- Email: [email protected]
Pelvic Pain
617
avoidance of milk intolerance.
Techniques for training health.workers and mothers must be further explored in various cultural settings. And it will be important to evaluate the full impact of national ORT programmes on mortality and morbidity. If there is a tendency to overestimate the impact of ORT on child mortality, this may lead to expectations that cannot be met.
Pelvic Pain be one of the in commonest presenting symptoms medical practice. The general practitioner will think of pelvic inflammatory disease, the surgeon of bowel disease, particularly appendicitis, and the gynaecologist of conditions affecting the female genital tract. In consequence, the management varies widely and ranges from the conservative to the radical. In 1958, MORRIS and O’NEILLI reported that pelvic pain was the most common complaint in women attending as gynaecological outpatients in their clinic; and disquiet at some of the more radical forms of management was already apparent in TAYLOR’s2 comment in 1957 that "premature resort to surgery is the characteristic error in the present day management of pelvic pain". The contribution that laparoscopy has made to improving diagnosis and hence therapeutic potential has been highlighted by two studies, one by GILLIBRAND3 from the U.K. and the other by MURPHY and FLIEGNER4 from Australia. In the British study, 331 women presented with some form of lower abdominal pain which was of sufficient severity to warrant investigation by laparoscopy. Only 37% had any form of pelvic disease, meaning that in almost twothirds there was no visible lesion which could account for their pain. Both studies attest to the difficulty in arriving at a reliable diagnosis from the history and physical signs before laparoscopy. While the existence of some form of pelvic disease was correctly predicted in 75-82% of cases, the nature of the disease was correctly diagnosed in only 50% of the women. In MURPHY and FLIEGNER’s study, pelvic inflammatory disease was diagnosed before laparoscopy in 22 women but was confirmed in only 7. 6 of!the women had an entirely normal pelvis and, if treated conservatively in the accepted manner with antibiotics, could have become one of the familiar "pelvic cripples". These women, reminded by any twinge of pain that their future fertility is threatened, their anxiety fuelled by doctors prescribing repeated courses of antibiotics for "chronic PID", may well be appearing in increasing numbers in doctors’ surgeries because of the rising LOWER abdominal
pain
must
-
1 Morris N, O’Neill D. Outpatient gynaecology. Br Med J 1958; ii: 1038-39 2 Taylor HC The Problem of pelvic pain. In: Meigs JV, Somers HS, eds. Progress in gynecology, vol III New York. Grune and Stratton, 1957; 191-208. 3 Gillibrand PN Investigation of pelvic pain. Communication at the Scientific Meeting on Chronic Pelvic Pain - a Gynaecological Headache, Royal College of Obstetricians and Gynaecologists, May, 1981. 4 Murphy A, Fliegner J. Diagnostic laparoscopy - role in management of acute pelvic pain. Med J Aust 1981; i: 571-73.
