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Acute and Chronic Pelvic Pain
Adolescent Gynecology
0031-3955/89 $0.00
+ .20
Acute and Chronic Pelvic Pain
Donald Peter Goldstein, MD*
Acute and chronic pelvic pain accounts for a substantial number of office and emergency department consultations for the gynecologists who deal with the adolescent age group. The reasons are twofold: first, there is a tendency to attribute all pain "below the umbilicus" in perimenarchal and postmenarchal females to a gynecologic etiology; second, most physicians are reluctant to perform a pelvic examination in the young patient. The differential diagnosis of pelvic pain, in fact, includes a wide variety of gynecologic, non gynecologic, and functional or psychosomatic causes. The purpose of this article is to suggest an efficient approach to this common and challenging problem.
ACUTE PELVIC PAIN Acute pelvic pain necessitates aggressive management because of the intensity of symptoms and the possibility that a potentially life-threatening condition may exist.
DIFFERENTIAL DIAGNOSIS
The differential diagnosis of acute pelvic pain in adolescents is summarized in Table 1. The gynecologic causes can be divided into three categories: infection, rupture, and torsion. In general, symptoms associated with infection usually develop progressively over a few days. In cases of rupture or torsion, pain occurs suddenly and the patient can most often tell precisely at what time symptoms began. Nongynecologic etiologies involve mainly the digestive or the urinary tract.
*Assistant
Clinical Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Harvard Medical School; Chief, Division of Gynecology, Department of Surgery, The Children's Hospital, Boston, Massachusetts
Pediatric Clinics of North America-Vol. 36, No.3, June 1989
573
574
DONALD PETER GOLDSTEIN
HISTORY AND PHYSICAL EXAMINATION
The history should define, as exactly as possible, the sequence of events, the pain location and its radiation, and associated gastrointestinal, urinary tract, and systemic symptoms. A careful menstrual, contraceptive, and sexual history is also mandatory. A complete physical examination should, of course, be performed. Special attention is paid to the abdomen to localize the pain, define the presence of and identifY peritoneal signs and evidence of bowel obstruction. A pelvic exam must be performed on every patient to determine the uterine size, shape and symmetry, the presence of adnexal or cervical tenderness, and to identifY adnexal masses or thickening. A rectoabdominal examination in the lithotomy position is adequate when the hymen is "tight."
DIAGNOSTIC STUDIES
The basic laboratory workup should include a complete blood count with differential, an erythrocyte sedimentation rate, a complete urinalysis, a urine culture, a pregnancy test, and a cervical culture for gonococcus and chlamydia. The finding of a high white count or sedimentation rate suggests the presence of either an infectious or inflammatory process, or the presence of ischemia, usually secondary to adnexal torsion or bowel obstruction. Hemoglobin and hematocrit are usually poor indicators of bleeding because in acute hemorrhage hemodilution may not have occurred. Depending on the type of pregnancy test used, it should be remembered that a negative result does not always rule out early intrauterine or an ectopic pregnancy. A pelvic ultrasound may be valuable to confirm the presence of a mass when the pelvic examination is not completely satisfactory, to identifY the presence of free fluid in the cuI de sac, and to localize a suspected pregnancy.
MANAGEMENT
After these first steps have been taken, all patients fall into one of the following clinical categories: 1. There is a definite surgical emergency that necessitates immediate attention. In this situation, the suspected diagnosis is usually an acute hemoperitoneum, a ruptured tubo-ovarian abscess, an acute or ruptured appendicitis, or some other gastrointestinal surgical emergency. 2. The patient is suffering from a medical condition and adequate treatment is started (e.g., urinary tract infection, gastroenteritis, pelvic inflammatory disease, etc). 3. The problem needs further investigation (e.g., urinary calculi). 4. The condition remains undiagnosed and the question usually is "Does this patient have PID, an ectopic pregnancy, appendicitis, or a ruptured or torsioned ovarian cyst?"
575
ACUTE AND CHRONIC PELVIC PAIN
Table 1. Differential Diagnosis of Acute Pelvic Pain in Adolescent Females Nongynecologic Causes Gastrointestinal Appendicitis Meckel's diverticulitis Gastroenteritis Mesenteric adenitis Intestinal obstruction Urinary Cystitis Pyelonephritis Calculi
Gynecologic Causes Infection Pelvic inflammatory disease Rupture Follicular cyst Corpus luteum cyst Endometrioma Tumor Torsion Ovarian cyst Tube Hydatid of Morgagni
At this point, laparoscopy becomes an invaluable diagnostic tool. The potential risk of a surgical diagnostic procedure remains a concern for many physicians. In fact, a laparoscopy provides an immediate diagnosis that allows for appropriate medical or surgical treatment. It is also more cost effective to perform an immediate laparoscopy than to subject the patient to a long period of inpatient observation during which a surgical catastrophe, such as a ruptured appendicitis or ectopic pregnancy, remains a possibility. In cases of ruptured ovarian cysts or hemorrhagic corpus luteum, in which there is no more active bleeding, it is possible to aspirate free blood and clots and ensure hemostasis by fulguration of bleeders. This technique may save the patient several days of agonizing pain and usually allows her to be discharged within 12 hours of the procedure. In our judgment, the advantages of laparoscopy certainly outweigh the minimal surgical risk in these generally healthy teenagers, particularly where appendicitis is a real possibility. Table 2 summarizes the principallaparoscopic diagnosis in 121 patients ages 11 to 17 who presented at Boston Children's Hospital with acute abdominal pain between 1980 and 1986. In general, the most common cause of pain was due to some complication of an ovarian cyst. It is of interest that the causes of acute abdominal pain in the adolescent do not appear to be age related (Table 3).
