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How prevalent is pelvic pain?
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| Organ | Disorder / Disease | Question Number |
| Vagina | Vaginitis | |
| Prolapse | ||
| Cervix | Cervicitis | |
| Uterus | Fibroids | |
| Intrauterine contraceptive device | ||
| Endometrial polyp | ||
| Fallopian tubes | Ectopic pregnancy | |
| Pelvic inflammatory disease | ||
| Ovaries | Endometriosis | |
| Mittelschmerz (Ovulation pain) | ||
| Ovarian cyst | ||
| Peritoneum | Endometriosis | |
| Pelvic congestion | ||
| Peritonitis | ||
| Retrograde menstruation | ||
| Bowel | Appendicitis | |
| Crohn's disease | ||
| Constipation | ||
| Diverticulitis | ||
| Gastroenteritis (Acute diarrhoea and vomiting) | ||
|
|
Irritable bowel syndrome | 23.34 |
|
|
Ulcerative colitis | |
|
Bladder / urinary tract |
Renal colic (kidney stones) | |
|
|
Urinary tract infection | |
| Musculo-skeletal system | Ligament and muscle pain. | |
| Psychological |
|
There are times when despite careful investigation, a physical explanation for the pelvic pain cannot be found. Sometimes the pain may be psychosomatic (a subconsciously mediated physical manifestation of a mental disorder).
Dysmenorrhoea (pain associated with menstruation) is the commonest type of gynaecological pelvic pain in young women. Pain may occur at the time of ovum (egg) release about 14 days before the next period is due; this pain is called mid-cycle pain or Mittelschmerz. Cysts (fluid filled sacs) within the ovaries occur frequently and indeed naturally throughout the reproductive years; these may be called physiological or functional cysts. Sometimes, bleeding may occur into a physiological cyst resulting in acute pain. Pelvic pain may be an indication of a problem during early pregnancy (Miscarriage;12.23).
Other gynaecological causes of pelvic pain include pelvic inflammatory disease (Q 20. 2), fibroids (fibroids) and endometriosis (Q 23.18). Utero- vaginal prolapse (Q30.1) may cause a dragging pelvic ache or pain.
Related Medical Abstracts - Click on the paper title:-
- Chronic pelvic pain: the occurrence of interstitial cystitis in a gynecological population. (2005-01)
- The prevalence of interstitial cystitis, endometriosis, adhesions, and vulvar pain in women with chronic pelvic pain. (2005-02)The evil twins of chronic pelvic pain syndrome: endometriosis and interstitial cystitis. (2002-01)
- Criteria that indicate endometriosis is the cause of chronic pelvic pain (1998)
What are the more common non-gynaecological
causes of pelvic pain?
Constipation is probably the commonest cause of pelvic pain. Many patients have irritable bowel syndrome - IBS (Q 23.34). Typically there is a story of intermittent diarrhoea and constipation.
Infection in the urinary tract (e.g. cystitis) is another common cause of lower abdominal and pelvic pain. If a "mid-stream urine" sample shows evidence of infection, the problem should respond to an appropriate antibiotic.
The musculo-skeletal system (the bones, muscles, tendons and joints) may be the source of pain in the pelvic area.
As the womb enlarges, there is often some associated discomfort so there may be nothing wrong. At the other extreme, the pregnancy may have implanted outside the womb (ectopic pregnancy Q12.23) which can be dangerous. It is, therefore, essential that you seek medical advice.
What is Pelvic Inflammatory Disease and how can it be treated?
Pelvic inflammatory disease and its treatment have been discussed in Chapter20.
Related Medical Abstracts - Click on the paper title:-
A full history, examination and possibly some investigations will be required (Q4.4). The story and examination findings may allow your doctor to make a diagnosis and initiate treatment. Although pain related to the menstrual cycle suggests a gynaecological problem, it is not always the case (Q 23.39). Symptoms relating to the bladder or bowel may suggest that the problem is not gynaecological. Frequently, there may be a variety of symptoms and clinical skill is required to determine the more significant symptoms and prioritise investigations.
The more common conditions can often be diagnosed by your general practitioner. Specialist advice is usually sought when there is difficulty establishing a diagnosis, when there has been a poor response to initial treatment, if the pain is particularly severe or if specialist investigations such as laparoscopy may be required.
What is a retroverted uterus?
The womb is generally positioned with its body pointing forwards and the cervix pointing backwards the uterus is described as being anteverted. The body of the womb points backwards with the cervix pointing forwards in about 20% of women and this uterine retroversion is a variation of normality (Figure 23.3).
