The smart way to learn. The smart way to teach.

MRCOG PART 2 SBAs and EMQs

Course PAID
notes336
EMQ1502
SBA2115
Do you realy want to delete this discussion?
Forum >>

ESSAY 186 - PELVIC PAIN

Posted by Sarwa aldoori A.
pelvic pain can be caused by gynecological and non gynecologic cause among gynecologic cause are endometriosis , pelvic inflammtory disease, polycystic ovary disease, adenomyosis, pelvic venous congestion fibroid uterus .Anon gynecologic involves gastrointestinal as irritible bowel disease, diverticulitis.Urinary tract problems as calculus, aldo X ray of spine as osteoarthrits , disc prolapse.
Diagnostic approach starts with blood work up with full blood count , ESR, differential, urine exam, x ray lumbar spin, also psychologic assement of the patient. Ultrasound scan will help to rule out fibroid uterus, polycystic ovary diseae, endometrioma, adenomyosis. Laproscopy isvery useful as it laooows direct visualisation of adhesion ,powder burn ,deposits of endometriosis on the ovary , uterosacral ligamnt.A wide range medical treatment is available depending on the patient aspiration , from steroids as danazol, continuous progestogen, gestrinon, GnRh analogu. Non steroidal antiinflammatory are helpful in releivivng the pain associated with endometriosis.Also surgicla approach from ablation using electrosurgical, or laser evaporation. rdical surgery if the aptient feel acceting it however she need to know that it might not releive the pain.
Adhesions of pelvic inflammtory dieses can be seen also aspirate for microscopy ,culture and sensitivity,and directed antibiotic therapy .As for pelvic venous congestion it maight be diagnose after negative laproscopy ,and positive history, also somtimes the use of B mode of uss and measurement of vein diameter, and teansuterine pevic venogram. the amnagement here will be high dose continuous progestogenwill help suppress ovulation . Hysterectomy will almost universally cure the patient. Psychotherapy is very effective in these patietn particularly if no assocaited abnormality cn be seen and psychologic assesment is very important, probing into history of child abuse,unresolved grief,whcih preferably done by referring to professional. negative laproscope may provide reassurance which will help tro resolve symptoms.
Posted by Srivas  P.
The likely diagnosis in this patient with dyspareunia and secondary dysmenorrhoea is Endometriosis, Chronic Pelvic Inflammatory disease, genital tuberculosis, pelvic venous congestion, adenomyosis, inflammatory bowel disease and fibroid uterus.

Complete history of pattern of pain, menstrual pattern, metrorrhagia, post coital bleeding, bowel habits, sexual history including STI, number of partners, history of IUCD use, any investigation which involved uterine instrumentation, HSG should be taken. She should be asked to maintain pain chart and pictorial chart for subjective assessment of blood loss. Inflammatory bowel disease may be diagnosed by using clinical symptoms alone in over 90 % cases by applying Rome?s criteria. Her psychological state of mind should also be assessed as her relationship with partner may be strained by dysmenorrhoea and thereby loss of confidence in herself.

Clinical examination to assess degree of anemia gives idea of severity of menstrual bleeding, pelvic examination to see if any gynecologic pathology, presence of cervical excitation pain with pelvic infection, size of uterus, presence of irregularity for possible fibroids, fixity of uterus and nodularity in pouch of douglas for endometriosis, any Tubo ovarian masses suggesting pelvic inflammation or genital tuberculosis can aid in diagnosis.

Investigations include FBC for anemia, TBC, ESR, CRP to aid in diagnosing pelvic inflammation, urethral swab, vaginal swab, and rectal swab to look for STI, Chlamydia, and gonococcus should be done. If PID is suspected clinically, it is best managed by a genitourinary medicine physician in order that up-to-date microbiological advice and contact tracing can be arranged. Opportunistic cervical smear should also be done. Transvaginal scanning and magnetic resonance imaging (MRI) are useful tests to diagnose adenomyosis, fibroids, ovarian mass. The role of MRI in diagnosing small deposits of endometriosis is uncertain.

