304

CHAPTER 11

Pelvic Pain

PAIN PATHOPHYSIOLOGY . . . . . . . . . . . . . . . . . . . . . . . 304 PAIN PATHOPHYSIOLOGY

ACUTE PAIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306 Pain is a protective mechanism meant to warn of an immediate
threat and to prompt withdrawal from noxious stimuli. Pain
CHRONIC PAIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
is usually followed by an emotional response and inevitable
DYSMENORRHEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318 behavioral consequences. These are often as important as the
pain itself. Merely the threat of pain may elicit responses even
DYSPAREUNIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319 in the absence of actual injury.
When categorized, pain may be considered somatic or vis-
DYSURIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320 ceral depending on the type of afferent nerve fibers involved.
Additionally, pain is described by the physiologic steps that
FUNCTIONAL BOWEL DISORDERS . . . . . . . . . . . . . . . . . 321
produce it and can be defined as inflammatory or neuropathic
MUSCULOSKELETAL ETIOLOGIES . . . . . . . . . . . . . . . . . . 323 (Kehlet, 2006). Both categorizations are helpful in diagnosing
the underlying sources of pain and selecting effective treatment.
NEUROLOGIC ETIOLOGIES . . . . . . . . . . . . . . . . . . . . . . . 326

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328 ■ Somatic Pain

Somatic pain stems from nerve afferents of the somatic ner-
vous system, which innervates the parietal peritoneum, skin,
muscles, and subcutaneous tissues (Fig. 23-3, p. 611). Somatic
pain is typically sharp and localized. It is found on either the
right or left within dermatomes that correspond to the innerva-
tion of involved tissues (Fig. 11-1).
Pain in the lower abdomen and pelvis is one of the most com-
mon patient complaints. In addition to the human costs of
illness and distress, the economic results can be measured in ■ Visceral Pain
billions of dollars from medical charges as well as lost wages Visceral pain stems from afferent fibers of the autonomic ner-
and productivity. Accurate diagnosis and treatment offers an vous system, which transmits information from the viscera and
opportunity to minimize this toll. visceral peritoneum. Noxious stimuli typically include stretch-
Pain is subjective and often ambiguous, and thus, difficult to ing, distension, ischemia, necrosis, or spasm of abdominal
diagnose and treat. Therefore, clinicians should understand the organs. The visceral afferent fibers that transfer these stimuli
mechanisms underlying human pain perception, which involves are sparse. Thus, the resulting diffuse sensory input leads to
complex physical, biochemical, emotional, and social interac- pain that is often described as a generalized, dull ache.
tions. Providers are obligated to search for organic sources of Visceral pain often localizes to the midline because visceral
pain, but equally important, they should avoid overtreatment innervation of abdominal organs is usually bilateral (Flasar,
for an illness or injury that is minor or short lived. 2006). Also, visceral afferents follow a segmental distribution,
 Pelvic Pain 305

Tissue innervated by
peripheral somatic nerves

CHAPTER 11
Spinal cord level

Dorsal
horn

Viscera

FIGURE 11-2 Viscerosomatic convergence. Pain impulses origi-

nating from an organ may impact dorsal horn neurons that are
synapsing concurrently with peripheral somatic nerves. These
impulses may then be perceived by the brain as coming from a
peripheral somatic source such as muscle or skin rather than the
diseased viscera. (Redrawn from Perry, 2000, with permission.)

Visceral afferent fibers are poorly myelinated, and action

A potentials may easily spread from them to adjacent somatic
nerves. As a result, visceral pain may at times be referred to der-
matomes that correspond to these adjacent somatic nerve fibers
(Giamberardino, 2003). In addition, both peripheral somatic
and visceral nerves often synapse in the spinal cord at the same
dorsal horn neurons. These neurons, in turn, relay sensory
information to the brain. The cortex recognizes the signal as
coming from the same dermatome regardless of its visceral or
somatic nerve origin. This phenomenon, termed viscerosomatic
convergence, may lead to difficulty in a patient distinguishing
internal organ pain from abdominal wall or pelvic floor pain
(Fig. 11-2) (Perry, 2003).

■ Inflammatory Pain
With acute pain, noxious stimuli such as a knife cut, burn,
or crush injury activate sensory pain receptors, more formally
termed nociceptors. Action potentials travel from the periph-
ery to dorsal horn neurons in the spinal cord. Here, reflex arcs
B may lead to immediate muscle contraction, which removes and
FIGURE 11-1 Dermatome maps. A dermatome is an area of protects the body from harm. Additionally, within the spinal
skin supplied by a single spinal nerve. A. Body dermatomes. cord, sensory information is augmented or dampened and may
B. Perineal dermatomes. (Redrawn from Rogers, 2000, with then be transmitted to the brain. In the cortex, it is recognized
permission.) as pain (Janicki, 2003). After an acute stimulus is eliminated,
activity of the nociceptor quickly diminishes.
If tissues are injured, then inflammation typically follows.
and visceral pain is typically localized by the brain’s sensory Body fluids, along with inflammatory proteins and cells, are
cortex to an approximate spinal cord level that is determined called to the injury site to limit tissue damage. Because cells
by the embryologic origin of the involved organ. For example, and most inflammatory proteins are too large to cross normal
pathology in midgut organs, such as the small bowel, appendix, endothelium, vasodilation and increased capillary permeability
and caecum, cause perceived periumbilical pain. In contrast, are required features of this response. Chemical mediators of
disease in hindgut organs, such as the colon and intraperitoneal this process are prostaglandins released from the damaged tis-
portions of the genitourinary tract, cause midline pain in the sue and cytokines, which are produced in white blood cells and
suprapubic or hypogastric area (Gallagher, 2004). endothelial cells. Cytokines include interleukins, tissue necrosis
 306 Benign General Gynecology

factors, and interferons. These sensitizing mediators are released

TABLE 11-1. Etiologies of Acute Lower Abdominal
into affected tissues and lower the conduction threshold of
and Pelvic Pain
nociceptors in these tissues. This is termed peripheral sensitiza-
tion. Similarly, neurons within the spinal cord display increased Gynecologic
SECTION 1

excitability, termed central sensitization. As a result, within Dysmenorrhea

inflamed tissues, the perception of pain is increased relative to Incomplete or complete abortion
the strength of the external stimulus (Kehlet, 2006). As inflam- Pelvic inflammatory disease
mation decreases and healing ensues, the increased sensitivity to Ovarian torsion
stimuli and thus the perception of pain subsides. Ectopic pregnancy
Tuboovarian abscess
Mittelschmerz
■ Neuropathic Pain
Ovarian mass
In some individuals, sustained noxious stimuli can lead to per- Prolapsing leiomyoma
sistent central sensitization and to a permanent loss of neuronal Outflow tract obstruction
inhibition. As a result, a decreased threshold to painful stimuli
remains despite resolution of the inciting stimuli (Butrick, Gastrointestinal
2003). This persistence characterizes neuropathic pain, which is Gastroenteritis
felt to underlie many chronic pain syndromes. The concept of Colitis
neuropathic pain helps explain in part why many with chronic Irritable bowel disease
pain have discomfort disproportionately greater to the amount Appendicitis
of coexistent disease found. During central sensitization, neurons Diverticulitis
within spinal cord levels above or below those initially affected Inflammatory bowel disease
may eventually become involved. This phenomenon results in Constipation
chronic pain that may be referred across several spinal cord levels. Small bowel obstruction
Thus, in assessing patients with chronic pain, a clinician Mesenteric ischemia
may find an ongoing inflammatory condition. In these cases, Gastrointestinal malignancy
inflammatory pain dominates, and treatment is directed at
resolving the underlying inflammatory condition. However, for Urologic
many, evaluation may reveal no or minimal current pathology. Cystitis
In these cases, pain is neuropathic, and treatment thus focuses Pyelonephritis
on management of pain symptoms. Urinary tract stone
Perinephric abscess
Musculoskeletal
ACUTE PAIN
Hernia
Acute lower abdominal pain and pelvic pain are common com- Peritonitis
plaints. The definition varies based on duration, but in gen- Abdominal wall trauma
eral, discomfort is present less than 7 days. The sources of acute
Miscellaneous
lower abdominal and pelvic pain are extensive, and a thorough
Diabetic ketoacidosis
history and physical examination can aid in narrowing the list
Herpes zoster
(Table 11-1).
Opiate withdrawal
Hypercalcemia
■ Diagnosis Sickle cell crisis
A timely and accurate diagnosis is the goal and ensures the best Vasculitis
medical outcome and prognosis for the patient. Accordingly, Abdominal aortic aneurysm rupture
one should attempt to obtain a patient’s history while per- Abdominal aortic aneurysm dissection
forming the initial physical examination element, that of Porphyria
observing the patient. Her general appearance and specific Heavy metal toxicity
physical and emotional attributes are noted. Although history
and examination are described separately here, in the clinical
setting they should be performed almost simultaneously for ture, or ischemia. The nature of pain may add value. Patients
optimal results. with acute pathology involving pelvic viscera may describe vis-
ceral pain that is midline, diffuse, dull, achy, or cramping. They
History may repeatedly shift or roll to one side to find a comfortable
In addition to a thorough medical and surgical history, a verbal position. One example is the diffuse midline periumbilical pain
description of the pain and its associated factors is essential. For of early appendicitis.
example, duration can be informative, and pain with abrupt The underlying pelvic pathology may extend from the vis-
onset may be more often associated with organ torsion, rup- cera to cause inflammation of its adjacent parietal peritoneum.
 Pelvic Pain 307

In these cases, sharp somatic pain is found, which is localized, increase of 30 beats per minute or a systolic blood pressure drop
often unilateral, and focused to a specific corresponding derma- of 20 mm Hg or both, between lying and standing after 1 min-
tome. Again using appendicitis as an example, the classic migra- ute, is often reflective of hypovolemia. If noted, establishment
tion of pain to the site of peritoneal irritation in the right lower of intravenous access and rehydration may be required prior to

CHAPTER 11
quadrant illustrates acute somatic pain. In other instances, completion of the examination. However, certain neurologic
sharp, localized pain may not originate from the parietal peri- disorders and medications, such as tricyclic antidepressants or
toneum, but from pathology in specific muscles or in isolated antihypertensives, may also produce similar orthostatic blood
areas of skin or subcutaneous tissues. In either instance, with pressure changes.
somatic pain, patients classically rest motionless to avoid move-
ment of the affected peritoneum, muscle, or skin. Abdominal Examination. Visual inspection of the abdo-
Colicky pain may reflect bowel obstructed by adhesion, men focuses on prior surgical scars, which may increase the
neoplasia, stool, or hernia. It may also result from increased possibility of bowel obstruction from postoperative adhesions
bowel peristalsis in those with irritable or inflammatory bowel or incisional hernia. Additionally, abdominal distension may
disease or infectious gastroenteritis. Alternatively, colic may fol- be seen with bowel obstruction, perforation, or ascites. After
low forceful uterine contractions with the passage of products inspection, auscultation of the abdomen may identify hyper-
of conception, prolapsing submucous leiomyomas, or endome- active or high-pitched bowel sounds characteristic of bowel
trial polyps. In addition, stones in the lower urinary tract may obstruction. Hypoactive sounds, however, provide less diag-
cause spasms of pain as they are passed. nostic information.
Associated symptoms may also direct diagnosis. For exam- Palpation of the abdomen should systematically explore each
ple, absence of dysuria, hematuria, frequency, or urgency will abdominal quadrant and begin away from the area of indicated
exclude urinary pathology in most instances. Gynecologic pain. Peritoneal irritation is suggested by rebound tenderness
causes are often associated with vaginal bleeding, vaginal dis- or by abdominal rigidity due to involuntary guarding or reflex
charge, dyspareunia, or amenorrhea. Alternatively, exclusion of spasm of the abdominal muscles.
diarrhea, constipation, or gastrointestinal (GI) bleeding lowers
the probability of GI disease. Pelvic Examination. In general, pelvic examination should
Vomiting complaints, however, are less informative, be performed in reproductive-aged women, as gynecologic
although the temporal relationship of vomiting to the pain pathology and complications of pregnancy are a common cause
may be helpful. In the acute surgical abdomen, if vomiting of pain in this age group. The decision to proceed with this
occurs, it usually follows as a response to pain and results from examination in geriatric and pediatric patients may be based
vagal stimulation. This vomiting is typically severe and develops on clinical information.
without nausea. For example, nausea and vomiting have been Of findings, purulent vaginal discharge or cervicitis may
found in approximately 75 percent of adnexal torsion cases reflect PID (Chap. 3, p. 93). Vaginal bleeding may stem from
(Descargues, 2001; Huchon, 2010). Therefore, the acute onset pregnancy complications, benign or malignant reproductive
of unilateral pain that is severe and associated with a tender tract neoplasia, or acute vaginal trauma. Pregnancy, leiomyo-
adnexal mass in a patient with nausea and vomiting should alert mas, and adenomyosis are common causes of uterine enlarge-
one to the increased probability of adnexal torsion. Conversely, ment, and the former two may also create uterine softening.
if vomiting is noted prior to the onset of pain, a surgical abdo- Cervical motion tenderness indicates peritoneal irritation
men is less likely (Miller, 2006). and may be seen with PID, appendicitis, diverticulitis, and
In general, well-localized pain or tenderness, persisting for intraabdominal bleeding. A tender adnexal mass may reflect
longer than 6 hours and unrelieved by analgesics, has an increased ectopic pregnancy, tuboovarian abscess, or ovarian cyst with
likelihood of acute peritoneal pathology. torsion, hemorrhage, or rupture. Alternatively, a tender mass
may be an abscess of nongynecologic origin such as one involv-
Physical Examination ing the appendix or colon diverticulum. Rectal examination
General Appearance. Initial examination begins with obser- can add information regarding the source and size of pelvic
vation of a patient while obtaining her history. A woman’s masses as well as the possibility of colorectal pathologies. Stool
general appearance, including facial expression, diaphoresis, guaiac testing for occult blood, although less sensitive when
pallor, and degree of agitation, often indicates the urgency of not performed serially, is still warranted in many patients
the clinical problem. (Rockey, 2005). Those with complaints of rectal bleeding,
painful defecation, or significant bowel habit changes are
Vital Signs. Elevated temperature, tachycardia, and hypo- examples.
tension should prompt an expedited evaluation, as the risk In emergency room settings, women with acute pain may
for intraabdominal pathology increases with their presence. experience waits between their initial assessment and subse-
Constant, low-grade fever is common in inflammatory condi- quent testing. For these patients, recent literature supports
tions such as diverticulitis and appendicitis, and higher tem- early administration of analgesia. Fears that analgesia will mask
peratures may be seen with pelvic inflammatory disease (PID), patient symptoms and hinder accurate diagnosis have not
advanced peritonitis, or pyelonephritis. been supported (McHale, 2001; Pace, 1996). Thus, barring
Pulse and blood pressure evaluation should assess ortho- significant hypotension or drug allergy, morphine sulfate may
static changes if intravascular hypovolemia is suspected. A pulse be administered judiciously in these situations.
 308 Benign General Gynecology

