Introduction

As illustrated throughout this book, female pelvic pain may be caused by a wide variety of conditions and is often multifactorial. Surgery serves an important role in the treatment of many of these conditions and is best addressed specifically rather than generally. This chapter aims to address the use of each procedure by specific indication or diagnosis. For many procedures, there may be only limited data by which to judge the efficacy of the surgery for treatment of pelvic pain.

Among women with chronic pelvic pain of unknown etiology, certain procedures may help identify or confirm a cause of their pain, as in the case of laparoscopy identifying endometriosis or adhesions, or hysterectomy identifying adenomyosis. While rarely addressed within clinical studies, there may be psychological benefits to patients from identifying a cause of their chronic pain.

Any decision about surgery involves counseling the patient about risks, benefits, alternatives, indications, and contraindications of performing surgery. Risks of not performing surgery should also be discussed, including the risk of delaying diagnosis and treatment for the cause(s) of the patient’s pain. Surgical risk is influenced by patient factors such as obesity or other medical comorbidities, as well as by surgeon factors such as experience with the proposed procedure, surgical volume, comfort managing complications, and availability of surgical assistance for management of a complication.

Laparoscopy for the Evaluation of Acute Pelvic Pain

While the primary focus of this chapter is chronic pelvic pain, a manual on management of pelvic pain merits discussion of acute pelvic pain: both isolated and superimposed upon chronic pelvic pain. A woman of reproductive age presenting with acute pelvic or lower abdominal pain represents a broad differential diagnosis, as pain may include gynecological, urological, musculoskeletal, gastrointestinal, vascular, or metabolic disorder etiologies [1, 2]. Initial assessment should include testing for pregnancy, as ectopic pregnancy may be a life-threatening cause of acute pain in women. Additional causes of acute pelvic pain requiring urgent assessment and management include acute appendicitis, pelvic inflammatory disease, obstructive renal stones, and/or ovarian torsion. Ovarian cyst, cyst rupture, or ovulation pain may also result in acute pelvic pain, but rarely requires surgical management unless ovarian torsion is present, significant and ongoing blood loss from a hemorrhagic cyst is suspected, or imaging suggests dermoid cyst rupture. Surgical management of symptomatic, presumed benign ovarian cysts should be through a laparoscopic approach, with a goal of fertility preservation [3]. Presentation of complicated myomas may be varied, with myomectomy indicated for cases of torsion versus expectant management for other instances of acute myoma degeneration.

Imaging is crucial in the evaluation of acute female pelvic pain; abdominal ultrasound can accurately identify most gynecological pathologies requiring emergent intervention, and further characterization may be provided through the use of transvaginal ultrasound, computed tomography, or magnetic resonance imaging [4]. Absence of Doppler flow on imaging is diagnostic for torsion of an ovary or of a pedunculated myoma.

A benefit to diagnostic laparoscopy in the evaluation of acute female pelvic pain is the ability to diagnose and institute appropriate care for disease of the appendix or female reproductive tract. A Cochrane review looked at the use of laparoscopy among women of childbearing age presenting with acute lower abdominal pain and/or suspected appendicitis; they concluded that the use of laparoscopy was more likely to result in a specific diagnosis before discharge when compared to open appendectomy (odds ratio [OR] 4.10) or to a ‘wait and see” strategy (OR 6.07), without a change in adverse events (OR 0.46 compared to open appendectomy, OR 0.87 compared to “wait and see”). The rate of normal appendix removal with laparoscopy was lower compared to open appendectomy (OR 0.13), but higher compared a “wait and see” strategy (OR 5.14) [5]. Early laparoscopy (within 18 hours of admission) for nonspecific abdominal pain has also been shown to result in a greater improvement in well-being scores at 6 weeks follow-up compared to a close-observation approach (149 points from baseline of 134 points vs. 143 points from baseline of 132 points using a 177-point scale) [6]. In a review of 2365 patients with acute and chronic pelvic pain, laparoscopy was used to evaluate 736 (31.1% of) patients with acute pelvic pain, and yielded a diagnosis in 681 (92.5% of) cases, with salpingo-oophoritis and pelvic adhesions each diagnosed among 168 (22.8% of) patients [41].

