Scope of the problem

Abdominal pain accounts for 5% of total visits to emergency departments; women with pelvic pain represent 12% of this population.[1] The majority are reproductive age. The differential diagnosis of APP is listed in Table 18-1. The severity of the different causes of APP ranges from life-threatening conditions to conditions that can be managed with simple pain relief.

The presentation of even life-threatening conditions can be vague, nonspecific, or involve only symptoms from a system different to the one from which the pathology arises. Women with ectopic pregnancy, for example, may present with gastrointestinal symptoms.[2] A careful clinical assessment aided by laboratory tests and imaging can help to identify women who need surgery or medical treatment and reassure the ones with normal findings. In 80% of women with pelvic pain and a normal pelvic ultrasound the pain improves or resolves without any complication.[3]

Pelvic pain accounts for 25% of referrals for pelvic ultrasound.[3] The cost of surgery performed in the United States for pelvic pain (acute and chronic) is more than $2 billion annually.[4]

Approach to acute pelvic pain

The clinician must urgently assess and resuscitate the acutely ill patient.

Life threatening conditions such as ectopic pregnancy, hemorrhagic corpus luteum, appendicitis, and sepsis must be considered. A pregnancy test and an early ultrasound examination can be essential. It is important to evaluate for conditions that may threaten long-term fertility and the development of chronic pelvic pain such as pelvic sepsis, endometriosis, and accidents to ovarian cysts. The pain should be addressed early. Administration of analgesia does not affect diagnosis and should not be delayed.

If a diagnosis cannot be established, further imaging in the form of CT or MRI can be considered.

Laparoscopy is the gold standard for assessing acute pelvic pain and conditions such as ectopic pregnancy, accidents to ovarian cysts, and appendicitis can be treated with minimally invasive techniques.

History

The history should establish the chronology and the characteristics of the pain. The onset, duration, location, intensity, nature, type, radiation, associated symptoms, and alleviating and aggravating factors should be noted. Symptoms related to the urinary, gastrointestinal, musculoskeletal and nervous system should be assessed.

The gynecological history should include questions about dysmenorrhea, dyspareunia, abnormal uterine bleeding, and vaginal discharge. History should uncover any recent gynecological procedures that involved instrumentation of the cervix or uterus as these can increase the risk of pelvic inflammatory disease. Previous medical and surgical history and current medications should also be noted. The patient’s sexual history will help to stratify the risks for PID.[5] (See Tables 18-2 and 18-3.)

Clinical examination

Examination should include assessment of the patient’s general condition and vital signs. Although fever is suggestive of an infectious cause of pelvic pain, it is absent in 60% of patients with PID and in more than 30% of patients with appendicitis. Remember that young women tolerate blood loss well and even with significant bleeding into the abdomen, peritoneal irritation may be a late sign. The absence of signs of peritonitis does not rule out either hemoperitoneum or PID.

The abdomen should be examined for surgical scars, distention, tenderness, signs of peritonitis, and palpable masses. Right upper quadrant tenderness associated with pelvic pain may be indicative of Fitz-Hugh-Curtis syndrome.

A speculum examination of the vagina and cervix may demonstrate discharge, bleeding, or erythema.

A bimanual examination will assess the position and mobility of the uterus as well as the presence of masses or tenderness in the adnexa. Pain on moving the cervix is strongly suggestive of pelvic pathology. Cervical excitation is said to occur in a quarter of women with appendicitis.[6]

The sensitivity of pelvic examination for detecting an adnexal mass is low.[7] Body habitus and tenderness also hinder the palpation of pelvic masses.

Investigations

A urine pregnancy test and urinalysis should be done quickly. A complete blood count and C-reactive protein may be helpful if an infectious cause is suspected. A normal white cell count does not exclude the possibility of PID or appendicitis.

Swabs to detect chlamydia and gonorrhea should be obtained.

Positive results support the diagnosis of PID whereas negative results do not exclude it.

The absence of pus cells in separately obtained endocervical or vaginal swabs has a good negative predictive value for PID.

Imaging

Transvaginal (TVS) and transabdominal (TAS) ultrasound examination of the pelvis can be helpful in establishing a diagnosis. TVS and TAS can identify conditions requiring emergency care such as ruptured ectopic pregnancy, hemorrhagic ovarian cyst, or ovarian torsion. Imaging can assist in the diagnosis of ovarian cysts, tumors, uterine fibroids, and complications of PID such as pyosalpinx, tubo-ovarian abscess. Appendicitis can be diagnosed by ultrasound examination. A normal examination makes the diagnosis less likely.

Computed tomography (CT) can detect acute appendicitis, other bowel pathologies such as inflammatory bowel disease, diverticulitis, infectious colitis, as well as ureteral calculi.

Invasive diagnosis

Diagnostic laparoscopy should be considered in symptomatic women with pregnancy of unknown location in which serum hCG is above the discriminatory zone of 1,000 IU/L–2,000 IU/L and the TVS has failed to demonstrate an intrauterine or ectopic pregnancy. In nonpregnant women diagnostic laparoscopy can be considered if the pain is unresolved after a period of 24–48 hours of observation.

The most common laparoscopic findings in women with nonspecific low abdominal pain were appendicitis, PID, and ovarian cysts. Diagnosis may not be established in 20% of women.[8]

Laparoscopy in women of reproductive age with nonspecific low abdominal pain is associated with an increased rate of specific diagnosis and a shorter hospital stay compared to a wait and see approach.[9]

Treatment of acute pelvic pain

The aim of the treatment is to provide pain relief and address the pathologic process that accounts for the symptoms.

