Pelvic Pain

There are many causes of pain within the pelvis or abdomen and it can often be very difficult to unravel what is at the root of the pain.

Many women have concern that there is an underlying serious cause which may affect their fertility or may even signify something more serious, such as cancer.

If severe it can affect quality of life and be disabling.  

Uterine causes

• Adenomyosis.  
  This is a common cause of uterine pain.  This is where lining cells from the uterus become embedded within the muscle causing enlargement and profound tenderness.  
  
  Over the months and years, the uterus becomes increasingly “boggy”, tender and enlarged.  Pressure on this causes excruciating pain.  Pain is most severe during period times and during intercourse.  
  
  
• Fibroids.
  Fibroids are usually painless, however, if they enlarge rapidly leading to inadequate blood supply, then they can become painful and infected. This can be extremely painful and can last for sometime and result in an acute hospital admission.  Occasionally it will resolve on its own and settle down.
  
  
• Pregnancy.
  
  • Uterine pregnancy – early miscarriage.
    As the pregnancy progresses the uterus cramps and the pregnancy is usually expelled.
    
    
  • Non-uterine pregnancy (ectopic pregnancy).
    This is where the pregnancy lies in the tube or peritoneal cavity and causes swelling, bleeding and pain in that area.  This may settle on its own as the pregnancy dies away, but usually will require a laparoscopy and treatment under general anaesthetic.

 Ovarian causes

• Ovarian Cysts.
  Enlargement of the ovaries due to cysts will enlarge the capsule of the ovary resulting in stretching and severe pain.  Occasionally if the cyst ruptures and the contents of the fluid spill into the peritoneum this will result in severe pain, similar to mild appendicitis, as this irritates the peritoneum.  This is usually self-limiting but can be severe enough to warrant hospital admission.  
  
  Severe polycystic ovaries with sudden enlargement can be extremely painful.
  


• Cyst Torsion.
  This means that an enlarged cyst within the ovary twists on itself, resulting in cutting off of blood supply.  This is excruciatingly painful and will usually require surgical treatment in hospital.  Occasionally it settles if it is mobile and untwists temporarily but nearly always it twists back on itself and the pain recurs.
  


• Bleeding into ovarian cysts.
  This can cause considerable pain and should be investigated and treated much in the same way as cyst torsion and endometriosis.
  


• Endometriosis.
  This is a condition where lining cells from the uterus are deposited on the ovary, surface of the uterus or peritoneum tubes and other organs within the pelvis.  Each month these cells behave as if they are still within the lining of the uterus, build up and shed as if they were in a normal menstrual pattern.  The blood of course is unable to escape and causes severe irritation on the areas where it is attached.  This becomes progressively worse and classically tends to worsen during the menstrual cycle when blood loss and irritation is at its peak.
  
  With time, inflammation worsens and this can cause scarring and adhesions within the pelvis, blocking the fallopian tubes and infertility.  
  
  Endometriomas are large collections within the body of the ovary, which are the result of deposits of these cells which monthly bleed and shed but are unable to escape and therefore remain within the ovary itself.  This can cause enlargement, irritation and severe pain as well as interference with ovulation.

 

Bowel causes

The small bowel lies in the centre of the abdomen and the large bowel loops around the outside ascending on the right, crossing over the abdomen and descending on the left side.  

Bowel activity can be affected by the menstrual cycle with delayed activity coming up to the period with bloating, stretching of the bowel wall and pain.  The bowel lies very close to the female pelvic organs and therefore this pain can often be confused with a uterine or ovarian cause of pain.  

Often this pattern of swelling and discomfort can be labelled as “irritable bowel” but in reality it is simply exaggeration of the normal pattern of bowel activity.  Alterations in diet and medication to improve forward movement of the bowel can help.  