For patients with chronic pelvic pain, assessment of an acute pain flare should take into consideration the patient’s underlying chronic pain diagnoses, but also consider the possibility of a superimposed acute abdominopelvic process [7]. In our clinical experience, acute pelvic pain flares are often related to worsening pelvic floor muscle spasm in women with this spastic pelvic floor syndrome and may respond to treatment with muscle relaxant medications. Ultrasound imaging for women with unilateral exacerbation of pelvic pain may demonstrate a new ovarian cyst; for women with a known ovarian cyst, adnexal torsion should be considered as a cause of worsening pain and evaluated appropriately. In our experience, laparoscopy is rarely indicated for evaluation of an acute flare of chronic pelvic pain. Evidence for laparoscopy for evaluation of acute pelvic pain: Level II-2.

Laparoscopy for the Evaluation of Chronic Pelvic Pain

Laparoscopy can be instrumental in diagnosing and managing chronic pelvic pain arising from endometriosis, adnexal masses, adhesions, or peritoneal cysts. Appropriate patient selection for laparoscopy is crucial to avoid delaying diagnosis and treatment among women with chronic pain causes amenable to laparoscopic treatment, while not subjecting to unnecessary surgical risks women whose chronic pelvic pain likely arises from other causes, or whose pain may be adequately controlled with medical management. There are no clinical guidelines or quality evidence to guide the timing of laparoscopy for evaluation and treatment of women with unknown cause of chronic pelvic pain, and most authors agree that this decision should be made collaboratively between a patient and her physician [7]. A study of 370 women with chronic pelvic pain evaluated in a specialty clinic showed similar improvements in pain and depression scores at one year among women recommended to undergo surgery compared to those recommended to undergo nonsurgical treatment [8].

In our practice, the initial evaluation of a patient often leads us to suspect multifactorial causes of their chronic pelvic pain. If abdominopelvic visceral causes are suspected in additional to musculoskeletal causes, we usually recommend early laparoscopic evaluation and treatment prior to referral to pelvic physical therapy for treatment of spastic pelvic floor syndrome. We find this approach more effective than delaying surgery and subsequently interrupting a patient’s pelvic physical therapy course for several weeks to allow for surgical recovery.

Conscious laparoscopic pain mapping was historically advanced as a useful tool in the evaluation of chronic pelvic pain, and despite difficulties in study design, small case series demonstrated high success of this approach in identifying visceral sources of pain [9]. More recent literature on this procedure suggests that it may be helpful in establishing a diagnosis in only a small portion of patients (27%) [10], and there is presently inadequate evidence to support its routine use in treatment of chronic pelvic pain [11].

Large studies have shown varied outcomes for laparoscopic evaluation of chronic female pelvic pain, with negative or nondiagnostic findings reported in 15% to 35% of cases [12–14, 15]. Reasons for this variability in findings may relate to patient selection factors, as well as variability in the use of peritoneal biopsies for histological diagnosis confirmation. Studies comparing visual identification of endometriosis by the surgeon with histological diagnosis confirmation have shown poor specificity of visual identification (77%–79.23%) [16–1875]. Sensitivity of visually identified endometriosis is reported to be better than specificity, 94% per one meta-analysis [18]; however, within our practice, routine biopsy of normal-appearing peritoneum in laparoscopy for patients with symptoms suggestive of endometriosis has yielded a histological diagnosis of endometriosis in up to 39% of patients, suggesting poor sensitivity of visual identification. For these reasons, within our practice we often routinely obtain peritoneal biopsies from the anterior and posterior cul de sac and right and left ovarian fossae on patients undergoing laparoscopy for chronic pelvic pain of unknown cause with intraoperative findings of normal anatomy and no clear endometriosis or adhesive disease.

Negative laparoscopy may still benefit patients, resulting in a lasting reduction in pain scores. A study of 71 patients undergoing laparoscopy for evaluation of chronic pelvic pain included 34 women with no pathology at time of surgery (47.9%); the entire cohort demonstrated reduction in visual analog scale (VAS) usual pain and VAS worst pain scores from presurgery baseline to 6 months postsurgery [19]. Subgroup analysis of women with no surgical findings of pathology was not performed. Evidence for laparoscopy for evaluation of chronic pelvic pain: Level II-2.

