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case study
Management of chronic pelvic pain
This case of persistent pelvic pain illustrates the multifactorial nature of the condition. By Mr Philip Kaloo
well as the probable findings (recurrent endometriosis and case study
pelvic adhesions) and the risk of complications. Laparoscopy Miss aP, a 28-year-old nulliparous woman, presented to the showed significant large bowel adhesions in the right iliac fossa/ pelvic pain/endometriosis clinic in 2008 with a four-year flank (figure 1) and an adherent right ovary to the pelvic side history of right-sided pelvic pain. the pain was intermittent in wall and posterior aspect of the uterus (figure 2). The pelvis was nature, rated as nine out of 10 at worst, and associated with otherwise normal, with no obvious endometriosis or evidence of the patient described the pain as burning and stabbing, The bowel adhesions were divided laparoscopically and the requiring bed rest and tramadol analgesia when at its worst. right ovary was mobilised from the pelvic side wall. Meticulous She had no significant urinary or bowel symptoms. triple swabs haemostasis was ensured. In addition, 500ml icodextrin had previously been taken and were negative for chlamydia. In instillate was left within the abdominal cavity with the object of addition, she experienced significant deep dyspareunia and worsening dysmenorrhoea within an otherwise regular cycle. Preoperatively, the abdominal trigger point was marked on She used the combined oral contraceptive pill and was up to the abdominal wall and local anaesthetic and steroid were instilled intraoperatively in an attempt to deal with the Miss aP had a history of endometriosis diagnosed by neuropathic pain element of her symptoms.
laparoscopy in 2000, with a subsequent right ovarian At three-month follow-up, Miss AP rated her abdominal pain cystectomy via a transverse laparotomy in 2004.
as three out of 10 at worst and her deep dyspareunia was now a ‘minor problem’. She still had a mildly positive Carnett’s test and What is the diagnosis and management?
subsequently had a repeat local anaesthetic infiltration to her trigger point. She was offered psychological support for her Chronic pain is described by the International Association for At six-month follow-up, Miss AP rated her abdominal pain as the Study of Pain as an unpleasant sensory and emotional two out of 10. Her deep dyspareunia persisted but remained a experience associated with actual or potential tissue damage. ‘minor’ problem. She stated that she was very happy with the The incidence in UK general practice is similar to that for migraine, back pain and asthma, at 21.5 per 1,000 consultations.1 Chronic pelvic pain is usually multifactorial. It can be constant discussion
or intermittent and can last more than six months. Postoperative This case is an example of how chronic pain can often be adhesions are common and may cause pelvic pain. Endometriosis multifactorial in nature. Although Miss AP had clinical and irritable bowel syndrome are common copathologies. evidence of nerve entrapment, she was considered to be highly Carnett’s test2 can help to differentiate between abdominal likely to have additional pelvic pathology in view of her wall and intra-abdominal pathology. This test for nerve entrapment involves palpating the area of maximal abdominal Nerve entrapment is not uncommon following a Pfannenstiel tenderness with the patient supine, then asking them to tense incision (3.7 per cent)3 and to a lesser extent, laparoscopic their abdominal wall by lifting their head off the couch. If nerve surgery. Such peripheral neuropathic pain may also occur de entrapment within the abdominal wall is present, tensing the novo and up to 10 per cent of patients with suspected GI muscles usually leads to increasing pain (a positive test). If pain pathology actually have abdominal wall ‘pathology’.4 is reduced, this may suggest intra-abdominal pathology, the The early diagnosis of this pathology could prevent splinting effect of the muscles ‘protecting’ the affected organs.
unnecessary gynaecological or GI intervention. Carnett’s test is a useful way to help triage patients in primary or secondary care.
examination and investigation
Adhesions following surgery can lead to significant In Miss AP’s case, abdominal examination elicited pain in the morbidity and recently, increasing litigation.5 They are right iliac fossa without evidence of peritonism. Carnett’s test predominantly a result of extensive and/or open surgery but was positive superior to the right lateral edge of her laparotomy may occur after any operative procedure.6 incision. Vaginal examination elicited the same localised There is uncertainty as to the true benefit of adhesiolysis, but tenderness in the right adnexal region, but with no cervical a Cochrane review suggests it is only beneficial when severe excitation. Musculoskeletal examination by a women’s health adhesions are present.7 Anecdotally, many patients find significant relief with adhesiolysis of firm adhesions, especially Pelvic ultrasound revealed a normal uterus and ovaries, but when they cause reduced organ mobility.