Where pain is strikingly cyclical and no abnormality is palpable at vaginal examination, a therapeutic trial of a GnRH agonist may be more helpful than a diagnostic laparoscopy. Besides conditions such as irritable bowel syndrome and adenomyosis are not visible at laparoscopy and one-third to one-half of diagnostic laparoscopies may be negative thereby increasing the woman?s apprehension at not having found a cause for her ailment. Diagnostic laparoscopy also carries an estimated risk of death of approximately 1.0/10 000 and a risk of injury to bowel, bladder or blood vessel which may require a laparotomy.

Even if initial clinical assessment suggests endometriosis such as a fixed retroverted uterus or recto-vaginal nodularity or she has atypical symptoms such as rectal bleeding during menses she may respond to medical treatment and diagnostic laparoscopy may be deferred unless she fails to respond to medical treatment and it is required to laproscopically treat these unresponsive lesions.

Treatment principally involves treating anemia, treating pelvic infection with appropriate antibiotics depending on organism involved, IBD if found to be treated with antispasmodics and diet modification.

Ovarian suppression with COCP, continuously progestogens for 6 months or LNG IUS may control excess menstrual bleeding and associated pain due to endometriosis. Pelvic venous congestion, also appear to be well-controlled by ovarian suppression. Danazol, gestrinone, GnRH are equally effective but have unpleasant side effects and this limit their prolonged use beyond 6 months. Danazol may cause hot flushes, acne and virilization while GnRH can cause hot flushes and significant bone loss. NSAIDS like fenamates and tranexamic acid may help reduce bleeding and control pain. She should be introduced to National endometriosis society to help her understand and cope with her condition better.

If she does not respond she may be referred to pelvic pain clinic. Non Pharmacologic treatments with acupuncture, transcutaneous nerve stimulation may also be tried.

Multidisciplinary approach to this chronic pain is more effective with involvement of urologist, gastroenterologist, genitourinary medicine physician, physiotherapist, psychologist or psychosexual counselor

Posted by Farzana N.
Differential diagnosis in this case would be gynecological causes such as endometriosis, pelvic inflammatory disease, adenomyosis and fibroids or Non-gynecological causes such as IBS, inflammatory bowel disease or chronic constipation
To reach a diagnosis a good history should be taken followed by a thorough clinical examination and relevant investigations.
H/o cyclical pelvic pain, worse premenstrual and infertility, if present with Dysmenorrhea and dyspareunia are diagnostic symptoms of endometriosis.This may also be associated with cyclical rectal bleeding and hematuria.Sexual history,any h/o of PID and its treatment,whether partner was also treated is important since inadequately treated PID and exposure to multiple partners is highly suggestive of chronic PID.Menstrual hist, regarding excessive bleeding ?suggestive of adenomyosis.
H/o of bowel habits ,any change in frequency or appearance of stools-h/o wt loss,. suggestive of inflammatory bowel disease/IBS.
General examination for any pallor due to menorrhagia.Abdominal examination for any abdominopelvic masses. Pelvic examination should assess size, position and mobility of uterus. which may be fixed,rretroverted and tender in case of endometriosis. Cervical excitation in case of PID,Adnexae palpated for any masses or tenderness.
Investigations include,FBC,ESR and CRP to detect infection. or inflammation ,in cases of IBD /PID.Urine dipstix for hematuria due to bladder pain.Swabs for pathogens such as chlamydia.CA 125 . raised in endometriosis and PID.Bowel studies-Barium studies if considerable bowel symotoms are present.Pelvic USS,TVS may identify endomerioma.A negative scan would be reassuring.MRI is non invasive and useful in the diagnosis of deep infilterating endometriosis.Laparoscopy may have to be undertaken as a last resort.Finding of endometriotic tissue and adhesions would confirm the diagnosis of endometriosis.But the procedure carries risk of anesthetic and surgical complications including visceral injury..
Therapeutic options would be guided by any positive findings on examination and investigations.If no underlying cause is found reassurence may be sufficient.Antibiotics should be given if infection.Pt may need to be referred to GI physician if bowel symptoms are significant.or to GUM if PID is diagnosed Simple analgesics or NSAIDs may be given to relieve pain.
In case of endometriosis COCP may be given if she is not desirous of conception.Danazol and GnRH analogues and Gestrinone can be given but they have significant side effects, which limits their use Danazol may cause hirsutism, acne and breast atrophy,.GnRHa may cause hot flushes and loss of bone mineral density. Resistant cases may benefit from treatment by the pain clinic.Altrernative therapies such as acupuncture and transcutaneous nerve stimulation(TENS) may be helpful in some cases.Psychological support should be given all along as it forms an important part of treatment..
Posted by Vaani M.
The most likely diagnosis in this woman would be endometriosis. The other possible diagnoses would be pelvic inflammatory disease, adhesions, or irritable bowel syndrome.

