Gynaecologist Mr Philip Owen answers GP Dr Pam Brown’s questions on a common presenting symptom
Gynaecologist Mr Philip Owen answers GP Dr Pam Brown's questions on a common presenting symptom
1. What points in the history are particularly useful when a patient presents with pelvic pain?
The initial consultation should elicit the nature of the pain, the location, exacerbating or relieving factors, bladder or bowel symptoms and psychological or social issues.
A pain/symptom diary for two or three menstrual cycles is helpful to help identify any pattern to the patient's symptoms. Sexual history should be obtained as acute pelvic inflammatory disease is an important cause of pelvic pain. Previous history of pelvic infection may suggest the possibility of chronic pelvic inflammatory disease.
A pattern of cyclical symptoms that worsen a few days before the onset of menses suggests endometriosis, but this is unlikely in the absence of deep dyspareunia. There may also be a family history of endometriosis or personal history of sub-fertility.
Bowel symptoms are common in women with chronic pelvic pain, occurring in as many as 50%. Irritable bowel syndrome is an important differential diagnosis of pelvic pain and can often be made based on the history (Rome criteria: ?3 months of intermittent or constant pain relieved by defecation and associated with ?2 of altered stool frequency, bloating, altered stool passage, altered stool form).
Bladder symptoms indicative of interstitial cystitis or overactive bladder also commonly occur with pelvic pain. Another important cause is musculoskeletal problems which are present in up to 75% of women with pelvic pain. Previous surgery resulting in adhesions may also cause continuing pelvic discomfort. Residual ovary syndrome occurs after hysterectomy where the conserved ovary or ovaries become buried in dense adhesions, thus causing pelvic pain.
Psychological problems are common in women with pelvic pain. A history of depression, sexual or physical abuse should be sought by sensitive questioning. Allowing the patient to talk through her symptoms and speculate on potential causes for pain can be therapeutic and has a positive effect on eventual outcome.
2. What features in the history and examination should alert us to a likely diagnosis of endometriosis?
Endometriosis is the presence of endometrial tissue outside the uterus. This tissue responds to circulating hormones and results in chronic inflammation within the abdomino-pelvic cavity. Typically, symptoms include cyclical pelvic pain which may radiate to the lumbar area or thighs and is exacerbated in the few days before menses.
In addition, women may report chronic, non-cyclical pelvic pain, severe dysmenorrhoea and deep dyspareunia. There may be associated bladder or bowel upset. Menstrual flow may be heavy due to associated adenomyosis. Infrequently there may be haematuria, rectal bleeding or umbilical bleeding depending on the site of the ectopic endometrial tissue. Some women may be asymptomatic with the diagnosis discovered during investigations for sub-fertility.
Women with minimal endometriosis often have normal abdominal and pelvic findings on examination. In others, the findings of tenderness, a fixed (immobile) retroverted uterus and tender uterosacral ligaments are suggestive of endometriosis. There may be palpable ovarian cysts suggestive of endometriomata.
Deeply infiltrating nodules of endometriosis may be palpable in the pouch of Douglas or on the uterosacral ligaments. Very occasionally, you can see dark blue or purple spots of endometriosis in the vagina or on the cervix during a speculum examination.
3. Are analgesics or NSAIDs more effective for primary dysmenorrhoea, and which specific therapy has the lowest NNT and best evidence base?
Primary dysmenorrhoea (period pain in the absence of an organic cause) is a common problem affecting 40-70% of women of reproductive age.
The most effective non-surgical treatments are NSAIDs which inhibit the production of prostaglandins. Prostaglandins are central to the pathogenesis of dysmenorrhoea by promoting uterine contractions.
A systematic review of analgesics in primary dysmenorrhoea revealed that naproxen, ibuprofen and mefenamic acid are effective for at least 50%, with aspirin being less effective. These drugs were also effective at reducing absence from work or school and reducing the restrictions of daily living.
Naproxen had the lowest NNT of 2.4 but the authors concluded that ibuprofen was the drug of choice as it had fewer side-effects and the NNT was not significantly different at 2.6.
A more recent Cochrane review found that NSAIDs were effective for at least moderate pain relief over three to five days, and there was most information on naproxen. Paracetamol was an ineffective treatment for this condition.
4. Does a retroverted uterus cause pelvic pain or other symptoms?
As 20% of women have a retroverted uterus it can be considered a variation on normal. However, a retroverted uterus may be a consequence of inflammation within the pelvis, principally secondary to endometriosis or pelvic inflammatory disease.
