An explanation of the causes of pelvic pain and its evaluation

1. PELVIC PAIN
Associate Professor Dr Hanifullah Khan

2. Objectives
1. Understand the definition & terminology
2. Identify the causes & form a differential diagnosis
3. Clinically evaluate a patient with this problem

3. Introduction
• Pelvic pain is discomfort in the lower abdomen
– Below the umbilicus
• may originate in
– reproductive organs (cervix, uterus, uterine adnexa)
– or other organs
● Urological
● Gastrointestinal
● Musculoskeletal
● Neuropathic
● Other
• Sometimes the cause is unknown

4. Causes
Pelvic pain
Gynae Non-gynae
cause cause
Other
Cyclical Discrete
organs

5. Pelvic region

6. Female pelvis

7. Vulva

8. Definitions
• Acute pelvic pain: symptom of underlying tissue
injury.
• Chronic pelvic pain: pain becomes the disease
– Recurrent, unrelated to menses, intercourse, pregnancy
Chronic pain: pain lasting 6 months or longer.
 Chronic pelvic pain syndrome: chronic pelvic pain
causing emotional and behavioral changes.

9. Rule out pregnancy!
REPRODUCTIVE AGE GROUP

10. Pain related to menstrual cycle
Pain related to menstrual cycle Unrelated to menstruation
• Primary dysmenorrhoea • Pelvic inflammatory disease
• Endometriosis • Endometriosis
• PID • Fibroids
• Mittleschmerz • Cysts

11. ENDOMETRIOSIS

12. Sites

13. Peritoneal Lesions and an Ovarian Endometrioma Due to Endometriosis
Giudice L. N Engl J Med 2010;362:2389-2398

14. Lesions

15. Laparoscopy

16. Symptoms
• Cramping pain – may be localized or radiate
• Can be continuous
• Dysmenorrhoea – usually secondary
• Dyspareunia
• Abnormal menstruation
• Infertility
• Others – bowel, urinary, systemic

17. Pathophysiology of Pain and Infertility Associated with Endometriosis
Giudice L. N Engl J Med 2010;362:2389-2398

18. Radiographic Images of Endometriomas
Giudice L. N Engl J Med 2010;362:2389-2398

19. Major Guidelines from Professional Societies for the Diagnosis and Management of
Endometriosis-Related Pain and Infertility
Giudice L. N Engl J Med 2010;362:2389-2398

20. Medical and Surgical Therapies for Endometriosis-Related Pelvic Pain
Giudice L. N Engl J Med 2010;362:2389-2398

21. ADENOMYOSIS

22. Definition
• Ectopic endometrial tissue within the myometrium
• Older age group than endometriosis patients
• Associated with any sort of uterine trauma that may
break the barrier between the endometrium and
myometrium

23. Symptoms
• Similar to endometriosis and other pelvic pathology
– Pain more likely to be suprapubic
– More likely to have abnormal bleeding
• Usually older patient
• Less likely to be infertile
• May have secondary infertility
• Previous pregnancies or procedures to uterus
• Mimic fibroids – frequently coexist

24. Pathophysiology

25. Adenomyoma

26. Adenoma & fibroids

27. Adenomyosis vs endometriosis

28. Laparoscopically Resected Uterine Adenomatoid Tumor with Coexisting
Endometriosis: Case Report
Nobuyuki Sakurai, MD, PhD, Yasuhiro Yamamoto, MD, Yasuyuki Asakawa, MD, PhD, Hideki Taoka, MD, Kei Takahashi, MD, PhD
and Kaneyuki Kubushiro, MD, PhD
Journal of Minimally Invasive Gynecology
Volume 18, Issue 2, Pages 257-261 (March 2011)
DOI: 10.1016/j.jmig.2010.11.009
Copyright © 2011 AAGL Terms and Conditions

29. FIBROIDS

30. Definition
• Noncancerous growths of the uterus
• Often appear during childbearing years
• Also called fibromyomas, leiomyomas or myomas
• Mostly discovered incidentally

31. Locations

32. Symptoms
• Heavy menstrual bleeding
– Usually cyclical
– Prolonged menstrual periods — seven days or more of
menstrual bleeding
– More likely to be associated with anaemia
• Pelvic pressure or pain
• Frequent urination
• Constipation
• Backache or leg pains

33. Subserosal

34. Multiple fibroids

35. Pain
• Rarely, a fibroid can cause acute pain
– when it outgrows its blood supply
• Deprived of nutrients, the fibroid degenerates
• Causing pain and fever
• Pedunculated fibroids can trigger pain by twisting on its
stalk and cutting off its blood supply

36. Pelvic inflammatory disease/pelvic infection
PID

37. Definition
• Pelvic inflammatory disease (PID) - infection of the
female reproductive organs
• Occurs when sexually transmitted bacteria spread from
the vagina to the uterus and upper genital tract
• Important to avoid because it can result in infertility or
ectopic pregnancy
• Prompt treatment of a sexually transmitted disease can
help prevent PID.

