++
Pelvic pain is often considered synonymous with gynecologic pain.
Such pain can be acute or chronic. Acute pain is caused by structural
disruption or physiologic dysfunction, whereas chronic pain may
be the result of persistent pressure on nerves, inflammation of
arteries, diseases of the female reproductive organs, and factors
not demonstrable by present-day imaging techniques.
++
The differential diagnosis of acute pelvic pain includes ectopic
pregnancy and complications of pregnancy, ruptured cysts, ovarian
and adnexal torsion, uterine fibroids, and pelvic inflammatory diseases.
Ninety-eight percent of women with ectopic pregnancy experience
unilateral pain, which may be accompanied by light or missed menses.
Symptoms of pregnancy, such as nausea and breast tenderness, also
may be present.3
++
The pain of ovarian cysts may be dull and aching, localized to
the side of the abscess, and accompanied by pelvic tenderness. An
ovarian cyst with a twisted pedicle can cause acute pain, which becomes
intermittent when the pedicle untwists. Other symptoms include nausea
and vomiting, diarrhea or constipation, and leukocytosis.
++
Symptoms of a palpable mass, delayed menses, and pelvic tenderness
also occur with corpus luteum cysts, which can bleed into the peritoneum
and mimic pelvic inflammatory disease (PID). PID is defined as a
spectrum of upper genital tract inflammatory disorders that may
include endometritis, salpingitis, tubo-overian abscess, and pelvic
peritonitis. The diagnosis should not be considered conclusive without
additional findings, such as a positive cervical culture. The primary
pathogens are Neisseria gonorrhea and Chlamydia trachomatis. Cervical
cultures for Chlamydia can detect up to 80% of cervical
infections; antibody testing, enzyme-linked immunosorbent assay,
and DNA probe testing can detect 60% to 90% of
infections. Because of this wide range in positive findings, culturing
of specimens from the urethra and anus also should be considered.
Tubo-ovarian abscess may occur as a complication of PID as well
as in postpartum and postoperative patients and in women who use
intrauterine devices. The bacteria present in tubo-ovarian access
occur in the lower genital tract and may not be the same agents
involved in PID.4
++
Chronic pain may begin as an acute episode, change into episodic
pain, and then persist for 6 months or longer. From a clinical perspective,
chronic pelvic pain can be a symptom of a disease or part of a syndrome.
Endometriosis and malignancies are examples of primary illnesses, whereas
syndromes include dysmenorrhea, premenstrual syndrome, and chronic
pelvic pain disorders.
++
Endometriosis is the presence of ectopic endometrial glands and
stroma outside the uterine cavity. Patients with endometriosis may
have dysmenorrhea, dyspareunia, back pain, and rectal discomfort
in addition to persistent pelvic pain. The symptoms are related
to the site of the endometrial implant. However, the intensity of
the pain may not correlate with the size of the implant.5 The
incidence is 1% to 2% of the general female population
and 15% to 25% in infertile women. Patients may
remain asymptomatic until they are being evaluated for infertility.
Definitive diagnosis can only be made by laparoscopy, although elevated
serum CA-125 levels correlate with severity and reflect the course
of the disease. Treatment includes medical and surgical options. The
medical treatment for endometriosis includes oral contraceptives,
medroxyprogesterone acetate, danazol, and gonadotrophin-releasing
analogues. The goals of surgery are to restore normal pelvic anatomy
and to resect, coagulate, or vaporize all endometriotic implants.
++
Adenomyosis is a benign invasion of the wall of the uterus by
endometrial tissue. Most patients are 35 to 50 years of age and
have had children. Presenting complaints usually dysmenorrhea and menorrhagia.
++
Uterine leiomyomas (fibroids) are painful when they press on
or become entangled in other structures, and cause discomfort when
they grow. Dyspareunia, dysmenorrhea, and pelvic pressure are frequent
symptoms, along with intermenstrual, postmenstrual, and heavy menstrual
bleeding. A degenerating leiomyoma may cause only episodic pain
at first and then fever, increased pain, and leukocytosis with a
left shift later. Leaking purulent material can cause peritonitis.
