L19 - Pelvic Pain & Endometriosis

Pelvic Pain
Acute Pelvic Pain

1. Definition
 Acute lower abdominal pain and pelvic pain that is present less than 7 days

2. Pathogenesis
Somatic & Visceral pain
Somatic  Stems from nerve afferents of the Somatic Nervous System
Pain  Innervation: Parietal peritoneum, Skin, Muscles, Subcutaneous tissues
 Typically sharp & localized, often unilateral & focused to a specific corresponding dermatome
 Found left or right within dermatomes
Visceral  Stems from afferent fibres of the Autonomic Nervous System (Viscera  Visceral peritoneum)
Pain  Noxious stimuli: Stretching, Distension, Ischemia, Necrosis, Spasm of abdominal organs
 Diffuse sensory input  Generalized pain, Dull, Achy, Cramping
 Visceral pain often localizes to the midline because visceral innervation of abdominal organs is
usually bilateral
Inflammatory or Neuropathic pain
Inflammatory Pain
 Tissue injury  Inflammation (Prostaglandins & Cytokines)
 Body fluids, Inflammatory proteins & cells go to injury site to limit tissue damage

Neuropathic Pain
 Sustained noxious stimuli  Persistent central sensitization  Permanent loss of neuronal inhibition
 Decreased threshold to painful stimuli remains despite resolution of the inciting stimuli  Persistence
characterizes neuropathic pain

3. Causes of Acute Lower Abdominal & Pelvic pain

Gynaecologic Gastrointestinal
 PID  Dysmenorrhea  Gastroenteritis  Irritable Bowel Syndrome
 Tubo-Ovarian abscess  Ovarian mass  Colitis  Obstructed small bowel
 Ectopic pregnancy  Ovarian torsion  Appendicitis  Mesenteric ischemia
 Incomplete miscarriage  Obstructed Outflow  Diverticulitis  Malignancy
 Prolapsing leiomyoma Tract  Constipation
 Mittelschmerz (Mid-cycle ovulation pain)  Inflammatory Bowel Disease
Urologic Musculoskeletal Miscellaneous
 Cystitis  Hernia  Peritonitis  Sickle Cell Crisis
 Pyelonephritis  Abdominal Wall Trauma  DKA  Vasculitis
 Urinary stone  Herpes Zoster  Abdominal Aortic Aneurysm
 Perinephric abscess  Opiate withdrawal Rupture

4. Investigations
Laboratory  Urine/Serum βhCG (reproductive age without prior hysterectomy)
Testing  FBC (Identify haemorrhage)
 Urinalysis (evaluate possible Urolithiasis or Cystitis)
 Microscopic evaluation & culture of vaginal discharge (if PID suspected)
Radiologic  Ultrasound
Imaging TVS Superior resolution of reproductive organs
TAS Uterus/Adnexal structure - Significantly large or lie beyond TVS probe
Colour Doppler Vascular qualities of pelvic structures
Imaging Acute pain  Adnexal torsion or Ectopic pregnancy
 CT scan
- Evaluate acute abdominal pain in adults
- Potential increased cancer risk in younger patents and women
 MRI
- Done when sonography is non-diagnostic
- First line tool often selected for pregnant patients (should limit ionizing radiation exposure)
Laparoscopy  Useful if no pathology can be identified by conventional diagnostics

5. Clinical approach for diagnosis

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History Taking
 Abrupt onset  Organ torsion, Rupture or Ischemia
 Pain may be Visceral or Somatic (rest motionless - Peritoneum, Muscle, Skin)
- Colicky  BO (adhesion, neoplasia, stool, hernia), Forceful uterine contractions, Stones in LUT
- Well-localised persisting > 6 hours & unrelieved by analgesics  Acute peritoneal pathology
 Urinary pathology  Dysuria, Haematuria, Frequency, Urgency
 Gynaecologic causes  Vaginal bleeding, Vaginal discharge, Dyspareunia, Amenorrhea
 Vomiting  Adnexal torsion(75%), If prior to pain then surgical abdomen is less likely
Physical Examination
General Examination
 Urgency of condition  Facial expression, Diaphoresis, Pallor, Degree of agitation
 Intra-abdominal pathology risk  Tachycardia, Elevated temperature, Hypotension
 Constant, Low-grade fever  Diverticulitis, Appendicitis
 High temperature  PID, Advanced peritonitis, Pyelonephritis