38. Causes
• Unsafe sexual practices
• IUDs may increase risk of PID
• Barrier method, such as a condom, reduces the risk
• Bacteria may also enter the reproductive tract as a result
of an IUD insertion, childbirth, miscarriage, abortion or
endometrial biopsy
• Most common
– Chlamydia
– Gut organisms
– Fungal

39. Liver adhesions

40. Uterine adhesions

41. Complications
• EP
• Infertility
• Chronic pelvic pain

42. PID

43. Symptoms
• Pain in the lower abdomen and pelvis
• Heavy vaginal discharge with an unpleasant odor
• Irregular menstrual bleeding
• Dyspareunia
• Low back pain
• Fever, fatigue, diarrhea or vomiting
• Painful or difficult urination

44. PID Video

45. EVALUATION

46. Differential Diagnosis for Chronic Pelvic Pain
Gynecologic Gastrointestinal
•Endometriosis •Irritable bowel
•Adhesions •Chronic appendicitis
–Endometriosis
•Inflammatory bowel disease
–PID
•Diverticulosis
•Leiomyomata
•Meckel’s diverticulum
•Adenomyosis

47. HOCI
• Rule out pregnancy
• Gynecologic history
– onset, duration, location, and character of pain
– gravity, parity, menstrual history, history of STI
– Severity of pain & its relationship to the menstrual cycle
• Important associated symptoms
– include vaginal bleeding
– vaginal discharge
– symptoms of hemodynamic instability (eg, dizziness, light-
headedness, syncope or near-syncope)

48. Types of pain
• Visceral pain
• Referred Pain
• Somatic Pain
• Myalgia
• Hyperalgesia
• Neuroinflammation

49. System review
• Seek symptoms suggesting possible causes
– morning sickness, breast swelling or tenderness, or missed
menses (pregnancy)
– fever and chills (infection)
– abdominal pain, nausea, vomiting, or change in stool habits
(GI disorders)
– urinary frequency, urgency, or dysuria (urinary disorders)

50. Past history
• Note history of
– Infertility
– ectopic pregnancy
– pelvic inflammatory disease
– Urolithiasis
– Diverticulitis/GI prolems
• Any previous abdominal or pelvic surgery should be
noted

51. Physical examination
• Begins with review of vital signs for signs of instability
– eg, fever, hypotension
• Focus on abdominal and pelvic examinations
• Begin with inspection

52. Thrombosis of the Inferior Vena Cava and Dilated Veins of the Trunk
Roncato C, Lefant PY. N Engl J Med 2011;364:2535-2535.

53. Abdominal examination
• Palpation for
– Tenderness
– Masses
– peritoneal signs
• Location of pain and any associated findings may
provide clues to the cause
• Rectal examination is done to check for tenderness,
mass, and occult blood.

54. Pelvic examination
• Inspection of external genitals, speculum examination,
and bimanual examination
• Cervix - inspected for discharge, uterine prolapse, and
cervical stenosis or lesions
• Bimanual examination - assess cervical motion
tenderness, adnexal masses or tenderness, and uterine
enlargement or tenderness

55. Investigations
• Pregnancy tests
• Urinalysis
• Ultrasonography
• Blood tests

56. Ultrasound hydosalpinx

57. Lap endometriosis

58. KEY POINTS

59. Key points
1. Pelvic pain is common and may have a gynecologic or
nongynecologic cause.
2. Pregnancy should be ruled out in women of
childbearing age.
3. Quality, severity, and location of pain and its
relationship to the menstrual cycle can suggest the most
likely causes.
4. Dysmenorrhea is a common cause of pelvic pain but is a
diagnosis of exclusion

60. References
• The Merck Manual – Pelvic Pain
• Mayo Clinic - mayoclinic.com/health/chronic-pelvic-
pain/DS0