Laboratory Testing ing tools, it has superior performance in identifying GI and

Despite benefits from a thorough history and physical exami- urinary tract causes of acute pelvic and lower abdominal pain
nation, the sensitivity of these two in diagnosing the cause of (Andreotti, 2009). Noncontrasted renal colic CT has largely
abdominal pain is low (Gerhardt, 2005). Thus, laboratory and replaced the conventional intravenous pyelogram looking for
SECTION 1

diagnostic testing are typically required. In women with acute ureteral obstruction. The combination of both oral and intrave-
abdominal pain, complications of pregnancy are common. nous contrast is preferred in the evaluation of GI abnormalities
Thus, either urine or serum β-hCG testing is recommended such as appendicitis.
in those of reproductive age without a history of hysterectomy. CT has several advantages in addition to its high sensitiv-
Complete blood count (CBC) can aid in assessment of hemor- ity for most nongynecologic disorders. It can be performed
rhage, both uterine and intraabdominal, and assess the possi- quickly; is not perturbed by gas, bone, or obesity; and is not
bility of infection. Urinalysis may be used to evaluate possible operator-dependent. Disadvantages include the occasional lack
urolithiasis or cystitis. In addition, microscopic evaluation and of availability, high cost, inability to use contrast media in
culture of vaginal discharge can add support to clinically sus- patients who are allergic or have renal dysfunction, and expo-
pected cases of PID. sure to low levels of ionizing radiation (Leschka, 2007).
Currently, there is considerable ongoing debate regarding
Radiologic Imaging the safety and possible overuse of CT. Of major concern is the
potential increase in cancer risk directly attributable to ioniz-
Sonography. In women with acute pelvic pain, several imag-
ing radiation, which is estimated to be even higher in younger
ing options are available. However, transvaginal and trans-
patients and women (Einstein, 2007). Radiation doses from
abdominal pelvic sonography are preferred modalities if an
CT scans are generally considered to be 100 to 500 times
obstetric or gynecologic cause is suspected (Andreotti, 2009).
those from conventional radiography (Smith-Bindman, 2010).
Sonography provides a high sensitivity for detection of struc-
Investigators in a large multicenter analysis found that the
tural pelvic pathology. It is widely available, can usually be
median effective radiation dose from a multiphase abdomen
obtained quickly, requires little patient preparation, is relatively
and pelvic CT scan was 31 mSv, and this correlates with a life-
noninvasive, and avoids ionizing radiation. Disadvantageously,
time attributable risk of four cancers per 1000 patients (Smith-
examination quality is affected by the skill and experience of the
Bindman, 2009). By way of comparison, health care workers
sonographer (Angle, 2010).
at risk of repeated radiation exposure are generally limited to
In most cases, the transvaginal approach offers supe-
100 mSv over 5 years with a maximum of 50 mSv allowed in
rior resolution of the reproductive organs (Chap. 2, p. 38).
any given year (Fazel, 2009).
Transabdominal sonography may still be necessary if the uterus
In the acute clinical setting, the benefits of CT imaging fre-
or adnexal structures are significantly enlarged or if they lie
quently outweigh these risks. One analysis conducted in the
beyond the transvaginal probe’s field of view. Color Doppler
Netherlands found that the rate of false positive diagnoses of
imaging during sonography permits evaluation of the vascu-
appendicitis among adults decreased from 24 to 3 percent from
lar characteristics of pelvic structures. In women with acute
1996 to 2006. They noted that this decrease correlated with
pain, the addition of Doppler studies is particularly useful if
the increased rate of CT use during the same interval (Raman,
adnexal torsion or ectopic pregnancy is suspected (Twickler,
2008). Appendiceal perforation rates also decreased from 18 to
2010). Perforation of the uterine wall by an intrauterine device
5 percent. Considering that the false positive diagnosis of appen-
(IUD) and hematometra caused by menstrual outflow obstruc-
dicitis in women has been found to be as high as 42 percent, this
tion from müllerian agenesis anomalies are less common causes
certainly represents improvement in clinical outcomes.
of acute pain. For determining IUD location, imaging mülle-
rian abnormalities, and other indications, 3-dimensional (3-D)
Magnetic Resonance (MR) Imaging. If available, MR
sonography has become invaluable (Bermejo, 2010; Moschos,
imaging is becoming an important tool for women with acute
2011).
pelvic pain if initial sonography is nondiagnostic. Common
Conventional Radiography. Although the sensitivity is low reasons for noninformative sonographic evaluations include
for most gynecologic conditions, plain film radiographs may patient obesity and pelvic anatomy distortion secondary to large
still useful when obstruction or perforation of the bowel is sus- leiomyomas, müllerian anomalies, or exophytic tumor growth.
pected (Leschka, 2007). Dilated loops of small bowel, air-fluid As a first-line tool, MR imaging is often selected for pregnant
levels, the presence or absence of gas in the colon, or the finding patients, for whom ionizing radiation exposure should be limited.
of free air under the diaphragm are all significant findings when However, for most acute disorders, it provides little advantage
attempting to differentiate between a gynecologic and GI cause over 3-D sonography or CT (Bermejo, 2010; Brown, 2005). Lack
for acute pain. of availability can be a disadvantage after hours, on weekends, or
in smaller hospitals and emergency departments (Brown, 2005).
Computed Tomography. Computed tomography (CT) and,
more recently, multidetector computed tomography (MDCT) Laparoscopy
have been increasingly used to evaluate acute abdominal pain Operative laparoscopy is the primary treatment for suspected
in adults. CT offers a global examination that can identify appendicitis, adnexal torsion, or some ectopic pregnancies and
numerous abdominal and pelvic conditions, often with a high for cases of ruptured ovarian cyst associated with symptomatic
level of confidence (Hsu, 2005). Compared with other imag- hemorrhage. Moreover, diagnostic laparoscopy may be useful
 Pelvic Pain 309

if no pathology can be identified by conventional diagnos- decisively unless there are overwhelming clinical contraindica-
tics. However, in stable patients with acute abdominal pain, tions to immediate surgery.
noninvasive testing is typically fully exhausted before consider-
ing this approach (Sauerland, 2006).

CHAPTER 11
CHRONIC PAIN
Decision to Operate. The decision to perform a surgical pro- Persistent pain may be visceral, somatic, or mixed in origin.
cedure in the clinical setting of acute pelvic pain is not always As a result, it may take several forms in women and include:
an easy one. If the patient is clinically stable, the decision can be dysmenorrhea, dyspareunia, vulvodynia, chronic pelvic pain
made in a timely manner, with appropriate evaluation and con- (CPP), musculoskeletal pain, intestinal cramping, or dysuria.
sultation. In a less stable patient with signs of peritoneal irri- The list of pathologies that may underlie these chronic pain
tation, possible hemoperitoneum, organ torsion, shock, and/ symptoms is extensive and includes both psychological and
or impending sepsis, the decision to operate should be made organic disorders (Table 11-2). Moreover, pathology in one

TABLE 11-2. Sources of Chronic Pelvic Pain in Women

Gynecologic Musculoskeletal
Endometriosis Hernias
Adenomyosis Muscular strain
Leiomyomas Faulty posture
Intraabdominal adhesions Myofascial pain
Ovarian mass Levator ani syndrome
Adnexal mass Fibromyositis
Reproductive tract cancer Degenerative joint disease
Pelvic organ prolapse Lumbar vertebrae compression
Pelvic muscle trigger points Disk herniation or rupture
Intrauterine contraceptive device Coccydynia
Endometrial or endocervical polyps Spondylosis
Chronic ectopic pregnancy
Ovarian retention syndrome Neurologic
Ovarian remnant syndrome Neurologic dysfunction
Postoperative peritoneal cysts Abdominal cutaneous nerve entrapment
Chronic PID Neuralgia of iliohypogastric, ilioinguinal, lateral femoral
Chronic endometritis cutaneous, and/or genitofemoral nerves
Outflow tract obstruction Pudendal neuralgia
Broad ligament herniation Piriformis syndrome
Pelvic congestion syndrome Spinal cord or sacral nerve tumor

Urologic Miscellaneous
Chronic urinary tract infection Psychiatric disorders
Detrusor dyssynergia Physical or sexual abuse
Interstitial cystitis Shingles
Radiation cystitis
Urinary tract stone
Urinary tract cancer
Urethral diverticulum
Gastrointestinal
Irritable bowel syndrome
Constipation
Diverticular disease
Colitis
Inflammatory bowel disease
GI tract cancer
Celiac disease
Chronic intermittent bowel obstruction

GI ! gastrointestinal; PID ! pelvic inflammatory disease.

 310 Benign General Gynecology

organ can commonly lead to dysfunction in adjacent systems.

TABLE 11-3. Questions Relevant to Chronic Pelvic Pain
As a result, a woman with chronic pain may have more than
one cause of pain and overlapping symptoms. Thus, a compre- What is the pain’s quality, severity, and location?
hensive evaluation of multiple organ systems and psychological When and how did your pain start, and how has it
SECTION 1

state is essential for complete treatment. changed?

What makes your pain better or worse?
Other symptoms or health problems?
■ Chronic Pelvic Pain Do you have frequency, urgency, or bloody urine?
Do you have nausea or vomiting, diarrhea, constipation,
Chronic pelvic pain is a common gynecologic problem, and
or rectal bleeding?
Mathias and colleagues (1996) estimated its prevalence in repro-
Do you have pain with your periods?
ductive-aged women to be 15 percent. There is no universally
Did your pain start initially as menstrual cramps?
accepted definition of chronic pelvic pain. However, many
Have you had surgery? What was the reason?
investigators distinguish it from dysmenorrhea and dyspareu-
How many pregnancies have you had?
nia and define it as: (1) noncyclic pain that persists for 6 or
How did you deliver? Was there an episiotomy?
more months; (2) pain that localizes to the anatomic pelvis, to
Current and prior birth control?
the anterior abdominal wall at or below the umbilicus, or to the
Prior sexually transmitted disease or pelvic infection?
lumbosacral back or buttocks; and (3) pain that is of sufficient
Pain with deep penetration during intercourse?
severity to cause functional disability or lead to medical inter-
Are you depressed or anxious?
vention (American College of Obstetricians and Gynecologists,
Treated for mental illness in the past?
2008).
Have you been or are you now being abused physically
or sexually?
Etiology Prior evaluations or treatments for your pain?
Causes of chronic pelvic pain fall within a broad spectrum, but Have any previous treatments helped?
endometriosis, symptomatic leiomyomas, and irritable bowel What medications are you taking now?
syndrome are commonly diagnosed. Importantly, endometrio- How has the pain affected your quality of life?
sis is a frequent cause of CPP, but it typically is also associated What do you believe or fear is causing your pain?
with cyclic symptoms. Diagnosis and treatment of pain related
to this condition are discussed fully in Chapter 10 (p. 289).
Evaluation and management of chronic pain secondary to leio-
myomas is described in Chapter 9 (p. 250). these, the Visual Analog Scale, Numerical Rating Scale, and
The pathophysiology of CPP is unclear in many patients the Verbal Descriptor Scale are shown in Figure 11-3.
and may have a significant association with neuropathic pain,
described earlier (p. 306). Chronic pelvic pain shows increased Obstetric History. Pregnancy and delivery can be traumatic
association with irritable bowel syndrome, interstitial cysti- to neuromuscular structures and have been linked with pel-
tis, and vulvodynia. These are also considered by many to be vic organ prolapse, pelvic floor muscle myofascial pain syn-
chronic visceral pain syndromes stemming from neuropathic dromes, and symphyseal or sacroiliac joint pain. Paterson
pain ( Janicki, 2003).