Laparoscopic Surgery for Treatment of Endometriosis

The goal of laparoscopic surgery for endometriosis is to remove or destroy all visible endometriotic lesions and to restore normal anatomy. There is strong evidence that excision or ablation of minimal to moderate endometriosis results in an improvement in chronic pelvic pain. A Cochrane review looked at seven studies comparing operative laparoscopy to diagnostic laparoscopy for management of endometriosis, and found that excision or ablation was associated with decreased pain score at 6 months (OR 6.58, p = 0.00001) and 12 months (OR 10.00, p = 0.001) [20]. A single randomized controlled trial (RCT) from the meta-analysis included data from 3 months postsurgery comparing laparoscopic ablation to diagnostic laparoscopy and found no difference in pain scores at that time point (OR 1.37, p = 0.53), which may be attributable to placebo effect from surgery within the diagnostic laparoscopy group. The Cochrane meta-analysis included only a limited number of patients with severe endometriosis, and therefore recommends that conclusions regarding surgery for treatment of severe endometriosis “should be made with caution.” Regarding duration of pain reduction after local surgical treatment of endometriosis, a retrospective study of 850 women showed a surgery-free percentage of 79.4% at 2 years, 53.5% at 5 years, and 44.6% at 7 years [21].

There is insufficient evidence to recommend a surgical approach of excision versus one of ablation of endometriosis lesions, with similar outcomes for overall pain, pelvic pain, dyspareunia, and dyschezia when the two approaches are compared within meta-analysis [20], and limited studies comparing the two approaches directly [22]. An RCT of 103 patients with superficial endometriosis showed similar VAS score outcomes at 1 year postsurgery between patients who had undergone ablation versus excision approaches, but did not address treatment of deep infiltrating endometriosis [23]. An RCT of 24 patients with mild endometriosis compared ablation versus excision and found similar outcomes at 6 months postsurgery [24]. In our practice, we prefer an excisional approach, which allows for histopathological confirmation of endometriosis; and exception is diaphragmatic endometriosis lesions, which we treat with argon beam ablation. Evidence for excision or ablation of mild to moderate endometriosis: Level I.

Treatment of Deep Infiltrating Endometriosis

Deep infiltrating endometriosis (DIE), defined as lesions penetrating more than 5 mm into the affected tissue, is a severe form of endometriosis that manifests as retroperitoneal nodules associated with severe pelvic pain as well as organ-specific symptoms when localized to the urinary or gastrointestinal tracts. Preoperative imaging with ultrasound and magnetic resonance imaging can help identify lesions prior to surgery; additionally, organ-specific symptoms can be evaluated through cystoscopy and colonoscopy prior to a laparoscopic procedure and allow for appropriate multidisciplinary surgical planning [25]. Complete surgical excision of DIE is considered definitive treatment, as symptoms may not respond to medical management and often recur after the medication is discontinued. Best surgical practice is controversial, as complete surgical excision entails greater risk of complications and morbidity, and literature comparing complete versus incomplete excision of DIE is limited.

A retrospective cohort study of 93 women undergoing surgical treatment of DIE looked at postoperative outcomes with complete and incomplete excision, but involved a heterogeneous cohort including 46 rectovaginal septum lesions and 5 uterosacral ligament lesions that were completely excised as well as diverse genitourinary and gastrointestinal lesions that were both partially and completely excised, and included 3–36-month postoperative follow-up [26]. Patients with complete excision had a greater reduction in VAS postoperative pain scores, which was not improved by postoperative gonadotropin-releasing hormone (GnRH) agonist use (6.9 vs. 5.5, p = 0.317); patients with incomplete excision had less reduction in VAS postoperative pain scores and GnRH significantly improved these scores (1.2 vs. 4.5, p = 0.003). Recurrence rate was not significantly reduced by use of GnRH agonists and was higher for the incomplete excision group versus the complete excision group (0–10% vs. 29.4–41.2%).

A retrospective cohort study of 132 patients with histologically proven DIE surveyed at a mean of 3.3 years postsurgery analyzed patients according to a proposed surgical classification based on anatomical location: uterosacral, vaginal, bladder, or intestinal [27]. For 78 patients with uterosacral lesions and 25 patients with vaginal lesions included in the study, complete surgical excision resulted in significant improvements in dysmenorrhea (delta 4.36 and 5.17, p = 0.0001), deep dyspareunia (delta 4.30 and 4.41, p = 0.0001), painful defecation during menstruation (delta 3.72, p = 0.0001 and delta 5.17, p = 0.0007), and noncyclic chronic pelvic pain scores (delta 4.11, p = 0.0001 and delta 6.00, p = 0.0171). These results strongly support the efficacy of complete excision of posterior DIE lesions for management of pain symptoms.

