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Chronic Pelvic Pain and the

Role of Diagnostic
Laparoscopy
Womens Health Case Report
Word Count: 1064

Womens Health Case Report 2015

Student Number: 24140767

CHRONIC PELVIC PAIN

Introduction
Pelvic pain is a common presenting complaint in women and is associated with
substantial human and economic burden (1). There are a multitude of aetiologies for
it, and occasionally, no apparent cause can be found. This report outlines the case of
a patient with chronic pelvic pain (CPP) and discusses the role of diagnostic
laparoscopy for such patients.
History
Gabrielle is a 27-year old G0P0 female who presented to hospital for a diagnostic
laparoscopy to investigate CPP. She has had moderate to severe stabbing pain in
the right iliac fossa intermittently for five years, and in the last six months it has been
increasing in severity and has become almost constant. The pain has no relationship
to her menstrual cycle. It is not alleviated or aggravated by positional changes. The
pain has caused significant distress and is increasingly interfering with her work and
social life. She has presented to the emergency department several times for
exacerbations of the pain. She also experiences deep dyspareunia.
In addition, she has always had menorrhagia with clots despite having been on the
oral contraceptive pill (Yasmin) for six years. She bleeds for 5-6 days out of a 28 day
cycle.
She has been sexually active with the same male partner for many years and has
never been diagnosed with any sexually transmitted infections. Her pap smears are
up to date and there have never been any abnormalities.
Gabrielle currently takes oxycodone three times daily to control her pain. She had
previously used non-steroidal anti-inflammatory drugs, but they no longer provide
relief. She also takes esomeprazole for gastro-oesophageal reflux and escitalopram
for anxiety. She had a laparoscopic cholecystectomy two years ago for acute
cholecystitis.
She has no other past medical or family history. She is allergic to tramadol and
Elastoplast, both of which cause a rash. She is a non-smoker and drinks alcohol
socially.

Womens Health Case Report 2015

Student Number: 24140767

Examination
Gabrielle appears generally well. Her vital signs were as follows:

Heart rate

75 bpm

Blood pressure

126/74mmHg

O2 saturation

99% on room air

Temperature

36.2C

On abdominal inspection, there were small surgical scars in the right upper quadrant
from her previous cholecystectomy. There were no other skin changes or visible
masses. There were no palpable masses.
On speculum examination there was cervical ectropion, but the genitalia appeared
otherwise normal. Her bimanual examination revealed an anteverted uterus of
normal size. There was no tenderness and no palpable adnexal masses. There was
no discernible pelvic organ prolapse.
Further, she does not show signs of anaemia such as pallor of the conjunctivae or
palmar creases.
Investigations
In the years since the onset of her symptoms, Gabrielle has had abdominal and
transvaginal pelvic ultrasound scans, as well as numerous computed-tomography
scans of the abdomen and pelvis. They have all been normal.
She has also been screened for sexually transmitted infections including chlamydia
and gonorrhoea.
Gabrielles laparoscopy showed no abnormalities on her ovaries, fallopian tubes,
uterus, pelvic walls, bladder, or liver. Specifically there was no evidence of
endometriosis or adhesions.
Management
Gabrielle was discharged from hospital on the day of her procedure and booked for
follow-up with a gynaecologist in 4-6 weeks. She was told in the meantime to
continue her current pain management regimen.