A detailed history of her duration of pain, severity, site, and how much it is affecting her daily life should be taken. History of previous surgeries, abortions, should be elicited. Past history of treatment for sexually transmitted infections should be noted. History of use of intrauterine device in the past should be elicited. History of previous treatment for the same condition should be verified.

Examination would include abdominal examination to know the location and extent of pain. Pelvic examination for site of pain, adnexal tenderness, adnexal masses. A menstrual examination may help in the diagnosis of endometriosis with nodules of endometriosis felt.

Investigations would be a full blood count and urine analysis. The other investigations would be as per the examination findings. A course of analgesics as paracetamol or codeine and dietary modification could be tried if not given in the past before further investigations. If endometriosis is suspected a laparoscopy needs to be done to confirm diagnosis and extent and location of disease. MRI would help in diagnosis of ovarian endometrioma and peritoneal disease.

Treatment would depend on woman\'s desire for relief of pain, future fertiliy plans, her disease severity, location, site and extent of disease. For mild disease pain relief could be obtained with hormonal treatment as oral contraceptive pills, gonadotrophin releasing hormone analogue, or danazol all being equally effective but with differing side effects. Pills would lead to contraceptive effect and loss of fertility, GnRHa have menopausal effects, danazol has androgenic effects and chances of pregnancy is not increased or advisable with these medical treatments. Fertility could be increased with surgery as ablative surgery in the form of laser or electrocautery. Endometriosis of moderate to severe nature could be treated surgically by stripping of cyst wall or cystectomy if affecting ovary. Stripping of cyst wall or fenestration and coagulation could be followed by 3 months of GnRH analogue, if recurrence occurs cystectomy could be done. Cystectomy would again lead to decrease in fertility due to loss of ovarian volume and primordial follicles. Adhesions if present could be managed by adhesiolysis at the same laparoscopic surgery. Management would involve the surgeon, anaesthetist, gynaecologist, and the woman herself and her wishes after appropriate informed consent for surgery if required.

Posted by Sreekala S.
The differential diagnosis in a woman with dyspareunia and dymenorrhoea would be Pelvic endometriosis, Pelvic inflammatory disease, Adenomyosis, Irritable bowel syndrome, Pelvic venous congestion and fibroid uterus.
The woman should be approached sympathetically and examined systematically to know the exact cause of her pain.
A speculum examination and bimanual examination should be performed to look for any discharge P/V, size and position of the uterus, mobility and tenderness on examination.
Swabs should be taken to detect the presence of Chlamydia or Gonococci. A positive swab result supports but does not prove the diagnosis of PID. The absence of infection however does not rule out the diagnosis of PID. She should be referred to the GUM physician, antibiotics started in liaison with the microbiologist and contact tracing arranged if PID is diagnosed.
Pelvic endometriosis should be ruled out. A transvaginal scan should be done to detect any uterine or adnexal pathology. Transvaginal scan lacks the sensitivity to detect peritoneal endometriosis although it can detect ovarian endomtriomas.
MRI is a useful non-invasive test to detect deep peritoneal implants and extra peritoneal deposits.The main disadvantage is that it is expensive, not easily available, requires expertise and misses small endometrial deposits and therefore not generally recommended.
Diagnostic laparoscopy is the gold standard test in diagnosing endometriosis and adhesions.A tubal patency test can also be carried out if sub-fertility is also an issue at the same sitting. Laparoscopy carries the risk of death approximately 1/10000 and visceral injury 2.4/1000, of whom 2/3 may require laparotomy. The other disadvantage is that it cannot be used to diagnose adenomyosis or irritable bowel syndrome. In the presence of endometriosis, the disease severity on laparoscopy may not be proportional to the severity of symptoms. The risks and benefits of laparoscopy and the possibility of negative findings should be explained to the woman before embarking upon laparoscopy.
A therapeutic trial of COCP or GnRH analogues should be considered before going ahead with laparoscopy. It has been shown that there was both patient and physician satisfaction along with economic benefits with the use of COCP or GnRH analogues in making the diagnosis of endometriosis before laparoscopy.
NSAIDS remain the first choice in pain relief during periods. COCP, Progestogens,Danazol or GnRH analogues can be prescribed for symptom relief. She should be counselled that use of these medications may prevent her becoming pregnant during the usage. Laparoscopic ablation may be considered depending the severity of the lesions and if medical treatment fails. Treatment should be individualized taking into account her wishes. Hyseterectomy, although can relieve dysmenorrhoea, may not completely remove dyspareunia and therefore she should be discouraged from this option.
If no cause is found, then referral to the gastroenterologist, urologist, GUM physician, Physiotherapist, Psychologist or Psycho sexual counsellor should be considered.
Posted by lola A.
Respected sir:
Would you please mark my answer.
Thank you

