Investigations for chronic pelvic pain.pdf

Investigations for chronic pelvic pain

Ying Cheong a,*, William Stones b

aPrincess Anne Hospital, Southampton SO16 6YD, UKbUniversity of Southampton, Southampton, UK

Received 22 April 2004; accepted 6 July 2005

Available online 19 September 2005

Abstract

Chronic pelvic pain (CPP) is a common problem with a prevalence of about 38/1000 among women aged 20–50 years. The main

gynaecological diagnoses include endometriosis, pelvic inflammatory disease and adhesions. The most common gastrointestinal diagnosis is

irritable bowel syndrome and genitourinary diagnosis includes pathology such as interstitial cystitis. It is a challenge instigating the right

investigations for patients with chronic pelvic pain because there is a considerable symptom overlap. They also have a higher prevalence for

symptoms such as dysmenorrhea and dyspareunia. In this review, we aim to discuss the clinical consultation necessary to help us decide upon

which investigative tools we need to use to help diagnose the cause(s) of CPP, although one needs to stress that a specific cause may not be

found in patients with CPP and symptom focused multidisciplinary management of CPP is at least as important as diagnosis of specific

pathology and disease focused treatment.

# 2005 Elsevier B.V. All rights reserved.

Keywords: Chronic pelvic pain; Investigations; Ultrasound; Magnetic resonance imaging; Venography; Laparoscopy; Pelvic congestion syndrome;

Adhesions; Endometriosis; Adenomyosis

www.elsevier.com/locate/rigp

Reviews in Gynaecological Practice 5 (2005) 227–236

1. Introduction

Chronic pelvic pain (CPP) may be defined as a non-

cyclical pain of greater than 6 months’ duration that is

localised to the pelvis, anterior abdominal wall at or below

the umbilicus, the lumbosacral area, or buttocks, and is of

sufficient severity as to cause functional disability or lead to

medical care [1]. Pain is generally defined as an unpleasant

sensory and emotional experience associated with actual or

potential tissue damage. It is therefore most important for

health professions to appreciate the emotional and subjective

nature of pain, in particular CPP. Historically, gynaecolo-

gists have tended to discount pain symptoms with an undue

emphasis on visible pathology as validating the patient’s

experience.

CPP is a common problem: the prevalence of the

condition is about 38/1000 among women aged 20–50 years,

not dissimilar to the prevalence of common conditions such

* Corresponding author.

E-mail address: [email protected] (Y. Cheong).

1471-7697/$ – see front matter # 2005 Elsevier B.V. All rights reserved.

doi:10.1016/j.rigp.2005.07.001

as asthma (37/1000), back pain (41/1000) and migraine (21/

1000) [2,3]. There is also evidence that the prevalence of

CPP is probably underestimated in clinical studies, as up to

40% of women in a large questionnaire survey reported not

seeking any medical help for their pelvic pain [3]. In a cohort

study, approximately 5000 women were followed up over a

period of 3–4 years from their first contact with primary

care. CPP had median symptom duration of 15 months and a

third of women had persistent symptoms after 2 years. The

study also showed that a quarter of women had no diagnosis

made in that 3–4 years follow-up period, and only 40% were

referred to a hospital specialist. CPP has been shown

significantly to affect women’s daily activities, and has a

significant negative impact on their mental and physical

health [3].

The main gynaecological diagnoses include endome-

triosis, pelvic inflammatory disease and adhesions. The most

common gastrointestinal diagnosis is irritable bowel

syndrome and possible genitourinary diagnosis includes

pathology such as interstitial cystitis. The laparoscopic

findings of women with CPP, in increasing order of

Y. Cheong, W. Stones / Reviews in Gynaecological Practice 5 (2005) 227–236228

frequency: these were endometriosis (33%), adhesions

(24%) and ‘‘no pathology’’ (35%) [1,3]. This contrasts

with the diagnosis of CPP in the community, where causes

related to urinary (31%) and gastro-intestinal (37%) systems

was more common than gynaecological (20%) diagnoses.

