PELVIC PAIN

By

Dr. Najmah Mahmood

Objectives

1. Understand the definition & terminology

2. Identify the causes & form a differential

diagnosis

3. Clinically evaluate a patient with this problem

Can be :

Acute pelvic pain

Cyclical pelvic pain

Chronic pelvic pain

The initial approach to the patient

with pelvic pain should include a

detailed history and physical

examination

The history should include

characterize the pain [location, duration

(constant or intermittent),onset, radiation,

associated symptoms, severity sharp pains,

cramping, dull aching pain.

alleviating and aggravating factors.

system symptoms (eg, urinary,

gastrointestinal, and musculoskeletal) to

exclude non gynecological causes.

Examination

abdominal examination

pelvic examination

Performance of a pelvic examination is the

standard of care for women with lower

abdominal and pelvic symptoms

Acute pelvic pain

Pain of sudden onset

Gynecological causes

Non Gynecological causes

Gynecologic Causes of Acute Pelvic

Pain Aden
b

Adnexal accidents[ torsion, Ruptured,

TTA
heamorrage].

Pelvic inflammatory disease.

Ectopic pregnancy, abortion.

Normal ovaries and fallopian tubes rarely undergo torsion, but cystic or inflammatory enlargement predisposes to these ad- nexal
accidents. The pain of adnexal torsion can be in- termittent or constant, is often associated with nausea, and has been described as
reverse renal colic because it originates in the pelvis and radiates to the loin. An enlarging pelvic mass is found on examination and
ultrasound with decreased or absent blood flow to the adnexa on Doppler ultrasound studies. The need for surgical intervention is
common and urgent.

PID Salpingo oophoritis

Nongynecologic Causes of acute

Pelvic Pain

enteritis

Appendicitis ,Diverticulitis.

Bowel obstruction.

Adhesions.

Hernia.

Urinary tract infection. cystitis Genitourinary

Urolithiasis. ureteral stones

Urethral syndrome

Pelvic thrombophlebitis. other

Cyclical pelvic pain

Dysmenorrhoea is defined as painful

menstruation.

It is experienced by 45 95 per cent of

women of reproductive age.

Dysmenorrhea

Types

Primary [no underline disease]

Secondary [secondary to pelvic disease]

Primary Dysmenorrhea

Description: Pain associated with

ovulatory menses that usually start at or

g n

just before the onsets of menses; and

last 1-3 days.

Age group: 17-22 years. Secondary dysmen in older women

Etiology : due to uterine contraction

with ischemia and prostaglandin

production.

Symptoms: Crampy lower abdominal

pain; +/- nausea, emesis, diarrhea or

headache.

normal physical examination. in Pelvic exam



Pathophysiology

Primary dysmenorrhea occurs during ovulatory cycles and usually appears within 6 to 12 months of the men- arche. The etiology of primary
dysmenorrhea has been attributed to uterine contractions with ischemia and production of prostaglandins. Women with dysmenor- rhea have
increased uterine activity, which results in increased resting tone, increased contractility, and in- creased frequency of contractions. During
menstrua- tion, prostaglandins are released as a consequence of endometrial cell lysis, with instability of lysosomes and release of enzymes that
break down cell membranes.

The evidence that prostaglandins are involved in primary dysmenorrhea is convincing. Menstrual fluid from women with this disorder have higher
than nor- mal levels of prostaglandins (especially prostaglandin F2α [PGF2α] and PGE2), and these levels can be reduced to below normal with
nonsteroidal antiinflammatory drugs (NSAIDs), which are effective treatments. Infu- sions of PGF2α or PGE2 reproduce the discomfort and many of
the associated symptoms such as nausea, vomiting, and headache. Secretory endometrium con- tains much more prostaglandin than proliferative
en- dometrium. Women with primary dysmenorrhea have upregulated cyclooxygenase (COX) enzyme activity as a major cause of their pain.
Anovulatory endometrium (without progesterone) contains little prostaglandin, and these menses are
usually painless.

Figure 21-1 summarizes the relationships among endometrial cell wall breakdown, prostaglandin syn- thesis, uterine contractions, ischemia, and
pain.

i nifedipine salbutamol

treatment

Reassurance

NSAIDS

Hormonal Therapy (OCPs, progestagins,

Mirena IUD, Depo-Provera Depo-Provera, a contraceptive injection that's given every
three months, contains the hormone progestin

GnRH analogues LsNedroxy metate Progesterone

acupuncture Acupuncture[note 1] is a form of alternative medicine[3] in which thin needles are inserted into
the body.[4] It is a key component of traditional Chinese medicine (TCM).