Pulse & Blood Pressure

 Ideally assess orthostatic changes if intravascular hypovolemia is suspected
-Pulse increase 30bpm or SBP drop of 20mmHg or both between lying and standing after 1 minute  Hypovolemia

Abdominal Examination
Inspection  Prior surgical scars  possible BO from post-operative adhesions or incisional hernia
 Abdominal distension  Bowel obstruction, Perforation, Ascites
Palpation  Rebound tenderness or Abdominal rigidity  Peritoneal irritation
Auscultation  Hyperactive or High-pitched bowel sounds  Bowel Obstruction

Pelvic Examination
 Purulent Vaginal discharge or Cervicitis  PID
 Vaginal bleeding  Pregnancy complications, Benign/Malignant reproductive tract neoplasia, Acute vaginal trauma
 Uterine enlargement  Leiomyoma, Pregnancy, Adenomyosis
 Cervical motion tenderness  Peritoneal irritation, PID, Appendicitis, Colon diverticulum
 Tender adnexal mass  Abscess of non-gynaecologic origin (e.g. Appendix, Colon diverticulum)

Rectal Examination
 Stool guaiac testing for occult blood (Complaints - Rectal bleeding, Painful defecation, Significant bowel changes)

Chronic Pelvic Pain

1. Definition
 Intermittent or constant pain in the lower abdomen or pelvis for at least 6 months duration, not occurring exclusively
with menstruation (not dysmenorrhea) or intercourse (not dyspareunia) and not associated with pregnancy (not
ectopic pregnancy or miscarriage)
 It may be associated with incomplete relief with most treatment, significantly impaired function at home or work, signs
of depression, such as early awakening, LOW and may significantly impact a woman’s QOL

2. Causes
Musculoskeletal Neurologic Miscellaneous
 Hernia  Neurologic dysfunction  Psychiatric disorders
 Muscular pain  Pudendal neuralgia  Physical or Sexual abuse
 Faulty posture  Piriformis syndrome  Shingles
 Myofascial pain  Abdominal cutaneous nerve
 Degenerative Joint Disease entrapment
 Levator ani Syndrome  Neuralgia of iliohypogastric,
 Fibromyositis ilioinguinal, lateral femoral
 Spondylosis cutaneous, genitofemoral nerves
 Vertebral compression  Spinal cord or Sacral nerve
 Disc disease tumour
 Coccydynia
 Peripartum pelvic pain
3. Clinical approach for diagnosis
History Taking
 L19 - Pelvic Pain & Endometriosis
 Pattern of pain, Clinical measurement of pain level and Main concern about the pain (pain & treatment expectation)
 Bladder & bowel symptoms
 Results of previous attempts at treatment & amount of medication used
 Daily pain diary (2 – 3 menstrual cycle may be helpful in tracking symptoms or activities associated with the pain)
 Impact of pain on the patient’s QOL (e.g. effect of pain on daily activities, work, relationships, sleep, sexual function)
 Psychological assessment (e.g. Symptoms such as sleep or appetite disturbance & tearfulness, Current stress in life)
 Abuse history (Past/Present assault, Particularly intimate partner violence)
 Gynaecological factors (Worsened by stress and menstruation)
 Pregnancy & Delivery
 Prior abdominal surgery
 Psychologic risk factors
Physical Examination (Allodynia = pain from innocuous stimulus, Hyperalgesia = Extreme response to painful stimulus)
General Examination
 Demeanour (facial expression)
 Mobility
 Posture (e.g. abnormal gait, guarding, careful positioning)
Back Scoliosis, Sacroiliac tenderness, Trigger points, Pelvic asymmetry
Abdomen Head-raise test (for diastasis  partial/complete separation of Rectus Abdominis muscle or hernias)
Vulva Cotton swab to perform sensory examination & Identify area of tenderness