The discrepancies in the diagnosis obtained in these patients

may be due to differences in the population studied, to the

limited diagnostic scope of gynaecology clinics and the

different approaches to the management of the condition in

the community as opposed to tertiary centres.

In this review, we aim to discuss the clinical consultation

necessary to help us decide upon which investigative tools

we will need to use to help diagnose the cause of CPP. We

also aim to discuss how these investigations can best help us

manage CPP. In many cases, a specific cause may not be

found in patients with CPP and symptom focused multi-

disciplinary management of CPP is at least as important as

diagnosis of specific pathology and disease oriented

treatment.

2. The consultation in the gynaecology clinic

Less than half of women with CPP get referred to a

gynaecological specialist [3]. Often, when referred, women

have high expectations of the gynaecologist. Furthermore,

the gynaecologist may be looking for organic pathology,

which may not exist. In our chronic pelvic pain clinic at the

Princess Anne Hospital, Southampton, we try to minimise

this mismatch by identifying the individual needs of each

patient so as to meet their expectations as much as possible.

For some patients, the priority may be to gain an explanation

of the cause(s) of their pain, although most are in search of

more effective symptom control.

In a series of patients referred from general practice, Selfe

et al. showed that the initial gynaecological consultation has

significant impact on the clinical outcome of women with

chronic pelvic pain [4]. The individual doctor undertaking

the consultation was shown to influence the patients’ pain

scores 6 months later. Thus, as clinicians, we need to be

aware of our own consultation styles and attitudes, which

may enter into the dynamics of the management of such

patients. It is obvious that patients with CPP require more

time and effort on the initial consultation, and many will

benefit from a multidisciplinary team assessment and

management setting but there are important practical

limitations to making this universally available.

Table 1

Referred pain from the various somatic nerves are shown

Somatic nerve Dermatome V

Ilioinguinal L1-2 P

Genitofemoral L1-2 P

Lateral femoral cutaneous L2-3 L

Pudendal S2-4 L

Besides enquiring about the routine gynaecological

symptoms, it is also prudent to be aware of psychological

morbidity. Whether a woman with CPP has endometriosis

or not, the likelihood of her having a concomitant mood

disorder is the same [5,6]. Mood disorder is easily missed

in general gynaecology clinic. Simple enquiry about sleep

and mood should be routine in clinic. There is no evidence

that antidepressants per se can ameliorate the symptoms

of CPP, but treatment of depression or anxiety can

improve the patient’s general quality of life. The

awareness of multiple unexplained symptoms in women

with CPP may prompt psychological/psychiatric referral,

thus minimising the risk of inappropriate surgical or

medical intervention. The key feature for somatisation is

the presence of multiple physical symptoms, for example,

referral to many specialists for many complaints. The

latter history would represent a prompt for involving a

liaison psychiatrist. There is a well-defined psychiatric

diagnosis of somatisation disorder but more often women

with CPP seen in a gynaecological setting do not manifest

the full blown syndrome. Specific criteria for mental

health referral include: (1) the presence of significant

mood disorder identified on a questionnaire or in the

history (e.g. suicidal ideation); (2) a history of abuse

(sexual or physical) although it is worth noting that many

patients with a history of abuse have resolved the

psychological consequences, and do not necessarily need

intervention or specific support, although clearly this

needs to be offered; (3) a history of drug or alcohol abuse

and/or addictive behavior; (4) ongoing concomitant

psychiatric illness, for example, an individual with

schizophrenia on multiple medications may still present

with problems needing help from a gynaecologist; in this

situation, it is advantageous to liaise with the mental

health team, although there is no suggestion that that

pelvic pain is due to schizophrenia.

During the clinical examination, it is important to

perform an anterior abdominal wall examination. Trigger

points identified on the anterior abdominal wall may suggest

nerve entrapment. Trigger points are areas of discrete

hyperalgesia. When palpated with fingertip pressure, they

elicit sharp pain that can refer to distant dermatomes.