Differential diagnosis of this case include: endometriosis , PID , ovarian cyst, pelvic adhesions ,inflammatory bowel disease , irritable bowel syndrome ,and chronic appendicitis .
Management of this patient should be sympathetically with continuous psychological support as chronic pain is associated with psychological distress.
To reach a diagnnosis, detailed history about the nature of pain , previous pelvic operations ,vaginal discharge and previous treatment for the condition and its results.
Examine the general condition, abdominal tnderness,right hypochondrial pain, and pelvi-abdominal mass.
Vaginal examination for cervical motion tenderness, adnexal tenderness ,adnexal mass and nodules in Douglas pouch .
Investigations should include CBC ,MSU for microscoy ,culture and sensitivity.
High vaginal smear , endocervical samples for infection screening.
Transvaginal ultrasonography for ovarian and adnexal mass.
Laparoscpy to detect ovarian and adnexal masses, tubo ?ovarian abcess,Douglas pouch, uterosacral or peritoneal endometrial lesions.
Treatment will be according to the cause.
Endomeriosis can be treated medically for reduction of pain ( NSAIDs ,COC , progestogens ,danazol ,and GnRHa . If fertility is required,laparoscopic destruction of the lesions may be beneficial otherwise,IVF should be considered.

If PID is diagnosed,antibiotics should be prescribed according to local sensitivities and culture results.
Laparoscopic adhesolysis and appendictomy if ppelvic adhesions and chronic appendicitis respectively.
Physician inclusion if non gynecological cause is suspected.
Exsersise balanced diet and stopping smoking may be of help.
In brief ,management of patient with chronic pelvic pain will depend on the cause.
Support groups and information leaflets are of great help.



Posted by adnan S.
The likely differential diagnoses are ?endometriosis
Chronic PID
Adenomyosis
Fibroids
Pelvic venous congestion ,non gyneacological causes are
IBS&inflammatory bowel disease.
Detailed history is taken regarding menstrualtion heavy painful menses,any inter-menstrual bleeding,h/ocontraception like IUCD which may be the cause,h/o post-coital bleeding and cervical smear history should be enquired .Regarding pain during sexual intercourse ,is the pain shooting pain on deep penetration indicate endometriosis orPID, as a dull ache following intercourse point towards pelvic congestion syndrome radiating to back or down to legs which exacerbate on standing and relieved on lying down however this assumption should only be made after excluding an underlying organic cause.H/OSTD or uterine instrumentations ,vaginal discharge may indicate PID.

Examination includes any signs of aneamia.Abdominal examination for palpable mass ,tenderness.Speculum examination of vagina is done to look for discharge . ,bluish or dark brown spots .Bimanual examination is done to assess the size, position ,tenderness& mobility of uterus fixed retroverted tender uterus ,rectovaginal nodules indicate endometriosis.Adenexal mass with tenderness along with cervical exitation point towards PID.

