Surgical Indications for Chronic Pelvic Pain Case File

Surgical Indications for Chronic Pelvic Pain Case File

Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG

Case 34

A 33-year-old G4P3013 woman, with a recent last menstrual period, presents to the office complaining of intermittent, lower abdominal pain for 2 years. During the last 6 months, she reports pain with her

menstrual cycle and occasional pain during sexual intercourse. When she is not on her menses, she has intermittent pain four to five times a week. She denies any urinary or bowel complaints associated with the pain. For the last 12 months she has been taking oral contraceptives daily, prescribed by her last OB/GYN physician. In addition, she is taking an NSAID two to three times a day for the last 4 months, with minimal relief of her pain. The pain lasts for 1 to 2 hours and is not affected by changes in positions.

Other significant history consists of a mother with endometriosis, diagnosed in her 30s and three prior surgeries, two cesarean sections, and a bilateral tubal ligation. She denies having any medical problems.

On examination, her vitals are temperature, 98.9°F; BP, 110/70 mm Hg; pulse, 90 beats/min. Pertinent findings include abdominal examination, without rebound or guarding; no distention or fluid wave, no tenderness to deep palpation. Pelvic examination reveals normal external genitalia, no cervical motion tenderness, no uterine or left adnexal tenderness, with only mild right adnexal tenderness. An ultrasound of the pelvis is normal.

➤ What is the most likely diagnosis?

➤ What is your next step?

ANSWERS TO CASE 34:

Surgical Indications for Chronic Pelvic Pain

Summary: A 33-year-old multiparous woman presents with chronic pelvic pain, dysmenorrhea, dyspareunia, family history of endometriosis, and no specific etiology of pain clinically or with ultrasound.

➤ Most likely diagnosis: Chronic pelvic pain (possibly endometriosis).

➤ Next step: Laparoscopy.

ANALYSIS

Objectives

1. Know some common differential diagnoses for chronic pelvic pain.
2. Recognize women at risk for developing chronic pelvic pain.
3. Be able to understand that surgical therapy for chronic pelvic pain is indicated once medical management has failed.
4. Identify surgical options available in treating chronic pelvic pain.

Considerations

This patient has a long history of pelvic pain. She has been taking medications, for a minimum of 4 months and a maximum of 1 year, and still experiences pain. She has a pertinent negative history for depression and domestic/sexual abuse. A positive history for either can increase the risk of developing pelvic pain. This persistent pain can also increase the chance of her losing time from work.1 This patient has both cyclic and noncyclic pain. She has pelvic pain, for greater than 6 months duration, and failed medical therapy. She has an abnormal pelvic examination that shows mild right-sided tenderness, with an ultrasound that reveals normal pelvic organs. Before surgical therapy is offered, sending her to a gastroenterologist should be considered. Studies reveal that irritable bowel syndrome is the most common nongynecologic etiology for chronic pelvic pain.2 This patient should be offered a laparoscopy as the next step. This will enable a diagnosis to be established. In the presence of an abnormal pelvic examination, studies reveal that up to 80% may have pelvic pathology on laparoscopy.3 Kresch et al. found that 83% of women with pelvic pain had pathologic findings at laparoscopy.4 Depending on the diagnosis, treatment can also be offered. In this patient, diagnoses can be multiple. Endometriosis, associated with cyclic pain, is a genetically linked disease and her risk is increased, since her mother also had it. Taking into account that her pain is also noncyclic, one has to rule out other gynecologic causes, such as pelvic adhesions. Her history of three prior surgeries increases her risk for adhesive disease. Since she denies any urinary urgency, or frequency, interstitial cystitis is unlikely. Procedures for midline pain should not be offered in this patient because her pain is not just limited to the midline of the pelvis. If after treatment with laparoscopy and other indicated procedures, via the laparoscope, the patient still has pain, a hysterectomy can be offered as a last resort. Counseling the patient preoperatively is important, remembering that persistent pelvic pain can exist after a hysterectomy.5,6

APPROACH TO

Chronic Pelvic Pain

DEFINITIONS

PAIN: An unpleasant sensory or emotional experience associated with actual or potential tissue damage.

CHRONIC PELVIC PAIN: Pain in the lower abdomen for greater than 6 months’ duration.

ENDOMETRIOSIS: The presence and growth of glands and stroma identical to the lining of the uterus in an aberrant location.

PRIMARY DYSMENORRHEA: Painful, crampy sensation in the lower abdomen that occurs prior to, or during, menses and is not associated with pelvic pathology.

SECONDARY DYSMENORRHEA: Painful, crampy sensation in the lower abdomen that occurs prior to, or during, menses and occurs with pelvic pathology.

PRESACRAL NEURECTOMY: A surgical procedure that consists of excision of the superior hypogastric plexus (“presacral nerve”).