Referred pain from different somatic nerves is illustrated in

Table 1 and Fig. 1. Because of a physiological phenomenon

called ‘viscerosomatic convergence’, subjective discrimina-

tion of somatic and visceral pain can be difficult. This is

because the somatic nerves synapse in the same dorsal horn

isceral field

roximal tube, uterine fundus

roximal tube, uterine fundus

ower uterine segment

ower uterine segment, cervix, bladder, distal ureter, upper vagina, rectum

Y. Cheong, W. Stones / Reviews in Gynaecological Practice 5 (2005) 227–236 229

Fig. 1. Dermatome distribution of peripheral somatic nerves.

of the spinal cord as the visceral nerves, thus the brain

perceives the pain as coming from the same dermatome

irregardless of whether the stimulus it is somatic or visceral

in origin. Injection of local anaesthetics (lidocaine or

bupivicaine) into the trigger point can help relieve pain and

confirm the diagnosis of nerve entrapment [7,8]. The

ilioinguinal nerve is not uncommonly trapped in a very wide

Pfannenstiel incision scar. Evaluation with the patient’s head

raised off the table and the rectus muscles tense

distinguishes abdominal wall from intra-abdominal pathol-

ogy. The tense rectus muscle protects the peritoneum from

stretch and tenderness that diminishes with head raised is

likely to be intraperitoneal, whilst discomfort not relieved by

this method originates form the abdominal wall. Examina-

tion of the anterior abdominal wall can also help detect

undiagnosed abdominal wall or femoral hernias.

A bimanual examination can help assess uterine

mobility. A fixed retroverted uterus, which is tender on

palpation, and the presence of nodules on the utero-sacral

ligaments and recto-vaginal septum suggest endometriosis.

Adnexal examination will help detect ovarian cysts or

endometriomas. During the vaginal examination, a single

digit is then use to palpate the muscular attachments along

the pubic arch and the insertion of the levator ani and

coccygeus muscles. Any areas of previous trauma or scars

for example those from previous episiotomies or tears can

be explored for pinpoint tenderness. Chronic patterns of

muscle holding following serious accidents or surgery that

require prolonged immobilisation, prolonged or repetitive

positions at work, relationship conflicts, poor health and

lifestyle habits, lack of exercise, poor posture and a history

of sexual abuse can all result in perineal muscle tension and

with time, this turns to chronic vulval, perineal or pelvic

pain. The general management of women with pelvic

muscle tension includes patient education so that she

understands and can participate in her own rehabilitation.

Pelvic floor relaxation exercises can be taught. In our centre,

women are referred to our physiotherapy colleagues

whereby biofeedback techniques using EMG can be

offered, manual massage exercises and general postural

exercises can be taught. The transcutaneous electric nerve

stimulation (TENS) machine is sometimes used over trigger

points externally or internally but the amplitude has to be

low as high amplitude TENS treatment can lead to an

unpleasant sensation. Trigger point injections with local

anaesthetics can be performed but this is generally reserved

for those who do not respond to physical therapy or used as a

means to diagnose trigger point tenderness due to nerve

entrapment. Some women may require combinations of

analgesics and adjunctive medications such as tricyclic

antidepressants or gabapentin [9].