psychothearpy

transcutaneous nerve stimulation

Primary dysmenorrhea Secondary dysmenorrher

Pain associated at ovulatory menses Pain that is not limited to menses

that occur atjust before

or can occur days before or after

onset of menstruation last menses it is also less related

l 3 days to first day of flow

No underlying dis Secondary to Pelvic dis

Age GP 17 22 yrs Age gpi older f Bos 404

Symptoms i crampy lower 1 b pain Symptoms related to underlying

nausea Vomiting diarrhea dis In general infertility dyspareurial

headache abnormal uterine bleeding

normal physics examination physical exam Can be abnormal

Tx Reassurance Ex a

NSAIDs

Hormonal Therapy Treat underlying dis

OCP Progestagins Mirena

IUD DePo Provern i endometriosis

GnRH analogues adenomyosis fibroids

Trans cut nerve Stirn Cervical stenosis of hematometra

acupuncture

is Adenexa ovarian congestion

Psychotherapy

ovarian cyst

Causes T uterine activity cont Causes

ai uterine ischemia associated E Pelvic inflammation

PG Production


Thheaffggggaza

If a patient fails to respond to hormonal contracep- tion and

NSAID therapy, the diagnosis of primary dys- menorrhea should

be questioned, and consideration given to a secondary cause.

Ultrasonic imaging, lapa- roscopy, and possibly hysteroscopy

should be per- formed to exclude pelvic disease.



Secondary dysmenorrhea

Pathophysiology:

depends on the underling secondary cause

Clinical feature

Develop in older women. 30 or Hos

Can occur days before and after the menses.

Associated with dyspareunia, infertility and

abnormal uterine bleeding.

Causes of secondary dysmenorrhea:

Endometriosis

Pelvic inflammation

Adenomyosis

cervical stenosis and haematometra (rare).

Hematometra or hemometra is a medical condition involving collection or
5 Fibroid retention of blood in the uterus. It is most commonly caused by an imperforate
hymen or a transverse vaginal septum.

Ovarian congestion

Ovarian cyst

Treatment :

By treating the underlying causes.

Chronic Pelvic Pain

Definition

Is pelvic pain for more than 6 month

and affect the quality of life.

CPP includes re- productive and nonreproductive organ–related pelvic pain that is primarily acyclic.

Gynaecological causes

endometriosis, adhesions .

fibroids, adenomyosis, endometritis.

Pelvic congestion syndrome.

PID/salpingitis, hydrosalpinx.A hydrosalpinx is a distally blocked fallopian tube filled
with serous or clear fluid. The blocked tube may
become substantially distended giving the tube a

IUD/infection. characteristic sausage-like or retort-like shape.

severe prolapse.

Non- gynaecological causes

Urologic

UTI/urethritis, interstitial cystitis (IC), urine retenion,

urethral diverticulum, nephrolithiasis, malignancy.

GIT

constipation, IBS, C h disease, bowel obstruction,

diverticulitis, malignancy.

Musculoskeletal

myalgia of pelvic floor, hernias, neuralgia, low back

pain.

Other

psychiatric depression, ; abdominal cutaneous

nerve entrapment in surgical scar.

Diagnosis

Obtaining a

COMPLETE and DETAILED HISTORY

is the most important key to

formulat a diagnosis of chronic pelvic pain

History of Chronic Pelvic Pain

1.Duration of Pain 5.Timing of the Pain

Intermittent or

2.Nature of the Pain constant?

Sharp, stabbing, Temporal relationship

throbbing, aching, dull? with menses?

Temporal relationship

3.Specific Location of Pain with intercourse?

Associated with Predictable or

radiation to other areas? spontaneous onset?

4.Modifying Factors 6.Detailed medical and

Things that make worse surgical history

or better?

Specifically abdominal,

pelvic, back surgery

Investigation of chronic pelvic pain

Basic Testing Specialized Testing

Gonorrhea and MRI or CT Scan

Chlamydia Endometrial Biopsy

Urinalysis Laparoscopy

Urine Culture Referral to Specialist

Pregnancy Test

CBC with Differential

ESR

PELVIC ULTRASOUND

laboratory studies of limited utility index of CPP

CBC ISRT.my tinecuTaotnurmm4Pregn

I chlamydia Test

A in any f

inflammatory Pt having

condition Sexnd intercom

non specific not Postmenop

neither had

hysterectomy

imaging

pelvic US CTIMRI

To detect adnexal

Mass missed in

examination

procedures

Laproscopy
endometrial biopsy
ultimate meth dot

DX for CPP i undetermined

etiology

performed if n etiology can

be identified


Management of chronic pelvic pain

By treatment of underlying causes

ENDOMETRIOSIS

&

ADENOMYOSIS

Definition :-

is a benign condition

Endometriosis defined as

presence of endometrial

surface epithelium & or

endometrial glands &

stroma outside the uterine

cavity.