Speculum Examination
 Cervical lesions, Infections & Endometriosis implants can be identified
 Palpate vaginal vault with long cotton swab  Post hysterectomy dyspareunia(Nerve entrapment/Localised lesions)

Pelvic Examination
 Tone & muscle control
 Presence of vaginismus (painful spasmodic contraction of vagina)
 Cervical motion tenderness
 Uterine mobility
 Uterine & adnexal tenderness and masses

Rectovaginal Examination
 Assess for any rectovaginal nodules, scarring or tethering & to determine its extent

4. Initial Management of CPP at Primary Care

Red Flag Signs  Bleeding per rectum
& Symptoms  Post-coital bleeding
 Excessive weight loss
 New bowel symptoms in patients > 50 years of age
 New pain after the menopause
 Pelvic mass
 Suicidal intention
 Irregular vaginal bleeding in woman > 40 years of age
Investigations  Screen for Chlamydia and Gonorrhoea (PID Suspected)
 Offer screening for STIs for all sexually active women
Treatment Cyclic  Ovarian suppression (COCs, Progestogens, Danazol, GnRH agonist) for a period of 3 –
pain 6 months  Effective for pain associated with endometriosis
- Cyclical pain + no abnormalities on VE  GnRH agonist
 Levonorgestrel-releasing Intrauterine system (LNG-IUS)
- Pelvic venous congestion can appear well controlled by ovarian suppression
- Progesterone  Dilate or open up blood vessels
Genera  Analgesic – Regular NSAIDs +/- PCM
l pain  Amitriptyline or Gabapentin  Neuropathic pain
 Non-Pharmacological modalities
- Transcutaneous Electrical Nerve Stimulation (TENS), Acupuncture, Acupressure,
Vitamin B1, Magnesium supplementation, Other complementary therapies

5. Indications for Investigations at Secondary level

 Pain has not been explained to the woman’s satisfaction or when pain is inadequately controlled
 History suggests that there is a specific non-gynaecological component to pain
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6. Investigations at Secondary level

Imaging TVS  To screen and assess adnexal masses such as endometriomas, hydrosalpinxes or fibroids
 Endometriomas can be accurately distinguished from other adnexal masses by TVS
 Useful to diagnose adenomyosis
MR  Useful to diagnose adenomyosis
I
Diagnostic  Gold standard in diagnosing Chronic Pelvic Pain
Laparoscopy  Better seen as a second-line investigation if other therapeutic interventions fail
 The only test capable of diagnosing peritoneal endometriosis and adhesions
 Note that IBS & Adenomyosis are NOT visible at laparoscopy
 Micro-laparoscopy or conscious pain mapping

7. Management
Positive Diagnosis on Laparoscopy Negative Diagnosis on Laparoscopy
 Adhesions - Adhesiolysis  Presacral neurectomy
 Ovarian Remnant Syndrome  Laparoscopic Uterosacral Nerve Ablation (LUNA)
- Unintentional, incomplete dissection & removal of the  Sacral Nerve Stimulation
ovary during a difficult or emergency oophorectomy  Injection of the Trigger points of Abdominal wall,
 Pelvic Congestion Syndrome (Dilated pelvic veins) Vagina & Sacrum with LA
- Ovarian vein ligations & Percutaneous embolization  Antidepressants
- Progestogens daily in high doses  Hysterectomy (effective for CPP + Reproductive
 Residual Ovary Syndrome symptoms)
- Recurrent pelvic pain
- Persistent pelvic mass after hysterectomy

Endometriosis
1. Definition
 Presence of endometrial glands and stroma outside of the uterus