Recurrence of DIE lesions remains a risk even with complete lesion excision at time of primary surgery. A recent meta-analysis identified elevated body mass index (BMI) and younger age at primary surgery as risk factors for DIE recurrence [28]. Evidence for resection of DIE: Level II-2.

Treatment of Intestinal Deep Infiltrating Endometriosis

In patients with intestinal DIE, treatment may involve a conservative nodulectomy approach of lesion shaving or discoid resection, versus a radical approach of segmental bowel resection with colorectal anastomosis. Segmental bowel resection is appropriate when lesions exceed 3 cm size or involve >50% of the bowel circumference [29]. Nodulectomy may be safely performed in multicentric disease if lesions are separated by at least 5 cm of healthy bowel [30]. A retrospective comparative study of 77 women undergoing surgical treatment of DIE of the rectum showed a recurrence rate at 5 years postsurgery of 8.7% for those undergoing rectal shaving compared with colorectal resection; the authors concluded that for colorectal resection be performed in lieu of rectal shaving, the number needed to treat is 11 patients to prevent one patient recurrence [31]. Given postoperative complications including anal incontinence and lower quality of life scores with colorectal resection, conservative treatment is preferred in appropriate candidates [32]. Preoperative imaging and multidisciplinary consultation is appropriate for patients with intestinal DIE. Evidence for discoid bowel resection of DIE: Level II-2.

Treatment of Urinary Tract Deep Infiltrating Endometriosis

In patients with urinary tract DIE, treatment may involve resection of bladder endometriosis nodules with full or partial thickness bladder cystectomy, advanced ureterolysis, and segmental ureteral resection with end-to-end anastomosis or ureteroneocystotomy. Literature on this topic is limited to retrospective noncomparative studies, so there is a lack of evidence-based practice guidelines. A retrospective study of 81 women treated for urinary tract DIE including 42 cases of ureteral endometriosis and 50 cases of bladder endometriosis looked at outcomes and postoperative complications through 5 years postsurgery [30]. Ureterolysis was preferred over segmental ureter resection, unless there was evidence of ureteral muscularis infiltration; end-to-end reanastamosis was preferred over ureteroneocystotomy unless ureteral stenosis exceed 2–3 cm or was located adjacent to the vesicoureteral junction. Of the 42 patients treated for ureteral nodules, 28% experienced postoperative complications: seven presented with complications requiring reintervention, five had complications requiring medical management. Among the 50 patients treated for bladder endometriosis, four (8%) experienced postoperative complications, all requiring reintervention. None of the patients in the study had recurrence of urinary tract endometriosis at 5-year follow-up. Evidence for resection of urinary DIE: Level II-2.

Laparoscopic Appendectomy

Incidental appendectomy at time of laparoscopy has been explored as a treatment option for women with both known and unknown causes of pelvic pain. Elective coincidental appendectomy performed for a normal-appearing appendix at the time of another surgical procedure may be considered for purposes of reducing risk of subsequent appendicitis and simplifying the differential diagnosis for an acute pain flare in a patient with chronic pelvic pain [33]. There is no evidence from RCTs to guide whether the increase in cost and surgical morbidity from elective coincidental appendectomy outweigh the cost and risk from patients developing future appendicitis. Studies suggest benefit to removal of a normal or abnormal-appearing appendix during laparoscopy or laparotomy for chronic abdominopelvic pain. A retrospective study reported 63 cases of appendectomy performed for abnormal-appearing appendix at the time of laparoscopy for chronic female pelvic pain: all patients reported pain in the right lower quadrant pain before surgery [34]. Pathology was present in 92% of appendiceal specimens, and 89% of patients reported complete and permanent relief of pain at 1-year postoperative follow-up. A retrospective cohort study of women undergoing laparoscopic surgery for chronic pelvic pain without identifiable intraoperative pathology (including normal-appearing appendix) showed improved postoperative pain score in women undergoing appendectomy (n = 19) compared to those who did not (n = 76) [35]. Women who underwent appendectomy were more likely to have reported right-sided pain preoperatively (58% vs. 22%, p = 0.002); only 2 of 19 patients had pathology noted at the appendix (mild acute and chronic appendicitis). At 6 weeks postsurgery, improvement in pain was reported by 93% of appendectomy group patients versus 16% of nonappendectomy group patients (OR 69.9, p < 0.001); when surveyed at an average of 4.2 years postsurgery, only 38% of patients responded, but results indicated greater improvement in Pain Disability Index Scores following surgery among appendectomy patients. Among women with DIE, there is an increased risk of appendiceal endometriosis compared to women with superficial endometriosis (39.0% vs. 11.6%, OR 2.7, p < 0.001) [36].

