Pelvic Pain Mr James Campbell

Overview Causes of pelvic pain Gynaecological terminology Common gynae. pathologies Chronic pelvic pain Case study

Causes of pelvic pain Gynaecological – Dysmenorrhoea Endometriosis Adenomyosis Infection Fibroids Post-operative pain Ectopic pregnancy

Causes of pelvic pain Gastrointestinal IBS Inflammatory bowel disease Diverticulitis Colon / rectal carcinoma appendicitis

Causes of pelvic pain Urological Musculoskeletal Psychological Painful bladder syndrome Bladder infection Musculoskeletal Referred pain from lower back Psychological Depression; sexual abuse

Terminology Dysmenorrhoea Primary / spasmodic Secondary / congestive pain associated with menstruation Primary / spasmodic not associated with organic pathology Secondary / congestive due to organic pathology

Dysmenorrhoea Prostaglandin production Myometrial contractions Decreased blood flow PAIN

Dyspareunia Pain associated with intercourse Superficial – pain at / around the labia Deep – pelvic pain (associated with organic pathology)

Gynaecological Pathology

Endometriosis Deposits of endometrial tissue outside the uterine cavity Most common sites are the ovary (chocolate cysts) and uterosacral ligaments

Aetiology Implantation theory Coelomic metaplasia theory Retrograde menstruation Coelomic metaplasia theory Mullerian duct Peritoneal and pleural cavities Ovaries (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

Investigations Laparoscopy USS / MRI Tissue biopsy

Management Conservative Medical Surgical Analgesia (+ counselling) Hormonal agents Surgical Laparoscopic ablation Cystectomy Hysterectomy

Adenomyosis Endometrial tissue within the myometrium Main risk factor is high parity Causes HMB and dysmenorrhoea

Histological diagnosis

Pelvic inflammatory disease Chlamydia Gonococcus Lower abdominal pain Deep dyspareunia Abnormal bleeding / discharge IMB in young patient think chlamydia

PID - examination Cervical discharge / tenderness Adnexal mass

Management Investigations – Treatment Temperature Bloods Swabs Urinary PT USS Treatment Antibiotics (oral / IV) Partner tracing / treatment

Ovarian cysts Simple / complex Benign / malignant

Cysts are painless unless - Twist – torted ovary Haemorrhage Rupture They are very large and cause pressure

Ectopic pregnancy Symptoms – Investigations Management Acute unilateral lower abdominal pain Bleeding Collapse Investigations PT / serial HCG’s USS Management Supportive / medical / surgical Collapse in young woman think ectopic

Fibroids Benign tumours of the myometrium Common – 1 in 3 over 30 years Hormone dependent Symptoms related to size and position

Fibroids Asymptomatic HMB Pressure Pain rarely occurs Usually associated with complications Degeneration torsion

Chronic pelvic pain Can 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 study 45 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 Speculum Normal Bimanual Bulky uterus No adnexal masses

Investigations PT – 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?