Pelvis Pain and Pregnancy

Acute pelvic pain - positive pregnancy test (beta-hcg)

ectopic pregnancy
• tubal
• cornual
• ovarian
• abdominal
• cervical
miscarriage
• threatened abortion
• inevitable abortion
• incomplete abortion
• complete abortion
gestational trophoblastic disease
• complete mole - 46XX
• complete mole - 46XY
• partial mole - triploidy
• corpus luteum hemorrhage or torsion
• acute degeneration of fibroid (leiomyoma) during pregnancy
• uterine (gestational) incarceration
• round ligament stretching
• pelvic adhesions and pregnancy

Background

While acute pelvic pain is uncommon during pregnancy, the fact that pregnancies are frequent makes this category an often encountered medical problem. Clinical miscarriages causing significant pain are associated with one out of every 7 to 8 pregnancies. Ectopic and molar pregnancies are less frequent but still seen. They are serious problems and always must be considered.

Goals

In this category, it is especially important to rule out any type of ectopic pregnancy since significant internal (and occult) bleeding can occur. Maternal deaths due to hemorrhage from ectopic pregnancy still occur and cause maternal mortality. Molar pregnancies (a tumor like growth of placenta tissue) sometimes behave like an invasive malignancy so that category should be differentiated as well. Finally, it must be remembered that any process which gives acute pelvic pain in the non- pregnant state can be superimposed upon a pregnant state; so therefore this category is actually much more inclusive.

Acute pelvic pain - negative pregnancy test (beta-hcg)

• ovulation
  corpus luteum
  • distension (persistent)
  • hemorrhagic/rupture
  • torsion
  • follicular cyst
  • ovarian hyperstimulation syndrome
• polycystic ovaries
• ovarian torsion
• torsion of pedunculated paramesonephric cyst
• leiomyomata degeneration/torsion
• pelvic thrombophlebitis
• acute salpingo-oophoritis
• exacerbation of pelvic inflammatory disease/abscess
• acquired immune deficiency
• endometriosis
• gastrointestinal inflammation/gastroenteritis
• appendicitis
• mesenteric lymphadenitis
• diverticulitis
• regional enteritis
• ulcerative colitis
• acute cystitis
• pelvic trauma
• pelvic adhesions
• black widow spider bites

Background

Many women will have one or more episodes of acute pelvic pain at sometime during their life, therefore this category occurs fairly commonly. The ovaries of women who are not on hormonal contraception undergo cystic change and egg ovulation each month. This process is not perfect and in many instances can be associated with pain even though it is a physiologic rather than a disease process.

Goals

Any pain below the level of the naval (umbilicus) in the abdominal cavity and above the legs may be referred to as pelvic pain. Structures present include the ovaries, fallopian tubes, uterus, peritoneum lining the abdominal cavity, sigmoid colon and the appendix and ascending colon on the right. Detecting which structure or structures are involved in the pain can be difficult and often we have to rely on imaging techniques to supplement history and physical findings. It is difficult but necessary to determine whether the process is infectious or inflammatory versus pain due to peritoneal distention. Infectious etiologies may respond to antibiotic therapy while many of the other categories require surgical intervention. A therapeutic trial of antibiotics may sometimes be used to determine whether the pain improves or not. If the pain is acute and very severe, surgical exploration is frequently necessary to make the diagnosis.

Dysmenorrhea - pain with menstrual periods

• primary dysmenorrhea
  secondary dysmenorrhea
  • adenomyosis
  • endometriosis
  • interstitial cystitis
  • intrauterine contraceptive device
    leiomyomata
    • intramural
    • submucosal
    obstruction to outflow
    • cervical stenosis
    • cystic (nabothian) cervicitis
    • retroflexion of uterus (severe)
      congenital anomalies
      • cervical atresia
      • transverse vaginal septum
      • blind uterine horn
      • intact hymen
  • pelvic inflammatory disease
  • endocervical polyps
  • endometrial polyps
  • post pelvic surgery adhesions

Background

Many women have pain with their menstrual periods. As the smooth muscle of the uterus contracts each month to expel menstrual tissue and blood, most women feel this increase in amplitude of intrauterine pressure as pain. The degree to which that pain is tolerated varies widely. While 70-80 percent of women have some sort of menstrual cramps, only about 2-3 percent are incompacitated by those cramps so that they miss work, school or other daily activities. Another significant number of women may not miss school or work because of the cramps however they require medications in order to allow them to function adequately, albeit with mild to moderate discomfort.

Goals

In this category of problems, pain originates for the most part from the uterus. If there is any obstruction to outflow, intrauterine pressure will build up before the contents of the uterus are expelled. This increased pressure produces pain. In general, women will have less cramps after they have delivered a pregnancy vaginally because the cervical os is open more than in women who have never had a pregnancy. On pelvic exam some degree of appreciation of whether the cervix is narrowed or not can be obtained by using a q-tip or endocervical brush to check the cervical os. Another major cause of pain is endometriosis, either external on the peritoneal surfaces around the uterus or internal (adenomyosis) deep within the uterine muscle. In this case, islands of menstrual like endometrium are sloughed but have nowhere to be expelled. Consequently, pain occurs from distention of the surrounding tissues and subsequent inflammation. While endometriosis is not a malignant process it can often behave like a malignant process in that it continues to worsen and destroy other normal reproductive tissues.

