Transcript BACK TO MEDICAL SCHOOL MAY 2006 PELVIC PAIN

BACK TO MEDICAL SCHOOL
MAY 2006
THE COMMON CAUSES OF
PELVIC PAIN
Nicholas Myerson
Consultant Obstetrician & Gynaecologist
Bradford Royal Infirmary
Objectives
• Define the anatomy / content of the female
pelvis
• Identify the common causes of pelvic pain
• Review key gynaecological causes
• Discuss the diagnosis of common causes
• Outline management strategies for 1ry & 2ry
care settings
Objectives
• Define the anatomy / content of the female
pelvis
• Identify the common causes of pelvic pain
• Review key gynaecological causes
• Discuss the diagnosis of common causes
• Outline management strategies for 1ry & 2ry
care settings
The Female Pelvis
Pain Sensation in the Pelvis
• Pain sensation mostly via the lumbar plexus
(T12 – L4)
• Pudendal nerve to anus, perineum and vulva
is from the sacral plexus (L4 – S3)
• Pain in pelvic viscera is often poorly defined
and poorly localised
• However if the peritoneum is involved pain
is often much sharper with typical
peritonism.
Objectives
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Revise the anatomy of the female pelvis
Identify the common causes of pelvic pain
Review key gynaecological causes
Discuss the diagnosis of common causes
Identify management strategies for 1ry & 2ry
care settings
Pelvic Pain
• Identifying cause(s) of pain can be difficult
• Pain can be multi-factorial
• Non-gynaecological causes can co-exist
e.g.
adhesions affecting bowel
endometriosis on bowel/bladder
IBS
• The initial diagnostic aim should be to
identify all contributory elements
Causes of Pelvic Pain
• Acute or Chronic
• Gynaecological or Non-gynaecological
Common Causes of Chronic Pain
Gastro-Intestinal
Constipation
Irritable Bowel Syndrome
Inflammatory Bowel Disease
Diverticulitis
Herniae
Gynaecological
Endometriosis
Adhesions
Physiological/Pelvic Congestion
Masses
Ovarian remnant
Urinary
Interstitial cystitis
Urethral syndrome
Other
Back/Postural Pain
Musculoskeletal
Hernia
Nerve Entrapment
Psychological
Common Gynaecological Causes
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ACUTE
Physiological
Pregnancy related
Infection
Ovarian
Endometriosis
Benign neoplasia
Malignant neoplasia
Appendicitis
Cystitis
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CHRONIC
Physiological
Musculoskeletal
Infection
Ovarian
Endometriosis
Benign Neoplasia
Malignant Neoplasia
Adhesions
Interstitial cystitis
Nerve entrapment
Neuropathic
Objectives
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Revise the anatomy of the female pelvis
Identify the common causes of pelvic pain
Review key gynaecological causes
Discuss the diagnosis of common causes
Identify management strategies for 1ry & 2ry
care settings
Endometriosis
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Exact aetiology uncertain
Symptoms may not correlate with extent
Site and nature of pain varies between pts.
Ectopic deposits endometroid tissue (inc.
adenomyosis)
• Symptoms often cyclical & worst before
menses
• Pain; deep dyspareunia; prolonged heavy
menses; subfertility
Adhesions
• History of surgery/infection/endometriosis
• Adhesions are frequently asymptomatic
• Most common reason for pain after
immediate post-operative period
• Pain often assoc. with bowel dysfunction
and stretching of viscera
• Type/pattern of pain variable but often not
(wholly) cyclical
Trapped or Residual Ovary
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Part of an ovary left after surgery
An ovary buried within adhesions
History of previous surgery (often difficult)
Past history of pelvic pain/adhesions
Typically pelvic pain and deep dyspareunia
with a cyclical element
• Pain localised to the relevant side
Pelvic Infection
• PID can be acute or chronic
If chronic
• Pain due to chronic inflammatory response
• OR chronic due to adhesions and
hydrosalpinges
• Not (wholly) cyclical pattern
• Deep dyspareunia often a feature
Pelvic Infection
•May get acute exacerbations with chronic
disease OR acute infection:
•Diagnostic criteria for acute PID
2 of
pain, cervical excitation, adnexal tenderness
and 1of
discharge/temperature/↑WCC/↑CRP/+ve
USS/ +ve laparoscopy
Pelvic Congestion
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Overfilling (congestion) of the pelvic veins
Dull aching pain, usually bilateral
Cyclical element is common
Worse at end of day/after prolonged
standing
• Standard investigations often negative
Psychological Factors
• Chronic pain causes psychological distress
• BUT women with relevant history are at
increased risk of pelvic pain
• Treatment of depression/sleep disorder can
improve function, even if caused by pain
• Complex linkage between chronic pelvic
pain and history of sexual/physical abuse
• Abuse may trigger a cascade of events
leading pelvic pain to develop but this is not
inevitable
Objectives
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Revise the anatomy of the female pelvis
Identify the common causes of pelvic pain
Review key gynaecological causes
Discuss the diagnosis of common causes
Identify management strategies for 1ry & 2ry
care settings
Diagnosis
• As always will depend on
history + examination + investigation
• History often the most informative element
• Full chronic pain history can take 30-45
minutes
• Examination is always useful but may elicit
significant discomfort
• Investigations are not always useful or
required at early stage
Key Gynae Points in the History
• Ask about
onset of pain
duration of symptoms (acute –v- chronic)
cyclical element (when in the cycle?)