Following investigations are requested ,infection screening is done with vaginal ,endocervical &urethral swabs for microbiology.Blood for FBC for aneamia,ESR&,CRPfor infection ,CA125 may be useful in dianosis of endometriosis but is also elevated in PID.Pelvic USS is of limited value especially if normal pelvic examination but may reassure the patient.MRI is useful in the diagnosis of endometriosis,and adenomyosis,it is a non invasive test.Laproscopy is the gold standerd but carries the risk of aneasthesia and surgical morbidityincluding visceral injury requiring laprotomy.Offers opertunity for treatment ofendometriosis/adhesiolysis.

Treatment involve ,treatment of aneamia.Antibiotics if suspected/detected PID but efficacy in treating long term sequale is not known.COCP if not contraindicated significantly reduces painful periods &shown to be effective treatment for endometriosis associated pain &provides contraception also.NSAID analgesic and effective in reducing endometriosis associated pain.Progestogens in sufficient doses cause amenorrhoea effective in relieving pain .Danazol ,gestrinone GnRH agonist are alternatives but have significant side effects.Danazol is associated with acne hirsutism, muscle ache,weight gain ,breast atrophy ?reversible and deepening of voice.Gestrinone is associated with androgenic side effects and can virulise female fetus therefore contraceotion is essential.GnRH agonists are associated with menopausal side effects and treatment should be limited for 6 months..as there is loss of 6% bone mineral density.3 months course is as effective as 6 months course.Risk of relapse after cessation of therapy.Complementary medicine have some benefits but these have not been formally evaluated.Levonorgestrel IUS effective treatment for if menorrhagia ,reduces dysmenorrhoea and may be effective in relieving adenomyosis related pain,and effective contraception also.
Posted by Zaibunnisa khan K.
The differential diagnosis include endometriosis ,pelvic inflammatory disease (pid)uterine fibroids ,ovarin cysts, endometrial polyps ,intrauterine adhesions ,pelvic congestion syndrome, cervical stenois,intrauterine contraceptive devices ( iucd ),irritable bowel syndrome,inflammatory bowel disease or renal or ureteric calculus .and psychosexual disturbances
Diagnostic approach include detailed history ,examination and relevant investigations.
History should include severity of the condition ,its effect on daily work ,social and sexual life ,need for medication to relive pain,amount of mensteral flow .Her sexual history should be explored pain on penetration or deep seated ,about sexual satisfaction ,and multiple sexual partner .history of contraception hormonal or iucd and her wishes for fertility should be asked .Medical and surgical history of previous pelvic or abdominal surgeries as adhesion is one of the cause of pelvic pain.Family history of endometriosis and history of any psychological disorders should be asked .
Her general physical and full gynaecological examination should be performed. Any likelihood of pid should be investigated during vaginal examination by taking endocervical and high vaginal swabs. On bimanual pelvic examination uterine mobility, ,adenexal and rectovaginal masses ,nodularity ,tenderness should be noted .
Investigation should be directed to the under lying cause .Full blood count if associated menorragia .Microscopy and culture of swab for Chlamydia and gonorrhea and other stds. White cell count and ESR are raised in chronic PID but nonspecific.Pelvic ultrasound will demonesterate fibroids,ovarine cysts and endometrioma .Transvaginal is preferable than abdominal as offer more resolution.Laparoscopy is single most useful investigation to diagnose endometriosis,ovarin,cysts,pelvic inflammatory disease and allow treatment in cases of endometriosis.Hysteroscopy may be indicated to evaluate intrauterine pathology if indicated by imaging and may be combine by resectionof endoeterial polyp or submucus fibroid .
Therapeutic approach depend on underlying pathology and taking in account severity of the symptom ,extent of the disease and patient wishes for fertility .Therapeutic option include medical ,surgical and combine .Nonsteriodal anti-inflammatory drugs naproxen and ibuprofen,mefnamic acid may be effective in reducing pain associated with endometriosis.In case of PID appropriate antibiotic course should be started.
If she is not trying to conceive and there is no mass on examination , there may be a role for therapeutic trial of combined oral contraceptive or a progestogen to treat the pain symptoms suggestive of endometriosis without performing laparoscopy first.
Medical treatment of endometriosis include progesteronr alone or in combination with esterogen to produce pseude pregnancy state .combined oral contraceptive pills ,danazole and gonadotrophine releasing hormone agonists. The guide line from the Royal college of Obstetrician and Gynaecologists on the medical management ,states that all medical treatment are equally effective in relieving endometriosis associated symptoms but the choice should be based on adverse effect profile which limit their long term use and compliance and symptom recurrence is common after medical treatment .Surgical treatment is the first line treatment if patient wish to conceive and pain symptom. Surgical treatment may consists of conservative laparoscopy or open surgery with adhesolysis ovarine cystectomy,ablation or excision of endometriotic deposits or hysterscopic resection of endmeterial polyp or intrauterine adhesion and submucus fibroid In severe cases hystrectomy with or with out bilateral oophrectomy may be required in case of severe endometriosis or severe PID .Post operative treatment with GNRH agonists significantly prolong pain free interval.Severe case should be referred to centers with relevant clinical expertise.
There is a role of support group in the management of endometriosis.








