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ESSAY 136 - CHRONIC PELVIC PAIN

Posted by Sarwat F.
The differential diagnosis in this case includes gynaecological and non gynaecological causes. Gynaecological causes include endometriosis, adenomyosis, chronic pelvic inflammatory disease, uterine fibroids, intrauterine contraceptive device, adhesios resulting from previous surgeries. Nongynaecological causes include gastrointestinal causes like diverticulitis, crohn’s disease, irritable bowel syndrome and chronic constipation. Urological causes include interstitial cystitis. Other illnesses like psychosocial illnesses depression, pelvic congestion syndrome and sexual abuse can also give rise to chronic pelvic pain.
Diagnostic steps would include history, examination and investigations. History will include the general introduction like the occupation and outlook of patient. This is important as nongynaecological causes like irritable bowel syndrome has association with personality types. It is also important for causes like depression and sexual abuse. Then details about pain are asked like its onset and radiation to get some clue about its origin, factors that increase or decrease pain like menstruation, defaecation, walking as pain associated with IUCD increases during menstruation and pain associated with irritable bowel syndrome is relieved by defaecation. Severity of pain is assessed by asking the effect of pain on daily activities, its timing and presence of various acute abdominal symptoms as can occur in patients with endometriosis. What treatment patient has taken already for this complaint and any investigations already done. Any associated symptoms like abnormal vaginal discharge, heavy periods, fever, headache, backache, nausea and vomiting if present should be asked for PID. Any symptoms related to urinary tract like frequency of micturition, dysuria and urgency are asked for the possibility of urological causes. Menstrual history should be asked like duration per cycle any history of passage of clots, any history of inter menstrual bleeding as bleeding may occur from fibroid polyps. History of contraception should be asked, like IUCD or any other. Sexual history is asked including number of sexual partners and use of any condoms. As she already has dysperunia it should be asked if it is superficial or deep. Past obstetric history is asked including number of previous pregnancies any history of miscarriages and any uterine evacuation needed, mode of previous child births. Past medical history is asked including any history of gastrointestinal disturbances, any chronic constipation or diarrhea and any treatment taken for it. Past surgical history is asked including the indication of surgery. Then psychological history is asked like patients outlook for future, her future plans. History of sexual abuse is also asked very carefully as this is a very sensitive issue. After history examination is carried out including general physical examination, abdominal and vaginal exam. On abdominal examination any abdominal tenderness or presence of any mass is noted as can occur with pelvic inflammatory disease or fibroid. Vaginal examination is done starting with inspection to note any vaginal discharge, then palpation (pervaginal examination) is done to check any tenderness on examination or mobility of uterus. This should be carried out very gently as patient is already complaining of dysmenorrohea and dysperunia. Size of uterus is checked as may be enlarged in adenomyosis, its shape, mobility and tenderness . Any mass in pouch of Douglas or adnexa as can occur in endometriosis. Then certain investigations are done. These include full blood count to check for hemoglobin, for menorrhagia associated with endometriosis and WBC count for leukocytosis associated with PID, C reactive protein is done which indicate any inflammatory process. Midstream specimen of urine is checked for any pus cells as may occur in cystitis. High vaginal swabs, urethral and endocervical swabs are taken for PID caused by Chlamydia and culture is sent. Transvaginal ultrasound will help in checking pelvic masses if clinical examination is suspicious. It will also be reassuring for woman if no abnormality is found on ultrasound. If history and examination suggest endometriosis, then laparoscopy is the gold standard for diagnosis of endometriosis. Multidisciplinary input may be needed if no case can be found to evaluate for gastrointestinal and urological causes.