Overall, evidence supports consideration of appendectomy at time of gynecological laparoscopy among women with chronic pelvic pain and should be especially considered if patients have preoperative right lower quadrant pain and/or an abnormal appearing appendix at time of laparoscopy. Among patients with endometriosis, appendiceal endometriosis is present in more than one third of patients with DIE and should be especially considered in this population. Evidence for appendectomy for chronic right lower quadrant pain: Level II-2.

Laparoscopy for Adhesiolysis

Although intraabdominal adhesions are considered a common cause for abdominopelvic pain, with 47% of adhesions shown to be a source of pain at the time of conscious laparoscopy [37], the efficacy of adhesiolysis remains controversial. A meta-analysis from 2015 looked at 25 studies with a total of 1281 patients, including three RCTs and 22 case-control studies, many of which were judged to be at high risk of bias [38]. Results of the three RCTs were highly varied, with one study showing benefit, one study showing benefit only within a subgroup of patients with dense and vascularized adhesions, and one showing no benefit for adhesiolysis. The majority of studies showed improvement in pain in more than 50% of patients. The authors of the review concluded that there was inadequate evidence to definitively conclude that adhesiolysis is effective in the treatment of chronic abdominal pain. Subsequent studies of adhesiolysis efficacy have shown variable results. An RCT of 100 patients randomized to laparoscopic adhesiolysis versus diagnostic laparoscopy showed poorer outcomes with adhesiolysis at 12-year follow-up, including lower risk of being pain free (relative risk [RR] = 1.3, p = 0.033), and higher risk of repeat surgery for persistent abdominal pain (RR = 1.67, p = 0.042) [39]. An RCT of 50 women with chronic pelvic pain randomized to laparoscopic adhesiolysis versus diagnostic laparoscopy showed improvement in VAS scores at 6 months postsurgery among the adhesiolysis group (−17.5 vs. −1.5, p = 0.048) [40]. Within our practice, adhesiolysis is performed when adhesions are noted at the time of surgery; clinical experience has shown us that patients often report improved pain following adhesiolysis, and that patients undergoing future surgery for recurrent pain typically have decreased adhesive disease burden compared to their primary surgery. Evidence of adhesiolysis for chronic pelvic pain: Level II-2.

Laparoscopic Ovarian Cystectomy

Most benign ovarian cysts are functional and asymptomatic, but may cause pain from large size, ovarian, torsion, or hemorrhage. Reasons for surgical management of an ovarian cyst include persistence over several menstrual cycles or increasing size on serial imaging. A laparoscopic approach is considered the gold standard for management of benign ovarian masses, with cystectomy favored over cyst aspiration or oophorectomy for purposes of fertility preservation in premenopausal women who have not yet completed child bearing [3]. For endometrioma cysts, ovarian cystectomy is recommended. A Cochrane review compared laparoscopic excision of the endometrioma cyst wall to laparoscopic drainage and ablation of the endometrioma and found excision to be associated with a reduced rate of dysmenorrhea (OR 0.15), dyspareunia (OR 0.08), nonmenstrual pelvic pain (OR 0.10), and recurrence of the endometrioma (OR 0.41) [41]. For ovarian mature cystic teratomas (dermoid cysts), a laparoscopic approach is preferred over laparotomy despite being associated with a longer operative time and higher risk of intraabdominal cyst rupture; cystectomy should be attempted in a young patient for purposes of fertility preservation, unless she requests oophorectomy [42]. Evidence for ovarian cystectomy with cyst wall excision for management of endometrioma: Level I.

Oophorectomy

Ovarian preservation is recommended for women under age 65 who are undergoing hysterectomy for benign indications, owing to decreased life expectancy associated with ovary removal [43]. Bilateral oophorectomy at time of hysterectomy is associated with having as many or more symptoms at problematic–severe levels at two years postsurgery compared to presurgery in a prospective cohort study of 1299 women undergoing hysterectomy for benign indications (OR 2.01, p = 0.02) [44]. A case-control study of 4931 women undergoing ovary-sparing hysterectomy compared to 4931 age-matched women who did not have hysterectomy showed the incidence of subsequent oophorectomy by 30-year follow-up to be 9.2% versus 7.3% for controls (hazard ratio [HR] = 1.20, p = 0.03) [45], suggesting that indications for hysterectomy may also raise the risk of subsequent oophorectomy, but that most patients with ovarian conservation at time of hysterectomy will not require subsequent surgery for oophorectomy.