Posted by Sarwat F.
Differential diagnosis in this case includes endometriosis, pelvic inflammatory disease, ovarian cyst, inflammatory bowel disease.
Diagnosis will involve history and examination. She will be asked about any investigations done so far, any medications if she has taken. Examination will be done including general physical examination especially temperature, abdominal examination and vaginal examination for any abdominal mass or nodules in the pouch of Douglas. Any abdominal tenderness and cervical excitation on pelvic examination should be checked. As she is not having any other symptoms, certain investigations will be done. Full blood count and CRP will be checked as this will give an idea about inflammation. High vaginal swab, endocervical and urethral swabs will be done to rule out sub clinical Chlamydia infection. Most likely diagnosis in this case is endometriosis. Laparoscopy will be required for diagnosis of endometriosis as it is the gold standard for diagnosis. Ca 125 can be done but it is nonspecific and can be raised in a number of conditions. Therapeutic approach depends on severity of symptoms and wishes of woman. She will be explained about the disease and therapeutic options available to her. Various options available include analgesics in the form of nonsteroidal anti inflammatory drugs, oral contraceptive pills to suppress the ovarian activity and hence endometriotic deposits. Progesterone in the form of medroxyprogesterone injections can be given. If these are not effective danazol can be given which is associated with side effects of hot flushes and breast changes of estrogen deficiency. GnRH analogues can also be given but they are also associated with side effects of estrogen deficiency. If the medical treatment is not effective or there are endometriotic deposits of considerable size usually > 5 cm then surgical management is done. Endometriotic deposits can be removed laparoscopically or if there are adhesions then adhesiolysis can be done. If this woman is also trying to conceive then surgical management of endometriosis is the preferred option. This will improve her symptoms as well as improving the chances of fertility. Written information should be provided in the form of information leaflets. Information about various support groups is provided.
Posted by hala M.
The differential diagnosis is endometriosis/adenomyosis, pelvic adhesion/PID, fibroid, chronic pelvic congestion CPC, psychosomatic illnesses (IBS) and IBD.

The diagnostic and therapeutic approach of this is by dedicating enough time listening to the patient views about her complaint and the consequent effect on her function and quality of life.
A detailed history of the dysmenorrhoea (nature of pain, location, relation to menses and defecation and its radiation), dysparunia (deep / superficial, constant/occasional) needs to be taken. Taking bowel history is relevant as IBS might present in a cyclical pattern.
A direct enquiry about her social life (work, family and relationship problems) helps in identifying psychological contribution to her complaint. In addition to this a sensitive enquiry about sexual abuse might identify the possibility of psychosexual contribution.
The contraception and fertility needs help in planning the diagnostic and therapeutic approach.
Past abdominal/ pelvic surgery indicate the possibility of adhesions as a cause. The knowledge of the previously given medications and their efficacy helps in the management planning.

The examination would note the size, position, mobility and tenderness of the uterus in addition to any adnexal masses and tenderness. This is important in suspecting endometriosis/endometrioma. The findings in chronic PID are minimal in the absence of exacerbation. The pelvic examination will be negative in CPC.
Blood test of CA125 and ESR are non invasive and help in the diagnosis of endometriosis and IBD. A referral to a gastroenterologist needs to be done if suspected IBD.