3. Investigations

Investigations are undertaken so as to diagnose the

underlying pathology and we are guided by patient’s

presenting symptoms and our clinical findings in order to

arrange the appropriate investigations. It is a challenge

instigating the right investigations for patients with chronic

pelvic pain because there is a considerable overlap in

symptoms in patients with CPP. Using a postal ques-

tionnaire, Zondervan et al. [3] surveyed 3916 women

selected from the Oxfordshire Health Authority Register

(74% respond rate, n = 2304) and found that half the women

with CPP (n = 483) also had genitourinary symptoms or

irritable bowel syndrome, or both [10]. There was a higher

prevalence of dysmenorrhea and dyspareunia in women

with CPP (81% and 41%, respectively) compared with

women without CPP (58% and 14%, respectively). Among

all women with CPP, 34% reported that they had undergone

at least one investigation for pain but the proportion of

women who had investigations varied from 30% to 48%

depending on their presenting symptoms but women with

genitourinary symptoms or irritable bowel symptoms tends

to get more investigations compared to women with CPP

only. The reported investigations in descending order of

frequency were: ultrasonography (21.5%), laparoscopy or

laparotomy (11.2%), sigmoidoscopy or colonoscopy

(9.3%), radiography (7.2%) or others (4%). Among all

women with CPP, 20% reported that they never had any

investigations but had received a diagnosis. Among these

women, the most common diagnosis was irritable bowel

syndrome (46%), ovarian cysts (26%), endometriosis (21%)

and stress (20%).

4. Blood tests

Inflammatory markers are non-specific and may not be

raised in chronic pelvic inflammatory disease. There is

therefore very little value in performing these tests as the

primary investigations as they can be raised in many other

conditions non-contributory to the CPP. We do, however,

recommend testing for inflammatory markers such as C-

reactive proteins and leukocyte count in the case of an acute

exacerbation of CPP so as to exclude a fresh attack of pelvic

inflammatory disease (Fig. 3).


5. Radiological

5.1. Endometriosis

Transvaginal ultrasonography (TVS) is helpful in

assessing endometriotic ovarian cysts. On TVS, endome-

triomas appear as ovarian cysts with low level internal

echoes, multilocularity or hyperechoic wall foci. TVS,

however, has little value in assessing the presence of

adhesions and mild peritoneal deposits. In deep infiltrating

disease, where endometriosis involves the Pouch of

Douglas, often hypoechoic linear thickening, or nodules/

masses with or without regular contours can be seen on TVS,

occasionally infiltrating into organs or on the uterosacral

ligaments. The Pouch of Douglas can also be obliterated

with or without free fluid. Bazot et al. [34] examined 142

women with clinical signs of endometriosis with transva-

ginal scanning (TVS) in a prospective cohort study where

ultrasound findings were compared to surgical and

histological findings. They found that the sensitivity,

specificity, positive and negative predictive values of TVS

for predicting deep infiltrating pelvic endometriosis were

79%, 95%, 95% and 78%.

More recently, the role of endoanal ultrasound has been

evaluated for the diagnosis of deep infiltrating endome-

triosis. Delpy et al. [6] studied the use of anorectal

endoscopic ultrasonographic examination (EUS) in the

diagnosis of severe rectovaginal septum endoemtriosis in

30 patients. EUS showed the presence of rectovaginal

septum endometriosis in 26 patients (88%), in the

uterosacral ligaments in 10 patients (33%) and in the

ovaries in 2 patients (6%). Subsequent surgical explora-

tion demonstrated RV septum endometriosis in 26 patients

(88%) and the uterosacral ligament in 22 (73%) cases, and

the ovaries in 6 (20%) cases. They concluded that EUS

has a sensitivity of 96%, specificity of 100%, positive

predictive value of 100% and negative predictive value of

83% in diagnosing endometriosis in the rectovaginal

septum [6].

It therefore appears that TVS and endoanal ultrasono-

graphy, in the right hands within an appropriate referral

population is reasonably accurate in diagnosing deeply

infiltrating posterior endometriosis although this degree of

accuracy may not be achievable in all units. More

importantly, although laparoscopy is the ‘gold standard’

for diagnosis of endometriosis, the correlation between

visible endometriosis and histological diagnosis can vary

[11,12]. As not all patients in these studies who have visible

endometriosis during laparoscopy have histologically con-

firmed endometriosis, the results may be confounded.

Further studies with larger sample sizes are needed to

confirm or refute the reliability and accuracy of routine use

of such radiological investigations for the diagnosis of deep

infiltrating pelvic endometriosis.