Posted by vijaya L.
Chronic pelvic pain is responsible for 10% of gynecological referrals, 40% of diagnostic laparoscopies and around 20% of hysterectomies.
The most probable underlying diagnoses in this parous woman with chronic pelvic pain associated with dysmenorrhoea and dysparuenia are adenomyosis of the uterus, pelvic endometriosis, post surgical adhesions, chronic pelvic inflammatory disease, fibroids, pelvic congestion syndrome, and irritable bowel syndrome.
The appropriate diagnostic workup constitutes complete history, followed by clinical examination and relevant investigations.
She should be asked about LMP, menstrual flow, previous surgeries, any change in the bowel habit and previous diagnostic and treatment interventions.
The impact of the symptoms on her daily routine and sleep should be noted.
Clinical examination may show enlarged tender uterus in adenomyosis, adnexal masses and or tenderness in endometriosis and chronic PID. In many cases it may be normal.
Blood should be taken for FBC and CRP to rule out acute inflammation.
Ultrasonography is useful in adenomyosis, fibroids and endometriomas. If doppler facilities are available pelvic congestion can be looked for. Negative ultra sonogram can be of reassurance
CA 125 is raised in many pelvic and general peritoneal conditions. It is not useful in diagnosis, but may lower the threshold for laparoscopy and is useful in follow up of certain conditions like endometriosis.
Diagnostic laparoscopy the most important step in diagnosing pelvic endometriosis, adhesions, pelvic congestion and fibroids. When done under local anesthesia, pain mapping is feasible. If appropriate counseling has been done can be converted into operative laparoscopy.
Negative laparoscopy is reassuring most of the time.
MRI is useful in diagnosing deep infiltrating endometriosis, which can easily be missed by both ultrasonography and laparoscopy.
Colonoscopy in case she has a change in bowel habit.


Posted by narmin B.
Differential diagnosis of chronic pelvic pain includes gynaecological and non gynaecological diseases. Gynaecological causes are: endometriosis in the form of peritoneal endometriosis, ovarian endometrioma; vaginal tears after normal delivery; primary or secondary dysmenorrhoea; cervical stenosis; chronic pelvic inflammatory disease in the form of hydrosalpinx, oophoritis, endometritis; pelvic adhesions due to infection or surgery ; pelvic congestion syndrome; functional ovarian cysts, ovarian neoplasm; fibroids or adenomyosis and genital tract prolaps in the form of rectocele,cyctocele and uterine procedentia.
Non gynaecological causes are: gastrointestinal diseases such as irritable bowel diseases or colitis; musculoskeletal problems; neurological diseases and psychogenic pain (for example due to sexual abuse or other psychological causes).


Obtaining a good history is very important. For example endometriosis is suspected in patients with cyclical dysmenorrhoea, deep dysparenuia and pain during defecation. Nevertheless other conditions may also present with these symptoms which they should be excluded. Enquiry about the mode of delivery is also important. Although deep vaginal tears and tight suturing can cause dysparenuia but they do not normally cause chronic pelvic pain or dysmenorrhoea. If the mode of deliveries were by caesarean section, there may be post operative adhesions which can explain this patient?s symptoms. Breastfeeding is associated with anovulation, amenorrhoea and atrophic vaginitis subsequently due to oestrogen deficiency. Although this may cause dysparenuia but it does not normally result in dysmenorrhoea or chronic pelvic pain. Presence of symptoms such as intermittent diarrhoea and constipation may indicate that the patient may have not only a gynaecology problem but also other conditions such as irritable bowel or colitis. In these cases a referral to gastroenterology team is required for further diagnostic tests such as rectosigmoidoscopy, colonoscopy and biopsy. Also enquiry about past sexually transmitted diseases such as Chlamydia and gonorrhoea and their treatment is mandatory. Her symptoms may be due to the long term consequences of those infections especially in untreated cases.

Examination of the patient is similarly important. An abdominal examination may reveal presence of an abdominal mass or tenderness. Speculum examination is useful in diagnosing conditions such as atrophic vaginal changes, vaginal discharge and cervical ectropion. An endocervical and high vaginal swabs can be taken during examination which may show Chlamydia or other infections. Also in bimanual examination consistency and mobility of masses can be assessed. As for example an irregular hard mass may indicate the presence of a fibroid uterus while ovarian cysts may be felt as smooth and cystic structures. If the mass occupies the pouch of Douglas it can cause deep dysparenuia. Also nodularity of uterosacral ligaments indicate possibility of uterosacral endometriosis which is a reason for dysparenuia.