The pelvic USS would identify the fibroid, endometrioma and CPC but it has limited benefit in diagnosing adhesions and PID. It can not diagnose the mild/ minimal endometriosis.


Diagnostic laparoscopy is the gold standard in the management. It helps in the diagnosis and grading of endometriosis, diagnosis of adhesion and fibroid.
In case of finding of minimal/moderate endomertiosis the lesion needs to be ablated but improvement in fertility is not expected. In the finding of severe endometriosis then the excision of the lesion needs to be employed as this improve the pain and fertility.

Hormonal treatment of endometriosis using COC, danazole, GnRH, and gesrinon have different side effect profile with high recurrence rate and do not improve fertility.

The finding of fibroid would lead to the discussion about the possible management such as myomectomy with the patient in relation to the effect on future fertility.

Attempting adhesolysis during laparoscopy might cause visceral injuries and increase the adhesion formation.
In case of negative findings the input from other colleagues (pain management team, psychologist) needs to be sought. The patient needs to be informed about the different support group.
Posted by BAHAA-Uddin BOR B.
The differential diagnosis includes gynaecological non-gynaecological causes.
Gynaecological disorders include: Endometriosis , chronic pelivic inflammatory disease,pelvic mass as uterine fibroids, adenomyosis,pelvic congestion syndrome
And psychosexual problems.
Non-gynaecological disorders are : Functional bowel disease-IBS, inflammatory bowel disease, interstitial cystitis and adhesions.
Detailed history should be taken including questions about the pattern of pain , timinig in relation to menses,micturition,defecation and movement.,nature of pain
colicky,spasmodic ,bushy pain, burning and soothing pain due to neuropathy ,duration of pain and effects on quality of her life,occupational family and social disruption to this problem. The cyclical symptoms may be afeature of non-gynaecological disease.,Good clinical history should also , include GI history, such as IBS ( Rome criteria ) ,history of diarrhea alternating with constipation ,flatulence,mucus in motion ,coliky abdominal pain,but actual diagnosis cannot be made only on basis of history.
History of urinary frequency,urgency,nocturia,dysuria and haematuria should be obtained., infertility,previous operations,STD , psychosexual history, history of sexual abuse in childhood, if suspected ,should asked subtly and sensitively.
Thorough clinical examination including abdominal examination to rule- out any palpable pathology or any abdominal tenderness.Finding on pelvic examination including uterine and adenxal tenderness, fixed retroverted uterus are suggestive of endometriosis,also,nodularity of of the Pouch of Douglas and cervical excitation.
The investigations including ESR / CRP are useful in inflammatory bowel disease.Barium bowel studies and colonoscopy should be undertaken by gastro-enterologist. Markers such as CA-125 may be useful in suspected endometriosis.
Endocervical swabs are typically negative in women with chronic PID and positive test may be incidental. Urine microscopy and culture ,where haematuria may indicate bladder pain. TV / Ultrasound is of limited value, especially in the presence of normal clinical findings.,but may be reassuring to the patient and sometimes may reveal pathology not noted on examination as endometriomas. MRI is of value in the diagnosis of peritoneal deep endometriosis , rectovaginal septum endometriosis and contents of pelvic masses but not routinely used ,as not widely available and expensive. Its main advantage is avoidance of surgery. Laparoscopy is gold standard but is not a first line investigation . It should be the final rung in the ladder of dignosis of pelvic pain.,as it may cause erroneous diagnosis.,but finding of minimal endometriosis or adhesions may lead to a firm diagnosis.
Initial treatment is directed towards diagnosis, woman\'priorities, wishes, future child-bearing and quality of life issues.Referral to GI physician if significant bowel problems. Constipation and symptoms of IBS treated with ant-spasmodics agents and dietary manipulation. Referral to GUM ,if chronic PID ,for partner screening ,treatment and follow-up. Simple analgesics or NSAIDs may be effective in treating endometriosis associated pain. COCP if no contraindications is effective treatment for endometriosis associated pain and provides contraception. Drugs such as Danazol ,Gestrinone,GnRH agonists are very effective ,but have significant side-effects,that may limit their long-term use and often produce poor compliance ,and should only be used after a firm diagnosis of endometriosis has been made.GnRH-agonists may lead to 6% of bone mineral density loss in 6 months.and V.M symptoms. ,while Danazol has androgenic side-effect profile .Laparoscopic ablation relieves pain and improves fertility in case of mild to moderate endometriosis. Severe endometriosis should be treated in specialist centre , with multidisciplinary team and patient reassurance ,very stressful partner counselling ., giving endometriosis support group patient information leaflet. Therapeutic trial for pelvic congestion syndrome.Myomectomy for fibroid uterus. LUNA ,laparoscopic uterine nerve ablation is useless.Alternative therapies such as acupuncture may be helpful in some women. Resistant cases may benefit from treatment by the pain clinic. If no underlying cause is found , reassurance may be sufficient ,psychosexual counsellors and referral to specialists ,support groups, woman centred care , follow-up and partner involvement .
Posted by SWATI M.
The possible gynaecological causes include endometriosis, adenomyosis, chronic PID , uterine fibriods and pelvic congestion syndrome. The non ?gynaecological causes include adhesions especially if dense may cause symptoms and psychosocial causes may be present.