Among patients with endometriosis, oophorectomy at time of hysterectomy is controversial. A retrospective study of 138 women undergoing hysterectomy for endometriosis compared rates of recurrent symptoms and reoperation among women with and without ovarian preservation: ovarian preservation was associated with 62% risk of recurrent symptoms compared with 10% among castrated patients (RR 6.1), and 31% risk of reoperation versus 3.7% (RR 8.1) [46]. A more recent study showed that among women with endometriosis undergoing surgical management, 77% of those who underwent hysterectomy with ovarian preservation had not undergone reoperation at 7-year follow-up, compared to 91.7% of those who underwent hysterectomy without ovarian preservation; this study showed that among the subgroup of women age 30–39, those undergoing hysterectomy with ovarian preservation had a reoperation risks similar to those of women who underwent hysterectomy without ovarian preservation (surgery-free percentage of 89.6% vs. 85.7%) [21]. The authors concluded that for women under age 40, bilateral oophorectomy did not substantially reduce the risk of reoperation, and therefore hysterectomy with ovarian preservation is preferable for these women. On the basis of these studies, ACOG recommends that in patients with normal ovaries undergoing hysterectomy, ovarian conservation with removal of endometriotic lesions should be considered. In our practice, we recommend ovarian preservation for women under age 40 undergoing hysterectomy for treatment of endometriosis, as the benefits of ovarian conservation outweigh the risk of disease recurrence.

When oophorectomy is performed for reasons of pain, proper surgical technique can help lower the risk of ovarian remnant syndrome, a cause of chronic pelvic pain that is discussed in a separate chapter. In our practice, retroperitoneal dissection is performed lateral to the infundibulopelvic ligament, to dissect the ovary, infundibulopelvic ligament, and obliterated broad ligament off of the pelvic sidewall and to identify and lateralize the ureter prior to transecting the infundibulopelvic ligament with a margin of vessel proximal to the ovary. Obliterated broad ligament and surrounding tissues are removed with the ovary. Evidence for oophorectomy for management of chronic pelvic pain from endometriosis: Level II-2.

Hysterectomy

Hysterectomy, both with and without ovarian conservation, is commonly performed for management of chronic pelvic pain, and is generally considered effective for appropriately selected patients. Of the 600,000 hysterectomies performed each year in the United States, approximately 12% have chronic pelvic pain as the primary indication [47]. A 2-year prospective study of 1299 women undergoing hysterectomy showed 63.1% of patients reporting pelvic pain prior to surgery, but only 7.8% reporting this symptom at 2 years postsurgery [44]. These findings are similar to those of prior studies demonstrating resolution of chronic pelvic pain among 74% of women for whom this was the primary indication for hysterectomy [48].

For patients with endometriosis, there is considerable evidence for the efficacy of hysterectomy for management of pelvic pain; however, the literature is not specific about different varieties of preoperative pelvic pain among patients undergoing hysterectomy, making it challenging to identify risk factors for poor response to hysterectomy [49]. Supracervical hysterectomy among patients with endometriosis may be associated with continued or recurrent pain and severe adhesions at time of trachelectomy for persistent symptoms, as well as risk of implantation of tissue at the incision through which the specimen is removed or dissemination from morcellation for tissue removal. Complete removal of endometriosis tissue at time of hysterectomy is recommended to avoid residual pain. Women with endometriosis should be counseled that even with hysterectomy, they remain at risk for continued symptoms or recurrence of endometriosis and chronic pelvic pain, which may occur in up to 62% among women with ovarian conservation [50]. A retrospective study of 120 women with endometriosis showed that among 47 women undergoing hysterectomy with ovarian preservation, 95.7% were surgery free at 2 years, and 77.0% at 7 years; among 50 women undergoing hysterectomy with bilateral salpingo-oophorectomy (BSO), 96.0% were surgery free at 2 years, and 9.17% at 7 years [21]. Evidence for hysterectomy for endometriosis: Level II.