incidence of venereal infection in big cities.5 The findings of these studies on lower abdominal pain make the point that the time has come for both gynaecologists and surgeons to include laparoscopy as part of their routine investigation of recurrent attacks of lower abdominal pain. The national survey by the Royal College of Obstetricians and Gynaecologists6 showed laparoscopy to be a thoroughly safe technique which does not require a long stay in hospital. The value of this technique to the general surgeon is uncertain but the finding, in two studies,7,8 of a non-inflamed appendix in 50% of individuals undergoing emergency appendicectomy for acute lower abdominal pain suggests that much might be gained by introducing laparoscopy into general surgical practice. What is one to make of the common failure to diagnose disease in individuals complaining of pelvic pain-often for many years? A wide variety of possible causes have been proposed. The syndrome of pelvic pain, dyspareunia, and excessive fatigue described by ALLEN and MASTERS9 was ascribed by them to traumatic laceration of the uterine supports, the most prevalent lesions being acute uterine retroversion and laceration of the posterior leaf of the broad ligament. Surgical repair is still advocated for the condition in many parts of the world but has never achieved popularity in the U.K. The studies of RENAER’O have convincingly disposed of this syndrome as a major cause of unexplained pelvic pain. Other hypothetical causes such as pelvic varicosities and adnexal oedema have also been satisfactorily discounted." One is left with the likely possibility that pelvic pain, in association with the laparoscopic finding of a normal pelvis, is often a stress-related disorder. Symptoms may date from childhood when abdominal pain is a common complaint. DODGE 12 concluded that, in 95% of children referred to a hospital clinic for abdominal pain, the symptoms were .emotionally determined. While this observation is not evidence that the same condition carries over into adult life, it is a possibility that cannot be discounted. GOMEZ and DALLY 133 studied a group of men and women who attended a medical or surgical outpatient clinic for recurrent or persistent abdominal pain for which no organic cause was apparent at their first visit. They concluded that psychiatric factors were primarily responsible for the pain in at least 84% of patients. This is an important 5. Weström L. Incidence, prevalence and trends of acute pelvic inflammatory disease and its consequences in industrialised countries. Am J Obstet Gynecol 1980; 138: 880-92. 6. Report on the Confidential Enquiry in Gynaecological Laparoscopy. London: Royal College of Obstetricians and Gynaecologists, 1978 7. Ingram PW, Evans G, Oppenheim AN. Right iliac fossa pain in young women. Br Med J 1965; ii: 149-51 8. Creed F. Life events and appendicectomy. Lancet 1981; i: 1381-85. 9. Allen WM, Masters WH. Traumatic laceration of uterine support. Am J Obster Gynecol 1975; 70: 500-13 10. Renaer M. Chronic pelvic pain without obvious pathology in women: Personal observations and a review of the problem. Europ J Obstet Gynecol Reprod Biol 1980; 10: 415-63 11. Renaer M In: Renaer M, ed. Chronic pelvic pain in women. Berlin: Springer Verlag, 1981. 12. Dodge JA. Recurrent abdominal pain in children. Br Med J 1976; i: 385-87. 13. Gomez J, Dally P. Psychologically mediated abdominal pain in surgical and medical
outpatient clinics. Br
Med J 1977; i: 1451-53.
618
study for it raises the possibility that pain may be used by the sufferer to manipulate life around him or her. GOMEZ and DALLY also showed that, while stressinduced abdominal pain is commoner in women than in men, the difference is by no means as great as is generally thought, the ratio being about 2:1. They also found that depression and what are loosely termed personality disorders were common in their study group, particularly amongst women. These observations have been confirmed by other workers, but an association between the complaint of pain and emotional disorder does not, of course, explain why the pain arises. The fact that the pain might be associated with psychological or psychiatric factors does not in any way suggest that the pain is imaginary and not real. There is no doubt that these individuals experience pain which may sometimes be so severe as to be abdominal crisis. DUNCAN and in pelvic blood flow fluctuations reported induced by acute mood changes such as anxiety, depression, and resentment. They postulated that local "congestion" in the pelvis could induce a sensation of pain. It seems unlikely that much advance will be made in this area until the changes in the pelvic organs can be measured. Perhaps some clue lies in the site of the pain. For example, in some individuals bowel symptoms prevail, giving rise to the irritable bowel syndrome,’s whilst in others it is the uterus or ovaries that is the site of the pain. Possibly the nature of’the emotional disturbance determines which organ is affected or, alternatively, the sensitivity of a particular organ mistaken for
an acute
TAYLOR 14
system. As yet, the
nature of the emotional disturbances in with pelvic pain has not been revealed. in which personality However, several studiesl4>’6>" have been examined suggest that such women profiles are more introverted and neurotic than the general population and have difficulty in forming rewarding relationships as well as having abnormal attitudes towards their own and their partner’s sexuality. It is possible that people with certain personality traits may respond to stressful events by getting pain. There was evidence to this effect in one study of young men and women who had an appendix, either normal or inflamed, removed for abdominal pain.’ Why is the management of pelvic pain so unsatisfactory? The answer is multifactorial. The philosophy of modern medicine demands that an organic cause for any symptom should be sought
women
exhaustively before a possible psychosomatic cause into the reckoning. Equally, patients seek an "organic" explanation, and have been told many times by their doctors that there is an organic explanation.
comes
14 15 16. 17.
