Pelvic pain in women of childbearing age is often attributed to the urogenital sphere. Patients suffering from such pain often turn to a gynecologist (5% of gynecological patients) either spontaneously or directed by another physician or surgeon. Often the general practitioner is facing the front lines of this type of symptoms. The key is to differentiate the urgent functional, to provide relief or treatment and direct when necessary to a specialized structure.
How to behave in front of pelvic pain of the woman raises both a diagnostic and therapeutic problem.Clinical examination combined with some simple additional tests, often allows to bring a solution and an etiological specific care differentiating extragynécologiques gynecological pain and acute symptoms of chronic symptoms. The acuteness of the pain sometimes evokes a surgical emergency requiring a rapid response in a surgical environment (gynecological or not). Cyclical pain diagnosed by a simple interrogation have supported.
Chronic pain requires the search for a cause and if possible should lead to an etiological and symptomatic treatment soothing the patient. The causes of pelvic pain of women are covering multiple pathologies of the first trimester of pregnancy, high or low genital infections, cystic masses or pelvic tumor, internal or external endometriosis, urological diseases, digestive, rheumatic and venous .The pain called “psychogenic”, often pelvic in women, should be a diagnosis of exclusion.
The examination and clinical examination often allow driving a diagnostic and effective therapeutic approach.
The examination appreciate the “context” psychological, domestic, familial, socioeconomic, and identifies the personality of the patient. For this, it must be excavated and non-directive to let the woman or the couple, expressing his pain. Are collected obstetric history, gynecological, surgical, medical, and psychiatric.
The characteristics of the present and past menstrual cycles must be specified. The type of pain are carefully studied: topography, radiation, intensity, mode of occurrence, evolution, periodicity, the situation in relation to the menstrual cycle, methods of sedation. Associated symptoms pointing to a gynecological etiology (leukorrhea, menorrhagia, metrorrhagia), digestive (transit disorders, vomiting, rectal bleeding, tenesmus), urinary (burning on urination, urinary frequency, hematuria) rheumatologic (arthralgias, cutaneous signs, overhead signs), vascular (venous insufficiency, arterial disease) or obstetric (sympathetic signs of pregnancy). The existence of contraception, LMP and desire of pregnancy must be completed.
Finally at the end of the interrogation, acute, chronic or cyclicality of pain must be defined. A well-conducted interview is two-thirds of diagnostic path.
Physical examination does not bring as many positive elements of the diagnostic examination.
However, it must be done rigorously in order to extract the data it can provide us before prescribing supplementary examinations to finalize the diagnostic investigation. The physical examination includes an inspection of the abdomen and vulva in search of scars and cutaneous signs.
Abdominal palpation search the site of pain and noted a possible defense that must quickly towards surgical emergencies.
It is the same for shock signs (pulse, blood pressure) sought immediately.
The gynecological examination begins with the laying of the speculum that should not be traumatic so as not to block the patient following the examination on vaginal examination.
Speculum examination clarifies the origin of bleeding, appearance of the cervix mucus, the presence of the son of an IUD, the existence of vaginal discharge, and if necessary perform the same time bacteriological and cytological samples. He looks for signs of infection (discharge and inflammatory appearance), cervical stenosis, prolapse, etc.
The vaginal precise character of the uterus and cervix: the volume, consistency, mobility (possibly painful), the position (anteversion, retroversion mobile or fixed), the opening of the cervix, the presence of a mass painful adnexal or not and flexibility of the vaginal cul-de-sac. It looks painful nodules or induration sitting on the uterus, its uterosacral ligaments or at the rectovaginal septum. A DRE is useful in young virgin when speculum examination and vaginal examination are cons-indicated. It also eliminates rectal pathologies or locate rectal endometriosis.
The clinical examination allows aetiological orientation with good sensitivity and good predictive value. Abnormal physical examination evokes a somatic pathology, unlike its normality does not allow to be reassuring.
To arrive at a diagnosis and appropriate therapeutic management, it is often necessary to rely on the results of additional tests.
As of childbearing three gynecological emergencies are to eliminate ectopic pregnancy (GEU) for the vital risk, adnexal torsion to the risk of ovarian necrosis and pelvic inflammatory disease for functional risk.