Diagnosis
Visual analogue scale
History. More than with many other gynecologic complaints,
a detailed history and physical examination are integral to No pain Worst pain imaginable
diagnosis. A pelvic pain questionnaire can be used initially
to obtain information. One example is available from the
International Pelvic Pain Society and may be accessed at: http://
Numerical rating scale
www.pelvicpain.org/resources/handpform.aspx. Additionally, a
body silhouette diagram can be provided to patients for them No pain Worst imaginable pain
to mark specific sites of pain. One example is the McGill Pain 0 1 2 3 4 5 6 7 8 9 10
Questionnaire and Short Form (MPQ, MPQ-SF), which
combines a list of pain descriptors with a body map for
Verbal rating scale
patients to mark sites of pain. This can be accessed at http://
www.npcrc.org/usr_doc/adhoc/painsymptom/McGill%20 0 No pain
Pain%20Inventory.pdf (Melzack, 1987). At minimum, the 1 Mild pain
2 Moderate pain
series of questions found in Table 11-3 may provide valuable 3 Severe pain
information.
In addition to questionnaires, pain scales can improve pain FIGURE 11-3 Rating scales for pain. The visual analogue,
assessment, and several types are available (Herr, 2004). Of numerical, and verbal rating scales are shown.
 Pelvic Pain 311

(2009) reported that 9 percent of postpartum patients con- sion may cause or result from chronic pelvic pain (Table 13-5,
tinue to experience genital and/or pelvic pain for more than p. 360).
1 year after delivery. In addition, injury to the ilioinguinal or
iliohypogastric nerves during Pfannenstiel incision for cesar-

CHAPTER 11
Physical Examination. The etiology of chronic pain is var-
ean delivery may lead to lower abdominal wall pain even years
ied, and information gathered from physical examination can
after the initial injury (Whiteside, 2003). Following delivery,
often clarify the source and direct further testing. In a woman
recurrent, cyclic pain and swelling in the vicinity of a cesar-
with chronic pain, even routine examination may be extremely
ean incision or within an episiotomy suggests endometriosis
painful. For example, in those with neuropathic pain, mere
within the scar itself (Fig. 10-5, p. 287). Alternatively, in a
light touch may elicit pain. Therefore, examination should
nulliparous woman with infertility, pain may stem from endo-
proceed slowly to allow relaxation between each step. Moreover,
metriosis, pelvic adhesions, or chronic pelvic inflammatory
the patient should be reassured that she may ask for the exami-
disease.
nation to be halted at any time.
Surgical History. Prior abdominal surgery increases a Terms used to describe examination findings include allo-
woman’s risk for pelvic adhesions, especially if infection, dynia and hyperesthesia, among others. Allodynia is a painful
bleeding, or large areas of denuded peritoneal surfaces were response to a normally innocuous stimulus, such as a cot-
involved. Adhesions were found in 40 percent of patients ton swab. Hyperalgesia is an extreme response to a painful
who underwent laparoscopy for chronic pelvic pain sus- stimulus.
pected to be of gynecologic origin (Sharma, 2011). The
incidence of adhesions increases with the number of prior Stance and Gait. Women with intraperitoneal pathology
surgeries (Dubuisson, 2010). Lastly, certain disorders persist may compensate with changes in posture. Such adjustments
or commonly recur, and thus information regarding prior can create secondary musculoskeletal sources of pain (p. 324).
surgeries for endometriosis, adhesive disease, or malignancy Alternatively, musculoskeletal structures may be the site of
should be sought. referred pain from these organs (Table 11-4). Thus, careful
observation of a woman’s posture and gait is integral in the
Psychosocial History. There is a significant association evaluation of chronic pelvic pain.
between chronic pelvic pain and physical, emotional, or sexual Initially, a woman is examined while standing. Posture should
abuse (American College of Obstetricians and Gynecologists, be evaluated anteriorly, posteriorly, and laterally. Posterior,
2011; Jamieson, 1997; Lampe, 2000). A metaanalysis by Paras inspection for scoliosis and horizontal stability of the shoulders,
and associates (2009) demonstrated that sexual abuse is asso- gluteal folds, and knee creases is performed. Asymmetry may
ciated with an increased lifetime diagnosis rate of functional reflect musculoskeletal disorders.
bowel disorders, fibromyalgia, psychogenic seizure disorder, and Lateral visual examination may reveal lordosis and con-
chronic pelvic pain. Additionally, for some women, chronic pain comitant kyphosis. This combination has been noted in some
is an acceptable means to cope with social stresses. For these women with CPP and termed typical pelvic pain posture (TPPP)
reasons, patients should be questioned regarding domestic vio- (Fig. 11-4) (Baker, 1993). Also, abnormal tilt of the pelvic
lence and satisfaction with family relationships. Furthermore, bones can be assessed by simultaneously placing an open palm
an inventory of depressive symptoms is essential, as depres- on each side between the posterior superior iliac spine (PSIS)

TABLE 11-4. Musculoskeletal Origins of Chronic Pelvic Pain

Structure Innervation Referred Pain Sites
Hip T12–S1 Lower abdomen; anterior medial thigh; knee
Lumbar ligaments, facets/discs T12–S1 Low back; posterior thigh and calf; lower abdomen; lateral trunk;
buttock
Sacroiliac joints L4–S3 Posterior thigh; buttock; pelvic floor
Abdominal muscles T5–L1 Abdomen; anteromedial thigh; sternum
Pelvic and back muscles
Iliopsoas L1–L4 Lateral trunk; lower abdomen; low back; anterior thigh
Piriformis L5–S3 Low back, buttock; pelvic floor
Pubococcygeus S1–L4 Pelvic floor; vagina; rectum; buttock
Obturator internal/external L3–S2 Pelvic floor; buttock; anterior thigh
Quadratus lumborum T12–L3 Anterior lateral trunk; anterior thigh; lower abdomen

Modified from Baker, 1993, with permission.

 312 Benign General Gynecology

Muscle weakness may also indicate orthopedic disease. A

Trendelenburg test, in which a patient is asked to balance on
one foot, can indicate dysfunction of hip abductor muscles or
hip joint. With a positive test, when a woman elevates a leg by
SECTION 1

Kyphosis flexing the hip, the ipsilateral iliac crest droops.

Gait may also be evaluated by having the patient walk
Lordosis Lordosis across the room. An antalgic gait, known as a limp, refers to a
posture or gait that minimizes weight bearing on a lower limb
or joint and indicates a higher probability of musculoskeletal
pain.

Supine. The anterior abdominal wall should be evaluated for

abdominal scars. These may be sites of hernia or nerve entrap-
ment or may indicate a risk for intraabdominal adhesive dis-
ease. Auscultation for bowel sounds and bruits should follow.
Increased bowel activity may reflect irritable or inflammatory
bowel diseases. Bruits should prompt investigation for vascular
Normal Lordosis Kyphosis-Lordosis
(TPPP) pathology.
While supine, a woman is asked to demonstrate with one
FIGURE 11-4 Concurrent lordosis and kyphosis are common pos-
tural changes associated with chronic pelvic pain. TPPP ! typical finger the point of maximal pain and then encircle the total
pelvic pain posture. (Redrawn from Howard, 2000, with permis- surrounding area of involvement. Superficial palpation of the
sion.) anterior abdominal wall by a clinician may reveal sites of ten-
derness or knotted muscle that may reflect nerve entrapment or
myofascial pain syndrome (p. 324). Moreover, pain with eleva-
tion of the head and shoulders while tensing the abdominal
and anterior superior iliac spine (ASIS). Normally, the ASIS lies wall muscles, Carnett sign, is typical of anterior abdominal wall
one-quarter inch below the level of the PSIS, and greater dis- pathology. Conversely, if the source of pain originates from
tances may suggest abnormal tilt. Pelvic tilt may be associated inside the abdominal cavity, discomfort usually decreases with
with hip osteoarthritis and other orthopedic problems (Labelle, such elevation (Thomson, 1991). Moreover, Valsalva maneuver
2005; Yoshimoto, 2005). during head and shoulder elevation may display diastasis of the
Anterior inspection should focus on symmetry of the rectus abdominis muscle or hernias. Diastasis recti can be dif-
ASISs, umbilicus, and weight bearing. If one leg is domi- ferentiated in most cases from a ventral hernia. With diastasis,
nant in weight bearing, the nonbearing leg is often exter- the borders of the rectus abdominis muscle can be palpated
nally rotated and slightly flexed at the knee. In addition to bilaterally along the entire length of the protrusion. Deep pal-
carriage, the anterior abdominal wall and inguinal areas should pation of the lower abdomen may identify pathology originat-
be inspected for hernias. Direct and indirect inguinal hernias ing from pelvic viscera. Dullness to percussion or a shifting
and femoral hernias are often noted only when the woman is fluid wave may reflect ascites.
standing. Hernias that involve the anterior abdominal wall and
pelvic floor are most commonly associated with CPP. Less fre-
quently, sciatic hernia, which is herniation of peritoneum and
peritoneal contents through the greater sciatic foramen, and
obturator hernia, which is that through the obturator canal,
have also been rarely described as sources of pain (Chang,
2005; Miklos, 1998; Moreno-Egea, 2006; Servant, 1998).
Inspection of the perineum and vulva with the patient stand-
ing may identify varicosities. These are often asymptomatic or
may cause superficial discomfort. Such varicosities may also
coexist with internal pelvic varicosities. These internal varicosi-
ties can create a deep pelvic ache and are the underlying cause
of pelvic congestion syndrome (p. 317).
Any observed limitation in mobility may also be informa-
tive. A patient should be asked to bend forward at the waist.
Limitation in forward flexion may reflect primary orthopedic A B
disease or adaptive shortening of back extensor muscles. This FIGURE 11-5 Mobility testing. A. Normal flexion of the lower
shortening is seen frequently in women with chronic pain and back. B. Limited flexion may be seen in those with orthopedic
TPPP (Fig. 11-5). In such cases, patients are unable to create a disease or in those with chronic pelvic pain. (From Baker, 1998,
normal convex curve with this motion. with permission.)
 Pelvic Pain 313

Tests of mobility may give additional information. In most coccygeus muscles may be noted by sweeping the index finger with
cases, a woman can elevate her leg 80 degrees from the horizontal pressure across these muscles (see Fig. 11-6). Lastly, stool testing
toward her head, termed a straight leg test. Pain with leg elevation for occult blood may be performed during digital rectal examina-
may be seen with lumbar disc, hip joint, or myofascial pain syn- tion at the initial visit. Alternatively, home test kits for occult blood