Adenomyosis is characterized by the presence of

heterotrophic endometrial glands and stroma in the

myometrium with adjacent smooth muscle hyperplasia.

Women with adenomyosis often present with pelvic pain,

dysmenorrhea and menorrhagia. Pre-operative diagnosis of

adenomyosis is poor, ranging from 2.6% to 26%.

Transabdominal ultrasound does not have as good a

resolution as the transvaginal ultrasound. Criteria used for

diagnosing adenomyosis on transvaginal ultrasound include

uterine enlargement not explained by the presence of

fibroids, asymmetric thickening of the anterior or posterior

myometrial walls, heterogeneous, poorly circumscribed area

in the myometrium, anechoic lacunae cysts of caring size

and increased echo texture of the myometrium [13]. The

most accurate modality for the diagnosis of adenomyosis is

probably MR imaging. It has a sensitivity and specificity

ranging from 86% to 100%. This high accuracy is attributed

by the excellent soft tissue differentiation of MR imaging

compared to other imaging modalities. It is important to note

that many of these studies are measured against histopatho-

logical findings after hysterectomy. MR is less operator-

dependent compared to ultrasound but is however limited by

the high cost and availability of this imaging modality,

especially when the symptoms of adenomyosis can be rather

non-specific.

5.2. Adhesions

No method currently is in use for rapid, inexpensive and

noninvasive identification of infra-umbilical bowel adhe-

sions before laparoscopy. Existing entry methods, such as

entering the left upper quadrant or performing a small

laparotomy, do not directly address the issue of adequately

identifying those with adhesions, and require tissue

dissection. Ultrasound is easily available to gynaecologists

and surgeons. Transabdominal ultrasound when used

together with the ‘‘visceral slide test’’ can help diagnose

the presence of anterior abdominal wall adhesions [14,15].

The visceral slide test refers to a phenomenon whereby

respiratory movement or manual ballottement induces the

viscera, as visualised on ultrasound, to slide just beneath

the anterior abdominal wall. In the presence of adhesions,

this sliding motion is limited and thus indicative of the

presence of anterior abdominal wall adhesions. This

technique may be particularly useful to aid in the initial

safe placement of instruments at laparoscopy in patients

with an increased risk of complications secondary to

anterior abdominal wall adhesions. A more recent study by

Tu et al. evaluated 60 women at risk for intra-abdominal

adhesions who underwent laparoscopy or laparotomy [15].

All participants underwent the visceral slide test with peri-

umbilical sonographic measurements. With a prevalence

of infra-umbilical bowel adhesions of 12%, they found that

the visceral slide test has sensitivity = 86%, specifi-

city = 91%, positive predictive value = 55% and negative

predictive value = 98%. Visceral slide testing can therefore

inform a decision on trocar site, and with a high negative

predictive value, can serve to expand on the number of


patients who might benefit from laparoscopy and avoid

laparotomy. It is however important to note that the above

study was not blinded and this could have confounded the

results. Further trials are required to evaluate the role of

ultrasound and the visceral slide test in determining the

best port site as well as decreasing port-related complica-

tions.

As for adhesions in the pelvis, Ubaldi et al. performed

TVS on 133 women who attended their fertility clinic in

Belgium [16]. They suspected pelvic adhesions when

there was poor definition of pelvic structures. Pelvic

adhesions were diagnosed by TVS in 13 patients and this

finding was confirmed at laparoscopy in 11 patients. Of

the 120 TVS findings that showed no adhesions, 113 were

confirmed by laparoscopy. In seven patients with filmy

adhesions, TVS failed to detect these. The sensitivity,

specificity, positive and negative predictive values of TVS

for diagnosing adhesions were 61%, 98%, 84% and 94%,

respectively. The authors also calculated the efficiency to

be 93%. Thus, it appears that TVS is poor in picking up

the presence of adhesions, but TVS is fairly accurate in

predicting the absence of adhesions except when the

adhesions are filmy [16]. Laparoscopy however, remains

the investigation of choice if one suspects clinically

significant adhesions.