The pregnancy test, the white cell count, measurement of C-reactive protein (CRP) and pelvic ultrasound are the key systematic reviews often sufficient to establish most diagnoses of pelvic pain.
The pregnancy test is widely reported regardless used contraception (pill, IUD, implant) even (and especially) for tubal ligation. Only certain virginity eliminates the need pregnancy test. A qualitative test (qualitative beta-HCG) positive enough to declare a state of pregnancy. In case of suspicion of ectopic pregnancy, it is necessary to quantify the beta-HCG levels (quantitative beta-HCG).
Pelvic ultrasound is used to view an intrauterine pregnancy (eliminating the diagnosis of ectopic pregnancy) or an adnexal mass and to study the morphology of the uterus and annexes. The transvaginal route should be systematically preferred to the abdominal unless virginity. This examination does not allow the examination of the gastrointestinal tract (the diagnosis of appendicitis single), but permits research of complications such as effusions (ascites, hemoperitoneum, abscess). Recall that the cystic ovary pictures smaller than 25 mm diameter are physiological (follicles) and intra-uterine gestational sac is visible by vaginal ultrasound when the rate of beta-HCG exceeding 1 000 units.
Vaginal swabs, urine and blood (complete blood count [CBC], CRP) are easily made if unexplained pain in young women.
Laparoscopy is the last stage of the diagnostic process in case of alleged surgical acute pain or in cases of chronic and disabling pain where the etiological investigation has been unsuccessful.
The first question to ask is: “Should we quickly transfer to the nearest emergency service gynecological? “
Any sudden or acute pelvic pain or accompanied a woman in childbearing should refer the woman to the service of gynecological emergencies where the diagnostic and therapeutic management is optimal. We need gynecological emergencies have full technical platform and available 24/24: endovaginal ultrasounds, pregnancy tests, surgical block with laparoscopy.
Gynecological diagnoses are quickly eliminate the GEU, adnexal torsion and pelvic inflammatory disease. Other non-gynecological diagnoses should be mentioned in order to guide appropriate patient: acute appendicitis, pyelonephritis and renal colic (Box 1).
Box 1. What to do before acute pelvic pain
Pregnancy test CRP + + + NFS pelvic ultrasound
Positive pregnancy test + uterus is empty:
– Early intrauterine pregnancy;
– False expelled layer.
Positive pregnancy test + bag intrauterine:
– Developing intra-uterine pregnancy;
– Not false expelled layer.
Negative pregnancy test + adnexal mass:
– Adnexal torsion;
– Hemorrhagic cyst;
– Infectious genital collection.
Negative pregnancy test + without adnexal mass:
– Follicular rupture (mid-cycle);
– Pelvic inflammatory disease (elevated CRP and white blood cells).
There are three types of pelvic pain: acute, chronic and cyclical
Acute pelvic pain the woman evokes three gynecological emergencies: ectopic pregnancy, adnexal torsion and pelvic inflammatory disease.
The USG must be systematically eliminated in any woman of reproductive age regardless of the mode and the observance of contraception.
It typically presents as a localized pelvic pain associated with bleeding.
Physical examination is sometimes a adnexal mass, a notion of delayed menstruation, pregnancy sympathetic signs.
It is the combination of a beta-HCG rate greater than 1000 IU and a vacuum uterus transvaginal ultrasound making the diagnosis. The patient should be managed in a specialized environment for the diagnostic and therapeutic approach whether surgical (laparoscopic most often), medical (methotrexate) or wait. The prognosis is vital for the patient with the risk of cataclysmic hemorrhage emergency justifying the consultation of all women with the association: breakthrough bleeding and / or acute pelvic pain + positive pregnancy test without knowledge of the location of the pregnancy. Diagnosis may be hesitant for up to ten days in the case of majority fortunately taken early diagnosis and load. Differential diagnoses are evolutionary very young intrauterine pregnancy (beta-HCG <1000 IU), intrauterine pregnancy expelled or not scalable. The ultrasound monitoring coupled to beta-HCG levels, which would normally double every 48 hours, allows the diagnosis. The heterotopic pregnancy (association of intrauterine pregnancy with ectopic pregnancy), very rare, is observed mainly in the context of medical assistance to procreation.
