

• Is there dyspareunia?

• Is there a history of sexually transmitted infection?

• Is there a history of fertility problems?

• Have there been previous pregnancy complications, such as ectopic, evacuation of retained products of conception or termination of pregnancy?

• Is the woman currently in a relationship? Are there any relationship or sexual problems?

• Is there a history of sexual abuse in childhood or adult life?

Examination

Inspection of the abdomen will identify scars from previous surgery. Abdominal palpation may reveal tenderness, peritonism, masses, renal-angle tenderness or a loaded colon. Sims speculum may show abnormal bleeding or discharge. Bimanual examination features may include cervical motion tenderness (‘cervical excitation’), adnexal tenderness, pelvic masses, uterine immobility or uterosacral nodules.

Investigations

All women with acute pelvic pain must have a pregnancy test. Other investigations should be performed according to the history and examination findings and generally include:

• Endocervical swabs and high vaginal swabs for Chlamydia, gonorrhoea and Trichomonas

• Midstream urine

• Pelvic ultrasound to exclude ovarian cysts, tubal masses or uterine pathology

• Renal tract ultrasound and/or intravenous urogram if a renal cause cannot be excluded.

Laparoscopy is the gold-standard investigation for gynaecological pathology and may reveal adhesions, endometriosis or evidence of PID (dilated, oedematous, tortuous or scarred tubes, with fine filmy adhesions). Fitz-Hugh–Curtis syndrome is the association of perihepatic adhesions (seen at laparoscopy) with previous Chlamydia or gonorrhoeal infection and supports the diagnosis of PID as the cause of the pain, even in the absence of obvious tubal damage.

Management

Acute pelvic pain

Pelvic pain in early pregnancy

Women with a positive pregnancy test need urgent ultrasound and serial human chorionic gonadotrophin beta-subunit to exclude an ectopic pregnancy. If an intrauterine pregnancy is confirmed, then the commonest cause of pain is an enlarged or haemorrhagic corpus luteum. This should be identified on ultrasound scan and managed conservatively. Other ovarian cysts, urinary tract infection or appendicitis should also be considered and managed accordingly.

Acute pelvic inflammatory disease

Suspected PID must be managed urgently, as described in Chapter 9. A low threshold for antibiotic treatment is important to minimize complications of tubo-ovarian abscess, chronic pain, subfertility or ectopic pregnancy.

Ovarian cyst accident

Ovarian cyst haemorrhage or rupture is managed conservatively with admission and analgesia. Laparoscopy is indicated if the pain does not settle within 24–48 hours.

Ovarian cyst torsion should not be missed, as failure to recognize the symptoms and signs may lead to irreversible ischaemia of the ovary. Urgent laparoscopy is indicated, after initial resuscitation, to confirm the diagnosis. Cystectomy may be possible, but signs of ischaemia or necrosis indicate oophorectomy by either laparoscopy or laparotomy.

Appendicitis

Women with appendicitis generally complain of anorexia, malaise, nausea and abdominal pain, which originates centrally and moves to the right iliac fossa. A low-grade pyrexia, tachycardia and localized tenderness and peritonism are clinical signs. The white blood count is usually raised.

Urgent referral to the general surgical team should be made, and the woman kept fasted, with intravenous fluids and analgesia given. Appendicectomy is performed laparoscopically or through an open procedure using a right iliac fossa incision. The appendix is normal in 10–20% of appendicectomy specimens.

Appendix mass and abscess

An appendix mass forms when an inflamed appendix becomes walled off by omentum and small bowel. This presents with a longer history of several days localized pain and pyrexia. A mass is palpable in the right iliac fossa and the diagnosis is confirmed with ultrasound or computed tomography (CT) scan. Management is conservative with fluids, analgesia and antibiotics, with consideration of appendicectomy after 6–8 weeks.

An appendix abscess is a collection of pus associated with appendicitis. Management depends on the clinical situation and may involve CT or ultrasound-guided drainage or an open procedure as well as fluids, analgesia and antibiotics.