Leiomyomas undergo malignant transformation in 2 to 3 per 100,000
women, but grow slowly. Surgery used in the treatment of women with
heavy bleeding, growths of large size, and additional symptoms.6
++
Cervical cancer may cause pelvic pain as it metastasizes. Ovarian
cancer may be asymptomatic until late stages, when it causes symptoms
that are vague and nonspecific. Endometrial cancer in 90% of
cases presents with vaginal bleeding or discharge. Pelvic pressure
or discomfort occurs from uterine enlargement and then spread of
the tumor into extrauterine structures. Any tumor that compresses
the bladder or rectum can cause pressure, pain, or dyspareunia.7
++
Women with ovarian remnant syndrome present with unilateral consent
or cyclical pain, as well as postcoital ache, and post-micturition
or post-defecation pain. They may have a history of the removal
of one or both residual ovaries for pain associated with pelvic
adhesions or endometriosis. Although localized abdominal pain is
a constant feature of the syndrome, often no mass can be found on
pelvic examination. Ultrasound examination is usually diagnostic,
revealing a mass that must be distinguished from accessory ovaries,
an embrylogic variant of normal development. Treatment is surgical
removal of the remnant.8
++
Women with major gynecologic diseases can have pelvic pain in
the form of dysmenorrhea. This term is applied to severe cramping
in the lower abdomen, lower back, and upper thighs that occurs during
menstruation. Primary dysmenorrhea is the most prevalent source
of chronic episodic pain in premenopausal women. It is caused primarily
by prostaglandin release from the endometrium at menses, in particular
prostaglandins F2 alpha and E2. The cramping pain
is often accompanied by nausea, vomiting, headache, diarrhea, and
fatigue. Secondary dysmenorrhea and atypical cyclic pain are caused
by underlying intrauterine or extrauterine pathology, such as endometriosis,
adenomyosis, and other pathology that alters blood flow, increases
pressure, or causes irritation of the pelvic organs.
++
The treatment of primary dysmenorrhea includes nonsteroidal anti-inflammatory
drugs (NSAIDs) and oral contraceptive pills. NSAIDs are effective
in up to 80% of cases. Other modes of menstrual hormonal
suppression are recommended for patients who obtain no relief with
NSAIDs and oral contraceptives. Secondary dysmenorrhea requires
a thorough evaluation and then treatment of the underlying cause.
++
Premenstrual syndrome (PMS) includes mood, behavioral, and physical
changes that occur during the luteal phase of most menstrual cycles.
Studies suggest that about one third of premenopausal women experience
some degree of PMS. As in the treatment of dysmenorrhea, underlying illnesses,
such as endometriosis and leiomyomas, should be ruled out. Treatment
includes NSAIDs for pain, diuretics such as spironolactone for fluid
retention, and antidepressants for dysphoria.
++
Pelvic congestion syndrome is usually seen in premenopausal women,
thus suggesting that there is a hormonal factor involved in the
venous dilation.9 The capacity of pelvic veins
to increase 60-fold by the end of pregnancy makes them, in the nonpregnant
state, vulnerable to chronic dilation and stasis. Weakened fascial
supports during parturition and the vasodilating effects of cyclically fluctuating
hormones aggravate the tendency to dilation.10 The
common symptom is a dull, aching pain in the pelvic area that worsens
on standing, walking, and lifting and is relieved by lying down.
Deep dyspareunia is one of the most consistent symptoms of pelvic
congestion syndrome, with an incidence ranging from 71% to
78%. The severity of the pain is determined by the extent of
the venous stasis, which leads to hypoxemia and local tissue damage
followed by the release of pain-producing substances. The presence
of dilated veins in the infundibulopelvic ligament, ovarian hilum,
or broad ligament, combined with polycystic changes in the ovary
(which may be apparent only on close inspection), is diagnostic
of pelvic congestion. Ultrasound and computed tomography (CT) scans
are important for revealing polycystic changes in the ovaries and
dilated veins in the broad ligament and uterus. Surgical treatment
includes hysterectomy and ligation of the ovarian vein. Medical
therapy consists of oral contraceptives to suppress ovarian function
and intermittent courses of anti-inflammatory agents and antibiotics
when inflammation occurs secondary to local infection.11 Radiologic
transcatheter embolization of the ovarian veins has been used with
varying success.
++
Sympathetic pelvic syndrome is a chronic pelvic pain disorder
that has been recognized because of developments in the study of
chronic pain. It is assumed that visceral illness occurs, with pain transmitted
to cutaneous areas. The area of innervation includes the cervix
and vagina (with innervation from the pudendal nerves, having derivation
from S2 through S4), along with the uterus, fallopian tubes, and
ovaries (with innervation from the sympathetic pelvic branches of
T10 through T12). Repeated local anesthetic nerve blocks are recommended
in addition to the medications used in patients with chronic pain.
++
Another chronic pelvic pain syndrome is focal vulvitis, characterized
by burning vulvar pain and superficial dyspareunia. One study found
that a majority of patients continued to have symptoms of vulvitis
after Woodruff perineoplasty. The authors concluded that surgery
was not the best treatment. They noted that these women often had
insufficient lubrication or hypertonia of the pelvic floor, or both,
during sexual intercourse. Thus, an integrated approach was recommended, including
protection of the vulvar skin, relaxation of pelvic muscles, and
treatment of psychosexual and relational aspects of the disorder.12
++
These treatment recommendations are similar to those for patients
with chronic pain for whom no pathologic findings have been found.