5.3. Pelvic congestion syndrome

Pelvic congestion is a condition associated with

dilatation and reduced venous clearance in the pelvis.

The exact patho-physiology is still a puzzle although it is

thought to be associated with psychological as well as

biological predisposition. The common symptoms are

shifting location of pain, deep dyspareunia and post-coital

pain and exacerbation of pain after prolonged standing

[17]. Venography is still considered the definitive

radiological investigation for women with pelvic conges-

tion syndrome. The radiological features are dilated

uterine and ovarian veins with reduced venous clearance

of contrast medium [18]. The absence of reflux on the

ovarian vein does not preclude the diagnosis of pelvic

congestion syndrome because other diagnostic features

include the diameter of the ovarian veins, the distribution

of vessels, and the delay in contrast medium. Ultrasound

does not appear to be as good as venography in the

diagnosis of the condition and the correlation between

ultrasound and venography is poor [19]. Diagnosis via

laparoscopy is also possible although there is no objective

measure of the diameter of the pelvic veins. Small

anecdotal studies have suggested retroperitoneal ovarian

vein ligation via laparotomy or laparoscopically, or

radiological embolisation of the ovarian veins has been

described. These surgical modalities of treatment are still

under research [20–22]. Treatment of the condition

primarily involves of ovarian suppression and physiolo-

gical intervention such as stress reduction.

6. Endoscopic

6.1. Laparoscopy under local anaesthesia

Conscious laparoscopic pain mapping (CLPM) is a

diagnostic laparoscopy performed under local anaesthesia in

women with chronic pelvic pain (CPP); the objective is to

localise the sources of tenderness with the aid of the patient

when mechanical stimulus is applied to areas in the pelvis

and the pelvic organs. During CLPM, the advantage is that

the patient can be conscious and can therefore alert the

clinician to the site of tenderness, the assumption is made

that pain stimulus in CPP must be mechanical. This, in fact,

has not been fully supported by the literature. The patho-

physiology of pain in CPP is often not mechanical. There is

little research on the actual effect of laparoscopy and

gaseous insufflations on pain perception. Furthermore, even

when pathology such as endometriosis is diagnosed, the pain

correlation with mechanical stimulus to the affected areas is

inconsistent [23].

However, the findings of CLPM can help to guide the

clinician as to the subsequent steps of management of CPP.

A clinical audit of all the women who underwent pain

mapping over the last 4 years in Southampton showed that

the number of women with tenderness over the following

areas in decreasing order of frequency were: ovaries and/or

uterus (38%, n = 15); generalised hyperalgesia, therefore

suggesting neuropathic pain (21%, n = 8); adhesions and

sterilisation clip (13%, n = 5); abdominal wall (8%, n = 3);

occult inguinal hernia (8%, n = 3); vaginal vault (5%, n = 2)

and others (5%, n = 2) [24]. As a result of the findings, we

are able to triage women who had CLPM in our study for

further surgery (41%, n = 16) further hormonal treatment

(28%, n = 11), further pain management via the multi-

disciplinary pain team 26% (n = 10) and 5% (n = 2) were

discharged back to the GP. Defining ‘‘success’’ as the

outcomes of benefit to the patient (Table 2), we concluded on

the basis of the case note review that 82% of the procedures

were successful. It should be noted that these audit findings

cannot be generalized to other settings and CLPM cannot be

recommended a routine investigation. In our clinical

practice, patients who are elect to undergo CLPM are a

specific sub-group where following a clinical history and

examination the assessment is that CLPM could (1) identify

a problem that can be resolvable by further surgery and/or

(2) demonstrate the presence of generalised non-localised

tenderness, a finding that may enable the patient to reorient

her goals towards pain management rather than a search for

specific focal pathology. No black and white rules exist in

the selection of these women for CLPM; rather the process is

seen as very much dependent on the consultation and the

goals and expectations of the individual patient. In

particular, given the unpleasantness of the procedure, it is

only to be considered when positively desired by the patient

after full counseling. The right theatre set-up with

appropriate anaesthetic support is required for the procedure


Fig. 2. Pain mapping with laparoscopy—surgical protocol.