The diagnosis and treatment usually require the completion of an emergency laparoscopy allows in one time to confirm the diagnosis and provide treatment.
This review should be done in a gynecological ward with a technical support center operating 24 hours 24.
The existence of an adnexal mass associated with acute pain evokes an adnexal torsion or hemorrhagic ovarian cyst. The situation in the cycle (ovulation), the notion of known ovarian cysts and pelvic ultrasound are used to guide the etiologic diagnosis.
However it is often the emergency laparoscopy indicated for the treatment of adnexal torsion which establishes the diagnosis with certainty.
The treatment is surgical.
When it’s actually a hemorrhagic cyst discovered incidentally during laparoscopy performed for suspected adnexal torsion, treatment is withheld or hemostasis if bleeding persists.
They are evoked when in association with pelvic pain, there are signs of infection (vaginal discharge, fever) or a recent notion of endo-uterine procedure (curettage, hysteroscopy, hysteroscopy, IUD, etc.). The infection may take several clinical forms: endometritis, salpingitis and pelvic inflammatory disease. As often bilateral pelvic pain are sometimes associated leucorrhoea, breakthrough bleeding or fever. The vaginal examination made the diagnosis of endometritis by the pain it causes uterine during mobilization. A impasto vaginal cul-de-sac can be seen in salpingitis. Pelvic inflammatory disease is characterized by a defense or signs of peritonitis.
Fitz-Hugh-Curtis syndrome (perihepatitis chlamydia) can simulate colic.
Biology eliminates pregnancy (negative) and can show leukocytosis and elevated CRP. The research ultrasound signs of intraperitoneal or tubal collections.
Antibiotics broad spectrum (effective against gram-negative bacilli, anaerobic and chlamydia) should be started without delay once made bacteriological samples.
Initially, as the context may be initiated intravenously. Laparoscopy is indicated immediately for tubal collection or peritonitis. It enables the diagnosis, levies and early treatment with abundant peritoneal lavage, surgical drainage in case of peritonitis proven, some associated with intraperitoneal antibiotics.
The pregnancy test is almost systematic in cases of acute pelvic pain in women of childbearing age, especially in order not to miss out on an EP. However intrauterine pregnancies, whether active or not, may be the cause of pelvic pain:
– The spontaneous miscarriage associated painful uterine contractions (colicky) with breakthrough bleeding. The cervix is open and sometimes expelled or being expelled pregnancy.
The combination of a corpus luteum cyst and false expelled spontaneously layer may mistakenly impose for an ectopic pregnancy.
The care in a specialized environment is medical (or abstention Methergin®) or surgery (under general anesthesia aspiration) depending on the context;
– A pregnancy normally developing intra-uterine may cause acute pelvic pain sometimes violent. They are due either to ligament pain and / or uterine contractions. The treatment (rest, natural progesterone, antispasmodic) makes it easy to calm these pelvic pain.
Necrobiosis is responsible for uterine pain sometimes hyperthermia.
Ultrasound diagnosis made by viewing a heterogeneous fibroid painful passage of the probe.
Treatment is symptomatic algic phase (non-steroidal anti-inflammatory drugs [NSAIDs], analgesics, ice pack), antibiotics are theoretically not required.
The extragynécologiques etiologies should be systematically given for not omit. Acute appendicitis, bowel obstruction, renal colic, pyelonephritis, pneumonia of the right base, biliary colic, etc. are the main non-gynecological etiology to remember.
The pain is cyclical when they are punctuated by the menstrual cycle. The first day of the cycle is defined as the first day of menstruation. Genital bleeding from the uterus are called bleeding outside the rules and menorrhagia during menstruation. Bleeding from the uterus during menstruation (menorrhagia) result in the presence of blood clots in the blood normally anticoagulated rules.
Dysmenorrhea (menstrual pain, menstrual cramps):
Dysmenorrhea are contemporary cyclical pelvic pain menstruation that can be primary or secondary functional mostly related organic pathology.
Functional primary dysmenorrhea begins in young girls a few months after the onset of menstruation during the first ovulatory cycles. Pelvic examination required to eliminate a secondary hematocolpos an imperforate hymen.