CHAPTER 11
dromes. Additionally, symphyseal pain with this test may indicate are available at most pharmacies and at many physicians’ offices.
laxity in the symphysis pubis or pelvic girdle. Both the obtura-
tor and iliopsoas tests may indicate myofascial pain syndromes Testing
involving these muscles or disorders of the hip joint. With the Laboratory Evaluation. For women with chronic pelvic pain,
obturator test, a supine patient brings one knee into 90 degrees of diagnostic testing may add valuable information. Results from
flexion while the foot remains planted. The ankle is immobilized, urinalysis and urine culture may indicate urinary tract stones,
and the knee is gently pulled laterally and then medially to assess urinary tract malignancy, or recurrent infection as sources of
for tenderness. With the iliopsoas test, a supine woman attempts pain. Thyroid disease can affect physiologic functioning and
to flex each hip separately against resistance from the examiner’s may be found in those with bowel or bladder symptoms. Thus,
hand. If pain is described with flexion, the test result is positive. serum thyroid-stimulating hormone (TSH) levels are com-
monly assayed. Diabetes can lead to neuropathy, and screening
Sitting. A patient’s posture in the sitting position should be may be completed with urinalysis or serum evaluation.
inspected. Myofascial pain syndromes involving pelvic floor
muscles often lead patients to shift weight to one buttock or to Radiologic Imaging and Endoscopy. These modalities
sit toward a chair’s front edge. may be informative, and of these, transvaginal sonography is
widely used by gynecologists to evaluate chronic pelvic pain.
Lithotomy. Pelvic examination should begin with inspec- Sonography of the pelvic organs may reveal endometriomas,
tion of the vulva for generalized changes and localized lesions leiomyomas, ovarian cysts, dilated pelvic veins, and other struc-
as outlined in Chapter 4 (p. 111). Specifically, erythema may tural lesions. However, despite its applicability for many gyne-
reflect vulvitis or chronic fungal infection. Alternatively, thin- cologic disorders, sonography has poor sensitivity in identifying
ning of vulvar skin may result from lichen sclerosus or atrophic endometriotic implants or most adhesions. Similarly, CT or
changes. The vestibular area should be carefully inspected next. MR imaging may be used, but often adds little additional infor-
One or more focal areas of redness involving the vestibular mation to that obtained with sonography.
gland openings, associated with exquisite tenderness to palpa- In those with bowel symptoms, barium enema may indi-
tion, indicate vulvar vestibulitis. cate internal or external obstructive lesions, malignancy, and
After inspection, systematic pressure point palpation of the diverticular or inflammatory bowel disease. However, flexible
vulva is completed with a small cotton swab to map areas of pain sigmoidoscopy and colonoscopy may offer more information
(Fig. 4-1, p. 112). Palpation of the vagina ideally begins with one because colonic mucosa can be directly inspected and biopsied
finger, which is gradually inserted 3 to 4 cm. Systematic sweeping if necessary. In those in whom pelvic congestion syndrome is
pressure against the pelvic floor muscles along their length may suspected, the use of transvaginal color Doppler ultrasound,
identify isolated knots of taut muscle in those with myofascial CT, and MR imaging have all been reported, however, pel-
pain syndrome of the pelvic floor. Typically, the pubococcygeus, vic venography is considered the primary tool. This technique
iliococcygeus, and obturator internus muscles can be reached with requires cannulation of the femoral vein to access the internal
a vaginal finger (Fig. 11-6). Additionally, tenderness of the ure- iliac vessels for contrast injection (p. 318).
thra and bladder are potential indicators of urethral diverticulum Cystoscopy, laparoscopy, flexible sigmoidoscopy, and
or interstitial cystitis, respectively. Pain with deep palpation of colonoscopy may each be employed, and patient symptoms
the vaginal fornices may be seen with endometriosis, and cervical will dictate their use. In those with symptoms of chronic
motion tenderness may be noted with acute and chronic PID. If pain and urinary symptoms, cystoscopy is typically advised.
pain follows gentle movement of the coccyx, then articular disease If GI complaints are dominant, then flexible sigmoidoscopy
of the coccyx, termed coccydynia, is suspected. or colonoscopy may be warranted. For many women with no
Assessment of the uterus may reveal an enlarged uterus, obvious cause of their CPP, laparoscopy is often performed.
often with an irregular contour, due to leiomyomas. Globular Approximately 40 percent of all gynecologic laparoscopies are
enlargement with softening is more typical of adenomyosis. performed for this indication (Howard, 1993). Importantly,
Immobility of the uterus may follow scarring from endome- intraoperative explanations for CPP are commonly found
triosis, PID, malignancy, or adhesive disease from prior surger- in those with normal preoperative examinations (Cunanan,
ies. Evaluation of the adnexa may reveal tenderness or mass. 1983; Kang, 2007). Laparoscopy allows direct identification
Such lateral tenderness may reflect endometriosis, diverticular and in many cases, treatment of intraabdominal pathology.
disease, or pelvic congestion syndrome. Therefore, laparoscopy is considered by many to be the gold
Rectal examination and rectovaginal palpation of the recto- standard for evaluation of chronic pelvic pain (Sharma, 2011).
vaginal septum should be included. Palpation of hard stool or One laparoscopic approach to CPP is performed under local
hemorrhoids may indicate GI disorders, whereas nodularity of anesthesia with the patient conscious and available for question-
the rectovaginal septum may be found with endometriosis or ing regarding sites of pain (Howard, 2000; Swanton, 2006).
neoplasia. Myofascial tenderness involving the puborectalis and Termed conscious pain mapping, this technique has resulted
 314 Benign General Gynecology

Obturator internus Pubic symphysis

Pubococcygeus
SECTION 1

Puborectalis

Anococcygeal raphe
Iliococcygeus
Coccyx
Coccygeus

A B Pubococcygeus

C Iliococcygeus D Obturator internus

E Puborectalis F Coccygeus

FIGURE 11-6 Pelvic floor muscle examination. (Images contributed by Ms. Marie Sena.)

in more targeted treatment and improved postoperative pain If satisfactory relief is not achieved, then a mild opioid such
scores. However, its clinical use to date has been limited. as codeine, propoxyphene, or hydrocodone may be added to
this regimen (Table 39-12, p. 965). Opioids are most effec-
Treatment tive and least addictive if given on a scheduled basis and at
In many women with CPP, an identifying source is found, and doses that adequately relieve pain. If pain persists, stronger opi-
treatment is dictated by the diagnosis. However, in other cases, oids such as morphine, methadone, fentanyl, oxycodone, and
pathology may not be identified, and treatment is directed hydromorphone can replace milder ones. Close and regular
toward dominant symptoms. surveillance is essential (Gunter, 2003). An alternative to clas-
sic opioids is tramadol hydrochloride, which in addition to its
mild central opioid effect also inhibits serotonin and norepi-
Analgesics. Treatment of pain typically begins with oral nephrine reuptake.
analgesics such as acetaminophen or nonsteroidal antiinflam-
matory drugs (NSAIDs) (Table 10-2, p. 293). Acetaminophen Hormonal Suppression. Endometriosis is a common disor-
is a widely used and effective analgesic despite having no signifi- der found in women with CPP and is estrogen-dependent. Thus,
cant antiinflammatory properties. Alternatively, NSAIDs are hormonal suppression may be considered, especially in those
particularly helpful if inflammatory states underlie the pain. with coexistent dysmenorrhea or dyspareunia and who lack
 Pelvic Pain 315

dominant bladder or bowel symptoms. As discussed in Chapter 10 antidepressants have repeatedly been shown to reduce neuro-
(p. 292), combination oral contraceptives, progestins, gonadotro- pathic pain independent of their antidepressant effects (Saarto,
pin-releasing hormone (GnRH) agonists, and certain androgens 2005). Moreover, antidepressants are a logical choice, as clini-
have proved effective. cally significant depression is commonly comorbid with pain.

CHAPTER 11
Amitriptyline (Elavil) and its metabolite nortriptyline (Pamelor)
Antidepressants and Anticonvulsants. For many, CPP have the best documented efficacy in the treatment of neu-
represents neuropathic pain, and therapy has been extrapo- ropathic and nonneuropathic pain syndromes (Table  11-5)
lated from treatment of such pain in other disorders. Tricyclic (Bryson, 1996). Selective serotonin-reuptake inhibitors do not

TABLE 11-5. Antidepressants and Antiepileptic Drugs Used in Chronic Pain Syndromes
Drug (Brand name) Dosage Side Effects

Antidepressants
Tricyclic antidepressants Dry mouth, constipation, urinary retention,
sedation, weight gain
Amitriptyline (Elavil)a For both, 10–25 mg at bedtime; increase by Tertiary amines have greater
Imipramine (Tofranil)a 10–25 mg per week up to 75–150 mg at anticholinergic side effects
bedtime or a therapeutic drug level
Desipramine (Norpramin)a For both, 25 mg in the morning or at bedtime; Secondary amines have fewer
Nortriptyline (Pamelor)a increase by 25 mg per week up to 150 mg anticholinergic side effects
per day or a therapeutic drug level
Selective Serotonin-Reuptake Inhibitors
Fluoxetine (Prozac)a For both, 10–20 mg per day; up to 80 mg per Nausea, sedation, decreased libido, sexual
Paroxetine (Paxil)a day for fibromyalgia dysfunction, headache, weight gain
Novel Antidepressants
Bupropion (Wellbutrin)a 100 mg per day; increase by 100 mg per Anxiety, insomnia or sedation, weight loss,
week up to 200 mg twice daily seizures (at dosages above 450 mg per
(400 mg per day) day)
Venlafaxine (Effexor)a 37.5 mg per day; increase by 37.5 mg per Headache, nausea, sweating, sedation,
week up to 300 mg per day hypertension, seizures
Serotoninergic properties in dosages below
150 mg per day; mixed serotoninergic
and noradrenergic properties in dosages
above 150 mg per day

Antiepileptic Drugs
First-generation agents
Carbamazepine (Tegretol) 200 mg per day; increase by 200 mg per Dizziness, diplopia, nausea, aplastic
week up to 400 mg three times daily anemia
(1200 mg per day)
Phenytoin (Dilantin)a 100 mg at bedtime; increase weekly up to Blood dyscrasias, hepatotoxicity
500 mg at bedtime
Second-generation agents
Gabapentin (Neurontin) 100–300 mg at bedtime; increase by 100 mg Drowsiness, dizziness, fatigue, nausea,
every 3 days up to 1800 to 3600 mg per sedation, weight gain
day taken in divided doses three times daily
Pregabalin (Lyrica) 150 mg at bedtime for diabetic neuropathy; Drowsiness, dizziness, fatigue, nausea,
300 mg twice daily for postherpetic sedation, weight gain
neuralgia
Lamotrigine (Lamictal)a 50 mg per day; increase by 50 mg every Dizziness, constipation, nausea; rarely,
2 weeks up to 400 mg per day life-threatening rashes
a
Not approved by the U.S. Food and Drug Administration for treatment of neuropathic pain.
Abbreviated from Maizels, 2005, with permission.
 316 Benign General Gynecology

appear to be as effective as tricyclic antidepressants (Gilron, pathology (Gunter, 2003). Almost 40 percent of women with
2006). no identified pelvic pathology will have persistent pain after
In addition to antidepressants, anticonvulsants have also hysterectomy (Hillis, 1995).
been used effectively in treatment of CPP. Of these, gabap-
SECTION 1

entin and carbamazepine are most commonly used to reduce Specific Causes of Chronic Pelvic Pain
neuropathic pain (Wiffen, 2005a,b). As noted earlier, endometriosis and leiomyomas are common
causes of CPP and are discussed in detail in Chapters 9 and
Polypharmacy. Combining drugs with different sites or
10. Additional potential gynecologic sources of chronic pain
mechanisms of action may often improve pain. For example,
include pelvic adhesive disease, ovarian remnant syndrome, and
an NSAID and an opioid may be partnered, especially in con-
pelvic congestion syndrome.
ditions in which inflammation is dominant. If muscle spasm
underlies pain, then pairing a tranquilizer or a muscle relax-
Pelvic Adhesions. Adhesions are fibrous connections between
ant with an opioid or with an NSAID may improve results
opposing organ surfaces or between an organ and abdominal
(Howard, 2003).
wall, at sites where there should be no connection. They vary
Surgery in vascularity and thickness. Adnexal adhesions may be classi-
Neurolysis. Nerve destruction, termed neurolysis, involves fied according to a system developed by the American Society
nerve transection or injection of a neurotoxic chemical. Nerve for Reproductive Medicine (Table 11-6) (American Fertility
transection cuts a specific peripheral nerve or may be performed Society, 1988).
on an entire nerve plexus. Adhesions are common, and in laparoscopies performed
Presacral neurectomy (PSN) describes interruption of for CPP, they are found in approximately one quarter of cases
somatic pain fibers from the uterus that course within the (Howard, 1993). However, not all adhesive disease creates pain.
superior hypogastric plexus (Fig. 38-13, p. 929). This proce- For example, Thornton and associates (1997) found no rela-
dure is performed by incising the pelvic peritoneum over the tionship between pelvic pain and women with intraabdominal
sacrum and then identifying and transecting the sacral nerve adhesions.
plexus. In women so treated, approximately 75 percent note a
greater than 50 percent decline in pain (American College of Pathophysiology. The relationship between chronic pelvic
Obstetricians and Gynecologists, 2008). pain and adhesions is incompletely understood. In those with
However, presacral neurectomy is technically challenging CPP, intraperitoneal adhesions are believed to cause pain when
and requires familiarity with operating in the presacral space. they distort normal anatomy or when movement stretches
Surgery has been associated with long-term constipation and the peritoneum or organ serosa. This theory is supported by
urinary retention postoperatively. Infrequently, life-threatening studies using conscious pain mapping. Filmy adhesions that
hemorrhage may be encountered from the middle sacral vessels, allowed significant movement between two structures had
which run in the presacral space.
Alternatively, laparoscopic uterine nerve ablation (LUNA)
involves the destruction of the uterine nerve fibers that pass to
the uterus with the uterosacral ligament. During LUNA, most TABLE 11-6. Adnexal Adhesion Scoring System
surgeons destroy approximately 2 cm of uterosacral ligament "1/3 1/3 to 2/3 #2/3
near its attachment to the uterus (Lifford, 2002). Based on pel- Adhesions Enclosure Enclosure Enclosure
vic innervation, these surgeries are indicated only for treatment
of centrally located pelvic pain and have been performed to Ovary R Filmy 1 2 4
treat refractory endometriosis-related CPP and dysmenorrhea. Dense 4 8 16
However, in one trial, almost 500 women with CPP were ran- L Filmy 1 2 4
domly assigned to laparoscopy and intraoperative treatment of Dense 4 8 16
identified pathology or to a combination of laparoscopy, treat-
Tube R Filmy 1 2 4
ment, and LUNA. The addition of LUNA did not improve
Dense 4a 8a 16
pain scores (Daniels, 2009). Moreover, comparisons of LUNA
L Filmy 1 2 4
and presacral neurectomy show significantly greater long-term
Dense 4a 8a 16
pain relief with presacral neurectomy (Proctor, 2005).
a
If the fimbriated end of the fallopian tube is completely
Hysterectomy. When thorough evaluation excludes an
enclosed, change the point assignment to 16.
organic cause and conservative medical therapy has failed, a
Scores 0 to 5 reflect minimal disease; those from 6 to 10
total hysterectomy and bilateral salpingo-oophorectomy is con-
indicate mild disease; those from 11 to 20 signify mod-
sidered definitive management. For many women with CPP,
erate disease; and those from 21 to 32 reflect severe
hysterectomy is effective in resolving pain and improving qual-
disease.
ity of life (Kjerulff, 2000; Stovall, 1990). However, for others,
L ! left; R ! right.
hysterectomy may fail to relieve CPP. This result may follow
From The American Fertility Society, 1988, with
more commonly in those who are younger than 30 years, those
permission.
who have mental illness, or those with no identifiable pelvic
 Pelvic Pain 317

the highest association with pain, whereas adhesions that Indeterminate cases may require CT or MR imaging. In cases
prohibited movement had the lowest pain scores. Moreover, where ureteral compression is suspected, intravenous pyelogra-
adhesions that had a relationship to the peritoneum had a phy may be warranted. Laboratory testing, specifically follicle-
high association with pain (Demco, 2004). Sensory nerve stimulating hormone (FSH) levels in reproductive-aged women