In the absence of disease, symptoms attributable to a retroverted uterus are uncommon but can include pain on intercourse. If symptoms are severe, short-term relief can be provided by a Hodge pessary, which is placed in the vagina to help tilt the uterus forward (this is seldom pursued in practice). Alternatively, laparoscopic surgery can divide adhesions or reposition the uterus in an anteverted position by shortening (placating) the round ligaments.
5. What investigations should we do in primary care before referring a patient with pelvic pain?
Useful investigations include urine or endocervical swabs for the diagnosis of chlamydia infection and a vaginal culture for diagnosing other infections such as bacterial vaginosis, gonorrhoea or trichomonas.
Blood should be sent for CRP and/or ESR if you suspect acute pelvic infection.
If an adnexal mass/tenderness is suspected or elicited on pelvic examination then an ultrasound is necessary. This will help to diagnose/exclude ovarian pathology (including endometriomas), chronic inflammatory disease (hydrosalpinges, free fluid), fibroid degeneration and, rarely, uterine malformations. This investigation is more easily achieved in secondary care and referral should not be delayed pending ultrasound scan if the patient's symptoms are severe.
Complications of pregnancy should always be considered and a low threshold for performing a urinary pregnancy test is appropriate.
6. Which patients with pelvic pain should be referred to the GUM clinic and which to a gynaecologist?
Women with symptoms suggestive of, or of proven sexually transmitted infections, urinary tract infections and those with HIV should be referred to GUM clinics. Women with pelvic pain due to acute pelvic inflammatory disease requiring systemic antibiotics and possible surgical intervention, or where the diagnosis is in doubt, should be referred for gynaecological assessment. A large proportion of women will undergo a diagnostic laparoscopy, carried out by a gynaecologist. Community-based gynaecologists are well placed to initiate and perform many of the relevant investigations.
7. How should continuing pelvic pain from pubic symphysis separation be treated after delivery?
Approximately 50% of women with pubic symphysis separation during pregnancy will continue to experience pelvic pain 12 weeks after delivery, although severe and persistent pain beyond six months is less common (7%). Occasionally, women experience a mild recurrence of symptoms with menstruation.
Standard treatment is mainly conservative. Women should be given tips on general daily living – such as correct techniques for lifting, exiting a car (keeping legs together).
Turning in bed is often painful and the use of pillows between the knees can be helpful.
These simple techniques, together with the use of analgesics or NSAIds are often enough to manage this generally self-limiting condition. For the more resistant cases, assessment and treatment by an obstetric physiotherapist is indicated, as general exercises, especially those directed at lumbar back pain as opposed to pelvic pain, may be harmful.
Pelvic stabilising exercises supervised by a physiotherapist are effective. In addition, there is some evidence that alternative therapies such as acupuncture can be effective alone and with physiotherapy. Those with severe symptoms are also likely to benefit from physiotherapy before embarking on future pregnancies, as symptoms are likely to recur.
8. What is pelvic congestion syndrome and how is it diagnosed and managed?
The development of varicose veins in the pelvis, usually of the ovarian veins, is associated with a collection of symptoms contributing to the pelvic congestion syndrome. The syndrome is more common in multiparous women, and pelvic pain which worsens in association with menstruation and sexual intercourse is the main complaint.
Other associated symptoms include backache, vaginal discharge, bloating and mood swings. Up to 15% of menstruating women will have varicose veins in the pelvis but many will be asymptomatic. The diagnosis is mainly one of exclusion, as similar symptoms occur with endometriosis or chronic pelvic inflammatory disease. Pelvic congestion syndrome may be suspected in the presence of varicosities of the legs and there is often pelvic tenderness on examination though but this is seldom discriminatory.
Diagnostic laparoscopy may reveal distended pelvic veins and exclude other causes of pelvic pain. Venography will confirm the diagnosis. Initially, women should be managed conservatively with an explanation of their symptoms (which may be therapeutic in itself), and with NSAIDs to relieve pain.
In addition, women may respond to continuous progesterone treatment which will abolish menses and often the symptoms of pelvic congestion too. If this strategy is successful, it is likely the woman will benefit from long-term progestogen treatment in the form of a levonorgestrel releasing intrauterine system (Mirena IUS).
Rarely, surgical treatments will be necessary and these include hysterectomy and bilateral salpingo-oophorectomy (with subsequent hormone replacement therapy) or bilateral ovarian vein ligation. Where expertise is available, ovarian vein embolisation is an effective and minimally invasive procedure performed by interventional radiologists.