CH, Taylor HC A psychosomatic study of pelvic congestion. Am J Obstet Gynecol 1952, 64: 1-12 Manning AP, Thompson WG, Heaton KW, Morris AF. Towards positive diagnosis of the irritable bowel. Br Med J 1978; ii: 653-54. Beard RW, Belsey EM, Lieberman BA, Wilkinson JCM. Pelvic pain in women. Am J Obstet Gynecol 1977; 128: 566-70 Renaer M, Vertommen H, Nijs P, Wagemans MA, van Hemelrijck MA. Psychological aspects of chronic pelvic pain in women. Am J Obstet Gynecol 1979; 134: 75-80. Duncan
The label of psychological is an affront to self respect, particularly in patients with pelvic pain who are striving hard to present themselves as being normal. The doctor confronted with this problem is often helpless. Personality studies, such as those described previously, may be of interest but in themselves provide no information on which to base management strategies. Logically, the treatment of choice for "stress-induced" pelvic pain is some form of psychotherapy. O’NEILL’8 reported that the two most valuable techniques were what amounted to discussion to determine the sources of anxiety, friction, and discontent, and relaxation therapy. Two prospective studies,16,19 one of which was a randomised control trial,19 have shown that a substantial reduction in the number of attacks of pelvic pain can be achieved by relatively simple psychotherapy. These were small trials of a preliminary nature and it is not clear at this stage what form of psychotherapy is most effective or how it is effective. However, it does seem that relief for women with pelvic pain can be secured through psychological interventions. Furthermore, such interventions seem to be more effective than mere reassurance, after laparoscopy, that the pelvis is normal. How might this psychological treatment be provided? Referral of women with pelvic pain to departments of psychiatry has been unrewarding. Many patients have considerable difficulty in accepting a non-organic basis for their pain and, in addition, they feel rejected by the gynaecologist. These difficulties can be partly circumvented by having the psychiatrist or psychologist working in the gynaecology clinic. The ready availability and safety of laparoscopy has opened a new sphere of medicine. In addition, perhaps, modern life is increasing the frequency of non-organic pelvic pain along with other stress-related disorders. Whatever the reason, there is a need for those who commonly see and treat abdominal pain to recognise that a surgical solution is often not satisfactory unless disease can be demonstrated with certainty. For the future, one can only hope that psychiatrists and psychologists will turn their interests to helping their surgical colleagues unravel the diagnostic and therapeutic intricacies of this condition. TRANSFUSION DISASTERS BLOOD transfusion is widely therapy available. Certainly
regarded as the safest form of
most transfusions are well but blood-transfusion services devote a great deal of tolerated, effort to promoting the safety and quality of their products. Two papers from the United Statesl,2 have reviewed the causes of fatal transfusion reactions reported to the Bureau of 18. O’Neill D. Tension
pain in gynaecological practice. J Obstet Gynaecol Br Emp 1958, 65: 106-09. 19. Pearce S, Knight C, Beard RW. Pelvic pain - a common gynaecological problem In van Hall EV, Bos G, eds Psychosomatische Verloskunde en Gynaecologie (Boerhaave Cahiers no 3). Stafleus Wetenschappelijke Uitgeversmaatschapij B B Holland 1981: 97-106. 1. Honig CL, Bove JR. Transfusion associated fatalities review of Bureau of Biologies reports 1976-78. Transfusion 1980; 20: 653-61. 2. Camp FR, Monaghan WP. Fatal blood transfusion reactions an analysis Am J Forens Med Pathol 1981; 2: 143-50.
avoidance of milk intolerance.