2. Causes/Pathogenesis
Retrograde  Retrograde menstruation through fallopian tubes
menstruation  Refluxed endometrial fragments invade the peritoneal mesothelium and develop a blood
supply for implant survival and growth
 Women with outflow tract obstruction have a high incidence of endometriosis
 Immunologic & angiogenic factors aid implant persistence
Stem cell theory  Undifferentiated endometrial cells (from endometrium basalis layer) differentiate into
epithelial, stromal & vascular cells as endometrium is routinely regenerated each cycle
 If displaced to an ectopic location (e.g. retrograde menstruation)  Endometriosis
Aberrant Lymphatic  Lymphatic spread to Pelvic Sentinel Lymph nodes
or Vascular spread of  Findings of endometriosis in unusual location such as the groin
endometrial tissue
Colemic metaplasia  Parietal peritoneum is pluripotent (metaplastic transformation to normal endometrium)
 Ovary & Müllerian ducts are derived from colemic mesothelium
 May explain cases of endometriosis without menstruation
- Premenarchal girls & males treated with estrogen & orchidectomy for prostate cancer

3. Ovarian endometriomas
a) Morphology
 Smooth-walled
 Dark-brown ovarian cysts (filled with a chocolate-appearing fluid)
 Unilateral or Multilocular (Large)

b) Theories
 Invagination of ovarian cortex implants
 Colemic metaplasia
 Secondary involvement of functional ovarian cysts by endometrial implants located on the ovarian surface
4. Anatomical sites
 Endometriosis may develop anywhere within the pelvis & extra-pelvic peritoneal surfaces
 Implants – Superficial/Deep Infiltrating Endometriosis (DIE) (infiltrate vital structures like bowel, bladder, ureters)
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 Most commonly in dependent areas of the pelvis
Commonly Rarely
 Anterior/Posterior cul-de-sacs  Rectovaginal septum  Surgical scars
 Oher pelvic peritoneum  Ureter  Pleura
 Ovary  Bladder
 Uterosacral ligaments  Pericardium

5. Classification

6. Differential diagnosis
 Primary dysmenorrhea  Congenital anomalies of Reproductive tract
 Adenomyosis  Interstitial cystitis or Recurrent UTI
 Uterine Fibroid  IBS or other bowel pathology
 PID  Cancer (e.g. Cervix, Uterus, Ovary, Rectum,
 Adhesions Bladder)
 Musculoskeletal disorders

