Case 23: Pelvic pain

 

Case 23: Pelvic pain

CASE 23: PELVIC PAIN

History

A 24-year-old woman presents with pelvic pain and painful sexual intercourse for 2 years.

She is worried that she may have an ovarian cyst. The pain occurs at any time of the menstrual cycle but is worse during menstruation. It can also be worse when she passes urine or

opens her bowels. There is no relation to exercise.

She has been with her current sexual partner for 6 months and the pain occurs nearly every

time she has intercourse unless penetration is very gentle. She has never been diagnosed with

any sexually transmitted infections. She was pregnant once at the age of 19 years but this

ended in a spontaneous complete miscarriage.

She opens her bowels regularly and denies any bloating, constipation, diarrhoea or mucus in

the stool. She had an episode of cystitis a few years ago which responded to antibiotics.

There is no other medical history of note and she takes no regular medications.

Examination

The abdomen is not distended and there is no organomegaly. No masses are palpable but

there is suprapubic tenderness. Speculum examination shows a normal smooth grey/white

coloured discharge and swabs are taken. The uterus is anteverted but has limited mobility

and is tender on movement. There are no adnexal masses but the adnexae are tender.

INVESTIGATIONS

Urinalysis: protein negative; blood negative; leucocytes negative; nitrites negative

Endocervical swab: negative

Chlamydial swab: negative

High vaginal swab: negative

Transvaginal ultrasound report: the uterus is normal sized and axial. The endometrium

measures 12 mm. Both ovaries are of normal morphology but appear adherent to the

posterior uterus and show limited mobility. There is no free fluid in the Pouch of Douglas.

Laparoscopy findings are shown in Figs. 23.1 and 23.2.

Figure 23.1 Laparoscopy image of the pelvis.100 Cases in Obstetrics and Gynaecology

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Questions

• What is the diagnosis?

• How would you manage this patient?

• What are the long-term implications of this disease?

Figure 23.2 Laparoscopy image of the right upper abdomen.Case 23: Pelvic pain

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ANSWER 23

The laparoscopy image shows in Fig. 23.1 pelvic adhesions suggestive of previous infection.

The ‘violin-string’ perihepatic adhesions in Fig. 23.2 are classical of Fitz–Hugh–Curtis syndrome, generally seen with previous chlamydial infection though also described with gonorrhoea. These findings can develop in the absence of a clinically recognized infective episode.

The woman therefore has chronic pain from pelvic inflammatory disease. Negative swabs

would suggest that she may no longer be infected with chlamydia.

Management

The pain may be helped with laparoscopic adhesiolysis. The perihepatic adhesions should be

ignored as they are not causing symptoms. Otherwise pain-management options are analgesics or possible uterosacral nerve ablation.

Even though there is no evidence of current active infection, the tests have limited sensitivity

so it is worthwhile treating the woman and her partner with a course of antibiotics for pelvic

inflammatory disease.

! Long-term complications of pelvic inflammatory disease

• Chronic pain.

• Infertility: tubal infertility is likely in this woman, and if she fails to conceive spontaneously then hysterosalpingogram should be performed with referral for assisted

conception if obstruction is confirmed.

• Ectopic pregnancy: spontaneous and in vitro fertilization pregnancies are at

increased risk of implanting in the damaged tubes, and an early transvaginal scan

should be advised if she becomes pregnant.

• The woman should also be advised that despite the likely subfertility, spontaneous

pregnancy may still occur so she should use effective contraception if she does

not want to conceive.

KEY POINTS

• Fitz–Hugh–Curtis syndrome is the presence of perihepatic adhesions in association with previous chlamydial or gonococcal infection.

• Treatment of both partners is appropriate.

• Chronic pain, ectopic pregnancy and tubal infertility are long-term consequences

of pelvic inflammatory disease.