PELVIC CONGESTION SYNDROME: Vascular engorgement of the uterus and the vessels of the broad ligament which may lead to pelvic pain.

LAPAROSCOPIC UTERINE NERVE ABLATION (LUNA): A surgical procedure that involves transecting the uterosacral ligaments for the relief of pain.

CLINICAL APPROACH

Chronic pelvic pain complaints can be frustrating and challenging to both the physician and the patient. It can have a profound impact on life. It is defined as a noncyclic, lower abdominal pain for greater than 6 months duration, unrelated to pregnancy.2 Pain is subjective and may be somatic or visceral. In somatic sensory nerves, perception of the pain is rapid and well localized. In visceral pain, pain is a result of transmission of impulses along the

Table 34–1 COMMON GYNECOLOGIC DIAGNOSES ASSOCIATED CPP
LEVEL A	LEVEL B	LEVEL C
Endometriosis		Adnexal ovarian cysts
Pelvic congestion syndrome	Adhesions	Dysmenorrhea
Pelvic inflammatory disease	Leiomyomas	Chronic endometritis

Level A evidence: good and consistent scientific evidence of causal relationship to CPP; Level B

evidence: limited and inconsistent scientific evidence showing causal relationship to CPP; Level C

evidence: Causal relationship to CPP per expert opinions

autonomic nervous system that innervates the internal reproductive organs. In general, pelvic pain is poorly localized, and is usually diffuse. The etiologies may be unclear and can range from many disorders, both gynecologic (Table 34–1) and nongynecologic (Table 34–2). An accurate workup is necessary and the appropriate treatment instituted. Treatment is twofold. One is to treat the pain as a diagnosis and the second is to treat the cause of the pain.7 When medical management fails, surgical therapy is the next step.

It is imperative to obtain a thorough history and physical in patients with chronic pelvic pain. Getting the history can be both, diagnostic and therapeutic for the patient. It shows concern for her well-being, in addition to allowing the patient to tell her story. Have the patient characterize the pain. Pertinent questions for the history include

• Duration of pain
• Location of pain
• Commencement of pain
• Is pain associated with menses or bowel habits?
• What positions (ie, sitting, lying, standing) affect the pain?
• Has the pain affected your quality of life?
• Have you lost time from work?
• Have you taken any over-the-counter medicines for the pain?

Table 34–2 COMMON NONGYNECOLOGIC DISORDERS ASSOCIATED WITH CPP
GASTROINTESTINAL (LEVEL A)	GENITOURINARY (LEVEL A)	MUSCULOSKELETAL (LEVEL B)
Irritable bowel syndrome
Constipation	Interstitial cystitis	Muscular strains or sprains
Inflammatory bowel disease	Urinary tract infection	Abdominal wall trigger points

The history will identify risk factors associated with pelvic pain. Obtain additional personal, medical, surgical, family, and social histories. Depression and a history of sexual abuse are predictors of pain severity. The association between domestic/sexual abuse and pelvic pain is significant. Sexual abuse is defined as penetration or other direct contact with the patient’s unclothed genitals.8 Patients with a history of sexual abuse have increasing rates of pelvic pain complaints.

Remember that a routine physical examination is very difficult for a patient with chronic pelvic pain. So, be gentle. Examine the patient supine and in the lithotomy positions. On the abdominal examination, have the patient point with one finger to identify the location of the pain. Inspect for abdominal distention, ascites, masses, and bowel sounds. Palpate lightly and deeply. Note any surgical scars and tenderness on the abdomen. On pelvic examination, inspect the external genitalia for any redness, induration, excoriations, ulcerations, and atrophic changes. Use a cotton Q-tip to evaluate for any tenderness or sensation abnormalities at the vestibule. Perform a speculum examination and fully visualize the entire vagina and cervix for any lesions. Obtain a Pap smear and cervical cultures, if necessary. Begin the manual portion of the examination with only one index finger. Palpate both the anterior and vaginal wall to elicit any pain or tenderness. Compress the uterus to evaluate for tenderness. A fixed uterus may indicate scarring in the pelvis. Palpate the rectovaginal septum last during the rectovaginal examination.

Diagnostic tests that may be ordered are based on the history and physical of the patient. All patients should not receive the same diagnostic workup. Establishing a differential diagnosis is important prior to instituting any treatment.

There are different levels of evidence in the medical literature associated with etiologies of chronic pelvic pain.7

• Level A: Good and consistent scientific evidence of causal relationship to chronic pelvic pain.
• Level B: Limited or inconsistent scientific evidence of causal relationship to chronic pelvic pain.
• Level C: Causal relationship to chronic pelvic pain based on expert opinions.

