Pelvic Pain
Many GYN conditions can cause pelvic pain, the most common being endometriosis, adenomyosis, fibroids, ovarian masses, scar tissue from infection and prior surgery, and others. Pelvic pain can also have a cause that is not directly related to the GYN system. The most common nonGYN cause of pelvic pain is interstitial cystitis, a chronic inflammatory process of the bladder, that can mimic pelvic pain. Irritable bowel syndrome can also cause pelvic pain, as can other GI problems such as diverticular disease. Although GYN causes, interstitial cystitis, and irritable bowel syndrome represent a large number of patients with pelvic pain, there is a fourth category of patients with pelvic pain that has no clinical explanation. This includes patients with a history of sexual abuse, pelvic trauma, and rarely those patients with the uterus causing pain but with no abnormality to the uterus identified. The following is a very brief description of the diagnosis and treatment regimens for patients with pelvic pain.
Diagnosis
- History and physical exam is important to establish possible causes. Patients with a prior history of endometriosis, fibroids, prior surgery causing scar tissue, prior infection causing scarring and inflammation, or history of psychiatric trauma or sexual abuse need to be identified.
- Imaging studies always include an ultrasound evaluation of the uterus, tubes, and ovaries to evaluate for fibroids, pelvic masses such as ovarian cysts or endometriomas, fluid collections or infection. MRI is necessary to evaluate for adenomyosis for those patients thought to have this condition by clinical evaluation. MRI is the only study that will detect adenomyosis.
- Diagnositic laparoscopy is necessary for those patients in whom imaging studies have not identified a specific cause. This is important, since many patients with early stage endometriosis or scar tissue will not have these abnormalities detected on ultrasound, MRI, or CT scan.
- Cystoscopy with hydrodistension (filling of the bladder with water) has some use for the diagnosis of interstitial cystitis. Interstitial cystitis, or IC, can also be diagnosed clinically with questionares on line that are useful for making this diagnosis.
- Colonscopy is sometimes used to rule in, or prove that irritable bowel syndrome (IBS) is the cause of pelvic pain. For those patients thought to have IBS by clinical evaluation, colonscopy may sometimes be used to ensure that there is not another cause of the bowel symptoms and pelvic pain, such as polyps, diverticular disease, etc. IBS is a diagnosis of exclusion, meaning that to make the diagnosis patients must have the clinical symptoms of IBS and not have another GI cause for pain, such as diverticular disease, that can be detected by colonoscopy.
Treatment
Medical therapy can sometimes be used for management for conditions causing pain. Lupron for endometriosis, birth control pills for endometriosis and fibroids are examples. Surgery is often required to treat ‘organic” causes of pain, ie causes due to overgrowth or abnormalities of the body such as fibroids and endometriosis. Myomectomy or hysterectomy can be used for fibroids, resection for removal of endometriosis, enterolysis for scar tissue, cystectomy or removal of the ovary for pelvic masses, and other procedures as required to remove the causes of pain. Please refer to spedific topics for the diagnosis and treatment of each of these conditions.