9. How can we diagnose and manage vulvodynia?
There are many symptoms of vulvodynia, ranging from burning, itching and soreness to pain with sexual intercourse (dyspareunia). Symptoms may be continuous or intermittent, mild or severe. There are seldom any clinical signs with the vulva appearing normal. If the vulva is biopsied, there is non-specific inflammation. The cause is unknown though there is often a history of frequent vaginal candidal infections, vulval injury or sexual abuse.
Alternative causes of vulval pain, including infections, skin conditions and allergies, should be ruled out.
A referral to a specialist vulval or combined gynaecology and dermatology clinic is appropriate if there is uncertainty regarding diagnosis, or there has been no response to simple treatments.
There is no specific cure and treatment is aimed at managing symptoms. General advice would be to avoid perfumed soaps and douches, tight clothing and nylon underwear. Keeping a diary of symptoms may reveal triggers for pain like a particular brand of washing powder, physical activity, or even food. Saline baths and cold compresses to the vulva may be beneficial. Itch may be relieved by antihistamines. Burning pain may respond to tricylic antidepressants or anticonvulsants (carbamazepine, gabapentin) or local anaesthetic creams.
If successful, more long-standing relief may be achieved with pudendal nerve blocks. Topical oestrogen or steroid creams may relieve discomfort. Biofeedback to relax the pelvic floor can help relieve pain due to overcontraction of the muscles. Occasionally, for severe intractable symptoms, laser treatment or surgical excision of painful tissue is attempted. The efficacy of these treatments is unproven and complications may worsen symptoms.
10. What is the aetiology and differential diagnosis of proctalgia fugax, and what relationship does it have to other pelvic pain?
Proctalgia fugax is severe, intermittent rectal pain. The pain lasts anything from a few seconds up to 30 minutes and characteristically occurs at night, waking the sufferer from sleep. The frequency of attacks varies but usually there are only about five per year. Men are affected as well as women. It may be caused by a spasm of the pelvic floor, and rectal examination reveals little other than general tenderness, but the cause is largely unknown. Constipation may exacerbate the problem and should be avoided. The differential diagnosis includes anal fissure, herpes simplex infection and pilonidal abscess. Physical examination should distinguish the diagnoses.
Common to other causes of pelvic pain, pelvic floor muscle contraction is a feature and biofeedback is an effective treatment
11. Is it appropriate to treat cystitis-type symptoms in postmenopausal women with antibiotics even if the midstream urine sample is negative?
Yes, studies have shown that symptomatic women who have dipstick or MSU-negative urine get better with a three-day course of trimethoprim or nitrofurantoin.
Topical oestrogens are often considered for postmenopausal women who are at higher risk of developing cystitis or urinary tract infection. However, there is no benefit to prescribing topical oestrogen for prevention of UTI unless there are also symptoms of genital atrophy. If cystitis symptoms are combined with persistent macro- or microscopic haematuria, referral for urological assessment is indicated to exclude urinary tract tumours.
12. Which patients with chronic pelvic pain may benefit from psychological therapy and how can we identify them?
Some multidisciplinary clinics specialising in the investigation and management of chronic pelvic pain will have an in--house psychology service, but most gynaecology clinics will not. The assistance of the GP in identifying and referring appropriate women for psychological assessment and support is, therefore particularly important.
Psychological symptoms may predate and predispose to chronic pelvic pain and likewise may be the consequence of chronic pain.
Women presenting with persistently lowered mood, who give a history of physical and/or sexual abuse or do not gain benefit from the re-assurance of negative investigations can be expected to gain most from psychological support
Mr Philip Owen is consultant gynaecologist at the Princess Royal Maternity Unit in Glasgow
Competing interests None declared
Dr Pam Brown is a GP in Swansea
What I will do now
Dr Brown reflects on the answers to her questions
• Encourage women to complete pain/symptom diaries while awaiting their outpatient appointment
• Ask about family history of endometriosis when this diagnosis is suspected
• Consider the differential diagnosis of irritable bowel syndrome in women with pelvic pain
• Encourage women with dysmenorrhoea to use naproxen or ibuprofen instead of analgesics
• Remember pregnancy as a cause of pelvic pain and do a pregnancy test if any doubt
• Refer women with persisting symptoms from pubic symphysis separation for specialist physiotherapy
• Consider Mirena for long-term management of women diagnosed with pelvic congestion syndrome
• Continue to prescribe a three-day course of antibiotics in postmenopausal women with cystitis despite negative urine culture