Scope of the problem

Chronic pelvic pain is persistent intermittent or constant pain perceived in structures related to the pelvis. It can be a symptom of a specific pelvic organ pathology or a syndrome in the absence of an underlying pathology. Prevalence for reproductive age women is between 14.7%–25%.[13, 14]

Pelvic pathology, history of abuse, and psychological morbidity are predisposing factors for CPP.[15]

Chronic pelvic pain has a negative impact on women’s activity at home, at work, and on their relationships.[16] A US-based study showed that 3.9% of women with CPP missed at least a day of work per month due to their symptoms.[16] Similarly 18% of employed women in the UK were off work for at least one day each year.[17] Many well-defined conditions can account for CPP (Table 18-4).

Approach to chronic pelvic pain

It should be remembered that patients with chronic pelvic pain may have discomfort arising from more than one system. Patients will often have a history of consultations with other specialties, and a variety of investigations may have already been performed. Specific questioning may be necessary. Psychological morbidity and physical or sexual abuse are associated with chronic pelvic pain.

The practitioner must assess the degree to which the pain is interfering in the patient’s professional, sexual, and social life. Exploration of her thoughts about the pain, factors related to the onset of pain, and what strategies improve the pain should be undertaken.

The patient can be reassured that her condition is common and that after investigations it is likely that long-term fertility is not affected. She should be made aware that laparoscopy, despite being the gold standard for the investigation of pelvic pain, is often negative; although it may show minor degrees of endometriosis or adhesions, these are unlikely to be the cause of pain. These minor findings may be fastened onto with a resulting increase in unnecessary treatment and invasive procedures. The woman deserves to know that laparoscopy is a frequent and profitable gynecological procedure but is not without its risks and complications.

History

Details about the duration, characteristics, and chronology of pain should be obtained. A pain diary for two to three menstrual cycles is helpful to identify aggravating and alleviating factors. Events or situations that women associate with the onset of pain and describe them as traumatic can be suggestive of underlying psychological trauma must be addressed. Women should be asked about red flag symptoms that may need urgent investigations and referral to a specialist (Table 18-5). Full body pain maps prompt women to report the location of the pain and rate the intensity of the pain on a scale from 0 to 10 on every area they experience pain. Symptoms that indicate some of the common pathologies of CPP should be elicited (Table 18-6).

Women should be asked about their mood, sleep, and appetite. The two-question Patient Health Questionnaire-2 can be used as a screening tool for depression (Table 18-7). A score of 3 or more requires further evaluation of the woman for depressive disorder.[18] Women with history of child or adult abuse are more likely to have and report CPP.[19, 20] In a safe, private setting with no one known to the woman present, the patient should be asked whether she has been threatened or hurt currently, in the past, or whether she has been forced to do something sexually that she did not desire.[21]

The impact of CPP on the ability to perform daily activities should be explored and documented. Women should be asked how the pain has affected their role in their family, their relationship, their performance at work, and their social life. Previous medical, surgical history and prior investigations and treatment should be noted. It is useful to establish the results of previous investigations and the effect of previous treatments.

Women should be invited to express their concerns about their pain and any possible explanations about causation that they may have heard. It is essential to establish the patient’s expectations at the initial consultation. Such information will help the clinician to tailor the interventions accordingly, clarify any misconceptions and shape their expectations. Questionnaires such as the one designed by the International Pelvic Pain Society (www.pelvicpain.org/pdf/FRM_Pain_Questionnaire.pdf) can facilitate a thorough pre-visit history and prompt to screen common causal conditions of chronic pelvic pain.

Clinical examination

Clinical examination of the abdomen may demonstrate the site of tenderness. Scars should be noted, and clinicians should check for scar hypersensitivity. The abdomen should be examined for highly localized trigger points. Light localized pressure on these points may elicit local tenderness or vigorous pain occasionally paired with a muscle twitch.

A cotton swab can be used to identify areas of tenderness on the vulva and the introitus.

A single-digit vaginal examination is advisable in women with CPP. The pelvic floor muscles should be palpated at rest and during contraction. The tone and areas of tenderness should be noted.

Specific palpation of the urethra, bladder base and vaginal walls should follow and the utero-sacral ligaments, posterior vaginal fornix and recto-vaginal septum should be examined for nodularity and localized tenderness.

The examination of the uterus should include an evaluation of the shape, size, and mobility. Areas of tenderness should be noted and motion tenderness elicited by gentle movement of the cervix should be checked (cervical excitation).

The adnexal areas should be examined for tenderness or palpable masses.

On speculum examination the vaginal walls, fornices, and cervix should be examined. Signs of infection, endometriotic implants, and cervical lesions can be identified. The pelvic support of the bladder, urethra, vagina, uterus, and rectum should be documented.

As chronic pelvic pain can be musculoskeletal in origin, an assessment of posture, back and pelvic joints should be included in the clinical examination. Women should be examined for scoliosis, pelvic asymmetry, and tenderness over sacroiliac joints and the symphysis pubis.

A normal clinical examination does not preclude the possibility of an anatomic condition responsible for CPP. Up to 50% of women with normal clinical examination have abnormal laparoscopic findings.[22]