Mr James Campbell

OverviewCauses of pelvic painGynaecological terminologyCommon gynae. pathologiesChronic pelvic painCase study

Causes of pelvic pain• Gynaecological –

– Dysmenorrhoea– Endometriosis– Adenomyosis– Infection– Fibroids– Post-operative pain– Ectopic pregnancy

Causes of pelvic painGastrointestinal

IBSInflammatory bowel diseaseDiverticulitisColon / rectal carcinomaappendicitis

Causes of pelvic pain• Urological

– Painful bladder syndrome– Bladder infection

• Musculoskeletal– Referred pain from lower back

• Psychological Depression; sexual abuse

TerminologyDysmenorrhoea

pain associated with menstruation

Primary / spasmodicnot associated with organic pathology

Secondary / congestivedue to organic pathology

• Prostaglandin production– Myometrial

contractions– Decreased blood

flow

– PAIN

DyspareuniaPain associated with intercourse

Superficial – pain at / around the labia

Deep – pelvic pain (associated with organic pathology)

EndometriosisDeposits of endometrial tissue outside the

uterine cavity

Most common sites are the ovary (chocolate cysts) and uterosacral ligaments

AetiologyImplantation theory

Retrograde menstruation

Coelomic metaplasia theoryMullerian ductPeritoneal and pleural cavitiesOvaries(all derive from the coelomic epithelium)

Symptoms and signs• Dysmenorrhoea• Dyspareunia• Sub-fertility• Menstrual dysfunction

– Signs in severe disease• Fixed tender uterus• Adnexal mass• Nodular POD

InvestigationsLaparoscopy

USS / MRI

Tissue biopsy

Management• Conservative

– Analgesia (+ counselling)

• Medical– Hormonal agents

• Surgical– Laparoscopic ablation– Cystectomy– Hysterectomy

AdenomyosisEndometrial tissue within the myometrium

Main risk factor is high parity

Causes HMB and dysmenorrhoea

Pelvic inflammatory disease• Chlamydia• Gonococcus

• Lower abdominal pain• Deep dyspareunia• Abnormal bleeding / discharge

• IMB in young patient think chlamydia

PID - examinationCervical discharge / tendernessAdnexal mass

Management• Investigations –

– Temperature– Bloods– Swabs– Urinary PT– USS

• Treatment– Antibiotics (oral / IV)– Partner tracing / treatment

Ovarian cystsSimple / complexBenign / malignant

Cysts are painless unless -Twist – torted ovary

Haemorrhage

Rupture

They are very large and cause pressure

Ectopic pregnancy• Symptoms –

– Acute unilateral lower abdominal pain– Bleeding– Collapse

• Investigations– PT / serial HCG’s– USS

• Management– Supportive / medical / surgical

• Collapse in young woman think ectopic

FibroidsBenign tumours of the myometriumCommon – 1 in 3 over 30 yearsHormone dependentSymptoms related to size and position

FibroidsAsymptomaticHMBPressure

Pain rarely occursUsually associated with complications

Degeneration torsion

Chronic pelvic painCan arise form any system either de novo or

following acute pelvic pain

“pain not occurring with menses, intercourse or pregnancy causing distress and /or disability that has persisted for greater than 6 months”

Types of chronic pelvic pain• Organic –

• Due to tissue damage (endometriosis)

• Psychological –• Can occur without tissue damage

• Cancer

• Benign• Occurs despite tissue healing (adhesions)

Case study45 yr old woman attends the clinic with

pelvic pain of 2 years duration

Consultant is away and you are in charge

History• Intermittent pain / 2-3 episodes daily• Unrelated to menses• Bilateral / no associated factors• Heavy periods• Sexually active / on cerazette• LSCS 1990 / appendicectomy 2006• Mother had hysterectomy• No bowel / urinary dysfunction

Examination

SpeculumNormal

Bimanual Bulky uterusNo adnexal masses

InvestigationsPT – negative

Swabs – negative

USS –Multiple small intramural fibroids, largest 2cm,

ovaries normal

Differential diagnosis• Surgery related pain• Fibroids / endometriosis• IBS• Psychological

• Diagnosis – made at laparoscopy– Post operative adhesions / ovarian entrapment

Ovarian adhesions

Pelvic pain

Thanks for your attention.Questions?