Ultrasound scan especially transvaginal scan is also useful in identifying the cause of chronic pelvic pain. Although It is useful in diagnosing uterine or ovarian masses and sometimes hydrosalpinx, but it cannot diagnose peritoneal endometriosis or pelvic adhesions. Nevertheless ovarian endometrioma may be suspected if there was an ovarian mass with a mixed echo. Measuring CA125 level is helpful in the presence of an ovarian mass. However it is not a diagnostic test and it may raise both in benign conditions such as endometriosis, infection and also in epithelial ovarian cancer.


Diagnostic laparoscopy is an important step in diagnosing the cause of pelvic pain. This test may cause surgical or anaesthetic complications but it is the gold standard for diagnosis of endomeriosis.and also other conditions such as pelvic congestion, peritoneal adhesions, sub serous fibroids and ovarian tumours can be seen. Additionally an ovarian biopsy can be taken if there is suspicion of malignancy. Also culture and sensitivity tests of peritoneal fluid may show presence of an infection. Aspirated fluid from an ovarian cyst or peritoneal fluid can be sent for cytology assessment if there is possibility of malignancy.
Posted by anuraag M.
Pelvic pain,dysmenorrhea&dyspareunia are the common presting symptoms of women of reproductive age with some pathology in the pelvis.various causes which can be thought of are endometriosis,ectopic preg,ovarian cysts,fibroid uters,PID,pelvic abcsess,TOmass,appendicitis,chronic cystitsand inflammatory bowel pathology.
A detailed history with leading questions will enable to derive to conclusion about possible condition.cyclical pain which increases with menstruation may be suggestive of endometriosis,severe degree pain withperiod of amenorrhea&infertility inectopic preg,pain with urinary symptoms like freqency.dysuria, urgency seen withUTI,irregular cycles with pain in one of the illiac fossa inovarian cyst,pain with menorrhagia points towards fibroid .diarrhoea may be present in bowel disease
general physical examination may find poor nourishment and anemia in UTI ,PID&bowel disease.Abdominal examination done to rule out any mass arising from the pelvis and for presence of
asites. tenderness in Macburneys point for appendicitis.
Discharge from cervix is found on local examination in PID.tender cervical movements inectopic pregnancy .nodularitymay be found in posterior fornix in endometriosis. Firm uterine mass with transmitted movements from cervix indicates fibroid.
FBC,C/S of urine ,high vaginal &cervical swabs identifies infection.cervical smear taken if not done earlier.urine routine& preg test,screening for HIV.hepatits B&C,chlamydia,syphilis,gonorrhea .CA125 levels are done which may be raised inendometriosis &ovarian tumours.Scanning preferabally TVS which can differentiate pelvic masses from each other isdone.
Laproscopy is the gold standard test for accurate diagnosis.direct visualisation and sampling can be done of suspicios areas. consent be taken after explaining the risks and benefits of diagnostic lap before procedure
The most likely diagnosis in this case is endometiosis and it can be confirmed by presence of endometriotic spots,endometioma.adhesions involving tubes, overy&POD.
Posted by Nibedita R.
Pelvic pain, deep dyspareunia and dysmenorrhoea are symptoms related to many gynaecological and non-gynaecological causes.
Gynaecological causes can be endometriosis, adenomyosis, chronic PID, uterine polyp/fibroid and intrauterine contraceptive device. Non-gynaecological causes may be gastrointestinal causes such as inflammatory bowel disease and irritable bowel syndrome; urological causes include UTI, interstitial cystitis, chronic urethral syndrome; others include pelvic congestion syndrome, musculoskeletal pain, psychiatric illness (depression) or even sexual abuse.

To reach a definitive diagnosis, a detailed history, examination and investigations are the necessary steps.

While taking a history, identification of a symptom group may be useful. It is very difficult to make a definitive diagnosis on history alone, as there is overlap of many symptoms. Nature of pain, whether cyclical or non-cyclical; as non cyclical pain may be associated with IBS, IBD and other non gynaecological causes. Deep dyspareunia, dysmenorrhoea and chronic pelvic pain may be symptoms of endometriosis, pelvic congestion syndrome or chronic PID. Pain of pelvic congestion and endometriosis gets worse premenstrually. Relief of pain at the onset of menstruation may signify pelvic congestion syndrome and persistent pain throughout menstruation may be suggestive of endometriosis. Pain of PID may be unrelated with menstrual cycle, although aggravation may occur premenstrually. Pain variable in nature and location, radiation through to back or down legs, exacerbated on standing or relieved on lying down may be suggestive of pelvic congestion syndrome.

