SUMMARY: Chronic Pelvic Pain is very common in women, runs a fluctuating course, and sometimes results in surgery that is ill-advised. History of abuse and co-existing psychological disability are common causal factors. Detailed clinical assessment and consideration of secondary referral should precede surgical intervention.
Chronic Pelvic Pain 3-4% of adult women in clinical studies 1, accounts for 1 in 5 gynecological referrals, 2 for a tenth of all outpatient gynecology visits, 15-40% of laparoscopies and 12% of hysterectomies in the US. 3 In a US population study, 16% reported problems with chronic pelvic pain. 4
Because a) it is so common, b) the fluctuating course may be incorrectly attributed to adverse effects of intervention, and c) invasive surgery may be undertaken ill-advisedly or without adequate disclosure, Chronic Pelvic Pain features fairly frequently in medical malpractice litigation.
History of abuse and co-existing psychological disability are common causal factors.
Commonest are endometriosis and adhesions 5; pelvic muscular tension, chronic Pelvic Inflammatory Disease (PID), pelvic congestion syndrome, ovarian remnant syndrome, fibroids, irritable bowel syndrome, and interstitial cystitis.
Because physical, emotional and sexual abuse are strongly associated with Depression 6, the consequent psychological disability may cause abused women to complain of Chronic Pelvic Pain more often than the non-abused. Chronic Pelvic Pain may also be viewed as a means of coping with intensely painful childhood memories.7
As well as frequently co-existing with a variety of psychological conditions, Chronic Pelvic Pain may, as any other type of chronic pain, also cause Depression.
Practical PointerCommonest causal factors in Chronic Pelvic Pain:
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Detailed clinical assessment and consideration of secondary referral should precede surgical intervention.
Thorough clinical assessment may obviate the need for surgical intervention.
A comprehensive questionnaire 8 highlights the elements needed for a thorough and accurate diagnosis and is, by some gynecologists, given to the patient before the initial assessment. This is a useful check-list for litigators.
The history questionnaire 8 doubles as an aide-memoire for completeness of the physical examination and a standard reporting format.
If a pelvic mass is found on physical examination or endometriosis is suspected, look for transvaginal ultrasonography and Magnetic Resonance Imaging (MRI) before diagnostic laparoscopy, though the latter is more sensitive for diagnosis of endometriosis.
Practical PointerA published clinical questionnaire 8 is available as a checklist for medicolegal assessment of the completeness of medical history and physical examination |
Look for, as required, referrals to urologist, gastroenterologist, neurologist, psychologist/psychiatrist, particularly before any invasive surgery.
Forty percent of gynecological diagnostic laparoscopy are undertaken for Chronic Pelvic Pain and 40% reveal nothing abnormal. Where there are abnormal findings, endometriosis and/or adhesions are present in 85%.5
Hysterectomy is frequently undertaken for inappropriate indications 9 [], and, when Chronic Pelvic Pain persists or complications result from the surgery, reference to the American College of Obstetricians and Gynecologists Guidelines 10 may indicate additional deviations from standard care.
Practical PointerHysterectomy for Chronic Pelvic Pain is often undertaken without appropriate indications 9 [] |
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