CHAPTER 11
fibers have been identified histologically, ultrastructurally, with a history of a bilateral oophorectomy, may be helpful.
and immunohistochemically in human peritoneal adhesions Levels in premenopausal range are suggestive of retained func-
obtained at laparotomy, lending additional support to these tioning ovarian tissue (Magtibay, 2005).
theories (Suleiman, 2001). Although medical treatment has included hormonal manip-
ulation to suppress functioning tissue, surgical excision is
Diagnosis. Risks for adhesions include prior surgery, prior required in many symptomatic cases (Lafferty, 1996). Because
intraabdominal infection, and endometriosis. Less commonly, the ureter is commonly intimately involved with adhesions
inflammation from radiation, chemical irritation, or foreign- encasing a remnant, laparotomy is warranted in many cases.
body reaction may be causes. Pain is typically aggravated by However, in those with advanced laparoscopic skills, successful
sudden movement, intercourse, or other specific activities. outcomes can be achieved (Nezhat, 2000, 2005).
Laparoscopy is the primary tool used to diagnose adhesions.
In general, sonography lacks sensitivity. However, Guerriero Pelvic Congestion Syndrome. Retrograde blood flow through
and coworkers (1997) noted a positive correlation with ovar- incompetent valves can often create tortuous, congested
ian adhesions if the ovarian surface borders appeared blurred. ovarian or pelvic veins. Chronic pelvic ache, pressure, and
Also, adhesions were suspected if the ovary appeared imme- heaviness may result and is termed pelvic congestion syndrome
diately adjacent to the uterus and if this position persisted (Beard, 1988).
despite manipulation of these organs with the sonography
transducer. Pathophysiology. Currently, it is not clear whether conges-
tion results from mechanical dilatation, ovarian hormonal dys-
Treatment. Surgical lysis is often used to treat pain symp- function, or both. Higher rates of ovarian varicosities and pelvic
toms, and a number of observational studies have shown pain congestion syndrome are noted in parous women. A mechanical
improvement (Fayez, 1994; Steege, 1991; Sutton, 1990). theory describes a dramatic increase in pelvic vein diameter dur-
However, two randomized studies comparing adhesion lysis ing late pregnancy that leads to ovarian vein valve incompetence
with expectant management found no difference in pain scores and pelvic varicosities. Additionally, estrogen has been impli-
after 1 year (Peters, 1992; Swank, 2003). Others who support cated in pelvic congestion syndrome in that estrogen acts as a
the continued judicious use of adhesiolysis in the treatment venous dilator. Moreover, pelvic congestion syndrome resolves
of pelvic pain question the statistical methods used in these following menopause, and antiestrogenic medical therapy has
studies (Roman, 2009). When performed, adhesiolysis is asso- been shown to be effective in these cases (Farquhar, 1989;
ciated with a significant risk of adhesiogenesis, especially in Gangar, 1993). Most likely, both factors play roles. The cause of
cases involving endometriosis (Parker, 2005). Thus, the deci- pain with pelvic congestion remains unclear, but increased dila-
sion to lyse adhesions should be individualized, and if lysis tation, concomitant stasis, and release of local nociceptive medi-
is performed, steps should be taken to minimize reformation ators have been suggested (Giacchetto, 1989; Soysal, 2001).
(Hammoud, 2004). Gentle tissue handling, adequate hemo-
stasis, and adhesion barriers have all been shown to be helpful Diagnosis. Affected women may describe pelvic ache or heavi-
(American Society for Reproductive Medicine, 2008). ness that may worsen premenstrually, after prolonged sitting or
standing, or following intercourse. During bimanual examina-
Ovarian Remnant Syndrome and Ovarian Retention tion, tenderness at the junction of the outer and middle thirds
Syndrome. Following oophorectomy, remnants of an excised of a line drawn between the symphysis and anterior superior
ovary may create symptoms that are termed ovarian remnant iliac spine or direct ovarian tenderness may be found. In addi-
syndrome. Distinction is made between this syndrome and ovar- tion, varicosities in the thigh, buttocks, perineum, or vagina
ian retention syndrome, also known as residual ovary syndrome. may be associated (Venbrux, 1999).
Ovarian retention syndrome involves symptoms stemming from The left ovarian venous plexus drains into the left ovarian vein,
an ovary intentionally left at the time of previous gynecologic which empties into the left renal vein. The right ovarian vein gen-
surgery (El Minawi, 1999). Although differentiated by the erally drains directly into the inferior vena cava. Both ovarian
amount of ovarian tissue involved, both syndromes have nearly veins may have numerous trunks (Fig. 11-7). Pelvic venography
identical symptoms and are diagnosed and treated similarly. of this vascular anatomy is a primary diagnostic tool in women
Although an uncommon cause of CPP, women with symp- suspected of pelvic congestion syndrome, and embolization can
tomatic ovarian remnants most typically complain of chronic be concurrently performed in identified candidates. Alternatively,
or cyclic pain or dyspareunia. The onset of symptoms is variable CT, MR imaging, sonography, and diagnostic laparoscopy can
and may begin years following surgery (Nezhat, 2005). identify varicosities. However, because these modalities are per-
Women with these syndromes may have a pelvic mass pal- formed while a woman is prone, some varicosities decompress in
pable on bimanual examination (Orford, 1996). Sonography this position and may be missed (Park, 2004; Umeoka, 2004).
is informative in many cases. In those with ovarian remnants,
ovaries may be identified in some cases by a thin rim of ovarian Treatment. Treatments for pelvic congestion syndrome have
cortex surrounding a coexistent ovarian cyst (Fleischer, 1998). included chronic progestin or GnRH agonist administration,
 318 Benign General Gynecology

The term primary dysmenorrhea describes cyclic menstrual

pain without an identifiable associated pathology, whereas
secondary dysmenorrhea frequently complicates endometriosis,
Ovarian
Inferior leiomyomas, PID, adenomyosis, endometrial polyps, and men-
SECTION 1

vein
vena cava strual outlet obstruction. For this reason, secondary dysmenor-
Embolization rhea may be associated with other gynecologic symptoms, such
coil as dyspareunia, dysuria, abnormal bleeding, or infertility.
Compared with secondary dysmenorrhea, primary dysmen-
Ovarian orrhea more commonly begins shortly after menarche. Pain
vein
characteristics, however, typically fail to differentiate between
the two types, and primary dysmenorrhea is usually diagnosed
following exclusion of known associated causes.
External
iliac vein Risks for Primary Dysmenorrhea
When other factors are removed, primary dysmenorrhea
equally affects women regardless of race and socioeconomic
status. However, increased pain duration or severity is posi-
tively associated with earlier age at menarche, long menstrual
periods, smoking, and increased body mass index (BMI). In
contrast, parity appears to improve symptoms (Harlow, 1996;
Sundell, 1990).

Pathophysiology
During endometrial sloughing, endometrial cells release pros-
taglandins as menstruation begins. Prostaglandins stimulate
myometrial contractions and incite ischemia. Women with
more severe dysmenorrhea have higher levels of prostaglandins
in menstrual fluid, and these levels are highest during the first
FIGURE 11-7 On the image’s right, pelvic varices have already
2 days of menstruation. Prostaglandins are also implicated in
been treated with sclerosant and coils in the left ovarian vein.
On the image’s left, a guiding catheter is threaded into the right secondary dysmenorrhea. However, anatomic mechanisms can
ovarian vein to perform ovarian venography and embolization. also be identified, depending on the type of accompanying
(From Kim, 2006, with permission.) pelvic disease.

ovarian vein embolization or ligation, and hysterectomy with Diagnosis

bilateral salpingo-oophorectomy (BSO), although none is In women with menstrual cramps and no other associated find-
definitive. For example, Beard and colleagues (1991) found ings or symptoms, no additional evaluation may be initially
that almost one third of women had some residual pain follow- required once pregnancy is excluded, and empiric therapy may
ing total hysterectomy with BSO for this condition. be prescribed (Proctor, 2006). In women at risk for PID, cul-
Embolization appears to afford effective treatment, and per- tures for Chlamydia trachomatis and Neisseria gonorrhoeae are
centages of women with pain improvement range from 65 to 95 indicated. Moreover, if pelvic evaluation is incomplete due to
percent (Kim, 2006; Maleux, 2000; Venbrux, 2002). Ovarian body habitus, then transvaginal sonography may be informative
vein sclerotherapy provided symptomatic relief at 1 year in 17 to exclude structural pelvic pathology.
of 20 patients who were treated (Tropeano, 2008). Chung and
coworkers (2003) compared embolization against hysterectomy Treatment
and oophorectomy and found embolization more effective. Nonsteroidal Antiinflammatory Drugs. Because prosta-
Long-term studies on its effects past 1 year, however, are lacking. glandins have been implicated in the genesis of dysmenorrhea,
Alternatively, medical treatment with GnRH agonists or administration of NSAIDs is logical, and studies support their
with medroxyprogesterone acetate, 30 mg orally daily, has been use (Marjoribanks, 2003; Zhang, 1998). These drugs and their
shown to be effective for some women with pelvic congestion dosages are found in Table 10-2 (p. 293).
syndrome, although symptoms typically recur after medication
is discontinued (Reginald, 1989). Steroid Hormone Contraception. Combination hormone
birth control methods are believed to improve dysmenorrhea by
lowering prostaglandin production, and observational studies of
■ Dysmenorrhea combination oral contraceptives (COCs) have noted improved
Cyclic pain with menstruation is common and accompanies dysmenorrhea in users (Brill, 1991; Gauthier, 1992; Hendrix,
most menses (Balbi, 2000; Weissman, 2004). This pain is clas- 2002; Milsom, 1990). In addition, extended or continuous
sically described as cramping and is often accompanied by low administration of COCs may be useful in women with pain not
backache, nausea and vomiting, headache, or diarrhea. controlled with traditional pill use (Chap. 5, p. 153) (Sulak, 1997).
 Pelvic Pain 319

Progestin-only contraceptives are also used to effectively coitarche, and secondary dyspareunia, which is painful inter-
treat dysmenorrhea. The levonorgestrel-releasing intrauterine course after a period of pain-free sexual activity. Sexual abuse,
system (LNG-IUS), depot medroxyprogesterone acetate injec- female genital mutilation, and congenital anomalies most fre-
tion, and progestin-releasing implanted rods have been shown quently lead to primary dyspareunia, whereas sources of sec-