7. Diagnostic evaluation
a) Physical Examination
Speculum  Blue or Red powder-burn lesions seen on the Cervix or Posterior Vaginal Fornix
Examination  These lesions can be tender or bleed with contact
Bimanual  Uterosacral ligament nodularity & tenderness  Active disease or Scarring along the ligament
Examination  Enlarged, Cystic adnexal mass, Mobile or Adhered to pelvic structures  Ovarian Endometrioma
 Retroverted, Fixed, Tender Uterus and Firm, Fixed posterior cul-de-sac
 DURING MENSES  Pelvic nodularities secondary to endometriosis (easily detected)
Rectal  Rectovaginal septum nodularity or tenderness
Examination
b) Symptoms from Specific Sites
Pain Common types of pain Rare types of pain
 Endometriosis-associated CPP  Dyschezia (Pain with defecation)
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 Dysmenorrhea  Dysuria
 Dyspareunia  Abdominal pain
 Non-cyclic pain
 Endometriosis-associated Dysmenorrhea
- Typically precedes by 24 – 48 hours
- Pain more severe & less responsive to NSAIDs & COC than Primary dysmenorrhea
- Presence of DIE positively correlates with severity of dysmenorrhea
 Endometriosis-associated Dyspareunia
- Often related to Rectovaginal septum, Uterosacral ligament or Posterior cul-de-sac
- Tension on diseased uterosacral ligament during intercourse  pain
- Suspected if pain develops after years of pain-free intercourse
 Non-cyclic CPP
- If Rectovaginal septum or Uterosacral ligament  Pain may radiate to rectum or lower back
- Sciatic nerve involvement  Pain radiating down the leg & causes cyclic sciatica
Infertility  Adhesions  Impair normal oocyte pick-up & transport by the fallopian tube
 Moderate to severe (Stage III to IV)  Tubal & Ovarian architecture are often distorted
 Severe > Mild undergoing IVF  Poorer implantation and pregnancy rates
Rectovaginal  Defecatory pain develops  Dyschezia (Chronic or Cyclic) associated with constipation,
lesions diarrhea or cyclic haematochezia
 Origin of symptoms  Fixation of rectum to adjacent structures or Rectal wall inflammation
 Symptoms may also stem from DIE to the GIT
 Bowel DIE – rectosigmoid colon (predominant), less common  small bowel, cecum, appendix
 Lesions are usually confined to Subserosa & Muscularis propria
- Thus, Colonoscopy offers poor diagnosis sensitivity
- More severe cases  Transmural  IO or Clinical picture suggesting malignancy
TVS Rectal DIE
MRI Clarify anatomy & Degree of invasion
Laparoscopy Definitive diagnosis
 Management
- No Obstructive symptoms  Conservative management with Hormonal therapy
- Treatment often surgical  Colorectal Segment resection
- Variables  Anatomic site, DIE depth, Lesion size, Number of foci
Urinary Tract  Endometriosis considered if UT symptoms persist despite negative urine culture results
lesions  Bladder disease (Symptoms)  Dysuria, Suprapubic pain, Frequency, Urgency, Hematuria
 Costovertebral angle pain  Urethral endometriosis with obstruction & hydronephrosis
- Can progress eventually to kidney function loss
TVS Suitable accuracy for bladder DIE, less for urethral disease
Cystoscopy with Biopsy Help clarify the diagnosis
 Treatment  Medical or Surgical
- Surgery for bladder  Partial cystectomy
- Surgeries for urethral involvement
1) Freeing the tethered ureter by Uretolysis
2) Segmental resection & Anastomosis
3) Ureter reimplantation into the bladder (Ureteroneocystotomy)
Anterior  Can be an endometrioma of the anterior abdominal wall
Abdominal Wall - Develop in the abdominal scar (e.g. Uterine surgery, C-section, Prior operations)
 Implants are usually found within the subcutaneous layer, are palpable & may involve the
adjacent fascia. Less often rectus abdominis muscle is infiltrated
- Surgically excised for pain relief & diagnosis18
 Diagnostic tools  Abdominal sonography, CT, MRI, FNAC
Thoracic lesions  Catamenial – Pneumothorax occurring in conjunction with menstrual periods
 Cyclic chest or Shoulder pain, Haemoptysis, Pneumothorax
 Preferred imaging  Chest CT
 Treatment
Pneumothora  Minimally invasive thorascopic surgery
x
Haemoptysis Hormonal or Surgical treatment
8. Investigations
 L19 - Pelvic Pain & Endometriosis
Laboratory To exclude infections & pregnancy complications
Testing  FBC
 Serum/Urinary βhCG
 Urinalysis & Culture
 High Vaginal & Endocervical swabs
 CA125 – elevated levels with endometriosis severity (poor for mild, better for stage III or IV)
Diagnostic TVS  Initial diagnostic tool
Imaging  Accurate in detecting & aids in exclusion of other causes of pelvic pain
 Endometrioma
- Cystic with homogenous, low-level internal echoes (Ground glass echogenicity)
- Normal surrounding ovarian tissue
- Unilocular, 1 – 4 septations can be found
- Cysts can display thick septations or walls (Rarely)
Colour  Pericystic
Dopple  Not intracystic flow
r
Diagnostic  Is the primary method used diagnosing endometriosis
Laparoscopy  Surgical findings  Discrete endometriotic lesions, Endometrioma (easily identified), Adhesions
 Implants  Pelvic organ serosa & Pelvic peritoneum
 Variably Coloured of Endometriotic lesions***
Red Red, Red-Pink, Clear Frequently vascularized
Whit White, Yellow-Brown Fibrosis & Few vessels
e
Black Black, Black-Blue Pigmented by hemosiderin deposition from trapped menstrual debris
 Morphological difference of Endometriotic lesions
- Smooth blebs on peritoneal surfaces
- Holes/Defects within the peritoneum
- Flat stellate(start shape) lesions (Points are formed by surrounding scar tissue)
Pathologic  DO NOT require biopsy & histologic evaluation for diagnosis
Analysis  Rely solely on laparoscopic findings in the absence of histologic confirmation (often overdiagnosis)
 Histologic diagnosis  Endometrial glands & Stroma found outside the uterine cavity
***Water/Serous/Mucin secretion  Red (heme)  Black (hemosiderin)  White (bilirubin

