Case 15: Pelvic pain

 

Case 15: Pelvic pain

CASE 15: PELVIC PAIN

History

A 29-year-old woman presents with lower abdominal pain for 4 years occurring with her

periods. She takes paracetamol and ibuprofen and goes to bed with a hot water bottle for up

to 2 days every month. For the last 18 months pain has also occurred in between periods.

The pain is dull and constant across the lower abdomen. Her periods are regular and there

is no menorrhagia, intermenstrual or postcoital bleeding. There is no other significant

medical history.

She has been married for 2 years and has deep dyspareunia which makes her interrupt intercourse. She does not use any contraception, as they are keen to start a family. She has never

been pregnant in the past.

Examination

There is generalized lower-abdominal tenderness, particularly in the suprapubic area but no

masses are palpable. Speculum examination is unremarkable. On bimanual palpation the

uterus is axial and fixed with cervical excitation. The Pouch of Douglas is very tender and

contains a mass. The adnexae are both tender but no adnexal masses are palpable.

INVESTIGATIONS

Transvaginal ultrasound scan is shown in Fig. 15.1.

The findings at laparoscopy are shown in Fig. 15.2.

Questions

• What is the diagnosis?

• How would you further manage this woman?

Figure 15.1 Transvaginal ultrasound scan

showing transverse view of the Pouch of

Douglas.

Figure 15.2 Findings at laparoscopy (see

colour insert).100 Cases in Obstetrics and Gynaecology

36

ANSWER 15

The history of dysmenorrhoea and dyspareunia is classic for endometriosis, and the ultrasound examination (‘kissing cysts’) and laparoscopy images show bilateral endometriomas

(‘chocolate cysts’), a complication of this disease.

Endometriosis is a common condition where active endometrial glands and stroma are

located outside the endometrial cavity. Endometriomas develop as ectopic endometrial tissue

on the ovary produces blood, which builds up into an encapsulated cyst with each consecutive menstrual cycle.

Endometriosis is benign but carries a high physical and psychological morbidity due to the

clinical features:

• pelvic pain

• dysmenorrhoea

• dyspareunia

• infertility.

Examination findings include tenderness or a pelvic mass, and may include palpable nodules

in the rectovaginal septum and a fixed retroverted uterus secondary to adhesions (the ‘frozen

pelvis’).

Diagnosis is made at laparoscopy, although ultrasound features such as these ovarian cysts

containing ‘ground-glass’ echoes can be suggestive.

Management

The mainstay of management for endometriosis is surgical, with ablation or excision of endometriotic deposits by laparoscopy. In this case there are bilateral endometriotic cysts that

need to be removed laparoscopically by incision and drainage and either cautery to or stripping of the cyst capsules. Surgical treatment should relieve the dyspareunia and dysmenorrhoea and may improve fertility in more severe disease.

Medical suppression of endometriosis is possible with the contraceptive pill or gonadotrophin-releasing hormone analogues, which inhibit ovulation and hence prevent stimulation

of endometrial deposits by oestrogen. However these are ineffective for endometriomas. The

levonorgestrel-releasing intrauterine device has also been used to suppress endometriosis

and reduce symptoms.

KEY POINTS

• Endometriosis classically presents with dysmenorrhoea, dyspareunia and infertility.

• Endometriosis is often diagnosed years after symptoms start.

• Surgical excision is the mainstay of treatment.