• Inflammatory Bowel Disease.
  Colitis and Crohn's disease are the most well known forms of inflammatory bowel disease.  These can be excruciatingly painful and either present constantly or intermittent.  The symptoms may be mild or severe and are often associated with change in bowel habit, passage of mucus, blood and weight loss in a more extreme form.  
  
  Pain is usually localised above the pelvis either in the central abdomen if it is related to the small bowel and in either the right or left side of the abdomen if it is associated with large bowel.  
  
  
                 

• Fallopian Tubes.
  Infection of these tubes is called salpingitis. This usually occurs during sexual intercourse, where infection can cause severe inflammation of the fallopian tubes with swelling, collections of pus and abscesses and ultimately damage to the fallopian tube.  
  
  If severe, there will be an accompanying high temperature and the patient will be very toxic and unwell.  If it is chronic and less severe there is often no temperature but the pain is more or less constant and worsened by intercourse or any form of pressure on the area.  This is more serious in the long term, in many ways, because if untreated due to not being diagnosed properly, it can result in blocked tubes and infertility, where as, an acute infection if treated quickly is less likely to do this.

 

Cervical causes

Inflammation of the cervix.
The cervix is very densely packed with nerve endings and when the area becomes inflamed or infected the nerves become hypersensitive.  This results in relayed pain signals into the pelvic organs and can be extremely painful.  It will often be highlighted at intercourse or if the cervix is touched such as during an examination by your doctor or cervical smear.

 

Bladder, Ureter and Kidney causes.

Bladder infections.
Inflammation of the urine collecting system including the kidneys and ureter are very common and can cause severe symptoms.  They may result in a high temperature, frequent trips to pass urine, pain on passing urine both in the urethra and up into the left loins.  

In its more severe form, it may be associated with a high temperature and toxicity.  If there is a pelvic infection, it can be difficult to differentiate between a urinary infection and infection within the pelvis which may exist side by side.

 

Peritoneal causes

The peritoneum is the lining of the pelvis and is very sensitive to inflammation such as with pelvic infection, ovarian cysts, bowel disease and blood within the pelvis.  

Infections such as with appendicitis or ruptured cysts can result in severe symptoms and what is called an “acute abdomen”, where the patient is in severe pain, hospitalisation will be required.

The abdomen is rigid and the bowels may also be affected.  If left untreated this may result in peritonitis or a wide spread infection of the peritoneal lining, which can be life threatening.  

In a less severe form, however, it may simply cause pain and settle down on its own or depending on the cause it may be easily treatable with low-grade antibiotics as an outpatient.  

Diagnosis of causes of pain

History and examination.
The majority of causes of pain will be clear from the history and initial examination.  Often your doctor will back this up with some simple tests including;

• Urine sample, to check for infection and blood cells.
• Blood tests, to check for infection and signs of peritoneal irritation.
• Ultrasound scan, to look for fibroids, adenomyosis, endometriosis, ovarian cysts, kidney problems and pregnancy related problems
• Laparoscopy This is where a telescope is inserted into the abdomen via the umbilicus and the pelvic organs are inspected by keyhole surgery. The abdominal cavity is filled with carbon dioxide to enable a clear view of the whole area and photographs and biopsies and samples for culture and sensitivity can be taken at the same time.
  
  Laparoscopy is particularly useful for conditions such as endometriosis, peritoneal problems or infection where scans and blood tests are not clear.  
  
  Sometimes, other conditions can be diagnosed hand in hand with the initial problem and this would then need referral onto different specialists.  
  
  Simple treatments, such as removal of ovarian cysts, drainage of abscess, ectopic pregnancy and laser to endometriosis can all be done via this keyhole approach.

 

Treatments

Pelvic pain
This, of course, involves treatment of the cause, including antibiotics for infection, removal of cysts, fibroids, laser to endometriosis and drainage of abscesses as indicated.

Where the problem is severe a prolonged hospital stay (more than 1-2 days) may be needed but many of these conditions can be treated with discharge home on the day or next day.