1. Pelvic Pain
Mr James Campbell

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

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

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

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

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

7. Dysmenorrhoea Prostaglandin production Myometrial contractions
Decreased blood flow
PAIN

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

9. Gynaecological Pathology

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

11. Aetiology Implantation theory Coelomic metaplasia theory
Retrograde menstruation
Coelomic metaplasia theory
Mullerian duct
Peritoneal and pleural cavities
Ovaries
(all derive from the coelomic epithelium)

12. Symptoms and signs Dysmenorrhoea Dyspareunia Sub-fertility
Menstrual dysfunction
Signs in severe disease
Fixed tender uterus
Adnexal mass
Nodular POD

13. Investigations
Laparoscopy
USS / MRI
Tissue biopsy

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

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

16. Histological diagnosis

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

18. PID - examination
Cervical discharge / tenderness
Adnexal mass

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

20. Ovarian cysts
Simple / complex
Benign / malignant

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

22. 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

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

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

25. 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”

26. Types of chronic pelvic pain
Organic –
Due to tissue damage (endometriosis)
Psychological –
Can occur without tissue damage
Cancer
Benign
Occurs despite tissue healing (adhesions)

27. Case study
45 yr old woman attends the clinic with pelvic pain of 2 years duration
Consultant is away and you are in charge

28. 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

29. Examination
Speculum
Normal
Bimanual
Bulky uterus
No adnexal masses

30. Investigations PT – negative Swabs – negative USS –
Multiple small intramural fibroids, largest 2cm, ovaries normal

31. Differential diagnosis
Surgery related pain
Fibroids / endometriosis
IBS
Psychological
Diagnosis – made at laparoscopy
Post operative adhesions / ovarian entrapment

32. Ovarian adhesions

33. Pelvic pain
Thanks for your attention.
Questions?