Techniques for training health.workers and mothers must be further explored in various cultural settings. And it will be important to evaluate the full impact of national ORT programmes on mortality and morbidity. If there is a tendency to overestimate the impact of ORT on child mortality, this may lead to expectations that cannot be met.
Pelvic Pain be one of the in commonest presenting symptoms medical practice. The general practitioner will think of pelvic inflammatory disease, the surgeon of bowel disease, particularly appendicitis, and the gynaecologist of conditions affecting the female genital tract. In consequence, the management varies widely and ranges from the conservative to the radical. In 1958, MORRIS and O’NEILLI reported that pelvic pain was the most common complaint in women attending as gynaecological outpatients in their clinic; and disquiet at some of the more radical forms of management was already apparent in TAYLOR’s2 comment in 1957 that "premature resort to surgery is the characteristic error in the present day management of pelvic pain". The contribution that laparoscopy has made to improving diagnosis and hence therapeutic potential has been highlighted by two studies, one by GILLIBRAND3 from the U.K. and the other by MURPHY and FLIEGNER4 from Australia. In the British study, 331 women presented with some form of lower abdominal pain which was of sufficient severity to warrant investigation by laparoscopy. Only 37% had any form of pelvic disease, meaning that in almost twothirds there was no visible lesion which could account for their pain. Both studies attest to the difficulty in arriving at a reliable diagnosis from the history and physical signs before laparoscopy. While the existence of some form of pelvic disease was correctly predicted in 75-82% of cases, the nature of the disease was correctly diagnosed in only 50% of the women. In MURPHY and FLIEGNER’s study, pelvic inflammatory disease was diagnosed before laparoscopy in 22 women but was confirmed in only 7. 6 of!the women had an entirely normal pelvis and, if treated conservatively in the accepted manner with antibiotics, could have become one of the familiar "pelvic cripples". These women, reminded by any twinge of pain that their future fertility is threatened, their anxiety fuelled by doctors prescribing repeated courses of antibiotics for "chronic PID", may well be appearing in increasing numbers in doctors’ surgeries because of the rising LOWER abdominal
pain
must
-
1 Morris N, O’Neill D. Outpatient gynaecology. Br Med J 1958; ii: 1038-39 2 Taylor HC The Problem of pelvic pain. In: Meigs JV, Somers HS, eds. Progress in gynecology, vol III New York. Grune and Stratton, 1957; 191-208. 3 Gillibrand PN Investigation of pelvic pain. Communication at the Scientific Meeting on Chronic Pelvic Pain - a Gynaecological Headache, Royal College of Obstetricians and Gynaecologists, May, 1981. 4 Murphy A, Fliegner J. Diagnostic laparoscopy - role in management of acute pelvic pain. Med J Aust 1981; i: 571-73.