Chronic pelvic pain

Pelvic inflammatory disease

PID can present with chronic pelvic pain. This may be associated with a history of previous sexually transmitted infection, a change of partner, an abnormal discharge or irregular bleeding. Reinfection may be occurring where a woman who has been treated for PID continues to have unprotected intercourse with an untreated partner. Even where the diagnosis is not certain, a trial of antibiotic treatment can be helpful, with appropriate treatment for the partner and avoidance of unprotected intercourse until treatment for both partners has been completed.

Adhesions

Adhesions may be present as a result of previous infection or surgery. The benefit of division of adhesions to relieve pelvic pain is not clear, but it is likely to be more helpful in women with severe adhesions and where division is performed laparoscopically. Adhesiolysis is associated with a high risk of visceral damage. The development of further adhesions is common after adhesiolysis, especially if an open (rather than laparoscopic) approach is used.

Ovarian cysts (see Chapter 7)

Ovarian cysts are managed according to the symptoms and investigation findings. Simple cysts should be managed conservatively and usually resolve spontaneously over 6–12 weeks. However, persistent pain is an indication for cystectomy. Endometriomas and dermoid cysts may be managed expectantly if small, but should be removed, preferably laparoscopically, if there is persistent pain or subfertility.

Suspicious ultrasound features of ovarian cysts or raised cancer antigen 125 (CA 125) are also indications for surgical removal.

Fibroids (see Chapter 7)

Fibroids do not normally cause pain. However, they may be painful where the size of the fibroid causes a pressure effect, where the fibroid is degenerating or where an intracavity fibroid is being expelled from the uterus. Myomectomy should be performed for intracavity fibroids causing pain or for large fibroids causing a pressure effect. Fibroid degeneration is managed conservatively initially, with analgesia, fluids and antibiotics, but persistent or recurrent pain is an indication for surgery.

Chronic pelvic pain syndrome

Chronic pelvic pain syndrome is long-term pelvic pain with no identifiable pathology at laparoscopy. The aetiology of chronic pelvic pain syndrome is poorly understood. Theories include undiagnosed IBS, congested dilated pelvic veins (pelvic congestion syndrome), disordered neurological signalling to the spinal cord (where normal sensation is perceived as painful) and functional pain.

Effective treatment options are laparoscopic uterosacral nerve ablation (effective in 30–90%), antidepressants and counselling.

Irritable bowel syndrome

IBS affects up to 20% of people in the UK, with three times as many women affected as men. Diagnosis is clinical (after excluding other pathology) and symptoms include constipation, diarrhoea, pelvic pain, passage of mucus with the stool and bloating. The symptoms are often worse with eating, defecation, stress and in the premenstrual period. Treatment is with antispasmodic agents (e.g. mebeverine hydrochloride) for pain; antimotility agents (e.g. loperamide) for diarrhoea; and bulk-forming laxatives (e.g. ispaghula husk) for constipation, and increased dietary fibre may be of benefit.

Constipation

Many women with pelvic pain are constipated and a detailed gastrointestinal history will elucidate this. On examination a palpable loaded colon may be present. Treatment is with laxatives and suppositories as well as dietary and fluid modification.

Urinary tract infection/interstitial cystitis/renal calculi

Recurrent infections and irritative bladder symptoms are often associated with bladder pain. Thorough questioning about urinary symptoms is essential in a woman presenting with pelvic pain. Investigations should include urine microscopy and culture, and if necessary, cystoscopy and biopsy to exclude interstitial cystitis. Calculi may be identified in the ureters or bladder by ultrasound or intravenous urogram. Referral to the urologist should be made accordingly for treatment.

Functional pain

All women undergoing investigation for pelvic pain should be informed that no specific cause might be found. This reassures most women and spontaneous resolution of symptoms is not uncommon. If pain persists, sensitive questioning around social and sexual circumstances may reveal an underlying problem, such as relationship difficulties, sexual abuse history or fears around sexuality or fertility.

Endometriosis

Definition

Endometriosis is the presence of functioning endometrial tissue outside the cavity of the uterus.

Incidence

Twenty-one per cent of women with infertility, 15% of women with chronic abdominal pain and 6% of women undergoing sterilization have endometriosis at laparoscopy.

Age

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