CHAPTER 11
to be effective in improving dysmenorrhea (Chap. 5, pp. 137 ondary dyspareunia are more varied. Lastly, dyspareunia should
and 157) (Baldaszti, 2003; Varma, 2006). be clarified as generalized, occurring in all episodes of inter-
course, or as situational, associated with only specific partners
Gonadotropin-Releasing Hormone Agonists and or sexual positions.
Androgens. The estrogen-lowering effects of these agents lead
to endometrial atrophy and diminished prostaglandin produc-
tion. Although gonadotropin-releasing hormone agonists and Diagnosis
androgens such as danazol have been shown to be effective in History taking in women with dyspareunia should include
treating dysmenorrhea, their substantial side effects preclude questions regarding associated symptoms such as vaginal dis-
their routine and long-term use. A fuller discussion and list of charge, vulvar pain, dysmenorrhea, CPP, or scant lubrication.
dosages for these agents and their side effects can be found in Onset of symptoms and their temporal association with obstet-
Chapter 9 (p. 254). ric delivery, pelvic surgery, or sexual abuse is often informative.
In addition, dyspareunia may be found in those who breast
Complementary and Alternative Medicine. Diet changes,
feed, presumably because of hypoestrogenism-derived vaginal
herbal medicine, and physical treatments have each been sparsely
atrophy seen with lactation (Buhling, 2006; Signorello, 2001).
evaluated in the treatment of dysmenorrhea. Oral vitamins E
Psychosocial topics such as relationship satisfaction or depres-
and B1 (thiamine), magnesium, fish oil, low-fat diet, and the
sion should also be covered.
herb Toki-shakuyaku-san have all been shown to improve dys-
Inspection of the vulva should mirror that for chronic pain.
menorrhea. However, evidence derives from small and typically
In particular, generalized erythema, episiotomy scars, or atro-
nonrandomized trials (Barnard, 2000; Gokhale, 1996; Harel,
phy is sought. Erythema may indicate contact or allergic der-
1996; Wilson, 2001; Ziaei, 2001). Additionally, data are limited
matitis or infection, particularly fungal infection. Accordingly,
but positive toward the use of exercise, topical heat, acupunc-
a historical inventory of potential skin irritants, a saline slide
ture, and transcutaneous electrical nerve stimulation (TENS)
preparation, vaginal pH testing, and vaginal cultures are per-
(Akin, 2001, 2004; Fugh-Berman, 2003; Golub, 1968; Helms,
formed. Specifically, a vaginal fungal culture may be required
1987; Kaplan, 1994).
in some cases. This is because several noncandidal species
Surgery. Cases of dysmenorrhea refractory to conservative may be difficult to detect if microscopic analysis is solely used
management are unusual, and in such instances, surgery may be (Edwards, 2003; Haefner, 2005).
indicated. Hysterectomy is effective in treating dysmenorrhea, Some, but not all, have found a positive correlation between
but may be unwanted in those desiring future fertility. For these degree of pelvic organ prolapse and dyspareunia (Burrows,
women, presacral neurectomy or LUNA may be indicated. 2004; Ellerkmann, 2001). If noted, its degree should be
assessed with pelvic organ prolapse evaluation (POP-Q)
(Chap. 24, p. 636).
■ Dyspareunia Physical examination should evaluate the distal, mid-, and
Dyspareunia is a frequent gynecologic complaint. In repro- proximal vagina. Evaluation may first begin with palpation of
ductive-aged U.S. women, the 12-month prevalence is 15 to the Bartholin and periurethral glands. Additionally, cotton-
20 percent (Glatt, 1990; Laumann, 1999). Painful intercourse swab testing is used to map painful areas (Fig. 4-1, p.  112).
may be associated with vulvar, visceral, musculoskeletal, neuro- Next, insertion of a single digit into the distal vagina may elicit
genic, or psychosomatic disorders. Moreover, coexistent etiolo- vaginismus, that is, reflex contraction of the muscles associated
gies may lead to similar symptoms. For example, women with with distal vaginal penetration (Basson, 2000). This contraction
vulvodynia have been shown in many cases to have coexistent response is normal, but prolonged spasm of the bulbocaverno-
pelvic floor muscle spasm, both of which may cause dyspa- sus, pubococcygeus, piriformis, and obturator internus muscles
reunia (Reissing, 2005). Because of the frequent association may cause pain. In some cases, spasm may be a conditioned
between dyspareunia and CPP and frequent overlap of etiolo- response to a current or former physical pain (Bachmann,
gies, physical examination and diagnostic testing often follow 1998).
that for women with CPP (p. 311). With deeper digital examination, midvaginal pain may be
Dyspareunia may be subclassified as insertional, that is, pain triggered. This may be seen with interstitial cystitis, congenital
with vaginal entry, or deep, which is associated with deep thrust- anomalies, or following radiation therapy or pelvic reconstruc-
ing. Of insertional dyspareunia cases, vulvodynia, vulvitis, and tive surgeries.
poor lubrication comprise the majority. Of deep dyspareunia Deep dyspareunia is more commonly caused by disorders
cases, endometriosis, pelvic adhesions, and bulky leiomyomas that also cause CPP. Focal points of this examination are dis-
are frequent causes. In many women, both insertional and deep cussed on page 311. Similarly, diagnostic testing for deep dys-
dyspareunia may be present. pareunia in great part mirrors that for CPP. Urine and vaginal
Additional terms include primary dyspareunia, which cultures may indicate infection, and radiologic imaging may
describes the onset of painful intercourse coincident with reveal structural visceral disease.
 320 Benign General Gynecology

Treatment
Resolution of dyspareunia is highly dependent on the under-
lying cause. For those with vaginismus, structured desen-
sitization is effective. Patients gradually gain control with
SECTION 1

comfortably inserting dilators of increasing size into the introi-

tus. Concurrent psychological counseling in such cases is often
warranted. Poor lubrication may be countered with education
directed toward adequate arousal techniques and use of exter-
nal lubricants.
Surgery may be indicated for structural pathologies and
may include ablation of endometriosis, lysis of adhesions,
and restoration of normal anatomy. For those with dys-
pareunia related to a retroverted uterine position, uterine
suspension has been shown in small studies to be effective
(Perry, 2005).

■ Dysuria
Evaluation of dysuria begins with a careful pelvic inspection
to exclude vaginitis, vulvar lesions, and urethral diverticulum.
A voiding diary can be informative, and for those with asso-
ciated dyspareunia, a sexual history should be obtained. The FIGURE 11-8 Cystoscopic photograph displays Hunner ulcers.
most common cause of dysuria is infection, and urinalysis and (From Reuter, 1987, with permission.)
urine culture are therefore initial tests. Similarly, N gonorrhoeae,
C trachomatis, and herpes simplex virus infections should be
excluded. For those with chronic dysuria, urodynamic stud-
table bowel syndrome, generalized pain disorders, fibromyalgia,
ies may help to identify those with detrusor overactivity, sig-
pelvic floor dysfunction, and depression (Aaron, 2000; Clauw,
nificantly decreased compliance, or bladder outlet obstruction
1997; Novi, 2005; Peters, 2007).
(Chap. 23, p. 621). Cystoscopy is used to identify the hallmark
mucosal findings of interstitial cystitis and exclude neoplastic Pathophysiology. The exact cause of IC is unknown, and
growths or stones (Irwin, 2005). Adjunctively, sonography current theories include increased mucosal permeability or mast
or laparoscopy may be indicated to exclude structural pelvic cell activation (Sant, 2007; Warren, 2002). Glycosaminoglycans
pathology or endometriosis. are an important component of the mucin layer that covers
and protects the bladder urothelium. One theory explains that
Interstitial Cystitis/Painful Bladder Syndrome IC symptoms originate from a defect in the protective bladder
This chronic inflammatory disorder of the bladder is typified glycosaminoglycan component. This leads to increased bladder
by symptoms of frequency, urgency, and pelvic pain (Bogart, mucosa permeability (Parsons, 2003).
2007). With interstitial cystitis (IC), this triad is found in com-
bination with characteristic mucosal changes and reduced blad- Diagnosis. Koziol (1994) reported symptoms in a series of
der capacity (Hanno, 1994). Cystoscopically, Hunner ulcers IC sufferers and found frequency, urgency, and pelvic pain
are reddish-brown mucosal lesions with small vessels radiating to be most common. Frequency occurs both in the day and
toward a central scar and are found in approximately 10 per- night, and voiding events average 16 times per day but can
cent of cases (Fig. 11-8) (Messing, 1978; Nigro, 1997). The reach 40 times daily. Pain is described as vaginal, suprapubic,
other more common finding is glomerulations, which are small or lower abdominal and often worsens during the week before
petechiae or submucosal hemorrhages. In addition to cases with menstruation. It is commonly exacerbated by spicy foods; by
classic IC findings, painful bladder syndrome describes chronic alcoholic, acidic, carbonated, or caffeinated beverages; and by
IC symptoms in those who lack cystoscopic findings of IC or coitus, stress, or exercise. Pain is often relieved with voiding,
other bladder pathology (Abrams, 2002). but typically recurs as the bladder refills. Additionally, women
commonly describe dyspareunia (Metts, 2001).
Prevalence. The prevalence of IC in the United States is Many other conditions can produce symptoms similar to
variable and cited at 30 to 60 per 100,000 (Curhan, 1999; those of IC, and most urologists have therefore regarded IC
Jones, 1997). It is diagnosed more commonly in women, in as being a diagnosis of exclusion. Accordingly, urine culture
Caucasians, in smokers, and in those in their 40s (Kennedy, is obtained, and patients suspected of having IC typically
2006; Propert, 2000). There is a strong association between undergo cystoscopy. Bladder biopsy is not required to diagnose
IC and endometriosis. The two conditions share similar symp- IC, but biopsies are often performed to exclude other bladder
toms, and many patients evaluated for chronic pelvic pain have pathology such as cancer. Urodynamic testing is recommended
been found to have either one or both conditions (Butrick, in those with urgency. In women with IC, both bladder capac-
2007; Paulson, 2007). In addition, IC is associated with irri- ity and compliance are decreased.
 Pelvic Pain 321

Treatment. Interstitial cystitis is a chronic disorder with ingestion of gluten creates an immune-mediated reaction that
exacerbations and remissions. There is no universally accepted damages the small intestine mucosa and leads to varying degrees
therapy, and for some, expectant management is appropriate. of malabsorption. Celiac disease is common, and its incidence
Of therapies, dietary restriction of acidic foods or drinks, oral in the general population approaches 1 percent (Green, 2007).

CHAPTER 11
pentosan polysulfate sodium (Elmiron), oral amitriptyline or Its incidence is suspected to be even higher if those with GI
antihistamines, intravesical instillation of agents such as hepa- symptoms are screened. There is a gender bias to the disease,
rin or dimethyl sulfoxide (DMSO), or hydrodistension of the and two to three times as many women as men are affected
bladder are among the more commonly used (Rovner, 2000). (Green, 2005).
The Interstitial Cystitis Association serves as an important The most common presenting symptoms are abdominal
resource to patients and clinicians for therapy options and can pain and diarrhea. Other findings include weight loss, osteo-
be accessed at: http://www.ichelp.org. penia, and fatigue from anemia; all of which stem from mal-
absorption. In addition, celiac disease has been associated
with infertility, although the mechanism is not understood.
GASTROINTESTINAL DISEASE Celiac disease should be suspected in those with charac-
In a significant number of cases, GI disease is found as an teristic findings and in those with a family history of the
underlying cause of chronic pelvic pain. Gastrointestinal disorder.
causes may be organic or functional (see Table 11-2). Thus, Diagnosis requires both duodenal biopsy and a positive
initial screening may follow that for CPP. However, symp- response to a gluten-free diet. However, a significant number
toms such as fever, GI bleeding, weight loss, anemia, and of patients presenting with abdominal pain and diarrhea do not
abdominal mass should prompt a stronger search for organic have celiac disease. Accordingly, many physicians will screen
pathology. Investigations may include sigmoidoscopy or with noninvasive serologic tests to avoid unnecessary biopsy. Of
colonoscopy to exclude inflammation, diverticula, or tumors. available diagnostic tests, serologic screening for IgA antiendo-
For those with diarrhea, stool examination for leukocytes or mysial antibodies and IgA antitissue transglutaminase antibodies
for ova and parasites may be indicated. Moreover, serologic is accurate more than 90 percent of the time (van der Windt,
testing for celiac disease may be valuable. When indicated, 2010).
sonography may aid in distinguishing gastrointestinal from
gynecologic pathology.
■ Functional Bowel Disorders
Also known as functional gastrointestinal disorders (FGIDs),
■ Colonic Diverticular Disease this group of functional disorders has symptoms attributable
Colon diverticula are small defects in the muscular layer of the to the lower GI tract and includes those listed in Table 11-7.
colon through which colonic mucosa and submucosa herniate. In defining these chronic conditions, symptoms must have
Diverticular disease of the colon is common in both men and begun more than 6 months previously and have occurred more
women. It develops in approximately 10 percent of adults than 3 days a month during the last 3 months (Longstreth,
younger than 40 years and in greater than 50 percent of those 2006). The diagnosis always presumes the absence of a struc-
80 years and older. The sigmoid and descending colon are tural or biochemical explanation for symptoms (Thompson,
typically affected. 1999).
Chronic symptoms of diverticular disease include abdomi-
nal pain that localizes to the left lower quadrant, obstipation, Irritable Bowel Syndrome
and rectal fullness. More seriously, diverticula may cause acute
or chronic GI bleeding or may become infected. Infection may Definition and Incidence. This functional bowel disorder
be difficult to distinguish clinically from PID or tuboovarian is defined as abdominal pain that improves with defecation
abscess. In these cases, CT is the recommended imaging tech- and is associated with a change in bowel habits. Subtypes are
nique and has a sensitivity for diagnosis greater than 90 per- divided by the predominant stool pattern and include consti-
cent and a specificity approaching 100 percent (Ambrosetti, pative, diarrheal, and mixed stool categories. Although defin-
1997). ing criteria are listed in Table 11-7, other symptoms that may
Chronic diverticular disease is usually treated with a high- support the diagnosis include abnormal stool frequency (fewer
fiber diet and long-term suppressive therapy with antibiotics. than three bowel movements per week or more than three per
With acute severe infection, hospitalization, parenteral antibi- day), abnormal stool form, straining, urgency, passing mucus,
otics, surgical or percutaneous abscess drainage, or partial col- and bloating (Longstreth, 2006).
ectomy may be required. Suspected rupture of a diverticular Irritable bowel syndrome (IBS) is common, and its
abscess with peritonitis is an indication for immediate surgical prevalence in the general population is estimated to be
exploration ( Jacobs, 2007). near 10 percent. The prevalences of diarrhea-predominant
and constipation-predominant IBS are equivalent (Saito,
2002).
■ Celiac Disease
This is an inherited autoimmune intolerance to gluten, which Pathophysiology. With IBS, neural, hormonal, genetic,
is a component of wheat, barley, or rye. In affected individuals, environmental, and psychosocial factors are variably involved
 322 Benign General Gynecology

TABLE 11-7. Functional Gastrointestinal (GI) Disorders

Functional Bowel Disorders
Irritable bowel Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months
SECTION 1

syndrome (IBS) associated with 2 or more of the following: (1) improved with defecation; (2) onset
associated with a change in stooling frequency; (3) onset associated with a change in
stool form
Functional abdominal Must include both of the following: (1) recurrent feeling of bloating or visible distension
bloating at least 3 days/month in 3 months; (2) insufficient criteria for a diagnosis of functional
dyspepsia, IBS, or other functional GI disorder
Functional constipation Must include two or more of the following: (1) straining during at least 25% of defecations;
(2) lumpy or hard stools in at least 25% of defecations; (3) sensation of incomplete
evacuation for at least 25% of defecations; (4) sensation of anorectal obstruction/blockage
for at least 25% of defecations; (5) manual maneuvers to aid at least 25% of defecations;
(6) fewer than three defecations per week
Loose stools are rarely present without the use of laxatives
There are insufficient criteria for IBS
Functional diarrhea Loose or watery stools without pain, occurring in at least 75% of stools
Unspecified functional Bowel symptoms not attributable to an organic etiology that do not meet criteria for the
bowel disorder previously defined categories
Functional Abdominal Pain
Functional abdominal At least 6 months of: (1) continuous or nearly continuous abdominal pain; and (2) no or
pain only occasional relation of pain with physiologic events (e.g., eating, defecation, or
menses); (3) some loss of daily functioning; (4) pain is not feigned (e.g., malingering);
(5) insufficient criteria for other functional gastrointestinal disorders that would explain
the abdominal pain
Unspecified functional
abdominal pain

Adapted from Longstreth, 2006, and Thompson, 1999.

