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chronicpelvicpain

chronic pelvic pain in women

introduction

  • a large proportion of women experience pelvic pain, often over years, most define chronic pain as pain lasting more than 6 months and such pains affect 2-20% of women depending upon definition
  • virtually every normal, physiologic event that occurs within a woman's pelvis is associated with pain which vary in duration, intensity and are associated with events such as ovulation, menstruation, pregnancy, labour and childbirth, thus not all pelvic pain needs surgical or pharmacologic intervention or even investigation.
  • the patient with acute pelvic pain should be managed as per the patient with acute abdominal pain in the ED
  • for patients with pelvic pain primarily related to menses - see dysmenorrhoea
  • however, some women experience more severe recurrent pains which do deserve clinical assessment and investigation, in particular to rule out potentially treatable conditions such as large ovarian cysts and other cysts in the adnexae, pelvic inflammatory disease (PID), and endometriosis, but also less well diagnosed causes such as neuropathic pelvic pain which is becoming increasingly recognised as a significant cause of otherwise idiopathic chronic pelvic pain.
  • chronic pelvic pain may be associated with:

aetiology of chronic pelvic pain

  • endometriosis, ovarian endomtrioma and adenomyosis
  • uterine fibroids
  • painful bladder syndromes
  • pelvic muscle pain
  • adhesions
  • venous causes:
    • “pelvic venous congestion” / “ovarian vein reflux”
      • said to be the cause of 13-40% of chronic pelvic pain
      • mainly in younger women who have had at least 2 children, usually unilateral but may be bilateral
      • may have a PH of vulval varicosities during pregnancy
      • pain is worse on standing
      • may require venography to diagnose
      • may respond to medroxyprogesterone acetate or goserelin, otherwise pelvic vein embolism may be tried 1)
    • May-Thurmer syndrome (rare cause)
      • left common iliac vein compression by the right common iliac artery
      • usually known for predisposition to deep venous thrombosis (DVT) but may cause pelvic pain which responds to stenting 2)
  • idiopathic chronic pelvic pain syndrome accounts for around 50% of cases
    • some may be related to a PH of sexual abuse or psychological morbidity
  • neuropathic pelvic pain (see below)

Mx

diagnostic workup

  • clear history
  • gynae examination
  • urinalysis / culture
  • FBE, U&E, CRP
  • pelvic USS
  • consider pelvic MRI
  • consider laparoscopy
    • invasive, may cause more harm than good but generally finds pathology in around 2/3rds, thus 1/3rd will be non-diagnostic
    • may increase nerve sensitization and chronic pain
    • may cause adhesions
    • may give false negative result as subtle endometriosis lesions and deep infiltrating endometriosis may be missed
    • 0.24% risk of bowel perforation of which 2/3rds require laparotomy
    • 4-8 per 100,000 mortality

neuropathic pelvic pain

  • generally results from damage to the nervous system including axons of peripheral nerves or deafferentiation of neurons within the CNS (neurons lose their accustomed afferent input).
  • this can and does cross neuroanatomical boundaries, often presenting viscerally as referred pain (thereby potentialy causing misdiagnosis) and eliciting pain descriptors such as burning, shooting, stabbing, and searing.
  • this may also be caused by inguinal or pelvic herniae which are commonly occult and difficult to detect clinically in women - abdominal fat and nerves may become entrapped causing neuropathic pain - often radiating to labia majora or anterior thigh if inguinal
  • eg. pudendal neuralgia
  • tools to help diagnosis neuropathic pain include:
    • questionnaires:
      • painDETECT
      • DN4 (Douleur Neuropathetique en 4)
      • LANSS (Leeds Assessment of Neuropathic Symptoms and Signs)
      • S-LANSS (self-assessed LANSS)
      • NPS (Neuropathic Pain Scale)

references

  • MJA vol 190 no 1: Letter to the editor. Vivian and Barnard. p47
  • Prevalence of chronic pain with neuropathic characteristics in the general population. Pain 2008; 136: 380-387
chronicpelvicpain.txt · Last modified: 2019/06/23 17:53 (external edit)