Chronic pelvic pain

• endometriosis
• peritoneal adhesions or scarring
• chronic pelvic inflammatory disease
• uterine leiomyomata
• uterine retroversion
  pelvic relaxation
  • uterine descensus
  • cystocoele
  • rectocoele
  • enterocoele
  genital tract obstruction
  • pyometra
  • cervical stenosis with hematometra
  • cystic cervicitis
  • transverse vaginal septum
  • cervical atresia
  • blind uterine horn
• adenomyosis
• pelvic vascular congestion
• endometritis (chlamydial)
  atypical functional pain
  • dysmenorrhea
  • ovulatory pain (mittelschmerz)
  • premenstrual syndrome
  • recurrent functional ovarian cysts
  myofascial pain
  
  Incisional problems
  • dysfunctional abdominal incision
  • incisional hernia (ventral)
  • ilioinguinal nerve entrapment syndrome
  • endometriosis
  Other hernias
  • inguinal
  • femoral (crural)
  • umbilical
  • obturator
  • Richter's (laparoscopic incisional)
  • spigelian
  gastroenterologic disorders
  • chronic cholecystitis
  • chronic cholelithiasis
  • chronic constipation
  • chronic recurrent appendicitis
  • diverticulitis
  • irritable bowel syndrome
  • regional enteritis
  • peptic ulcer disease
  • proctalgia fugax
  urologic disorders
  • urethral syndrome
  • interstitial cystitis
  • ureteral calculus
  • detrusor dyssynergia
  • status post urethral suspension
• degenerative bone and joint disease (lumbosacral)
• adrenal insufficiency (Addison's disease)
  psychogenic pain disorders
  • depression
  • malingering
  • physical abuse
  • sexual abuse
  • posttraumatic stress disorder
  • schizophrenia
  • sleep disorders
  • somatoform pain disorder
  • somatization disorder
  • stress reaction
  • substance abuse
  biochemical disorders
  • Sickle cell crisis/disease
  • acute intermittent porphyria
  • heavy metal poisoning

Background

By definition, chronic pelvic pain is that which has been present six months or longer. The pain can cyclically exacerbate with menses, however the hallmark is that the pain persists throughout the month. This is not an infrequent complaint and if the pain persists long enough, patients will soon have multiple secondary problems because of the pain and evolve into a chronic pain syndrome. In this instance, they have altered family roles and significant problems with depression and other psychologic changes.

Goals

It is important diagnostically to differentiate those patients who have evolved into a chronic pain syndrome versus those patients who have not. A multidisciplinary approach is always necessary for patients with chronic pain syndrome whether or not they have specific pathologic causes found for their pain. If a woman is unable to work either outside the home or within the home doing those tasks which she has previously performed, or if she has altered ability to communicate with other members of the family because of the chronic pain, no matter what the initial cause of the pain, attention should be directed therapeutically toward the secondary problems. If a chronic pelvic pain syndrome is not felt to be present, diagnosis can be directed entirely at the etiology by using imaging techniques and diagnostic laparoscopy along with history and physical findings.

Dyspareunia - deep - pelvic pain with sexual relations

• endometriosis
• adenomyosis
• interstitial cystitis of bladder
• ovarian cyst or tumor
• prolapse of fallopian tube
• uterine prolapse/descensus
• uterine retroversion
• posterior myoma
• other uterine tumors
  pelvic adhesions
  • bowel to uterus or end of vagina adhesions
  • omentum to uterus or end of vagina adhesions
  • sigmoid colon to uterus or end of vagina adhesions
  • ovary to uterus, broad ligament or endo of vagina adhesions

Background

Pain with sexual relations is uncommon but when it occurs, it may significantly disrupt interpersonal relationships. This category refers to pain that occurs only with deep penetration of the vagina and should be differentiated from pain that occurs at the opening of the vagina more superficially.

Goals

Deep pelvic pain is much worse when a woman is having intercourse and is on the "top" position. This results in the deepest penile penetration and often moves the pelvic organs. Pain with deep penetration during sexual relations often indicates that anatomical pathology is causing pain. This may be because the uterus is being moved and placed on stretch during thrusting with sexual relations or any of the adjoining structures such as the tubes or ovaries which should freely move around may be constrained from moving. Any tension placed on the peritoneum will give increased pain. A good bimanual pelvic exam and imaging studies are necessary in this category of problems.

Vaginal pelvic relaxation - pressure or fullness

• uterine prolapse
• cystocoele
• urethrocoele
• rectocoele
• paravaginal defect
• enterocoele

Background

Non-acute complaints of pelvic pressure or fullness are often associated with relaxation of the pelvic structures. This is especially true after women go through menopause. Prior to menopause the increased vascularity of the pelvis serves as a supportive network for the uterus, bladder, vagina and rectum. After menopause, vascularity is significantly decreased and if there has been prior disruption in the normal anatomical attachments of the pelvic structures, patients may complain of prolapse symptoms. This is almost always associated with having had vaginal deliveries; it is infrequent, but not non-existent, in women who have not delivered any children vaginally.

Goals

Most of the problems in this category can be diagnosed by pelvic exam alone. The examiner should determine what anatomy of the pelvis has become detached from its normally strong support to the remainder of the pelvic structures. The precise anatomical defect description is needed to determine therapy.