Age gp

classically occasionally 5 of new

Ix Bos infancy 1childhood Cases

multiparous Adolescence I

infertile obstructive genital post menopause

anomalies Women

uterine Vaginal

Septum

benign
Although endometriosis is a benign process, it shares many characteristics with malignancy. It is locally infiltrative,
invasive, and widely disseminated. It is also curious that cyclic hormones tend to induce growth, whereas continuous
hormonal exposure, especially in high doses, generally induces significant regression.

The term cul-de-sac is used specifically to refer to the

rectouterine pouch (the pouch of Douglas), an extension of the

Sites of endometriosis:- peritoneal cavity between the rectum and back wall of the
uterus.

Ovaries.

chocolate cyst

Fallopian tubes

The back of the uterus

Within the myometrium & called adenomyosis.

broad ligament.

Pelvic peritoneum

Intestines, most commonly the rectosigmoid

Urinary bladder and ureters.

Vulva , vagina

Lung

Abdominal scars.

Ruptured left endometrioma of

ovary

Poach f doughs

Endoscopic pcture of endometriotic spots in POD &

uterosacral ligament.

Endometrioma Due to

Endometriosis

Etiology &Pathogenesis:-

1. The implantation theory & menstrual

regurgitation .
2. Coelomic metaplasia theory.
3. Lymphatic & vascular dissemination.
4. Genetic & immunological factors.
The retrograde menstruation theory of Sampson proposes that endometrial fragments transported through the fallopian
tubes at the time of menstrua tion implant and grow in various intraabdominal sites. Endometrial tissue, which is normally
shed at the time of menstruation, is viable and capable of growth in vivo or in vitro. To explain some rare examples of
endometriosis in distant sites, such as the lung, forehead, or axilla, it is necessary to postu late hematogenous spread.

The müllerian metaplasia theory of Meyer proposes that endometriosis results from the metaplastic transformation of
peritoneal mesothelium into en dometrium under the influence of certain generally unidentified stimuli.

The lymphatic spread theory of Halban suggests that endometrial tissues are taken up into the lym phatics draining the
uterus and are transported to the various pelvic sites where the tissue grows ectopically. Endometrial tissue has been found
in the pelvic lymphatics of up to 20% of patients with the disease.
Pathogenesis:- Islands of endometriosis respond cyclically to ovarian steroidal hormone
production. The implants proli ferate under estrogenic stimulation and slough
Peritoneal endometriosis:- when support from estrogen and progesterone is removed with involution of the
corpus luteum. The sloughed material induces a profound inflammatory
response resulting immediately in pain and fibrosis in the long term.

1- Red endometriosis.

Endometriomas of the ovary are cysts filled with thick, chocolatecolored fluid

2- Black endometriosis. that sometimes has the black color and tarry consistency of crankcase oil. This
characteristic fluid represents aged, hemolyzed blood and desquamated
endometrium.

3- White endometriosis.

Clinical features :-
1- Asymptomatic.
2- Pelvic pain
as chronic pelvic pain, congestive
thrusting
dysmenorrhea deep dyspareunia( painful
intercourse, dysureagurinary urgency,
frequency, and sometimes painful
voiding, dyschesia
u
3- Infertility
4- Features of acute abdomen due to rupture or
torsion of endometrioma
5- Menorrhagia & irregular menses.
6- Abdominal & pelvic mass.
7- Cyclic heamaturia , cyclic rectal bleeding.
8- Cyclical pain & bleeding from umbilicus or
surgical scars.
9- Cyclical heamoptysis &
heamopneumothorax if involve the lungs.
10- O/E fixed RV uterus with hard tender
nodules, adnexial mass of endometrioma.
The characteristic triad of symptoms associated with endometriosis is
dysmenorrhea, dyspareunia, and dyschezia.

Dyspareunia is generally associated with deep thrust penetration during intercourse and occurs mainly
when the culdesac, uterosacral ligaments, and portions of the posterior vaginal fornix are involved. Deep
thrust dyspareunia can also result from uterine immobility due to significant internal scarring caused by
endometriosis.

Dyschezia is experienced with uterosacral, culdesac, and rectosigmoid colon involvement. As the stool
passes between the uterosacral ligaments, the charac teristic dyschezia is experienced.

Premenstrual and postmenstrual spotting is a characteristic symptom of endometriosis.

Characteristically, a tender, fixed adnexal mass is appreciated on bimanual examination. The uterus is fixed
and retroverted in a substantial number of women with endometriosis. Occasionally, no signs at all are
appreciated on physical examination.