incidence of venereal infection in big cities.5 The findings of these studies on lower abdominal pain make the point that the time has come for both gynaecologists and surgeons to include laparoscopy as part of their routine investigation of recurrent attacks of lower abdominal pain. The national survey by the Royal College of Obstetricians and Gynaecologists6 showed laparoscopy to be a thoroughly safe technique which does not require a long stay in hospital. The value of this technique to the general surgeon is uncertain but the finding, in two studies,7,8 of a non-inflamed appendix in 50% of individuals undergoing emergency appendicectomy for acute lower abdominal pain suggests that much might be gained by introducing laparoscopy into general surgical practice. What is one to make of the common failure to diagnose disease in individuals complaining of pelvic pain-often for many years? A wide variety of possible causes have been proposed. The syndrome of pelvic pain, dyspareunia, and excessive fatigue described by ALLEN and MASTERS9 was ascribed by them to traumatic laceration of the uterine supports, the most prevalent lesions being acute uterine retroversion and laceration of the posterior leaf of the broad ligament. Surgical repair is still advocated for the condition in many parts of the world but has never achieved popularity in the U.K. The studies of RENAER’O have convincingly disposed of this syndrome as a major cause of unexplained pelvic pain. Other hypothetical causes such as pelvic varicosities and adnexal oedema have also been satisfactorily discounted." One is left with the likely possibility that pelvic pain, in association with the laparoscopic finding of a normal pelvis, is often a stress-related disorder. Symptoms may date from childhood when abdominal pain is a common complaint. DODGE 12 concluded that, in 95% of children referred to a hospital clinic for abdominal pain, the symptoms were .emotionally determined. While this observation is not evidence that the same condition carries over into adult life, it is a possibility that cannot be discounted. GOMEZ and DALLY 133 studied a group of men and women who attended a medical or surgical outpatient clinic for recurrent or persistent abdominal pain for which no organic cause was apparent at their first visit. They concluded that psychiatric factors were primarily responsible for the pain in at least 84% of patients. This is an important 5. Weström L. Incidence, prevalence and trends of acute pelvic inflammatory disease and its consequences in industrialised countries. Am J Obstet Gynecol 1980; 138: 880-92. 6. Report on the Confidential Enquiry in Gynaecological Laparoscopy. London: Royal College of Obstetricians and Gynaecologists, 1978 7. Ingram PW, Evans G, Oppenheim AN. Right iliac fossa pain in young women. Br Med J 1965; ii: 149-51 8. Creed F. Life events and appendicectomy. Lancet 1981; i: 1381-85. 9. Allen WM, Masters WH. Traumatic laceration of uterine support. Am J Obster Gynecol 1975; 70: 500-13 10. Renaer M. Chronic pelvic pain without obvious pathology in women: Personal observations and a review of the problem. Europ J Obstet Gynecol Reprod Biol 1980; 10: 415-63 11. Renaer M In: Renaer M, ed. Chronic pelvic pain in women. Berlin: Springer Verlag, 1981. 12. Dodge JA. Recurrent abdominal pain in children. Br Med J 1976; i: 385-87. 13. Gomez J, Dally P. Psychologically mediated abdominal pain in surgical and medical
outpatient clinics. Br
Med J 1977; i: 1451-53.
618
study for it raises the possibility that pain may be used by the sufferer to manipulate life around him or her. GOMEZ and DALLY also showed that, while stressinduced abdominal pain is commoner in women than in men, the difference is by no means as great as is generally thought, the ratio being about 2:1. They also found that depression and what are loosely termed personality disorders were common in their study group, particularly amongst women. These observations have been confirmed by other workers, but an association between the complaint of pain and emotional disorder does not, of course, explain why the pain arises. The fact that the pain might be associated with psychological or psychiatric factors does not in any way suggest that the pain is imaginary and not real. There is no doubt that these individuals experience pain which may sometimes be so severe as to be abdominal crisis. DUNCAN and in pelvic blood flow fluctuations reported induced by acute mood changes such as anxiety, depression, and resentment. They postulated that local "congestion" in the pelvis could induce a sensation of pain. It seems unlikely that much advance will be made in this area until the changes in the pelvic organs can be measured. Perhaps some clue lies in the site of the pain. For example, in some individuals bowel symptoms prevail, giving rise to the irritable bowel syndrome,’s whilst in others it is the uterus or ovaries that is the site of the pain. Possibly the nature of’the emotional disturbance determines which organ is affected or, alternatively, the sensitivity of a particular organ mistaken for
an acute
TAYLOR 14
system. As yet, the
nature of the emotional disturbances in with pelvic pain has not been revealed. in which personality However, several studiesl4>’6>" have been examined suggest that such women profiles are more introverted and neurotic than the general population and have difficulty in forming rewarding relationships as well as having abnormal attitudes towards their own and their partner’s sexuality. It is possible that people with certain personality traits may respond to stressful events by getting pain. There was evidence to this effect in one study of young men and women who had an appendix, either normal or inflamed, removed for abdominal pain.’ Why is the management of pelvic pain so unsatisfactory? The answer is multifactorial. The philosophy of modern medicine demands that an organic cause for any symptom should be sought
women
exhaustively before a possible psychosomatic cause into the reckoning. Equally, patients seek an "organic" explanation, and have been told many times by their doctors that there is an organic explanation.
comes
14 15 16. 17.