Treatment for chronic pelvic pain consists of medical and surgical options. NSAIDs and oral contraceptive pills have been the mainstay of treatment.5 Tricyclic antidepressants have also been used with success. After a patient has been on medicines and continues to experience pain, it is time to offer surgical intervention. The patient’s desire for future fertility will play a role in the type of intervention available.

Laparoscopy should be offered first. It is a simple, cost-efficient, diagnostic tool that can be performed on an outpatient basis. It can be used to establish a diagnosis, treat, or even monitor the course of a specific disease. If the patient has endometriosis, ablative or excisional therapy can be offered through the laparoscope. Adhesiolysis via the laparoscope is another alternative, if the patient has extensive pelvic adhesions.

Complications of laparoscopy include hemorrhage, bowel injuries, uterine perforation, vascular injuries, and infection. Reports of complications in the literature range from 0.2 out of 1000 to 4.6 out of 1000.9 Cardiac arrest can occur at the time of induction of anesthesia, rapid or excessive insufflation of gas, or extreme Trendelenburg positions.9

In patients with midline pain, such as dysmenorrhea, and failed medical management, a presacral neurectomy or a LUNA procedure can be offered. Presacral neurectomy has become less popular over the years. Removing the “presacral nerve” or the superior hypogastric plexus has been shown to relieve pain in 60% to 80% of patients.10 The operation can be difficult and lengthy. Acute complications include laceration of the middle sacral vein, hemorrhage, hypotension, and small bowel obstruction.

The LUNA is another alternative in relieving midline pain in women desiring future fertility. It was first described in 1899.11 Through the laparoscope, the uterus is stretched upward and the uterosacral ligaments are coagulated and transected at their insertion into the posterior cervix. The goal is to interrupt the afferent-efferent sympathetic and parasympathetic neuronal pathways.11 Be careful to identify the ureters to avoid injury. With the uterosacral ligaments supporting the uterus, a side effect of this procedure can be uterine prolapse.

Presacral neurectomy and LUNA, done in conjunction, do not offer any additional pain relief.12

For women with persistent pelvic pain who completed of their childbearing and failed medical management, a hysterectomy should be offered. Chronic pelvic pain is the indication for 10% of hysterectomies reviewed.13 Before offering this final surgical alternative, it is imperative that nongynecologic etiologies for pain have been ruled out. Stovall et al. showed that, out of 99 women with pelvic pain followed 12 months after a hysterectomy (with or without a bilateral salpingo-oophorectomy [BOS]), 22% still had persistent pelvic pain.5 Hillis et al. showed results consistent with the latter, up to 24 to 40% with persistent pain, 1 year after surgery.6 If a treatable condition is found and treated before proceeding with surgery, it is possible that the patient’s pain may resolve. Once a hysterectomy is decided, the associated morbidity should be discussed with the patient. The risk of bleeding; infection; and damage to bowel, bladder, or vascular structures should be included in the consent form. Thrombotic complications are increased after a hysterectomy. There is an increase in both infectious and febrile morbidity after a hysterectomy. Risk factors for febrile morbidity have been documented in the literature secondary to a hysterectomy.14 Peipert et al. showed that febrile morbidity was 14% in over 680 charts reviewed. Morbidity can be decreased by the route of hysterectomy. Vaginal cases have less febrile morbidity than abdominal cases. Administering prophylactic antibiotics, 1 hour prior to starting the surgery, decreases febrile risk. In addition, meticulous surgical technique, by minimizing blood loss, also lessens febrile morbidity. With febrile morbidity, there are longer hospital stays and increasing costs to the patient.14 Reports show that after a hysterectomy, symptoms, and quality of life can be improved. The Women’s Health Study, of 1299 women, showed improvement in pain and overall participation in social functions after receiving a hysterectomy.15 After 1 year, 87% of women reported improvement and after 2 years 88% improved.

Hysterectomy is the final surgical option offered for treatment of chronic pelvic pain. It may give long-term improvement of symptoms.

Comprehension Questions

34.1 A 19-year-old G0P0 woman complains of pain with her menses that started at menarche. Her pain is relieved with monthly NSAIDs. Her pelvic examination and pelvic ultrasound are normal. What is her most likely diagnosis?

A. Primary dysmenorrhea

B. Secondary dysmenorrhea

C. Pelvic inflammatory disease

D. Ruptured right corpus luteal cyst

34.2 A 45-year-old G5P5 woman has a 5-year history of chronic pelvic pain secondary to endometriosis. Her surgical history consists of two laparoscopic laser treatments for her endometriosis. She has been on continuous oral contraceptives and NSAIDs for the last 6 months with continued pain. What is the next step?

A. Total abdominal hysterectomy (TAH) with a bilateral salpingooophorectomy (BOS)

B. Repeat laser therapy via the laparoscope

C. Six more months of medical therapy

D. Partial hysterectomy

34.3 A 35-year-old G2P2, thin, woman with a recent last menstrual period received a laparoscopy for persistent pelvic pain. At the initiation of the surgery, she became suddenly hypotensive, with a BP of 70/30 mm Hg and a pulse of 125 beats/min. What is the most likely surgical complication?

