Pain is defined by the International Association for the Study of Pain (1986) as 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage'. The Royal College of Obstetrics and Gynaecology (2005) stipulate that acute pain reflects fresh tissue damage and resolves as the tissue heals. In chronic pain, additional factors are involved, and pain may continue long after the original tissue injury, or may exist in the absence of any such injury.
CAUSES OF PELVIC PAIN
Table 11 Cause of pelvic pain
Common cause of pelvic pain
• Infection • Pelvic Inflammatory Disease
• Endometriosis • Endometriosis
• Ectopic pregnancy • Adhesions
• Dysmenorrhoea • Venous congestion Non-gynaecological Non-gynaecological
• Cystitis • Irritable bowel disease
• Appendicitis • Muscular - skeletal
• Neurological • Neurological
• Psychological • Psychological
Source: Thomas and Rock 1997.
Adequate time should be given for the initial assessment of women with pelvic pain, especially chronic pain. It has been shown that consultations that allow women to express their own ideas about their pain result in a better practitioner-patient (or therapeutic?) relationship, and therefore improved concordance with investigation and treatment (Selfe et al., 1998).
The initial history should include questions regarding the pattern of the pain, the onset, timing, severity and type of pain, its association with other problems involving the bladder or bowel, the effect of movement and posture on pain, and the extent and type of psychological involvement. If dyspareunia occurs, is it superficial or deep, and does it occur every time? Consider also recent infection or surgery. Does the pain bear any relationship to the menstrual cycle?
Examination in a Genito-urinary Clinic should include:
• Pregnancy test
• Abdominal examination
• Perianal and vaginal speculum examination
• Sample taking for sexually and non-sexually transmitted infections
• Bimanual examination.
It is worth noting that the examiner should be prepared for new information to be revealed at this point, as the woman may now have more time/ opportunity to explore her fears and anxieties.
Generally there is an acute onset of symptoms. The most significant symptoms include; unilateral pelvic pain, amenorrhoea, and vaginal bleeding. The most significant signs are lower abdominal tenderness, extreme tenderness in the lateral fornix on one side, and pain on moving the cervix. Pregnancy test -Positive.
This is more common in women who have had:
• A previous ectopic pregnancy
• Tubal surgery
• Tubal pathology - PID, endometriosis
• Progestogen-only methods of contraception
Urgent referral to gynaecology is imperative, as the condition may quickly become life-threatening.
Spontaneous miscarriage is the expulsion of a fetus before 24 weeks. History should establish details of the last menstrual period, bleeding per vaginam, abdominal pain, the first positive pregnancy test, and symptoms of pregnancy. If the first evidence of miscarriage is evident at vaginal speculum examination, the cervical os will appear open, and unequivocal products of conception may be evident. Any products of conception, if passed, should be sent for histology. The woman should be referred to the local gynaecology team on call, with provisions made for safe transfer as per clinic guidelines. This will be a psychologically traumatic experience for the woman, and her management must reflect this.
Benign ovarian cysts are common, frequently asymptomatic and often resolve spontaneously. They are the fourth most prevalent gynaecological cause of hospital admission (Soutter et al., 2003). Physiological cysts are simply large versions of the cysts formed in the ovary during the normal ovarian cycle. Most are asymptomatic, being found incidentally during pelvic examination. Management is conservative, though pelvic scan should be considered if the pain is moderate and there are few physical signs. If the patient presents with severe acute pain or bleeding a laparoscopy or laparotomy under the care of a gynaecology team is indicated.
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