Does a retoverted uterus cause symptoms?
A retroverted uterus is a uterus that is tilted backwards inside the pelvis. In the majority of women, the uterus is tilted forwards but one woman in five has a retroverted uterus. A retroverted uterus is, therefore, a common and natural finding and only rarely does this uterine position result in symptoms. Sometimes the uterus is retroverted because of other abnormality in the pelvis such as endometriosis. The symptoms, such as pelvic pain, are inveriably due to the other condition and not the uterus being retroverted.
Many women are simply born with a uterus that is retroverted, and this is entirely normal.
Some pelvic conditions, notably pelvic inflammatory disease and endometriosis, may cause scarring that causes the uterus to become retroverted.
Following the menopause, the level of the female hormone called oestrogen drops and as result the ligaments holding the uterus forward become weakened so that the uterus falls into a retroverted position.
Finally, in early pregnancy the uterus becomes heavier and sometimes becomes retroverted for a few weeks.
The majority of women with a retroverted uterus have no symptoms. The two more common symptoms associated with a retroverted uterus are:
Pain during sexual intercourse (dyspareunia).
Pain during periods (dysmenorrhoea).
Other problems that have been associated with the uterus being retroverted include:
Lower back pain.
Urinary incontinence.
Infertility.
Urinary tract infections.
The pain is due to the pressure and movement of the retroverted uterus.
Usually, a retroverted uterus is noted during pelvic examination. It may also be found during abdominal or pelvic ultrasound examination.
For the vast majority of women with a retroverted uterus there are absolutely no problems. When symptoms occur in women who have a retroverted uterus, they are usually due to scarring in the pelvis.
Very rarely during pregnancy, the enlarging uterus becomes impacted in the pelvis. In these circumstances, the retroverted uterus may cause pain or difficulty voiding urine. The remedy is usually simple. By lying on her abdomen for a day or two, the retroverted uterus of the woman will become anteverted.
Retroverted uterus is found in 20% of women and gynaecological problems such as painful periods, pain during sex and pelvic pain are extremely common. In the 1950s and 1960s many women with these symptoms underwent a simple abdominal operation to antevert the retroverted uterus called a ventrosuspension. The development of laparoscopic surgery has made this type of surgery even more simple.
Over the years, we have come to realise that when a woman with a symptom has a retroverted uterus, we should not assume cause and effect. Indeed, the retroverted uterus is rarely the cause of such symptoms. Some gynaecologists employ a simple test to see if the retroverted uterus is the cause or just an incidental finding. A special vaginal ring pessary, called a Hodge pessary is inserted (Figure 23.4). This holds the retroverted uterus into an anteverted position. If the symptom is alleviated, then there is some evidence that the uterine retroversion is the culprit.
A retroverted uterus without other disease, is unlikely to be the cause of infertility. It follows that surgery to correct a retroverted uterus is unlikely to enhance the fertility.
At one time operations designed to antevert the retroverted uterus (ventrosuspension) were frequently undertaken in the belief that this could cure virtually every gynaecological symptom including infertility, menstrual disturbance, pelvic pain and backache. Scientific validation of the benefits of such surgery were not undertaken. Nowadays, surgery to antevert the uterus is rarely performed. When symptoms develop relatively late in the reproductive years they are more likely to result from disease processes such as endometriosis, fibroids or prolapse.
It is generally considered prudent to introduce a Hodge vaginal pessary as a test (Figure 23.4). This pessary is designed to temporarily keep the uterus in an anteverted position. If the symptoms resolve with the pessary and return when the pessary is removed there would be some evidence that surgery may be beneficial. There are several operations to antevert the uterus. They tend to shorten the round ligaments; these are attached to the top corners of the uterus and reach the pelvic side wall. The ligaments may be stitched to the ligamentous tissue at the front of the abdominal wall. These operations are relatively simple to perform but as with any operation, they are not without potential complication (surgery risks).
What is pelvic congestion?
Pelvic congestion is characterised by dilated veins around the pelvis that may be diagnosed at ultrasound or laparoscopy. The dilated veins may be related in some way to varicose veins more usually seen in the legs. They can be seen at laparoscopy or ultrasound examination. Pelvic congestion can be associated with pelvic conditions such as infection.
Pelvic congestion may respond to medroxyprogesterone acetate administered continuously over six months at a dose sufficient to prevent menstruation.