For women with pain arising from pelvic congestion syndrome, hysterectomy with BSO results in significant improvement in pain: a prospective nonrandomized study of 36 patients showed complete pain resolution in 67% at 1 year, and only one woman (3%) had no improvement in her chronic daily pain after the procedure [51]. An RCT of 164 women with pelvic congestion syndrome stratified by preoperative stress score showed 39.5%–46.5% improvement in VAS score at 12 months postsurgery for 27 women undergoing hysterectomy with BSO followed by hormone replacement therapy, and 33.4%–34.6% improvement in VAS score at 12 months postsurgery for 27 women undergoing hysterectomy with unilateral salpingo-oophorectomy (USO) [52]. Evidence for hysterectomy for pelvic congestion syndrome: Level I.

The value of hysterectomy for patients without endometriosis or other identified extrauterine cause of pelvic pain has been demonstrated: a retrospective study of 99 premenopausal patients undergoing hysterectomy with no evidence of extrauterine pathology showed significant symptom improvement in 77.8% of patients at an average of 21.6-month postoperative follow-up [53]. Among these patients, no pathological alteration of the uterus was noted in 65.7% of patients (34.3% had leiomyomata and/or adenomyosis identified on pathology). While the majority of patients with pelvic pain demonstrate a positive response to hysterectomy, regardless of pelvic pain etiology, authors have called for greater research to identify risk factors for continued pain after hysterectomy and full preoperative evaluation of nonreproductive causes of pain [54]. A prospective cohort study of 1249 women undergoing hysterectomy for benign indications showed that women with both preoperative pelvic pain and depression were at a three to five times increased risk of continued impairment in quality of life at 2 years following hysterectomy, including OR 4.91 for continued pelvic pain and OR 2.41 for dyspareunia [55]. Evidence for hysterectomy for management of chronic pelvic pain: Level II-2.

Vaginal Cuff Revision

Patients with persistent or de novo pain at the vaginal cuff following hysterectomy may benefit from laparoscopic vaginal apex excision, although evidence for this procedure is limited to relatively small clinical trials with short follow-up. A case series of nine patients undergoing surgical excision of the vaginal apex for post-hysterectomy dyspareunia showed a decrease in mean coital VAS pain score from 9.22 presurgery to 3.11 postsurgery (p < 0.001), and an increase in coital frequency from 5.22 episodes per month to 11.11 episodes per month postsurgery (p = 0.02) [56]. A retrospective survey of 27 patients with vaginal apex pain and dyspareunia having undergone vaginal apex excision reported significant reduction in pain among 82%, with complete resolution of symptoms among 67% of patients for a median of 20 months, but only 26% of patients remained pain free at the end of the follow-up period [44]. A retrospective survey of 16 patients having undergone vaginal vault excision for post-hysterectomy dyspareunia and chronic pelvic pain reported improvement in dyspareunia among 81.25% of women at a mean postoperative interval of 1.8 months [57]. Evidence for vaginal apex excision: Level II–III.

Fertility-Sparing Pelvic Denervation Procedures

Surgical interruption of cervical sensory pain nerve fibers has been developed as a fertility-sparing treatment option for dysmenorrhea. Two techniques have been developed: laparoscopic uterine nerve ablation (LUNA), which involves the transection of the uterosacral ligaments at their attachment to the cervix, and presacral neurectomy (PSN), which involves total resection of a segment of presacral nerves lying within the interiliac triangle. A Cochrane review from 2005 sought to determine the effectiveness of these two surgical interventions for management of dysmenorrhea: the meta-analysis suggested that LUNA is superior to the control arm for management of primary dysmenorrhea at 12 months, but success rates decline rapidly thereafter; long term, presacral neurectomy was significantly more effective at reducing pain from primary dysmenorrhea when compared to LUNA (OR 0.10) [58]. Presacral neurectomy is associated with greater adverse effects than LUNA, including constipation, urinary urgency, and painless labor. For patients with secondary dysmenorrhea from endometriosis, LUNA was equivalent to a control arm at up to 3 years postsurgery; evidence for presacral neurectomy for secondary dysmenorrhea was mixed, with significant improvement evident for patients with midline abdominal pain. The largest trial of presacral neurectomy for secondary dysmenorrhea compared laparoscopic treatment of endometriosis to laparoscopic treatment of endometriosis plus presacral neurectomy; cure rate was higher within the PSN group (p < 0.05) at 6 months (87.3% vs. 60.3%), at 12 months (65.7% vs. 57.1%), and at 24 months (83.3 vs. 53.3%) [59]. Evidence for presacral neurectomy: Level I.