The organic secondary dysmenorrhea begins several years after menarche and more likely corresponds to an underlying organic pathology, particularly endometriosis. Associated symptoms guide the etiologic diagnosis and evoke painful menorrhagia adenomyosis (endometriosis located in the myometrium) and dysmenorrhea end rules with dyspareunia are in favor of external endometriosis. Other etiologies are possible and popular: cervical stenosis, adhesions, intrauterine devices, ovarian disease or pelvic varicose veins.
The treatment of primary dysmenorrhea is initially symptomatic based analgesics, antispasmodic even antiprostaglandins.
The blocking ovulation per pill remains the most effective treatment of primary dysmenorrhea. The low-dose generally sufficient to regress the symptoms.
NSAIDs administered during menstruation are an alternative to blocking ovulation they can effectively complete.Ultrasound as laparoscopy are not indicated except in case of persistent pain after medical treatments.
The treatment of secondary dysmenorrhoea includes anti-inflammatory associated with treatment of the causal disease.
Sometimes ovulation is algic. The diagnosis is easy through the interrogation reports of unilateral pain, brief lower to 48 hours, alternating with cycles, and located in mid-cycle. They are sometimes accompanied by small bleeding mid-cycle.
The ultrasound confirms the diagnosis by viewing the ruptured follicle and small peritoneal effusion associated. Pain can sometimes mimic the surgical emergency or occur in low-dose pills follicle ruptures at mid-cycle.
The treatment is to block ovulation by a progestin or estrogen plus progestin pill.
Ovarian disease (polycystic ovary syndrome):
The most characteristic form is manifested by acute pain, unilateral alternating from one cycle to another, concomitant ovulation, associated with ovulation disorders (irregular cycles, infertility) and endocrine (hirsutism, obesity) .
The diagnosis is confirmed by ultrasound that shows large dystrophic ovaries (multiple small cysts ultrasound variables to another).
The treatment is to stop ovulation sometimes in combination with anti-androgens. An unfulfilled desire for pregnancy can lead to medically assisted procreation.
Premenstrual syndrome has many symptoms (pelvic pain, breast tenderness, bloating, headache, mood disorders, venous disorders, etc.) appearing a few days before menstruation and disappear with them. It is due to a relative hyperestrogenism end of cycle.
Treatment involves the prescription of progestins in graduate part (from the 15th to 25th day of the cycle). Sometimes the use of a progestin climate contraception and / or psychotropic necessary.
This rare entity, hereditary, affecting ethnic groups in the Mediterranean. Pelvic pain can be brutal, intense, pseudochirurgicale, with fever and bowel dysfunction.
It can mimic gynecological pathology cyclical.
The notion of surgeries “white” (laparotomy, laparoscopy), the frequency of symptoms and the ethnicity of the patient are suggestive of the diagnosis.
Treatment with colchicine is a good therapeutic test.
These are persistent pain for several weeks which affect the quality of life and genital activity of patients.
They require a particular clinical and ultrasonographic assessment. Using laparoscopic surgical exploration is considered as second line if the pain persists or if the diagnosis wanders. Most often patients require specialized care.
The attending physician has a key role in identifying these often poorly defined complaints and conduct diagnostic approach in combination with suitable specialist (gynecologist or gastrologue).
It is the pain caused by sexual intercourse which can be superficial (intromission) or deep.
Different types of dyspareunia:
In many cases of superficial dyspareunia, etiology remains unknown. Seeking birth injury perineum must be done with tact and not to drive too fast in an etiologic diagnosis “easy” even if the patient suggests insistently.
The episiotomy, which has a bad press in the population, is not the cause of all the perineal or vulvar pain. Making episiotomy responsible dyspareunia does a disservice to the patient and does not relieve. A “painful episiotomy” for years without localized lesion has no treatment. However the review of episiotomy scar may reveal endometriosis nodule or a algic inflammatory granuloma including surgical excision completely relieves the patient.
Vulvitis cyclical painful erythematous candidiasis should evoke a cyclical or recurrences of genital herpes treated specifically.
Inflammations or vulvar infections are the cause of dyspareunia whose treatment must be supported, in case of persistence or recurrence, in a setting either gynecological or dermatological. The management of the partners should not be omitted.
Finally is the essential vulvodynia vulvar burning sensation caused no redness or pain, which may be secondary to a lesion of the pudendal nerve and whose treatment by antidepressants gives good results.