Dysmenorrhoea when associated with menorrhagia may suggest adenomyosis, uterine polyp/fibroid or pelvic congestion syndrome. Deep dyspareunia may be associated with non gynaecological causes such as IBS or interstitial cystitis.
Episodes of pain more than once monthly, diarrhoea/ constipation or alteration of bowel habits, relief of pain with defecation, bloatedness may suggest irritable bowel syndrome.
Dysuria, frequency, nocturia, haematuria and suprapubic pain relieved by micturation is suggestive of interstitial cystitis. Cyclical bleeding per urethra or per rectum occurs in endometriosis.
Impact of pain on patients lifestyle is important to assess severity of pain, although this may not correlate with the severity of the disease.

Past history of abdomino-pelvic operations may be suggestive of adhesions. Termination of pregnancy, instrumentation, IUCD insertion and STDs should be taken into consideration to reach a diagnosis of PID. Commencement of pain since childbirth and history of endometritis and pelvic infection following delivery may suggest PID.

History of any psychiatric illness specially mood disturbance should be elicited.

Examination- general examination may detect anaemia. Abdominal examination may detect abdominal mass, tenderness, rebound tenderness or guarding. Trigger point suggestive of nerve entrapment. Examination of lumbosacral area for any bony tenderness. Speculum examination may show a polyp and purulent discharge through os is suggestive of PID.
Bimanual examination ? Uterine size - enlarged in fibroid, adenomyosis. Shape ? maintained in adenomyosis or fundal fibroid, may be distorted in fibroid. Mobility ? restricted in pelvic adhesions or endometriosis. Fixed retroverted uterus may be due to pelvic adhesions or endometriosis. Nodularity in the pouch of Douglas in endometriosis. Cervical excitation ? positive test may be suggestive of PID. Adnexal mass may be present in PID and endometriosis. Adnexal tenderness may pin point pelvic congestion syndrome.
Rectal examination ? tenderness and nodularity in rectovaginal septum in endometriosis.

Investigations ?FBC for anaemia. CRP/ESR for evidence of inflammatory process. Encervical swab for culture of chlamydia, urethral and anal swabs for gonorrhoea. Urine- dipstix for blood, microscopy and culture to exclude urinary pathology. Cystoscopy if suggestive of interstitial cystitis. Barium meal/ proctoscopy/ sigmoidoscopy if IBS or IBD suspected. Pelvic ultrasound ? has limited value if normal pelvic examination, although a negative scan is reassuring. Cannot exclude adhesions and endometriosis. Helpful for the assessment of pelvic mass and uterine fibroid.