CH, Taylor HC A psychosomatic study of pelvic congestion. Am J Obstet Gynecol 1952, 64: 1-12 Manning AP, Thompson WG, Heaton KW, Morris AF. Towards positive diagnosis of the irritable bowel. Br Med J 1978; ii: 653-54. Beard RW, Belsey EM, Lieberman BA, Wilkinson JCM. Pelvic pain in women. Am J Obstet Gynecol 1977; 128: 566-70 Renaer M, Vertommen H, Nijs P, Wagemans MA, van Hemelrijck MA. Psychological aspects of chronic pelvic pain in women. Am J Obstet Gynecol 1979; 134: 75-80. Duncan
The label of psychological is an affront to self respect, particularly in patients with pelvic pain who are striving hard to present themselves as being normal. The doctor confronted with this problem is often helpless. Personality studies, such as those described previously, may be of interest but in themselves provide no information on which to base management strategies. Logically, the treatment of choice for "stress-induced" pelvic pain is some form of psychotherapy. O’NEILL’8 reported that the two most valuable techniques were what amounted to discussion to determine the sources of anxiety, friction, and discontent, and relaxation therapy. Two prospective studies,16,19 one of which was a randomised control trial,19 have shown that a substantial reduction in the number of attacks of pelvic pain can be achieved by relatively simple psychotherapy. These were small trials of a preliminary nature and it is not clear at this stage what form of psychotherapy is most effective or how it is effective. However, it does seem that relief for women with pelvic pain can be secured through psychological interventions. Furthermore, such interventions seem to be more effective than mere reassurance, after laparoscopy, that the pelvis is normal. How might this psychological treatment be provided? Referral of women with pelvic pain to departments of psychiatry has been unrewarding. Many patients have considerable difficulty in accepting a non-organic basis for their pain and, in addition, they feel rejected by the gynaecologist. These difficulties can be partly circumvented by having the psychiatrist or psychologist working in the gynaecology clinic. The ready availability and safety of laparoscopy has opened a new sphere of medicine. In addition, perhaps, modern life is increasing the frequency of non-organic pelvic pain along with other stress-related disorders. Whatever the reason, there is a need for those who commonly see and treat abdominal pain to recognise that a surgical solution is often not satisfactory unless disease can be demonstrated with certainty. For the future, one can only hope that psychiatrists and psychologists will turn their interests to helping their surgical colleagues unravel the diagnostic and therapeutic intricacies of this condition. TRANSFUSION DISASTERS BLOOD transfusion is widely therapy available. Certainly
regarded as the safest form of
most transfusions are well but blood-transfusion services devote a great deal of tolerated, effort to promoting the safety and quality of their products. Two papers from the United Statesl,2 have reviewed the causes of fatal transfusion reactions reported to the Bureau of 18. O’Neill D. Tension
pain in gynaecological practice. J Obstet Gynaecol Br Emp 1958, 65: 106-09. 19. Pearce S, Knight C, Beard RW. Pelvic pain - a common gynaecological problem In van Hall EV, Bos G, eds Psychosomatische Verloskunde en Gynaecologie (Boerhaave Cahiers no 3). Stafleus Wetenschappelijke Uitgeversmaatschapij B B Holland 1981: 97-106. 1. Honig CL, Bove JR. Transfusion associated fatalities review of Bureau of Biologies reports 1976-78. Transfusion 1980; 20: 653-61. 2. Camp FR, Monaghan WP. Fatal blood transfusion reactions an analysis Am J Forens Med Pathol 1981; 2: 143-50.