Evokes deep dyspareunia endometriosis first.
Endometriosis and adenomyosis:
Endometriosis is the ectopic endometrial cells or internal in the myometrium (adenomyosis) is external in the entire human body (endometriosis). Usually the external endometriosis is located on the inclined parts of the pelvic peritoneum but can be found in all organs including the brain. These ectopic cells, such as cells of the endometrium, are under hormonal control and follow the same cyclical changes with a succession of phases and proliferation of haemorrhagic inflammatory desquamation (menstruation). The symptoms are cyclical with algic increase in hemorrhagic stage during menstruation. Endometriosis typically associated dysmenorrhea typically appearing at the 2nd or 3rd day of menses, deep dyspareunia and sometimes infertility. Of extragenital signs can be associated as the location of endometriosis: tenesmus, cystalgia, etc. The sometimes perceived vaginal endometriosis nodules in the cul-de-sac peritoneum, uterosacral ligaments on and / or painful pelvic mass in relation to an endometrioma on the ovary.
Adenomyosis associates in a woman of forty: a late dysmenorrhea, premenstrual pains permanent upsurge, deep dyspareunia and painful menorrhagia. The vaginal examination found an increased uterine volume, regular shape and sensitive premenstrual.
Hysterosalpingography and hysteroscopy can participate in diagnosis. Ultrasound often allows diagnosis by the detection of nodular images serving in the myometrium giving a heterogeneous vascularized appearance (color Doppler). The passage of the probe is sensitive.
For endometriosis, laparoscopy is the key examination to take stock of the damage (classification) and treat the destruction. Medical treatment, by progestins and / or the LH-RH analogs, is prescribed for a minimum period of 3 to 6 months.
For adenomyosis, medical treatments (progestin and / or anti-inflammatory drugs) or surgical conservative (hysteroscopic endometrial ablation) are weak. The failure of these treatments often forces them to discuss radical treatment (hysterectomy), depending on the perceived disability, the age of the patient and the desire of pregnancy.
Menopause by stopping hormonal production physiologically treats endometriosis and adenomyosis.
Pelvic infections are responsible for chronic pain, which may be secondary to the persistence of the infection, the presence of adhesions, hydrosalpinx or to pyosalpinx and ovarian disease. The symptomatology depends on the pain mechanism: bilateral in cases of chronic infection, in case of cyclical ovarian disease, deep in case of adhesions. Physical examination may be contributory. Sometimes anamnesis allows to find a notion of pelvic infection.
Ultrasound can visualize tubal collection (hydrosalpinx or pyosalpinx) when it is large. Laboratory tests can diagnose persistent infection (sampling and serology) or inflammation (CRP, NFS).
The treatment of persistent infections consists of a double broad spectrum antibiotics, long duration associated with a blocking ovulation and steroidal or non-steroidal anti-inflammatory. Collections are surgically treated by laparoscopy. Surgical treatment of adhesions is trickier because the surgery can remain ineffective on symptoms and generate new adhesions.
Uncomplicated ovarian cysts are often asymptomatic or manifested by chronic pain by compression or gravity. The presence of significant pain must fear an adnexal torsion which associates the initially unilateral pain, a defense and a low-grade fever. The management should be surgical and under penalty of immediate ovarian necrosis. The rupture of a cyst can be painful initially as ovulatory pain. The effusion of the cystic fluid in the peritoneal cavity can cause peritoneal signs (pain of the cul-de-sac of Douglas, radiating pain in the rectum or shoulders, defense, etc.).The notion of known ovarian cyst had disappeared associated with effusion into the cul-de-sac makes the diagnosis of rupture of ovarian cyst. The rupture of corpus luteum cyst is sometimes responsible for hemoperitoneum may require surgical hemostasis. Ovarian cysts should be monitored by the gynecologist who must make a balance to determine the functional or organic.
All organic suspected ovarian cysts require surgical management, usually by laparoscopy, in a specialized environment.
Gynaecological cancers are generally not algic. The pain may be due to retention on haematic cervical stenosis or ureteral compression or invasion of lumbosacral roots. The ovarian cancers are not painful and are mainly manifested by digestive disorders if there is a peritoneal carcinomatosis.