For the diagnosis detail history ,clinical examination and investigations need to be undertaken.
Symptoms severity,cyclicity and their effects on the quality of life should be assessed.
In endometriosis uterus will be fixed and retroverted and ovaries are enlarged if endometriomas. Enlarged tender bulky uterus suggest adenomyosis.
PID is suggested by prior history of PID,multiple partners. Adnexal tenderness may be present and will have pain on cervical excitation. In pelvic congestion syndrome pain is aggravated by prolonged standing but there are no specific clinical findings.
In uterine fibroids it is enlarged.
Prior history of laparotomy particularly for tubo-ovarian abscess ,PID may suggest adhesions as cause of her symptoms.Psychosocial factors due to child and/or sexual abuse could be contributory factors and history should be obtained sensitively.

Investigations include CA 125 levels which will be moderately elevated in endometriosis and also in PID.
On pelvic ultrasound , ovarian endometriomas ,adenomyosis and fibroids can be diagnosed . Dilated pelvic vessels can be seen in pelvic congestion.
MRI is helpful to diagnose deep infiltrating endometrial deposits in the rectovaginal septum but not universally available and will be performed later if no response to initial treatment and clinically suspicious.Endocervical swabs are collected for infections.
Positive endocervical swabs support but does not prove the diagnosis of chronic PID.

Laporoscopy is the gold standard for the diagnosis of endometriosis. Laporoscopy can be offered , to exclude organic causes if no obvious pathology like fibroids is found .
Explain associated benefits and risks .Alternative is offer her initial treatment and it can be performed at later stage if symptoms are persistent .
If suspected endometriosis with associated subfertility ,laparoscopy should be recommended which is diagnostic and therapeutic with ablation of endometrial deposits.
If fertility is not an issue medical treatment for endometriosis should be offered .All drugs are equally effective and use is determined by the side effect profile.Drugs that can be used for endometriosis are COC?s , progesterone,danazol ,GnRHa.
Refer her to GUM physician for PID treatment and contact tracing.
In pelvic congestion symptoms can be relieved by ovarian suppression with COCs. Mefenamic acid or ibuprofen should be offered to reduce pain in fibroids .
Adhesiolysis may be helpful but there is no evidence for it and it should be explained to her. Psychological support is important in the management.
Posted by BAHAA-Uddin BOR B.
Dear Dr. PAUL
WOULD YOU MIND PLEASE, Dr.PAUL, CORRECT MY ANSWER , PLEASE.
THANK YOU VERY MUCH ,FOR READING MY ANSWER.
Posted by Aroosha B.
Dear Dr Paul
kindly can u tell us a logical approach as we have not read a single good answer
Thanks Dr Aroosha
Posted by Aroosha B.
Dear Dr Paul
kindly can u tell us a logical approach as we have not read a single good answer
Thanks Dr Aroosha