CA125 ? when raised may indicate endometriosis and PID.
Laparoscopy ? diagnostic laparoscopy is the gold standard but is associated with anaesthesia and surgical morbidity including visceral injury, which may require a laparotomy. A negative laparoscopy will provide reassurance and often resolve symptoms, but also may lead to inappropriate treatment for example in minimum endometriosis.
Laparoscopic conscious pain mapping is a new technique in which laparoscopy is performed under local anaesthesia, so trigger pain may be identified and treated.
Posted by SWATI M.
The differential diagnosis includes gynaecological and non gynaecological causes . Gynaecological causes include endometriosis,adenomyosis,chronic pelvic infection,residual ovarian syndrome,fibroid polyps and intrauterine devices.
Gastrointestinal causes are irritable bowel syndrome,inflammatory bowel diseases,diverticular disease.Urological causes include interstitial cystitis,radiation cystitis.It may be due to psychosocial causes such as sexual abuse,depressive illness,pelvic congestion syndrome.Musculoskeletal causes may lead to chronic pain.
Detail history will help for the diagnosis.History of chronic pain ,dysmenorrhea which persist after start of menstrual flow ,associated fertility problems,premenstrual spotting suggest endometriosis.Past history of acute pelvic infection with polymenorrhea suggest chronic pelvic infection.Fibroid polyp will cause labour like pain during menstrual flow .Past history of hysterectomy with cyclical pain suggest residual ovarian syndrome.Use of contraceptive,IUD noted.Sexual history ,history of child abuse,stress is important to find cause.Associated bowel symptoms of diarrhea,constipation,rectal bleeding along with poorly localizing pain suggest a gastrointestinal cause.Urinary frequency,dysuria suggest urological cause.
Clinical examination-ovarian point tenderness present in pelvic congestion syndrome . Endometioma may be palpable on abdominal examination.Speculum examination can see endometrial deposits,fibroid polyp.Nodularity in the posterior fornix with fixed retroverted uterus suggest endometriosis.In adenomyosis uterus will be tender and bulky.
Fibroid polyp can be palpated.Per rectal examination will be indicated if gastrointestinal symptoms.No differentiating clinical findings will be present in chronic pelvic infection,residual ovarian syndrome,urinary causes.
Investigations- depend on cause suggested by history and clinical examination. Endocervical and urethral swab taken for culture and ELISA or PCR test for chlamydia.Tests may be negative in chronic infection.
MSU collected for microscopy and culture.It may be negative.
Ultrasonography findings are usually normal and reassuring to most of the women .It can diagnose endometrioma but small endometrial deposits are missed.It can visualize follicular activity in residual ovarian syndrome and dilated pelvic vessels in pelvic congestion syndrome.
MRI scan helpful to dignose small endometrial deposits and in adenomyosis but expensive and availability is limited.
Laparoscopy is gold standard in the differential diagnosis.Woman can be reassured if normal findings.It has a potential for treatment for endometriosis,adhesiolysis.But has inherent risk of visceral,vascular injuries,anaesthesia complications.It may lead to overtreatment of adhesions.
Posted by Vaijayanti R.
Chronic pelvic pain could be due to gynecological as well as non gynecologicai causes
Gynecological causes include adenomyosis,endometriosis, fibroid uterus, tubal injury from infection/surgery,tubal ligation,ovarian cysts / neoplasia, remnant ovary, residual ovary, pelvic inflamatory disease, endosalpingosis, dysmenorrhoea.
Non gynecological causes include gastro intestinal disorders ( chronic constipation, irritable bowel syndrome, inflammatory bowel disease,diverticulosis, malignancy), neurological and skeletal involvement( lumbar disc prolapse, multiple sclerosis),
Urinary tract disease( interstitial cystitis, chronic urethral syndrome) muscular ( muscle spasm, pyriformis syndrome), peritoneal( adhesions, lacerations/ tears, irritation by blood or pus), metabolic disorders( acute porphyria, sickle cell disease
, hemachromatosis)vascular ( pelvic congestion syndrome) and Psychogenic.

Evaluation of this woman will include a detailed history, examination and investigations.
As she has long standing pain,the type of pain, site, radiation, any remissions and exacerbations, triggering factors relation to bowel and bladder habits and menstruation, progression in the intensity of pain, and requirement of pain relief is asked.Any treatment taken for the same is also noted.As she also complains of dysmenorrhoea, detailed history regarding the same should be elicited( progression, duration, requirement of pain relief)Pre/ post menstrual pelvic soreness would indicate endometriosis.Intermenstrual bleeding could indicate a submucous fibroid / polyp.Details of her bowel and bladder habits are elicited ? chronic constipation, alternating constipation and diarrhoea,blood in stools, pain on passing urine.Details of her contraceptive practise are asked for. An intrauterine device could give rise to chronic pelvic pain. Sterlization if done is asked for.Prior history of having any treatment for pelvic inflamatory disease,or high risk behaviour is necessary to rule out sexually transmitted disease.
Prior surgery on the abdomen or pelvis could indicate the development of adhesions.
History of sexual disorders , including sexual abuse must be elicited with sensitivity.
Familial background can reveal herediatry conditions like sickle cell disease.
Occupational history could indicate some environmental triggers of pain
While history can only indicate the probable underlying cause, it must be remembered that many disorders have similar clinical presentations.
The abdominal and pelvic examination should try to localize the pain as much as possible.Look for abdominal mass , tenderness, guarding rebound tenderness. Pelvic examination should look for the size, shape, mobility of the uterus,adnexal masses, tenderness on movement of the cervix , vaginal infections. A rectovaginal examination should identify any nodularity of the uterosacral ligaments, spasm of the levator ani.General physical appearence can indicate anemia, depression.Physical examination may not reveal any underlying cause of the pelvic pain.But history and examination together may indicate the same ( uteroscral nodularity with dyspareunia,dysmenorrhoea ,premenstrual pelvic soreness would be highly suggestive of pelvic endometriosis)