A. Cardiac arrest

B. Vascular injury

C. Ureteral injury

D. Bowel laceration

34.4 A 40-year-old G0P0 woman had a LUNA procedure for dysmenorrhea. On postoperative day 1, her H/H was 10.5/32 and a creatinine 1.0. On postoperative day 2, her hemoglobin level was unchanged, but her creatinine increased to 1.8 and she now has back pain. What is the most likely complication of this surgery?

A. Bladder laceration

B. Bowel injury

C. Ureteral injury

D. Kidney puncture

ANSWERS

34.1 A. Primary dysmenorrhea is the pain before or during menses with no organic cause that usually begins at menarche. Her normal pelvic ultrasound is absent of any pelvic pathology.

34.2 A. This patient has failed medical therapy and previous conservative surgery via the laparoscope. With persistent pelvic pain secondary to her endometriosis, she requires definitive therapy, a TAH/BSO.

34.3 B. This patient has a vascular injury secondary to insertion of the Veress needle. As a result of acute hemorrhage, there is sudden hypotension and tachycardia. The laparoscopy is immediately converted to a laparotomy for repair of the injured vessel.

34.4 C. The ureter has been compromised in this patient. Early diagnosis is the key. Her rising creatinine is a clue.

Clinical Pearls

See Table 1-2 for definition of level of evidence and strength of recommendation

➤ Chronic pelvic pain can be caused by gynecologic or nongynecologic disorders.

➤ Obtaining a detailed history and physical examination is the key in establishing a diagnosis for pelvic pain (Level B).

➤ After medical therapy has failed, a laparoscopy is offered in order to establish a diagnosis (Level B).

➤ Surgical therapy is directed based on the patient’s desires for future fertility (Level B).

➤ Presacral neurectomy and the LUNA procedures are performed in patients with midline or central pelvic pain (Level A).

➤ Ten percent of all hysterectomies are performed for chronic pelvic pain.

REFERENCES

1. Mathias SD, Kuppermann M, Liberman RF, Lipschutz AC, Steege JF. Chronic pelvic pain: prevalance, health-related quality of life, and economic correlates. Obstet Gynecol. 1996;87:321-327. 

2. Zondervan KT, Yudkin PL, Vessey MP, et al. Chronic pelvic pain in the community— symptoms, investigations, and diagnoses. Am J Obstet Gynecol. 2001; 184:1149-1155. 

3. Cunanan RG Jr, Courey NG, Lippes J. Laparoscopic findings in patients with pelvic pain. Am J Obstet Gynecol. 1983;146(5):589-591. 

4. Kresch AJ, Seifer DB, Sachs LB, Barraes I. Laparoscopy in 100 women with chronic pelvic pain. Obstet Gynecol. 1984;64(5):672-674. 

5. Stovall TG, Ling FW, Crawford DA. Hysterectomy for chronic pelvic pain of presumed uterine etiology. Obstet Gynecol. 1990;75(4):676-679. 

6. Hillis SD, Marchbanks PA, Peterson HB. The effectiveness of hysterectomy for chronic pelvic pain. Obstet Gynecol. 1995;86:941-945. 

7. Howard FM. Chronic pelvic pain. Obstet Gynecol. 2003;101:594-611. 

8. Jamieson DJ, Steege JF. The association of sexual abuse with pelvic pain complaints in a primary care population. Am J Obstet Gynecol. 1997;177(6):1408- 1412. 

9. Cunanan RG, Coury NG, Lippes J. Complications of laparoscopic tubal sterilization. Obstet Gynecol. 1980;55:501-506. 

10. Lee RB, Stone K, Magelssen D, Belts RP, Benson WL. Presacral neurectomy for chronic pelvic pain. Obstet Gynecol. 1986;68:517-521. 

11. Lichten EM, Bombard J. Surgical therapy of primary dysmenorrhea with laparoscopic uterine nerve ablation. J Reprod Med. 1987;32:37-41. 

12. ACOG Practical Bulletin. Chronic Pelvic Pain. No. 51. 2004:1184-1199. 

13. Carlson KJ, Nichols DH, Schiff I. Indications for hysterectomy. NEJM. 1993;328:856-861. 

14. Peipert JF, Weitzen S, Cruickshank C, Story E, Ethridge D, Lapane K. Risk factors for febrile morbidity after hysterectomy. Obstet Gynecol. 2004;103(1):86-91. 

15. Kjerulff KH, Langenberg PW, Rhodes JC, et al. Effectiveness of hysterectomy. Obstet Gynecol. 2000;95:319-326.

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