9. What determines the therapy for endometriosis?

 Woman’s specific complaints
 Symptom severity
 Location of endometriotic lesions
 Goals for treatment
 Desire to conserve future fertility

10. Management
Medical Analgesics  NSAIDs – very effective for endometriosis, SE: Gastric ulceration
 Paracetamol
 Codeine (add to PCM & NSAIDs when in adequate pain relief)
Hormonal  COCs (1st line) – taken conventionally, continuously or in a tricycle regimen
treatment  Progestogen – When COC is contraindicated
- Medroxyprogesterone acetate (MPA), Norethisterone (NET), POP, LNG-IUS,
Norplant (Subcutaneous contraceptive with levonorgestrel)
- Symptom relief not obtained after 3 – 6 months, consider switching
 LNG-IUS – Reduces pain with symptom control maintained over 3 years
 Androgens
Indications HMB, Endometriosis, Fibrocystic Breast disease, Breast pain
(mastodynia), Hereditary angioedema
Dose 100 – 200mg orally twice a day (BD)
Side Effects Androgenic – Hirsutism, Acne, Oily skin, Deepening of voice
Contraindication Pregnancy  Can masculinize a female fetus
 GnRH agonists
With add-back theory
- Low-dose estrogen & progestin, Danazol, Calcium-regulating agents (Calcitonin)
- Tibolone (Synthetic steroid  Mimics Estrogen & Progesterone)
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Surgical Conservative (minimally invasive – Fertility) Radical (fertility not required)
Aim to remove (excise) or destroy(ablate) areas of  Total Abdominal Hysterectomy +
endometriosis to improve symptoms Bilateral Salpingo-Oophorectomy
Mild to  Ablation &/ Excision of endometriotic  HRT after BSO
Moderate lesions reduce pain compared with  Unopposed estrogen, combined-
diagnostic laparoscopy alone continuous regimen or tibolone
Severe &  Excisional surgery - Note there is an increased risk in
DIE  Laparoscopic Uterosacral Nerve developing breast cancer associated
Ablation (LUNA) with combined estrogen &
 Laparoscopic Helium Plasma progestogen HRT & Tibolone
Coagulation
Complementary  Nutritional & Complementary Therapies
- Homeopathy, Reflexology, TCM, Herbal treatments
 Follow up  Relapse is common after surgical procedures
 Managing Relapse
- Explain the commonness of relapse, Exclude other conditions &/ medical treatment (e.g. COCs)
- Options: NSAIDs, &/ Medical treatment (e.g. COCs), Consider repeat surgery
Endometriosis Expectant Mild – Moderate
& Infertility  Couple conceive spontaneously
 Expectant approach is appropriate in these couples for up to 2 years

Severe
Probability of spontaneous pregnancy is significantly low
Medical  Suppression of ovarian function to improve fertility in minimal-mild/severe
endometriosis is not effective
 More harm than good may result from treatment because of adverse effects
& loss of opportunity to conceive
Surgical Minimal-Mild Moderate-Severe
 Laparoscopic ablation + adhesiolysis  Excision/Ablation of all visible
- May improve chance of endometriosis & adhesions to
pregnancy correct pelvic anatomy
Ovarian  Drainage
Endometrioma  Ablation
 Excision of the endometrioma is preferable to drainage & ablation in regard to
recurrence of symptoms, endometrioma and spontaneous pregnancy rate

11. What is the Mechanism of Action of:

a) Androgens (Danazol & Gestrinone)
 Inhibit ovarian steroidogenesis  ↓ secretion of estradiol
 Androgenic, anti-estrogenic & anti-progestogenic activity  Amenorrhea with reversible Post-menopausal state

b) GnRH agonist
 Induce a reversible postmenopausal state and regression of endometriotic deposits
- As effective as other medication in relieving the pain
- Limited use due to loss of Bone Mineral Density (BMD) in the first 6 months
***If treatment is to be used for >6 months, then use HRT ‘add-back’ therapy

12. Why do some women fail to respond to Surgical treatment?

 Incomplete excision
 Postoperative recurrence
 Pain not due to endometriosis