MSU for microscopy and culture to exclude any urinary tract infection.Urethral and endocervical swabs for chlamydia and gonococci which are associated with chronic pelvic infection.CBC and CRP identify any inflammation ; especially useful in inflamatory bowel disease. Though these markers are highly non specific.Anemia with characteristic appearance of RBC would suggest Sickle cell disease.
USG of the pelvis will identify any masses in the pelvis ? this is a cheap and easily available diagnostic tool; however is not of much use in detecting peritoneal causes/ endometriotic implants. A trans vaginal USG is the preferred mode of pelvic asessment, though some women would find this unacceptable.
Laparoscopy has been claimed to be the ?gold standard? in the diagnosis of chronic pelvic pain. While the obvious advantage is the simultaneous treatment that can be offered if a cause is detected ; the risk of over treatment especially in cases of mild endometriosis.Also the procedure is associated with inherent risks of surgery and anesthesia. Laparoscopic pain maping is a new procedure which helps is identifying the ? trigger points? for the pain and treating the same.
MRI is a non invasive technique that may be used for diagnosis ; especially useful in detecting adenomyosis, infilterating endometriosis. However, the patient may have to undergo a therapeutic procedure subsequently.
Gastrointestinal causes may require a colonoscopy
Posted by SWATI M.
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Posted by Rani M.
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Posted by Rani M.
Her symptoms may be due to gynaecological cause like endometriosis, fibroids chronic PID, adenomyosis, pelvic congestion syndrome; due to GIT cause like irritable bowel syndrome, inflammatory bowel diseases or bowel adhesions; due to urological cause like UTI or interstitial cystitis; due to musculoskeletal or neurological causes and due to psychosexual cause. Non gynecological disease can also present with cyclical pain and symptoms.

A good hostory can be very informative. history of alternating diarrloea & constipation, relief on defaecation and aggravation of pain on taking food may be due to irritable bowel syndrome
complaints like burning and frquency of mictuiration, suprapubic pain may suggest urological causes.
pelvic congestion syndrome is associated with paIN of variable nature, aggravted on standing and relived on lying down.
If sexual abuse or psychosexual causes are suspected, history should be taken with sensitivity and subtly and in a set up where psychological and psychiatirc help is available.
Detailed examination can not be underestimated. Abdminal examination may reveal sites of tenderness, any masses,& tender caecum..Pelvic examination will help to look for fibroids, pelvis masses. nodules in the pouch of douglas, and fixed retroverted uterus is seen in endometriosis. Chronic PID is suggested by tender fornices, or pelvic masses.
Investigations are directed as per clinical features.Complete blood counts, (WBC), ESR,&C RP are( non specific )markers of chronic infection but are simple and non invasive and therefore done.If clinical features suggest GIT problems, stool analysis, is done and she may need barium enema, endoscopy and referral to GIT surgeon.
MS.U. and urine culture is done if symptoms suggest UTI and other urological symptoms will require urological consultation. IVP or cystoscopy are done as directed by clinical features.
High vaginal swabs, and endocervical swabs are done if there is suspician of chronic PID ,& to look for chlamydia.
Ultrasound is a non invasive and sensitive method to detect fibroids, adnexal masses and endometriosis . there is evidence that if nothing , a negative ultrasound may be helpful in reassuring patient.
Laproscopy is gold standard for the diagnosis of endometriosis and chronic PID but it should not be undertaken unless the symptoms are highly suggestive of endometriosis and medical teeatment has failed .Routine laproscopy may cause erroneous diagnosis and in appropiate treatment as mild endometriosis may be attributed to be a cause of her symptoms. there is no evidence that routine laproscopy is helpful in reassurance of patients.