Download Differential Diagnosis of pelvic pain

Differential Diagnosis of Pelvic Pain (Endometriosis and Adenomyosis)
Acute Lower abdominal pain (LAP)
Gynaecological causes
Threatened, incomplete and septic miscarriage
Ectopic pregnancy
Acute salpingitis
Tubal or ovarian abscess
Endometritis
Pelvic peritonitis
Complication of an ovarian cyst: rupture,
haemorrhage into a cyst, torsion
Ovulation pain
Retrograde menstruation
Primary dysmenorrhoea
Trauma to the upper genital tract following
instrumentation
Non-gynaecological causes
Cystitis
Ureteric colic
Acute appendicitis
Diverticulitis
Bowel obstruction
Mesenteric thrombosis
Chronic LAP
Gynaecological causes
Chronic pelvic inflammatory disease (PID)
Endometriosis/adenomyosis
Ovarian masses – benign and malignant
Complications of uterine fibroids
Pelvic vascular congestion syndrome
Less common gynaecological causes
Unruptured ectopic pregnancy
Low-grade PID
Polycycstic ovary disease
Varicose veins in the broad ligament
Prolapsed ovaries into the pouch of Douglas
Genital prolapse
Non-gynaecological causes
Appendiceal abscess
Intra-abdominal adhesions
Diverticulitis
Irritable bowel syndrome
Inflammatory bowel disease
Malignancy of the small or large bowel
Bladder dysfunction, urinary tract calculi
Osteoarthritis, lumbar disc protrusion, other
musculoskeletal disorders
Endometriosis
Definition: endometriotic tissue containing glands and epithelium is found in sites outside the
endometrial cavity of the uterus, including the ovaries, the pouch of Douglas the uterosacral
ligaments and the broad ligaments, and other more distant sites, e.g. lungs. Endometriosis affects up
to 1 in 6 women.
Pathophysiology: exact mechanism still unknown. It is probably one of/ a combination of:
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Retrograde menstruation
Coelomic metaplasia
An altered autoimmune response to menstrual blood in the peritoneal cavity.
Embolic transport of endometrial cell svia the bloodstream or lymphatics.
Symptoms:
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Pain:
o Pelvic pain (most frequent sx), usually a chronic problem
o Dysmenorrhoea
o Dyspareunia
o Other pain – ovulation pain, pain with opening bowels, passing wind or dysuria.
Bleeding:
o Menorrhagia
o Irregular bleeding
o Premenstrual spotting
Other:
o Bowel symptoms
o Urinary symptoms
o Fatigue
o Mood changes
o Bloating
Signs: on abdominal and pelvic
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Tenderness in the pouch of Douglas, uterus and adnexa.
Palpable endometriotic nodules (rare).
Diagnosis: gold standard is laparoscopy to view endometrial implants within the pelvis. Other tests
include ultrasound and MRI.
Natural history: variable, ranging from asymptomatic to severely disabling. It may resolve with time,
remain static or progress.
Management:
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Aims include:
o Resolution of pain.
o Decrease in menstrual bleeding.
o Preparation for pregnancy.
Options:
o Medical (aim to manage pain):
 Analgesics
 Hormone stabilisation
 Oestrogen reduction or suppression
o Surgery:
 Laparoscopy: removal of lesions and resoration of anatomy to as normal as
possible.
 Complete pelvic clearance (removal or uterus, tubes, ovaries and other
endometriotic deposits): last resort; may not resolve all problems.
Adenomyosis
Definition: the occurrence of ectopic endometrial implants within the myometrium. Often coexists
with endometriosis and fibroids. Typically occurs in women in their 40s.
Pathophysiology: unclear; linked with uterine trauma that may break the barrier between the
endometrium and myometrium, e.g. surgery, pregnancy termination and pregnancy.
Diagnosis: clinical. Ultrasound and MRI may be useful.
Symptoms and Signs:
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Dysmenorrhoea.
Dyspareunia.
Dyschezia (difficult or painful defaecation).
Acyclical uterine bleeding.
Soft, tender uterus, especially around time of menstruation on examination.
Management:
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NSAIDs
COCP
Progesterone-only pills
Levonorgestrel intrauterine contraceptive devices
GnRH agonists
Hyesterectomy (last resort)
References: Women’s Health: A Core Curriculum, http://www.endometriosis.org.au