Table 2

Outcomes of CLPM: case note based rating of ‘success’ and ‘failure’

% (n)

Success (n = 32)

Procedure identified a problem amenable to surgery and patient was better after recommended surgery 38 (15)

Procedure indicated that surgery was going to be unhelpful and patient had alternative therapy and got better 36 (14)

Patient was better informed and reassured 8 (3)

Failure (n = 4)

Adhesions were removed but no better 3 (1)

Failed attempt of embolisation of pelvic veins and patient lost to follow-up 3 (1)

CLPM suggested abdominal wall tenderness, local injection of area did not work 5 (2)

Equivocal (n = 3)

Patient got pregnant, therefore treatment stopped 3 (1)

Recommended surgery but patient lost to follow-up 5 (2)


to run smoothly. A surgical protocol from our unit is

provided in Fig. 2 for reference.

6.2. Laparoscopy under general anaesthesia

Laparoscopy under general anaesthesia has a role in the

management of women with CPP although around 35% of

women with CPP have no obvious pathology. Of impor-

tance, a negative laparoscopy can provide reassurance to the

patient. Any surgery particularly laparoscopy has potentially

a large placebo effect [25]. Therefore, studies examining the

effects of surgery need to assess the outcome over periods

longer than at least 6 months.

Fig. 3. Flow chart management of acute e

Laparoscopy however, can help in the diagnosis of

conditions such as endometriosis and current evidence

suggests that laparoscopic treatment of minimal-moderate

endometriosis relieves pain. This evidence mainly came

from Sutton et al. [33] where in a RCT, the effects of

laparoscopic laser ablation of endometriosis was compared

with diagnostic laparoscopy alone. At 6 months’ follow-up

assessment, 62.5% of the treated patients reported improve-

ment or resolution of symptoms compared with 22.6% in the

‘no treatment’ group. Symptom relief continued at the 1-

year follow-up in 90% of those who initially responded.

The case for adhesions being the cause of pain is not as

clear-cut. Some declare that it is an ‘‘unsubstantiated myth’’

xacerbation of chronic pelvic pain.


that adhesions cause pain [26] while others think that

‘‘adhesions can cause pelvic pain and adhesiolysis relieves it

in 60–90% of the cases’’ [27]. It therefore appears that some

adhesions are associated with pain and some not. The

Cochrane review [28] concluded that although adhesiolysis

in general does not resolve CPP, there is some benefit if the

adhesions are vascular and dense, based on the results of a

single study by Peters et al. [29].

In terms of patho-physiology, it is hypothesised that the

peritoneum, when under traction and tension, produces pain

as a result of activation of nerves in the adhesion tissue and

the viscera. To date, the best evidence for the latter comes

Fig. 4. Illustration of a step down analgesia pain ladde

from Kresch et al. [30]. In this study, the investigators

compared the findings in 100 women with pelvic pain for a

minimum period of 6 months with a control group of 50

asymptomatic women who were undergoing laparoscopic

sterilisation. In the 100 women with chronic pelvic pain,

48% had adhesions involving their uterus, ovaries and

bowel and 32% had endometriosis, while in the control

group 14% had adhesions and 15% had endometriosis. The

investigators also observed that the adhesions in the

control group were loose and did not restrict bowel

mobility whilst adhesions in the group of women with

chronic pelvic pain were more restrictive of the mobility of

r used in Princess Anne Hospital, Southampton.


the viscera. In this study, the one important patient

inclusion criterion was that the pain needed to be in a

consistent location, regardless of its character. This

criterion is not always used in many other studies.