The diagnosis of endometriosis should be suspected in an afebrile patient with the characteristic triad of pelvic pain,
a firm, fixed, tender adnexal mass, and tender nodularity in the culdesac and uterosacral ligaments. The
characteristic sharp, firm, exquisitely tender “barb” (from barbed wire) felt in the uterosacral liga ment is the
diagnostic sine qua non of endometriosis, but this finding is generally present only in severe cases.

afebrile pt
yes
DX Susp s Triad of Pelvic Pain dyspar desmenorrh deschezig
firm fixed tender adenexal mass
tender nodularity in cul de Sac utero Sardlig
The characteristic triad of symptoms associated with endometriosis is dysmenorrhea,
dyspareunia, and dyschezia.

Premenstrual and postmenstrual spotting is a characteristic symptom

of endometriosis.

The definitive diagnosis is generally made by the characteristic gross and

histologic findings obtained at laparoscopy or laparotomy
Investigations:-
1) Laprascopy:-
it remain the goldstand means of diagnosing the condition
it visualize :-
# white thickening scar of endometriosis
# fixed RV uterus
# burn match stick appearance
#adhesion
# choclate cyst in the ovaries
# heamatosalpinx
# it allow take a biopsy from the lesion & give a benefit to
determine the extent of the disease & staging , also it
allow concurrent therapy at the time of laprascopy in the
form of cautery or laser treatment in selected cases.
 Investigations

laparoscopy USS G1 25 MRI

gold standar level

white thickening did af Tin detect

scar of endometriosis endometerioun endometriosis endometers inn

burn matchstick ovaries

appearance bladder
fixed bowel
Retroverted uterus Reatovagirl
adhesion Sept
chocolate cyst
in ovaries Serum levels of the cancer antigen CA 125 are frequently elevated in women with
endome triosis. However, the positive predictive value of CA 125 for detecting
endometriosis is low (about 20%), and this test should not used to diagnose
hematoSalpinx endometriosis.

Talc biopsy The definitive diagnosis is generally made by the characteristic

gross and histologic findings obtained at laparoscopy or
extent of dish laparotomy.

staging
Concurrent therapy
in Selected cases

cautery
laser
2) USS:- help in diagnosis of
endommetrioma.
3) Ca125 level :- this is a
glycoprotien expressed by some
epithelial cells of coelomic
origin it increase in cases of
endometriosis .
4) MRI:- this can detect
endometriosis in ovaries or
bladder or bowel &
rectovaginal septum .
30 – 40% of pt with endometriosis have infertility & about
15% of pt with infertility have endometriosis.
Mechanism by which endometriosis cause
infertility are :-
1) Ovarian function
2) Tubal function.
3) Coital function.
4) Sperm function.
5) Early pregnancy failure.
6) adhesions.
Treatment of endometriosis:-
Medical treatment or surgical treatment
1) Medical treatment :-
a) COC P.
b) Danazole & gestrinone. both are synthetic androgens
c) Progestogens.
d) LHRH analogue.
e) NSAID.
2) Surgical treatme:nt-
a) Conservative surgery by using 0
laprascopy
b) Radical surgery by TAH&BSO in old age pt
&who complete her family, postoperative
HRT can be used especially in young age
women but it is preferred to delayed for 6
months or more to minimize the risk of
recurrence.
 In of endometriosis

Medical Surgical

1st line i ConservativeSurg

combined
Continuous
oral contraceptivePills laparoscopy

NSAIDs Radial Surg includes

Low dose of Progestins Total Abdhysterectomy

2nd line Tx bilateral Salpingo

Dana 2ol l gestrinone oophorectomy

tr
old Pt completed
high dose of Progestin
their family
LARA analogue HRT delayed for 6 months
or more 9 risk of
recurrence
 Adenomyosis
# Repeated pregnancy.
# vigourous curretage.
# endometrial hyperplasia.
Pathology:-
The uterus is symetrically enlarged , the lesion
could be localized or diffused throught the
uterine wall , cystic space filled with blood within
myometrium on HP exam.
Adenomyosis is defined as the extension of endometrial glands and stroma into the uterine musculature more than 2.5 mm
beneath the basalis layer.
Clinical features:-
*** Menorrhagia
*** Secondary dysmenorrhea.
*** Pelvic discomfort & dysparonia.
*** O/E bulky symetrically enlarged tender uterus
with regular outline.
Diagnosis:-
1) USS 2) MRI 3) Biopsy & HP exam.
Treatment:-

1) Medical treatment as danazole,

gestrinone , GnRH agonist as for
endometriosis. D NSAIDs

2) surgical treatment:-
hysterectomy.
The size and location of the endometriotic implants do not appear to correlate
with the presence of pain,
L
there is no clear relationship between the stage of endometriosis and the frequency and severity of
pain symptoms.