Some studies of chronic pelvic pain in women report that 10% to
50% experience pelvic pain without pathology; other studies
cite 15% as the percentage of women who have chronic pelvic
pain. The studies citing these statistics then tend to look into symptom
clusters for this group of patients. The wide incidence range cited
suggests there may be some ambiguity in the definition of chronic
pain and in the procedures used to evaluate patients with pelvic
symptoms.
++
The initial patient group can be modified after further study
and treatment. Nevertheless, there remains a group for whom no physiologic
mechanisms have been elucidated.13,14 These patients have
a chronic pelvic pain syndrome that is considered a somatoform disorder
similar to irritable bowel syndrome. The prevalence of this syndrome
in primary care patients (38%) is comparable to that of
asthma and back pain.15 A syndrome of chronic pelvic
pain without obvious pathology (CPPWOP) has also been described,
but is unclear in these cases whether pathology has been overlooked
or limited to findings for specific diseases, such as endometriosis,
thus possibly excluding damage to ligaments and smooth and striated
muscle. Patients with CPPWOP have a group of symptoms that includes intermittent
pain that can vary with the menstrual cycle and is localized to
the low abdomen and back. Dyspareunia may be present. Patients tend
to be in their 20s and 30s and have a history of childhood sexual
abuse, rape, or incest. Present relationships are marked by abuse,
divorce, and prostitution.16
++
Treatment of chronic pelvic pain syndrome or CPPWOP is similar
to that of other chronic pelvic pain syndromes and includes NSAIDs
and antidepressants. Psychological interventions also have played
a role in the treatment of patients with these syndromes. The treatment
strategies resemble those for patients with chronic pain with a
specific pathology and include methods that help women distract
themselves from the pain and encourage them to cope despite the
pain.
++
Women with negative investigations that do not result in an organic
diagnosis may then be referred for psychiatric treatment. Despite
the apparent presence of anxiety, depression, and possible history
of sexual trauma, referral for psychiatric treatment may be resisted.
This response is not surprising, given the role psychobiological
factors have played in the treatment of women with chronic pelvic
pain. Studies of women with chronic pelvic pain syndrome and chronic
vulvar pain syndrome have shown a significantly higher incidence
of sexual abuse in the two chronic pain groups compared with women
who do not have these symptoms. In addition to physical and emotional
trauma, there is a significant association between sexual victimization
before age 15 years and chronic pelvic pain. Sexual abuse and somatization
are highly predictive factors for chronic pain. There also is a
higher incidence of depressive symptoms in this group of patients.
++
The association of sexual abuse, affect and pelvic pain was the
basis for psychoanalytic studies of personal development throughout
the past century. The first case studies were women with the diagnosis
of hysteria, whose symptoms had psychological meaning. The term
hysterus is Greek for uterus, and the concept of hysteria (derived
from a theory of a “wandering” womb as the basis for
inexplicable symptoms in women) historically was the basis for treatments
that reflected sociocultural values about the status of women. Hysteria
is no longer considered a valid diagnosis; it has been replaced
by in current practice by the diagnoses of conversion and somatoform disorders,
which may affect both men and women. Nevertheless, the legacy of
hysteria as a medical condition persists.
++
Hysterical conversion has been defined as a special type of somatization
in which physical symptoms express a psychological conflict (often
sexual) that includes affects that were not sufficiently expressed
at the time of the incident, and now represented symbolically. In
classical psychotherapy, after elucidating the traumatic precipitant,
the next step was to clarify how affects were not expressed directly
and were converted into physical symptoms. Patients were said to
be using the defenses of repression, denial, and somatization to
deal with their feelings. Because of social pressure to limit their
direct expression of aggression and their vulnerability to sexual
abuse, women were more likely to have chronic pain and to express
themselves somatically. Eventually, such women came to be identified
with their symptoms; the so-called painful woman who resisted the interpretations
put forth for her benefit.17,18
++
Even today pelvic pain may be considered psychogenic when there
is no explicit organic finding because of the persistence of the
triad of affect, sexual abuse, and somatization in clinical and psychometric
testing studies. Because not all women with chronic pelvic pain
have been abused, an alternative explanation has been sought for
pelvic pain that occurs without confirming laparoscopic and imaging
findings. The biopsychosocial model attempts to integrate physiologic
and psychological causes of pain, suggesting the existence of a
mind-body dualism in which psychological factors are secondary to
physical symptoms. Keeping in mind that physical symptoms in at least
one third of cases have no demonstrable organic findings, this model
can lead to clinical situations that are difficult to distinguish
from early models of hysteria and thus are subject to patient skepticism.
This approach is being replaced by theories of central pain mechanisms
focusing on neurotransmitters and neural networks that also express
affective and cognitive functions. However, a major deconstruction
of the studies for chronic pelvic pain needs to be carried out before
the diagnosis of hysteria can be considered obsolete.