Ligation of the pelvic veins has been performed laparoscopically. Occlusion of the pelvic veins (embolisation) may prove to be effective.
Related Medical Abstracts - Click on the paper title:-
- Embolotherapy for pelvic congestion syndrome: long-term results. (2006-01)
- Diagnosis of pelvic congestion syndrome using transabdominal and transvaginal sonography. (2004-01)
- Bilateral laparoscopic transperitoneal ligation of ovarian veins for treatment of pelvic congestion syndrome. (2003-01)
- Comparison of treatments for pelvic congestion syndrome. (2003-02)
- A randomized controlled trial of goserelin and medroxyprogesterone acetate in the treatment of pelvic congestion. (2001-01)
- A randomized controlled trial of medroxyprogesterone acetate and psychotherapy for the treatment of pelvic congestion. (1989-01)
- Medroxyprogesterone acetate in the treatment of pelvic pain due to venous congestion. (1989-02)
If there is a suggestion that there may be infection within the genital tract swabs may be sent to the laboratory for culture. Swabs taken from the lower genital tract including the cervix may not be representative of bacterial status higher up the genital tract. Some bacteria (e.g. Mycoplasma hominis) are increasingly being recognised as having clinical significance but few laboratories have the facilities to culture them.
A pregnancy test would be appropriate if there is any possibility that you have conceived. Ultrasound (pelvic ultrasound) can provide a picture of any swellings in the pelvic organs such as cysts in an ovary or fibroids. Sometimes direct visualisation of the pelvic organs by the gynaecologist (Laparoscopy - laparoscopy) may be required.
About thirty-five years ago, fibre optic technology was introduced. It was found that light could be transmitted along a flexible tube composed of thousands of glass fibres. Fibre optics has revolutionised medical diagnostic options. With fibre optics, it is possible to look into a body cavity with a variety of telescopes with the light source outside the body. Prior to fibre optics, the light would have to be within the body cavity with risks of heat damage to adjacent structures.
For thirty years-five, gynaecologists have been introducing a thin telescope (laparoscope Figure 18.1) into the abdomen to visualise the pelvic organs. Under a general anaesthetic, a small cut is made at the lower edge of the umbilicus (navel). A guarded needle is introduced into the abdominal cavity, which is then filled with about three litres of gas (carbon dioxide). The laparoscope can then be passed through and the gynaecologist can observe the womb, ovaries and Fallopian tubes as well as the surrounding areas. Laparoscopy may be indicated for persistent pain and also at times in the assessment of sudden (acute) pelvic pain. Sometimes minor surgery can be undertaken with the laparoscope (minimally invasive surgery Figure 18.1).
Figure 18.1
Although we now have a wealth of experience with laparoscopy, the investigation should not be undertaken lightly; as with any operation there can occasionally be complications (surgery risks) with damage to internal structures (about 1 in a thousand). Occasionally the gas is inadvertently introduced into the abdominal wall and the procedure may have to be abandoned or the surgeon may decide that a mini-laparotomy is required.
When laparoscopy was introduced around 1970, research showed that it frequently changed the provisional diagnosis. Since that time new investigation options, such as ultrasound and sensitive pregnancy tests, have increased our ability to evaluate the pelvis and exclude problems such as an ectopic pregnancy. These have decreased the need for laparoscopy.
A 1978 survey of laparoscopy found that 52% of laparoscopies were to investigate pelvic pain. Another study found that 86% of laparoscopies for pelvic pain revealed no abnormality.
Related Medical Abstracts - Click on the paper title:-
- Acute nonspecific abdominal pain: a randomized, controlled trial comparing early laparoscopy versus clinical observation. (2006-01)
- How long does laparoscopic surgery really take? Lessons learned from 1000 operative laparoscopies.(1999-01)
- The role of laparoscopy in the management of pelvic pain in women of reproductive age (1997-01).
When there is any form of inflammation, there is a natural response to form scar tissue. This scar tissue is designed to fill in any gaps and to leave the damaged area as small as possible. When the skin is damaged either as a result of surgery or injury such as a burn, the resulting scar tissue is obvious. The same process may occur internally when there has been infection (Q 20.2), endometriosis (Q 23.18) or surgery in the pelvis. Adhesions are areas of scar tissue that stick one structure to another. The ovaries, for example, should normally be reasonably mobile but they may adhere to the back of the uterus, to the pelvic side wall or to the bowel.