Furthermore, some organs such as the ovaries are richly

innervated, and during processes such as ovulation,

produces the long recognised phenomenon of Mittelsch-

mertz (ovulation pain). Similarly, when the ovary is been

trapped or stretched by adhesions, pain can result.

More interestingly, adhesion tissue contains nerve fibres.

Kligman et al. obtained adhesion tissue from 17 patients, ten

with chronic pain and seven without, and examined the

tissue by immunohistochemistry for nerve tissues [31]. Ten

of the 17 specimens contained nerve fibres. The nerve fibres

were evenly distributed between patients with and without

pain. Tulandi et al. performed a similar but larger study on

50 patients and found no difference in the amount and

quantity of nerve fibres in adhesions from women with

pelvic pain and from those without pelvic pain [32].

However, Tulandi et al. [32] remarked on the limitations of

the study: based on a 77% proportion of nerve fibres in

women without pelvic pain, to detect a 10% difference in the

proportion of nerve fibres in the two groups of women with a

5% level of significance and a power of 80%, a total of 502

women (251 women in each group) is needed. Therefore, the

two studies to date that have examined nerve fibres and

adhesion tissue did not have enough power to answer the

question. Nevertheless, the findings that adhesion tissues

contain nerves may help explain why only some adhesions

cause pain. Adhesions that are stretched during movement of

the viscera can result in stimulation of the pain fibres, thus

initiating the release of chemical mediators and pain

response. More fundamentally, it is unlikely that the

difference between adhesions associated with pain or not

is simply the number of fibres: there may be differences in

the pattern of new innervation following tissue injury, with

differential involvement of sensory afferents expressing sub-

classes of neurotransmitter such as substance P and CGRP,

and varying in sensitivity to capsaicin. At present the normal

innervation of the peritoneum, let alone changes in sensory

nerve distribution and thresholds for activation of sensory

nerves following injury are poorly understood even in

animal experimental models of nociception, let alone in the

human context.

7. Multidisciplinary team approach

The core elements of a multidisciplinary team include a

gynaecologist with special interest in pain management, a

psychologist, a pain clinic nurse and a physiotherapist. The

multidisciplinary ‘package’ in the United Kingdom even

when available is quite varied but may include cognitive

behavioral psychotherapy, nursing support (such as in

between clinic times where medications need readjusting),

and the use of complimentary therapy including acupunc-

ture. In our unit, the team includes a gynaecologist, a pain

physician who is able to offer pain management advice and

nerve blocks where appropriate, a clinical psychologist

focusing on cognitive behavioral aspects and a pain clinic

nurse. A pain ladder protocol (Figs. 3 and 4) is used for acute

on chronic pelvic pain ward admissions. The main evidence

to show that a multidisciplinary team approach works come

from Leiden, The Netherlands [12]. The randomised

controlled trial showed that multidisciplinary approach is

beneficial compared to a conventional approach in terms of

improvement of quality of life scores although the McGill

pain score were not different in the two approaches. There

are important questions about the optimal use of this

approach as it is time consuming and expensive. Realisti-

cally, many cases will continue to be seen by a single

specialist, emphasizing the need for skills relevant to CPP

being embedded in gynaecological specialist training.

8. Conclusion

There are at present a multitude of investigational tools

for women with chronic pelvic pain. The choice of

investigations will depend on the patient’s clinical history,

symptoms. Although many of the investigations may not

reveal a diagnosis but the simple reassurance of the normal

results may be enough for some women. Perhaps we can say

that in the absence of a specific identifiable cause, CPP can

be considered a diagnostic category in its own right, as with

other types of chronic pain (i.e. pain is the disease). Many

clinicians suffer ‘heart sink’ when they see women with

chronic pelvic pain. However, much can be done to improve

care for these women by taking a broad based approach.

Much lies in the clinicians’ insight into the condition,

individual attitudes towards women with CPP, and appro-

priate management and referrals. Time spend on the initial

consultation to delineate the problems and understand the

issues underlying the condition is time well spent.

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