Diagnosis of Pelvic Pain

Pelvic pain must be diagnosed accurately if the pelvic pain is to appropriately treated. In order to determine the cause of pelvic pain obtain the history of the pelvic pain. An examination is done. It is common to find a cause of pain that would otherwise go undetected by doing a vaginal probe ultrasound scan during the initial visit. I will describe the steps that I go through to determine the cause of pelvic pain.

Some questions that I ask:

• When did pelvic pain start? Has it been present for hours, days, weeks, or months?
• Is the pelvic pain better or worse during the menstrual period?
• Does intercourse effect the pelvic pain?
• Is the pelvic pain annoying, just worrisome, or severe enough to interfere with activities?
• Are there any risk factors for sexually transmitted diseases?
• What is the possibility of pregnancy?
• What else effects the pelvic pain? Eating? Having a bowel movement? Any history of kidney or bladder problems?
• Have any studies or surgery been done? It is very helpful to bring in any records of surgery (the operative report) or other major examinations with her.

What I look for during an examination:
When someone is having pelvic pain, I try to do the exam a gently as possible. Since I will be using the ultrasound, there is no need to press hard during the exam, and usually it can be done with very little discomfort in spite of the pain.

• I make a general assessment of my patient to determine her overall health and degree of pain.
• I look for tender areas in the abdominal wall, as well as deep in the abdomen.
• In doing the pelvic exam I look for signs of infection, and may do tests for chlamydia and gonorrhea. I feel the size of the uterus and ovaries, and look for tender areas. (I don't need to press hard if I am going to do an ultrasound exam.) Often endometriosis implants behind the uterus between the vagina and rectum. This area can only be felt by placing one of the examining fingers in the vagina and another in the rectum. An examination for pain is not complete unless a "recto-vaginal" exam is done.
• It is essential to be sure that any woman with pelvic pain is not pregnant. If there is even the most remote possibility of pregnancy a pregnancy test should be done.

Vaginal Probe ultrasound exam by the gynecologist:
A small probe placed inside the vagina makes pictures of the pelvic organs by using sound waves. This is not uncomfortable, and take only a few minutes. Many times the ultrasound will show cysts, fibroids, or other problems that cannot be felt on exam.

I feel that the gynecologist should do the ultrasound him or herself at the time of the initial evaluation. Much information on the source of the pain is obtained that lost if someone else does the scan. In addition, it is far less convenient to send a women elsewhere for a scan and then have to wait for the results, when the results are immediately available if the gynecologist does the ultrasound. It is also usually much less expensive for the ultrasound to be done by the gynecologist as compared to a hospital or other facility.

Laparoscopy:
Laparoscopy is a procedure in which a little telescope is used to examine the tubes and ovaries, and may be necessary to determine a diagnosis. Laparoscopy may just be diagnostic, in which case the gynecologist just looks at the pelvis. Whenever I do diagnostic laparoscopy I am always prepared to do operative laparoscopy. During operative laparoscopy the problem encountered is treated by using lasers and/or other instruments. Examples of operative laparoscopy include the freeing of adhesions, removal of endometriosis, or removal of ovarian cysts.

If you need a laparoscopy, it is important to have it done by a gynecologist who is an expert in both operative and diagnostic laparoscopy. There have been too many times where I have had to perform a second laparoscopy because disease was either not treated at all, or was inadequately treated during a laparoscopy in which the surgeon was not prepared to treat the problem that was found.

Other studies:
If a problem inside the uterus, such as a submucous fibroid is suspected, hysteroscopy can be done to look directly inside the uterus. This is usually a simple office procedure. Hysteroscopy may also show adenomyosis, which can cause severe pain with menstruation or even all month long.
If there are strong bladder symptoms, but urine cultures show no infection, than interstitial cystitis should be suspected. Cystoscopy (looking inside the bladder) is a simple procedure, but usually requires general anesthesia to test for interstitial cystitis. At times I will do cystoscopy at the same time as a laparoscopy if I suspect interstitial cystitis.
If the pain is suspected of coming from the intestine or stomach, I may refer a woman to a specialist in these areas for evaluation. This usually would be done prior to laparoscopy, even though endometriosis can cause intestinal problems.

What if no definite cause can be found?
I feel that it is important to develop a relationship with my patients so they understand that we may not be able to identify a cause for the pelvic pain. The fact that a cause cannot be found does not make the pain any less real. It is important to continue to work on ways to minimize the effect of the pain on her life.

References:

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