(Drossman, 2002). The primary pathophysiologic mecha- Treatment

nism of IBS, however, is thought to involve dysregulation in Diet. Traditionally, therapy to increase daily fiber intake has
interactions between the central nervous system (CNS) and been employed. Although dietary fiber is effective in treating
enteric nervous system (ENS). Such brain-gut dysfunction may constipation, it has not been shown to be effective for diarrhea-
eventually cause alterations of GI mucosal immune response, dominant cases of IBS or for IBS-associated pain (Quartero,
intestinal motility and permeability, and visceral sensitiv- 2005). Management of food intolerances can be another poten-
ity. In turn, these produce abdominal pain and altered bowel tially valuable treatment adjunct (Alpers, 2006).
function (Harris, 2006; Mayer, 2008). Specifically, serotonin
(5-hydroxytryptamine, 5-HT) is involved with regulating Medications. In general, drug therapy is directed toward
intestinal motility, visceral sensitivity, and gut secretion and dominant symptoms. For those with constipation-dominant
is thought to play an important role in IBS (Atkinson, 2006; IBS, commercial fiber analogs may help if increased dietary
Gershon, 2005). fiber is unsuccessful (Table 11-8) (Ramkumar, 2005). In
addition, stimulation of the serotonin receptor subtype
Diagnosis. Organic diseases such as those in Table 11-2 are 5-hydroxytryptamine-4 (5-HT4) increases colonic transit
excluded prior to the diagnosis of IBS. However, for young time and inhibits visceral sensitivity. Specifically, tegaserod
patients who have typical IBS symptoms and no symptoms of (Zelnorm), a partial 5-HT4-receptor agonist, increases colonic
organic disease, few tests are required. Testing is individualized, motility and has been effective in relief of constipation-pre-
and factors that typically prompt greater testing include older dominant IBS (Layer, 2005; Tack, 2005). However, in 2007,
patient age, longer duration and greater severity of symptoms, Novartis suspended U.S. sales of Zelnorm in compliance with
absent psychosocial factors, presence of organic disease symp- a request by the Food and Drug Administration (FDA). An
toms, and family history of GI disease. increased incidence of cardiovascular events in those using this
 Pelvic Pain 323

TABLE 11-8. Agents Used to Treat Irritable Bowel Syndrome (IBS)

Symptom Drug Oral Dosage

CHAPTER 11
Diarrhea Loperamide 2–4 mg when necessary; maximum 12 g/d
Cholestyramine resin 4 g with meals
Constipation Psyllium husk 3.4 g bid with meals, then adjust
Methylcellulose 2 g bid with meals, then adjust
Calcium polycarbophil 1 g qd to qid
Lactulose syrup 10–20 g bid
70% sorbitol 15 mL bid
Polyethylene glycol 3350 17 g in 8 oz. water qd
Magnesium hydroxide 2–4 tbsp qd
Abdominal pain Tricyclic antidepressants Start at 25–50 mg hs, then adjust
Selective serotonin-reuptake inhibitors Begin with a small dose and increase as needed

bid ! twice daily; hs ! at bedtime; qd ! daily; qid ! four times daily.

Modified from Longstreth, 2006, with permission.

agent prompted the FDA’s action. It is available now only for MUSCULOSKELETAL ETIOLOGIES
special cases (U.S. Food and Drug Administration, 2010).
For those with diarrhea-dominant symptoms, loperamide Clinical syndromes involving the muscles, nerves, and skel-
(Imodium) or diphenoxylate (Lomotil) are effective in slow- etal system of the lower abdomen and pelvis are frequently
ing bowel motility. As substances stay longer in the intestine, encountered but often overlooked by gynecologists in our
more water is absorbed from fecal matter. Thus, for those with never-ending quest to identify visceral sources of chronic pel-
severe diarrhea, alosetron (Lotronex), a selective serotonin vic pain.
5-HT3-receptor antagonist, interacts with receptors of enteric
nervous system neurons to slow bowel motility. Use of this
■ Abdominal Wall Hernia
drug decreases pain, urgency, and stool frequency (Camilleri,
2000; Chey, 2004; Ford, 2009). However, due to cases of isch- Defects in anterior abdominal wall or femoral fascia can lead to
emic colitis associated with its use, alosetron is now strictly herniation of bowel or other intraabdominal contents through
regulated and available only through an FDA prescribing pro- these rents. Such herniation can cause pain. Moreover, if the
gram (Chang, 2006; U.S. Food and Drug Administration, blood supply of herniated contents is compromised acutely,
2009). then bowel obstruction or bowel ischemia can necessitate
For patients with pain secondary to bowel spasm, antispas- prompt surgical intervention.
modic agents decrease intestinal smooth muscle activity and are Hernias may develop at sites of inherent anatomic weakness,
thought to decrease abdominal discomfort. Agents available in and common types in women include ventral, umbilical, and
the United States include dicyclomine (Bentyl) and hyoscya- incisional hernias. Indirect inguinal, direct inguinal, and femo-
mine (Levsin). In general, these agents are safe, are inexpen- ral hernias are types less commonly found in females. Spigelian
sive, and have been shown to be effective (Quartero, 2005). hernias are rare. As shown in Figure 11-9, ventral hernias are
However, evidence-based data supporting their use are few, caused by fascial defects typically occurring in the midline.
and anticholinergic side effects of these agents often limit their Umbilical hernias are those involving defects of the umbilical
long-term use (Schoenfeld, 2005). ring. Indirect inguinal hernias are those in which abdominal
Tricyclic antidepressants may help patients with IBS both contents herniate through the internal inguinal ring and into
by an anticholinergic effect on the gut and by mood-modifying the inguinal canal. As shown in Figure 11-10, contents may
action. Tricyclic antidepressants may slow intestinal transit then exit the external inguinal ring. In contrast, contents of
time and have been shown to be effective in treatment of a direct inguinal hernia bulge through a fascial defect within
diarrhea-dominant IBS (Hadley, 2005). Alternatively, another Hesselbach triangle. This triangle is bordered by the inguinal
class of antidepressant, the selective serotonin-reuptake inhibi- ligament, the inferior epigastric vessels, and the lateral border
tors (SSRIs), has been shown in small studies to be useful for of the rectus abdominis muscle. Spigelian hernias can occur
irritable bowel syndrome (Tabas, 2004; Vahedi, 2005). anywhere along the lateral border of the rectus abdominis.
However, the most frequent location is at the level of the arcu-
Psychological Therapy. Psychological or behavioral treat- ate line.
ments may help some patients. Of these, cognitive-behavioral Conditions that increase intraabdominal pressure such as
therapy and hypnotherapy have been shown to be effective pregnancy, ascites, peritoneal dialysis, and chronic cough are
(Drossman, 2003; Gonsalkorale, 2003; Payne, 1995). known hernia risk factors. Congenital or acquired anatomic
 324 Benign General Gynecology

A hyperirritable area within a muscle

can lead to persistently contracted fibers
and cause pain, weakness, or autonomic
reactions (Simons, 1999). The primary
SECTION 1

reactive area within the muscle is termed

Ventral a trigger point (TrP) and is identified
as a palpable taut, ropy band. These
Linea alba
Peritoneum myofascial trigger points can affect any
Cut rectus muscle, and those involving muscles
abdominis of the anterior abdominal wall, pelvic
floor, and pelvic girdle can be sources
of chronic pelvic pain. For this reason,
External oblique Umbilical the American College of Obstetricians
and Gynecologists (1997) recommends
Internal oblique
an assessment of the musculoskeletal
Transversus system prior to laparoscopy or hysterec-
abdominis tomy for CPP.
Transversalis
fascia below Pathophysiology
arcuate line Spigelian Trigger points are thought to form as
the end of a metabolic crisis within a
muscle. Dysfunction of a neuromus-
cular endplate can lead to sustained
acetylcholine release, persistent depo-
larization, sarcomere shortening, and
creation of a taut muscle band. Affected
fibers compress capillaries and decrease
local blood flow. The resulting isch-
emia leads to release of substances that
activate peripheral nerve nociceptors
FIGURE 11-9 Hernias that may involve the anterior abdominal wall include ventral, umbili- and in turn cause pain (McPartland,
cal, or much less commonly, Spigelian. (Image contributed by Mr. T. J. Fels.) 2004).
A persistent barrage of nociceptive
signals from TrPs may eventually lead
weakness or connective tissue disorders are also associated. to central sensitization and the potential for neuropathic pain
Because of the potential risks associated with organ herniation (p. 306). Signals may spread segmentally within the spinal cord
and strangulation, hernias are typically repaired once identified. to cause localized or referred pain (Gerwin, 2005). Trigger
Small ventral, umbilical, or incisional hernias may be repaired points can also initiate somatovisceral responses such as vomit-
by gynecologic surgeons. In these cases, the hernia sac is excised ing, diarrhea, and bladder spasm, which may add confusion to
and fascia reapproximated. Patients with larger hernias, which the diagnosis.
usually require mesh placement, or hernias in the inguinal area
are typically referred to a general surgeon.
Incidence and Risk Factors
The incidence of myofascial disease is unknown. However, in
an evaluation of 500 patients with chronic pelvic pain, Carter
■ Myofascial Pain Syndrome (1998) found 7 percent of patients primarily had trigger points
Many musculoskeletal conditions can lead to CPP and are listed as a source of their pain. Moreover, of nearly 1000 women eval-
in Table 11-2. In addition to these, chronic visceral inflamma- uated for CPP, 22 percent were found to have significant ten-
tory conditions such as endometriosis, interstitial cystitis, or IBS derness of the levator ani muscles, and 14 percent were found
may lead to pathologic changes in nearby muscles and/or nerves. to have significant tenderness of the piriformis muscles (Gomel,
In turn, these changes can be the genesis of myofascial pain syn- 2007). Prevalence appears to be greatest in those between 30
dromes of the abdominal wall or pelvic floor. Knowledge and and 50 years of age. Risk factors are varied, although many
awareness of these complex associations allows a physician to trigger points can be traced to a prior specific trauma such
more effectively address all the components leading to pain, as a sporting injury or to chronic biomechanical overload of
rather than narrowly focusing on an isolated visceral disorder. a muscle (Sharp, 2003). Accordingly, in evaluating patients
As a result, a patient is less likely to suffer misdiagnosis and with chronic pain and suspected myofascial pain syndrome,
inappropriate treatment. Instead, appropriate referral for physi- a detailed inventory of sporting injuries, traumatic injuries,
cal therapy or pain management can be initiated. obstetric deliveries, surgeries, and work activities is essential.
 Pelvic Pain 325

muscles may include diarrhea or urinary frequency, urgency,

or retention.
Within the rectus abdominis muscle, painful TrPs are fre-
quently found along the linea semilunaris, which is the term

CHAPTER 11
for this muscle’s lateral margin (Suleiman, 2001). Additional
TrP sites in the rectus abdominis muscle commonly develop at
the muscle’s insertion into the pubic bone and also below the
umbilicus. Within the external oblique muscle, trigger points

FIGURE 11-10 Indirect and direct inguinal hernias and femoral her-
nia. A direct hernia is cause by a fascial defect within Hesselbach
triangle. An indirect hernia forms from intraabdominal contents
exiting through the inguinal canal. Femoral hernias form from con-
tents exiting through the femoral ring. (Image contributed by
Ms. Kristin Yang.) A

Diagnosis
Marking by the patient of painful sites on a body silhouette dia-
gram can be an informative first step. Involvement of specific
muscles will often give characteristic patterns. Patients typically
describe the pain as aggravated by specific movement or activ-
ity and relieved by certain positions. Cold, damp exposure gener-
ally worsens the pain. Pressure on a trigger point causes pain and
produces effects on a target area or referral zone. This specific and
reproducible area of referral rarely coincides with dermatologic or
neuronal distribution and is the feature that differentiates myo-
fascial pain syndromes from fibromyalgia (Lavelle, 2007).
Muscle examination may be completed by flat palpation,
pincer palpation, or deep palpation depending on muscle loca-
tion. Flat palpation uses fingertips to roll over superficial mus-
cles, which are only accessible at the surface (Fig. 11-11). This
technique is commonly used to assess the anterior abdominal
wall muscles. In those muscles with greater accessibility, pin-
cer palpation grasps the muscle belly between the thumb and
fingers. With any of the palpation techniques, spot tenderness
and taut muscle bands can often be appreciated in those with
myofascial pain syndrome. Classically, the involved muscle dis-
plays weakness and restricted stretch. Additionally, TrP pres-
sure may also elicit a local muscle twitch response or reproduce
a patient’s referred pain or both.