dyspareunia (cyclical/every episode?)
dysmenorrhoea (worsening?)
menstrual cycle (changed?)
fertility
plans for future pregnancy
past history of pain/infection etc
Key Other Points in the History
• If no clear Gynae features specifically ask
previous history of pain
past investigation/treatment (inc Surgery)
associated GI symptoms
associated Urinary symptoms
effect of pain on quality of life
symptoms depression
consider possibility of abuse
does pain vary with movement/exertion
History Taking
• Taking a full history of chronic pelvic pain is
very time consuming
• A pain diary is a very useful diagnostic aid
• A menstrual diary can be kept concurrently
• Symptoms alone may be diagnostic
• There are certain ‘red flag’ symptoms which
should be sort and if present need prompt
referral
‘Red Flag’ Symptoms
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PR bleeding
New bowel symptoms if >50 yrs
New pain after menopause
Pelvic mass
Excessive (unplanned) weight loss
Irregular bleeding PV if >40 years
Post-coital bleeding
Severe depressive symptoms
Source: RCOG Guideline No.41 (April 2005)
The Examination
• Generally a full abdominal and vaginal
assessment
• Remember the limits of the pelvis and
location of the uterus & ovaries
• Particular attention to:
scars
site and degree of tenderness
presence, location & size of masses
Vaginal Examination
• Inspection for;
trauma, inflammation, blood, discharge
• Speculum;
discharge or blood, cervical appearances
• Bimanual palpation;
cervical excitation
size, axis, mobility of uterus
adnexal masses or adnexal tenderness
• Examination will often be unremarkable or
find only general tenderness
Key Examination Findings
• Atypical discharge - infection
• Cervical excitation - pelvic inflammation
• Uterus on the ‘citrus scale’
if very large – fibroids/neoplasia/pregnancy
if bulky – adenomyosis/infection/pregnancy
• Unilateral tenderness is not a specific sign
• Generalised tenderness can reflect several
processes including IBS
• Severe pain on examination –
inflammation/necrosis/psychological
Investigations
• Triple swabs for infection
• FBC/CRP for suspected infection
• USS; TVS is best for adnexal views
scans often negative if no physical changes:
masses and uterine pathology will be seen
ovarian change; endometrioma/masses;
hydrosalpinges
• USS will therefore often be negative
Objectives
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Revise the anatomy of the female pelvis
Identify the common causes of pelvic pain
Review key gynaecological causes
Discuss the diagnosis of common causes
Identify management strategies for 1ry & 2ry
care settings
Management
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Will depend on the cause/suspected cause
Referral may or may not be required
Referral not always to a Gynaecologist
Management in 1ry setting is often possible
Co-morbidities are common
Treatment of physical symptoms can
reveal psychological element to causation
Management (2)
• Generally, treat the most prominent
symptom complex first
• Even if no other therapeutic manoeuvres are
to be tried, try to achieve adequate analgesia
NSAIDs
e.g. Mefanamic Acid, Ibuprofen
Paracetamol/compound analgesia
Gabapentin / amitryptiline may work
Non-Gynaecological Causes (1)
• IBS can be diagnosed on symptoms alone
treat with dietary modification
antispasmodics
• Backache and dyspareunia caused by IBS
may also be relieved
• IBS and chronic pelvic pain are associated
with pain which has a psychological
component which may need referral
Non-Gynaecological Causes (2)
• Pain related to movement/position may be
musculo-skeletal
try analgesia +/- physiotherapy or other
• History of depression or other disorder
should be treated along usual pathways
• History of old or ongoing abuse will need
action with/before trying to treat pain with
usual strategies
Treating Gynaecological Symptoms
• Symptoms of possible infection/PID
triple swabs
antibiotics (chlamydia & broad spectrum)
• Markedly cyclical pain +/- dysmenorrhoea
consider OCP (can bi- or tri-cycle)
other ovarian suppression
• Endometriosis often recurs
trial OCP/progestogens (days 6-25 cycle)
possible GnRH analogues
Refer the ‘Red Flag’ Symptoms
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PR bleeding
New bowel symptoms if >50 yrs
New pain after menopause
Pelvic mass
Excessive (unplanned) weight loss
Irregular bleeding PV if >40 years
Post-coital bleeding
Severe depressive symptoms
Non-Gynaecological Referral
• Suspected adhesions may be referred to
general surgery
• Non-resolving predominantly GI symptoms
may need Gastroenterology
• Urological symptoms revealed or
predominating need Urology (or Urogynae.)
• Psychiatric symptoms as required
When to Refer to Gynaecology
• When the cause or nature of pain cannot be
defined
• When first-line gynaecological management
has been unsuccessful
• Where management of other systems
(GI/Urological etc.) has been unsuccessful
• When specific features are present in
history/examination or investigation
When to Refer to Gynaecology (2)
• Fertility problems/issues occurring
concurrently with pain
• Very severe or recurrent symptoms
• Abnormal findings on investigations
e.g. USS evidence of ovarian cysts
hydrosalpinx
• No apparent pathology
Summary Points
• Pelvic pain is common in women between
menarche and menopause
• It may be acute or chronic
• Pain is often not gynaecological in origin
• More than one cause may be present including
psychological/abuse factors
• Initial treatment of non- ‘red flag’ symptoms in
general practice will often succeed
• Ovarian suppression/hormonal manipulation
underlies much Gynae management