Pelvic varices are responsible for pelvic pain sometimes important.
Doppler ultrasound visualizes the venous packets and causes pain to the passage of the vaginal probe.
Disinsertion causes uterine retroversion which promotes venous stasis. The pain can be explained by the tearing of the uterine ligaments and venous congestion. It is a permanent center of gravity and less pronounced in standing position in the prone position or laying a pessary. The uterine body is too readily mobile and painful retroversion at ligamentous insertions.
Ultrasound coupled with color Doppler shows the uterine retroversion and images of dilated veins. Laparoscopy allows to take stock of pelvic congestion and looking for signs deinsertion womb (uterine retroversion, abnormal uterine mobility, tearing of the posterior leaflet of the broad ligament, Douglas deep) and venous stasis (marbled uterus, congestive, pelvic varices ).
For pelvic varicose veins, medical treatment by venous tonic is sometimes effective then to confirm the diagnosis. In cases hyperalgic resistant to medical treatment (venous tonics, analgesics, etc.), we can discuss coagulation of venous packets during a pelvic congestion balance laparoscopy Algonkian (research disinsertion uterine or endometriosis associated , etc.). Treating pelvic varicose veins may also be achieved by embolization in vascular radiology.
For disinsertion uterine laparoscopy also allows the surgical treatment of uterine retroversion by shortening the round ligaments. A douglassectomy and plasty of the uterosacral ligaments can be proposed. Medical treatment uses the rest in the prone position, venous tonic and anti-inflammatory.
Pelvic pain can have a gynecological origin but also urological, rheumatologic, gastrointestinal, dermatological, neurological or psychological. The diagnostic and therapeutic orientation is guided primarily by clinical examination and examination possibly associated with complementary examinations (bone and joint X-rays, urological and neurological explorations).
Irritable bowel syndrome, frequent in the female population, should not ignore an organic digestive underlying pathology. Signs direct cause pain to the digestive system: nausea, bloating, flatulence, altered bowel habits, stool color. Digestive pain often punctuated by meals, spasmodic, frame and relieved by gas or stools. Digestive pathologies are painful spastic colon, diverticulosis, inflammatory bowel disease, colon cancer, digestive endometriosis, etc.
If treatment with a high fiber diet and antispasmodic prescription is ineffective, the persistence of symptoms especially after 40 years or when there is a family history of colon cancer should consider doing a colonoscopy.
It is a progressive and sometimes postoperative pain or acute traumatic that occurs most often in women over 50 years. Pain seat on the perineum as paraesthesia or burning, unilateral or median, often exacerbated by sitting and relieved by walking. Physical examination may find pain caused next to the ischial spine. The remainder of the physical examination, such as neurotoxicity, is normal.
Treatment is based on infiltration or surgical decompression that yields few results.
Psychosomatic labeled pelvic pain must do before the rigorously etiological removing organic pathologies.However, signs directed towards the psychological origin of pain as the richness and variability of semiotics, dyspareunia not found during vaginal examination and psychological context.
The examinations (ultrasound, laparoscopy, biology, clinical examinations) remaining normal and that no etiological not invoked in favor of psychological etiology.
The treatment of a possible causal organic pathology does not improve the comfort of life of these patients. The management is then based on psychotherapy, anxiolytics and tricyclic antidepressants that have analgesic effect even in the absence of depression. The blocking ovulation can be proposed when the pain is cyclical. A psychological evaluation is necessary before proposing any radical gesture (hysterectomy) which can aggravate a pre-existing psychological disorder.
Pelvic pain are multiple and varied backgrounds ranging from surgical acute organic pathology at chronic psychosomatic disease. A careful clinical examination and simple additional examinations usually allow an etiologic diagnosis and appropriate treatment. Some cases, however, require a diagnostic laparoscopy. The face doctor, a woman with acute pelvic pain, directed him to a gynecological emergency ward to remove an ectopic pregnancy, an adnexal torsion or pelvic inflammatory disease.
In the treatment of chronic pain, the role of the physician is essential to coordinate care based on the special relationship and knowledge of the patient and her siblings. Whatever the quality of the etiological investigation, the pain should not be ignored or underestimated and requires an effective analgesic treatment.