Muscle Groups B
Anterior Abdominal Wall Trigger Points. The mus- FIGURE 11-11 Techniques for trigger point palpation. A. With
cles of the rectus abdominis, the obliques, and transversus flat palpation, fingertips stroke across the muscle surface. B. With
abdominis muscles may all develop TrPs that lead to chronic pincer palpation. The muscle is grasped and palpation for trigger
pain. Associated somatovisceral pelvic symptoms from these points is completed as the muscle slips through the fingers.
 326 Benign General Gynecology

frequently involve its lateral attach-

ment to the anterior iliac crest, and
pain usually refers to the pubic bone.
SECTION 1

Pelvic Muscle Trigger Points.

After examination of the anterior
abdominal wall, muscles of the pel-
vis should be evaluated. Following
careful inspection of the external
genitalia, vaginal examination should
proceed slowly and cautiously with
the index finger only and initially
without a palpating abdominal hand.
Muscles within the pelvis include
the levator ani, coccygeus, obturator
internus, and deep transverse peri-
FIGURE 11-12 Pattern of referred pain (red shading in the left image) created by trigger
neal and piriformis muscles. These points in the levator ani and coccygeus muscles (right image). (Images contributed by
are assessed for painful spasm or trig- Ms. Marie Sena.)
ger points (see Fig. 11-6) (Vercellini,
2009). Trigger points involving these ally clinical and based on findings during specific orthopedic
muscles and anal sphincter muscles are frequently associated joint manipulation tests. These are used to recreate or provoke
with poorly localized pain that may be described as involving the pain. Treatment includes physical therapy, exercise, and
the coccyx, hip, or back (Figs. 11-12 and 11-13). Dyspareunia analgesics typically used for CPP, as described earlier (p. 314)
is common. (Vermani, 2010; Vleeming, 2008).
Pain stemming from TrPs involving the levator ani muscles
has had a variety of names including levator ani spasm syndrome
and coccydynia. Currently, levator ani syndrome is the preferred NEUROLOGIC ETIOLOGIES
term. Coccydynia is reserved for coccygeal pain originating
from skeletal trauma to the coccyx. Nerve compression can lead to chronic pelvic pain and may
involve nerves of the anterior abdominal wall or those within
Treatment the pelvis.
The goal of treatment is inactivation of trigger points,
which then allows stretching and release of taut muscle
bands. Therapies are varied and include, among others: TrP
■ Anterior Abdominal Wall Nerve
release maneuvers, biofeedback, TrP dry needling or injec-
Entrapment Syndromes
tion, and local heat. Pharmacologic agents such as NSAIDs, As discussed, anterior abdominal wall pain is frequently mis-
other analgesics, muscle relaxants, or tranquilizers are also taken for visceral pain. Common neurologic causes include
employed. entrapment of the anterior cutaneous branches of the intercostal

■ Peripartum Pelvic Pain

Syndrome
Also known as pelvic girdle pain, this condi-
tion is characterized by persistent pain that
begins during pregnancy or immediately post-
partum. Pain is prominent around the sacro-
iliac joints and symphysis. It is thought to be
related to injury or inflammation of the liga-
ments in the pelvis and/or lower spine. Muscle
weakness, postural adjustments of pregnancy,
and hormonal changes, as well as the weight
of the fetus and gravid uterus, are all poten-
tial contributing factors (Mens, 1996). Pelvic
girdle pain is common. Significant pain is
estimated to afflict approximately 20 percent
of pregnant women and 7 percent of those FIGURE 11-13 An extensive pattern of referred pain (red shading in the left
during the 3 months following delivery image) can be created by trigger points in the obturator internus muscle (right
(Albert, 2002; Wu, 2004). Diagnosis is usu- image). (Images contributed by Ms. Marie Sena.)
 Pelvic Pain 327

nerves or compression of branches of the ilioinguinal, iliohy- Diagnosis and Treatment

pogastric, genitofemoral, and lateral femoral cutaneous nerves Criteria for diagnosing nerve entrapment are clinical and
(Greenbaum, 1994). include: (1) pain aggravated by patient movement or light skin

CHAPTER 11
pinching over the affected area and (2) pain improvement fol-
Pathophysiology lowing local anesthetic injection. In general, electromyography
Peripheral nerves can be compressed either within narrow ana- is not useful because it lacks adequate sensitivity (Knockaert,
tomic canals or rings or beneath tight ligaments, fibrous bands, 1996).
or sutures. Thus, common sites of compression for a given nerve In most cases, pain will improve with local injection of anes-
are often predictable based on their anatomy. For example, each thetic agents with or without corticosteroids. One- or 2-percent
anterior cutaneous branch of an intercostal nerve traverses ante- lidocaine and a 40-mg/mL concentration of triamcinolone can
riorly through the rectus abdominis muscle. Each branch and be combined in a 1:1 ratio. Less than half a milliliter is injected
its corresponding vessels travels through a fibrous ring found at each pain site. Additional treatments may include oral
within the lateral aspect of rectus abdominis muscle (Fig. 11-14). analgesics, biofeedback, and gabapentin. If conservative options
On crossing the anterior rectus sheath, each branch divides fail to bring sufficient relief, neurolysis with injection of 5- to
and then courses within the subcutaneous tissues. Fat surround- 6-percent absolute alcohol or phenol or surgical neurectomy
ing the neurovascular bundle appears to pad the enclosed struc- may be required (Madura, 2005; Suleiman, 2001).
tures within the fibrous ring (Srinivasan, 2002). However, if
this bundle receives excessive intra- or extraabdominal pressure, ■ Pudendal Neuralgia
compression of the bundle against the fibrous ring can cause
nerve ischemia and pain (Applegate, 1997). Pathophysiology
Alternatively, nerve entrapment, injury, or neuroma forma- Neuralgia is sharp, severe, shooting pain that follows the path
tion may involve branches of the ilioinguinal, iliohypogastric, of the involved nerve. Nerve entrapment of the pudendal nerve
lateral femoral cutaneous, or genitofemoral nerves (Chap. 40, may cause this type of pain in the perineum. Pudendal neural-
p. 983). Involvement may follow inguinal hernia repair, low gia is rare, usually develops after age 30, and is characterized
transverse abdominal incisions, and lower abdominal laparo- by pain in the sensory distribution of the pudendal nerve. The
scopic trocar placement. Hypoesthesia is the more common three branches of this nerve are the perineal nerve, the inferior
finding with these injuries, but pain may variably develop rectal nerve, and the dorsal nerve to the clitoris (Fig. 38-28,
within months of surgery or after several years. p. 944). Thus, pain can involve the vagina, vulva, mons vene-
ris, clitoris, labia, perineum, buttocks, inner leg, or anorectal
areas and is frequently usually unilateral. In affected individu-
Anterior rectus sheath als, allodynia and hyperesthesia may be extreme to the point of
disability. The pain is frequently aggravated by sitting, relieved
Fibrous web Rectus muscle
by standing or sitting on a toilet seat, and may increase during
the day.
In addition to an extensive sensory distribution, the puden-
dal nerve supplies motor innervation to the external anal sphinc-
ter muscle and to much of the pelvic diaphragm, including the
levator ani (Stav, 2009). Disturbance of the pudendal nerve can
create loss of motor function in the external anal sphincter and
Fibrous Anchoring thereby, fecal incontinence. In one study of patients evaluated
band tissue for fecal incontinence, 56 percent demonstrated a pudendal
neuropathy. In 67 percent of these patients, the neuropathy
was unilateral (Gooneratne, 2007). Fecal incontinence is more
Nerve
fully discussed in Chapter 25 (p. 659).

Diagnosis and Treatment

The diagnosis of pudendal neuralgia is clinical, and no one test
or combination of tests is pathognomonic for this condition.
Intraabdominal pressure That said, clinical suspicion may be supported by objective test-
ing. This may include neurophysiologic testing such as puden-
dal nerve motor latency and electromyography (EMG), both
Posterior rectus sheath Fat pad described in Chapter 25 (p. 668). Rarely, CT or MR imag-
ing may be informative, although these may be performed to
FIGURE 11-14 Drawing displays nerve entrapment of the ante-
exclude other pathology.
rior cutaneous branches of one of the intercostal nerves. The
nerve is compressed as it traverses the rectus abdominis muscle Treatment may involve physical therapy; behavioral
within a fibrous sheath. (Redrawn from Greenbaum, 1994, with modification; medications such as gabapentin or tricyclic
permission.) antidepressants; pudendal nerve blockade, with or without
 328 Benign General Gynecology

corticosteroids; and surgical nerve decompression. Lastly, Ambrosetti P, Grossholz M, Becker C, et al: Computed tomography in acute
left colonic diverticulitis. Br J Surg 84:532, 1997
pudendal nerve stimulation has demonstrated beneficial American College of Obstetricians and Gynecologists: Adult manifesta-
effects on pelvic floor functional impairments and pain tions of childhood sexual abuse. Committee Opinion No. 498, August
(Carmel, 2010; Spinelli, 2005). However, limited data exist 2011
SECTION 1

American College of Obstetricians and Gynecologists: Chronic pelvic pain.

regarding this modality. Practice Bulletin No. 51, March 2004, Reaffirmed May 2008
American College of Obstetricians and Gynecologists: Hysterectomy, abdom-
inal or vaginal for chronic pelvic pain. Criteria Set No. 29, November
■ Piriformis Syndrome 1997
American Fertility Society: The American Fertility Society classifications of
Pathophysiology adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal
Compression of the sciatic nerve by the piriformis muscle may ligation, tubal pregnancies, mullerian anomalies and intrauterine adhesions.
Fertil Steril 49:944, 1988
lead to buttock or low back pain in the distribution of the sci- American Society for Reproductive Medicine, Society of Reproductive
atic nerve (Broadhurst, 2004; Fishman, 2002). This is termed Surgeons: Pathogenesis, consequences, and control of peritoneal adhesions
the piriformis syndrome. Proposed mechanisms for compression in gynecologic surgery. Fertil Steril 90(5 Suppl):S144, 2008
Andreotti RF, Lee SI, Choy G, et al: ACR appropriateness criteria on acute
include contracture or spasm of the piriformis muscle from pelvic pain in the reproductive age group. JACR J Am Coll Radiol 6(4):235,
trauma, overuse and muscle hypertrophy, and congenital varia- 2009
tions in which the sciatic nerve or its divisions pass through this Angle RH, Ackerman SJ, Irshad A: Practical imaging of acute pelvic pain in
premenopausal women. Contemp Diagn Radiol 33(1):1, 2010
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Despite being first described more than 60 years ago, this ing to abdominal cutaneous nerve entrapment syndrome. J Am Board Fam
condition remains controversial regarding its existence as a true Pract 10:329, 1997
Atkinson W, Lockhart S, Whorwell PJ, et al: Altered 5-hydroxytryptamine
clinical entity. That said, Fishman and associates (2002) esti- signaling in patients with constipation- and diarrhea-predominant irritable
mate the piriformis syndrome to be responsible for 6 to 8 per- bowel syndrome. Gastroenterology 130(1):34, 2006
cent of cases of low back pain and sciatica in the United States Bachmann GA, Phillips NA: Sexual dysfunction. In Steege JF, Metzger DA,
Levy BS (eds): Chronic Pelvic Pain: An Integrated Approach. Philadelphia,
each year. WB Saunders, 1998, p 77
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Diagnosis and Treatment ment. Obstet Gynecol Clin North Am 20:719, 1993
Baker PK: Musculoskeletal problems. In Steege JF, Metzger DA, Levy BS (eds):
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tocks, with or without radiation into the posterior thigh. Pain 1998, p 232
Balbi C, Musone R, Menditto A, et al: Influence of menstrual factors and
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mon but variable association and has been demonstrated in 13 Baldaszti E, Wimmer-Puchinger B, Loschke K: Acceptability of the long-term
contraceptive levonorgestrel-releasing intrauterine system (Mirena): a 3-year
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on findings during specific orthopedic joint manipulation globulin, dysmenorrhea, and premenstrual symptoms. Obstet Gynecol
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a swollen or enlarged piriformis muscle or anatomic variation sifications. J Urol 163:888, 2000
Beard RW, Kennedy RG, Gangar KF, et al: Bilateral oophorectomy and hys-
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Surgery is reserved for refractory cases. sound in the diagnosis of müllerian duct anomalies and concordance with
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