Womens Health Case Report 2015

Student Number: 24140767

Discussion
CPP is defined as intermittent or constant pain in the lower abdomen or pelvis of a
woman of at least 6 months in duration, not occurring exclusively with menstruation
or intercourse and not associated with pregnancy (2). There are a variety of causes
for CPP in women and it is often multifactorial (2).
Common gynaecological causes of CPP are endometriosis and adenomyosis (2).
Endometriosis is defined as the presence of endometrial tissue outside of the
endometrium. When this tissue invades the uterine myometrium, it is called
adenomyosis (3). The pain in endometriosis and adenomyosis often varies over the
course of the menstrual cycle and is associated with deep dyspareunia (2). This is
consistent with Gabrielles history, and therefore was the primary differential
diagnosis.
Adhesions within the pelvic cavity were also considered, which may occur secondary
to endometriosis, surgery, or pelvic infections (2). Other causes considered were
musculoskeletal pathologies such as pelvic muscle spasms and nerve entrapments,
as well as conditions of other organs sharing visceral innervation with the female
reproductive tract such as bowel and bladder. These were excluded clinically.
Psychosocial issues may also contribute to chronic pelvic pain (2).
Diagnostic laparoscopy is the gold standard investigation to diagnose endometriosis
and adhesions. Endometriosis can be directly visualised in this investigation, and its
location and extent can be documented. The appearance of endometriosis on
laparoscopy varies. It may appear as clear vesicles, red or dark pigmented lesions
with haemosiderin or may have white adhesions (3). It is most commonly found in
the peritoneum and pelvic organs, and may manifest as cysts called endometriomas
in ovaries (3). Various systems have been created to classify the severity of
endometriosis found on laparoscopy, but they are subjective and severity has not
been shown to correlate well with symptoms (4,5). In addition to visualisation of the
lesions, biopsies may also be taken for histological diagnosis. However, negative
histology does not exclude endometriosis (4).

Womens Health Case Report 2015

Student Number: 24140767

Laparoscopy in the setting of CPP may also detect pathologies such as chronic
pelvic inflammatory disease, ovarian cysts (though usually asymptomatic unless
ruptured, which more commonly causes acute pain) and pelvic vessel congestion (4).
Gabrielles case of severe chronic pain with negative laparoscopy findings is not
uncommon. Approximately one-third to one-half of all women with CPP have no
findings on laparoscopy (2), and positive findings from the procedure may not be the
cause of the pain. In some cases the diagnosis may be missed (2), as endometriosis
infiltrating deeply into pelvic organs may not be easily visible (4). As such, patients
should be counselled prior to the procedure of the possibility of a negative result (4).
It is also important to note that a laparoscopy is considered an invasive procedure
with a number of risks. These include injury to intra-abdominal structures such as
bowel, bladder or blood vessels as well as more general risks like infections and
reactions to anaesthetic (2). This, combined with the high rate of negative findings
leads many gynaecologists to reserve this procedure for patients with severe,
debilitating pain which has not responded to pain relief therapies (4).
Conclusion
Diagnostic laparoscopy can be a useful method to diagnose particular pelvic
conditions causing CPP. As clinicians, it is important to remember that it is not
always a definitive test as many patients with symptoms do not exhibit any visible
pathology and so we must weigh up the risks and benefits of this invasive procedure.

Womens Health Case Report 2015

Student Number: 24140767

References
1. Faculty of Pain Medicine ANZCA. The $6 Billion Woman and the $600 Million
Girl The Pelvic Pain Report. 2011. [Online] Accessed 7 June, 2015 at:
http://www.fpm.anzca.edu.au/Pelvic_Pain_Report_RFS.pdf
2. Royal College of Obstetricians and Gynaecologists. The Initial Management
of Chronic Pelvic Pain, Green-top Guideline No. 41. United Kingdom. May
2012.
3. Kennedy S, Bergqvist A, Chapron C, DHooghe T, Dunselman G, Greb R et al.
ESHRE guideline for the diagnosis and treatment of endometriosis. Human
Reproduction 2005 Jun 24; 20(10):2698-2704.
4. Howard FM. The Role of Laparoscopy in Chronic Pelvic Pain: Promise and
Pitfalls. Obstet Gynecol Surv. 1993 Jun;48(6):357-387.
5. American Society for Reproductive Medicine. Treatment of pelvic pain
associated with endometriosis: a committee opinion. Fertil Steril 2014
March 13;101:927-35.