What is a pelvic mass?
A mass is medical term for a swelling. It is a non-specific term, applied to a swelling found during physical examination or during the course of investigation including ultrasound and radiology (x-ray). The mass may be due to inflammation, (e.g. an abscess) or a tumour, which can be benign (e.g. a fibroid) or malignant. On occasion, the mass may be present from birth but is first observed later in life. The kidneys, for example, normally develop as a pair, one on either side in the area of the loins but one kidney may develop in the pelvis (pelvic kidney).
Can we summarise the treatments for pelvic pain?
Ideally we would wish to determine the cause of your pain and provide the specific remedy particularly if the pain is of recent onset. Chronic pain also involves attempting to provide specific treatment for the underlying cause but we also need to consider analgesics (pain killers Q 24.17D) and very occasionally low-dose antidepressants (Q31.12).
- http://www.obgyn.net/cpp/cpp.asp
- http://www.pelvicpain.org
- http://womenshealth.about.com/health/womenshealth/msubchronicpain.htm
Please click on the required question.
- Q 23. 1 Pelvic Pain. Is this a common problem?
- Q 23. 2 What are the common causes of pelvic pain in women?
- Q 23. 3 What are the more common gynaecological causes of pelvic pain?
- Q 23. 4 What are the more common non-gynaecological causes of pelvic pain?
- Q 23. 5 What are primary and secondary dysmenorrhoea - painful periods?
- Q 23. 6 What is retrograde menstruation?
- Q 23. 7 How can dysmenorrhoea - painful periods be treated?
- Q 23. 8 What are ovarian cysts?
- Q 23. 9 How do ovarian cysts cause pain?
- Q 23. 10 How are ovarian cysts diagnosed?
- Q 23. 11 How are ovarian cysts treated?
- Q 23. 12 I think I may be pregnant and I have some pelvic pain. What should I do?
- Q 23. 13 What is pelvic inflammatory disease and how can it be treated?
FIBROIDS
- Q 23. 14 What are fibroids?
- Q 23. 15 I have fibroids. What difficulties might they cause for me?
- Q 23. 16 How are fibroids diagnosed?
- Q 23. 17 How could my fibroids be treated?
ENDOMETRIOSIS
- Q 23. 18 What is endometriosis?
- Q 23. 19 How prevalent is endometriosis?
- Q 23. 20 What causes endometriosis?
- Q 23. 21 How can my endometriosis be treated?
- Q 23. 22 How can my doctor determine the cause of my pelvic pain?
- Q 23. 23 What investigations might be recommended by my gynaecologist to investigate my pelvic pain?
- Q 23. 24 What is laparoscopy?
- Q 23. 25 What are pelvic adhesions?
- Q 23. 26 I have chronic pelvic pain. Could this be related to adhesions?
- Q 23. 27 What is uterine retroversion (retroverted uterus)
- Q 23. 28 Does a retroverted uterus cause symptoms?
- Q 23. 29 How is a retroverted uterus treated?
- Q 23. 30 What is pelvic congestion?
- Q 23. 31 What causes pain associated with sexual intercourse (dyspareunia)
- Q 23. 32 How can painful sexual intercourse (dyspareunia) be treated?
- Q 23. 33 What is a pelvic mass?
IRRITABLE BOWEL SYNDROME - IBS
- Q 23. 34 What is irritable bowel syndrome?
- Q 23. 35 How can we find out if I have irritable bowel syndrome?
- Q 23. 36 Is irritable bowel syndrome (IBS) a common condition?
- Q 23. 37 What causes IBS?
- Q 23. 38 What is the pain associated with IBS like?
- Q 23. 39 Can IBS be mistaken for gynaecological problems?
- Q 23. 40 How can my IBS be managed?
- Q 23. 41 What other treatments are available for IBS?
- Q 23. 42 What can be done to reduce the amount of bowel gas(flatus)
- Q 23. 43 What is constipation?
- Q 23. 44 What causes constipation?
- Q 23. 45 How can constipation be treated?
- Q 23. 46 How could we summarise the treatments that are available for my pelvic pain?
- Q 23. 47 Where can I obtain more information?
- Q 23. 48 Pelvic Pain Support Groups.
- Q 23. 49 Endometriosis Support Groups.
- Q 23. 50 IBS Support Groups.
DISCLAIMER
The aim of this web site is to provide a general guide and it is not intended as a substitute for a consultation with an appropriate specialist in respect of individual care and treatment.