marked tenderness in the right adnexal region. Chlamydia PCR persistent pelvic pain
Despite the identification and treatment of possible causes of
management and follow-up
pelvic pain, its persistence is not uncommon. A common A laparoscopy was offered and Miss AP accepted, having been cause of persisting pain is chronic overstimulation of sensory counselled about the possibility of a ‘negative’ laparoscopy, as nerves from the viscera to the spinal cord. Such persisting 42 MIMS woMen’S health vol 4, no 4, 2009
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figure 1: Laparoscopy showing significant large bowel adhesions
figure 2: the right ovary is shown to be adherent to the pelvic
in the right iliac fossa
side wall and to the posterior aspect of the uterus
stimulation causes permanent alteration in neuronal box 1: chronic pelvic pain management
function (neuroplasticity), leading to hyperalgesia (excessive sensitivity to pain) or allodynia (pain from stimuli that are not the basic rationale behind the management of chronic pelvic
pain is as follows:11-13
Such pain can be difficult to manage but neuromodulators such as amitriptyline, pregabalin, gabapentin and carbamazepine ● treat pain with, for example, nSaIDs and antispasmodics have been shown to be beneficial. Hormonal manipulation, ● hormonal manipulation with the combined oral psychological support and TENS, among other interventions, contraceptive pill, progesterone, gnrh analogues ● neuromodulation can be effected with, for example, amitriptyline, pregabalin, gabapentin or carbamazepine the negative laparoscopy
● Multidisciplinary approach involving gynaecologist, It is imperative that all patients undergoing a laparoscopy for anaesthetist, physiotherapist, psychologist chronic pelvic pain have the likely findings discussed, including a ‘negative’ finding. A negative laparoscopy, that is, one in which no definitive aetiology is visible, may occur in up to half of 5. Ellis H. Medicolegal consequences of adhesions. Hosp Med 2004; procedures. This can be seen as ‘positive’, in that there is no visible pathology but it is important to reassure patients that 6. Lower AM, Hawthorn RJ, Clark D et al. Adhesion-related although it is not visible, there is still a cause for their pain. readmissions following gynaecological laparoscopy or laparotomy in The aetiology of chronic pelvic pain is usually multifactorial. Scotland. Hum Reprod 2004; 19: 1877-85. Despite treatment, it can often persist. Patients have better 7. Stones W, Cheong YC, Howard FM. Interventions for treating outcomes if an integrated multidisciplinary approach (see box 1) chronic pelvic pain in women. Cochrane Database Syst Rev 2005, is adopted, involving clinicians who are experienced in the Issue 1. Art No: CD000387. DOI: 10.1002/14651858.CD000387. 8. Wiffen PJ, McQuay HJ, Rees J et al. Gabapentin for acute and Mr Philip Kaloo is consultant obstetrician and gynaecologist and chronic pain. Cochrane Database Syst Rev 2005, Issue 3. Art No:
runs the endometriosis/pelvic pain clinic at cheltenham General CD005452. DOI: 10.1002/14651858.CD005452.
Hospital, Gloucestershire NHs trust
9. Nnoaham KE, Kumbang J. Transcutaneous electrical nerve stimulation (TENS) for chronic pain. Cochrane Database Syst Rev 2008, Issue 2. Art No: CD003222. DOI: 10.1002/14651858. RefeReNces
10. Dworkin RH, O’Connor AB, Backonja M et al. Pharmacologic 1. Zondervan KT, Yudkin PL, Vessey MP et al. Prevalence and management of neuropathic pain. Pain 2007; 132: 237-51. incidence of chronic pelvic pain in primary care: evidence from a 11. Royal College of Obstetricians and Gynaecologists. The initial national general practice database. Br J Obstet Gynaecol 1999; 106: management of chronic pelvic pain. RCOG Guideline 41. London, 2. Carnett JB. Intercostal neuralgia as a cause of abdominal pain and 12. Jarrell JF, Vilos GA, Allaire C et al. Consensus guidelines for the tenderness. Surg Gynecol Obstet 1926, 42: 625-32. management of chronic pelvic pain. J Obstet Gynaecol Can 2005; 3. Perry CP. Peripheral neuropathies causing chronic pelvic pain. J Am Assoc Gynecol Laparosc 2000; 7: 281–7. 13. American College of Obstetricians and Gynecologists Committee 4. Srinivasan R, Greenbaum DS. Chronic abdominal wall pain: a on Practice Bulletins – Gynecology. ACOG Practice Bulletin No. 51. frequently overlooked problem. Am J Gastroenterol 2002; 97: 824-30. Chronic pelvic pain. Obstet Gynecol 2004; 103: 589-605. www.healthcarerepublic.com/wh
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