Table 2. Principal Laparoscopic Diagnoses in 121 Adolescent Females 11 to 17 Years old with Acute Pelvic Pain*
Ovarian cyst Acute PID Adnexal torsion Endometriosis Ectopic pregnancy Appendicitis No pathology
PATIENTS
PERCENT
47 21 9 6 4 13 21
39 17 8
*The Children's Hospital, Boston, MA-1980-1986
5 3 11 17
576
DONALD PETER GOLDSTEIN
Table 3. Age-related Prevalence of Principal Laparoscopic Findings in 121 Adolescent Females 11 to 17 Years old with Acute Pelvic Pain*
Ovarian cyst Acute PID Adnexal torsion Endometriosis Ectopic pregnancy Appendicitis No pathology Total
AGE 11-13
AGE 14-15
AGE 16-17
Patients (%)
Patients (%)
Patients (%)
12 (50) 4 (17) 0(0) 0(0) 0(0) 3 (13) 5 (20) 24 (20)
16 (35) 7 (16) 7 (16) 2 (4) 3 (7) 4 (9) 6 (13) 45 (37)
19 10 2 4 1 6 10 52
(37) (19) (4) (7) (2) (12) (19) (43)
*The Children's Hospital, Boston, MA-1980-1986
CHRONIC PELVIC PAIN Chronic pelvic pain (CPP) in adolescents is a common complaint and source of frustration for the patient, her parents, and her physician. CPP can be defined as 3 months or more of constant or intermittent, cyclic or acyclic pelvic pain, which has necessitated at least three separate visits to a physician without a definite diagnosis. Symptoms can be characterized by dull or severe pain, dysmenorrhea, dyspareunia, or vaginal pain. Very often these teenagers have been absent from school frequently, have seen several physicians, have undergone several radiologic examinations, and have tried a variety of analgesics without success. Many have already been referred for psychologic or psychiatric evaluation. Guzenski3 has drawn an excellent picture of the CPP patient with whom it is sometimes difficult to deal. After having been told, often more than once, that nothing is wrong with her, she may come to you with a considerable amount of anger, frustration, or desperation. It is therefore important to assure her that all efforts will be made to sort out her problem and that she will not be abandoned or her symptoms discussed as merely psychosomatic. DIFFERENTIAL DIAGNOSIS
Table 4 summarizes the differential diagnosis of CPP in adolescent females. It includes many organ systems that can be responsible for pelvic symptoms either directly or by referred pain, as well as those of functional or psychogenic etiology. An efficient approach to the problem depends on taking a thorough history and performing an adequate physical examination as well as the judicious use of diagnostic studies. HISTORY AND PHYSICAL EXAMINATION
It is essential to review the complete history of the problem, including description, location and radiation of the pain, exacerbating and relieving
577
ACUTE AND CHRONIC PELVIC PAIN
Table 4. Differential Diagnosis of Chronic Pelvic Pain in Adolescent Females Gynecologic Causes Dysmenorrhea (primary, secondary) MiUelschmertz Endometriosis Chronic pelvic inflammatory disease Ovarian cyst Genital tract malformations Pelvic congestion Pelvic serositis Gastrointestinal Causes Constipation, bowel spasms Appendiceal fecaliths Bowel inflammatory diseases Dietary intolerance (lactose)
Urinary Causes Urinary tract infection Hydronephrosis Urethral stricture Urethral caruncle Urinary retention Orthopedic Causes Lordosis, kyphosis, scoliosis Herniation of intervertebral disk Adhesions Postoperative Post pelvic infection Psychogenic
factors, association with the menstrual cycle or with gastrointestinal, urinary, and musculoskeletal symptoms. The past medical and surgical history also may provide a clue. All prior diagnostic procedures and trials of treatment should be recorded and, when possible, old medical records obtained. The familial and social history, as well as the association of the pain episodes with stressful events, should be detailed. A complete physical examination should be performed, the abdomen being carefully palpated in search of any masses, tender areas, and organomegaly. Special care should be taken to differentiate deep pain from abdominal wall tenderness, especially in patients who have undergone prior surgeries in which adhesions to the abdominal wall scar may be present. A skeletal assessment to identify any orthopedic abnormality that may be the cause of referred pelvic pain or associated with a congenital reproductive tract anomaly is also of great importance. A speculum examination should be performed to identifY any vaginal or cervical anomaly and obtain cultures and cytology specimens. The bimanual rectovaginal/abdominal palpation evaluates the pelvic structures and localizes tender areas. The posterior cuI de sac should also be assessed for pain and nodularity. DIAGNOSTIC STUDIES
The minimal laboratory workup in these patients consists of a complete blood count with differential and erythrocytic sedimentation rate, a urinalysis and culture, and cervical cultures for gonococcus and chlamydia. Other hematologic and biochemical studies are ordered, depending on clinical indications. Pelvic ultrasonography may be useful to define a mass, provide information about a suspected genital tract malformation, and to screen patients in whom a satisfactory pelvic examination is impossible. Routine sonography in every patient is probably not advisable. In a study of 96 adolescents evaluated for CPP at The Cleveland Clinic, Gidwani reported that of 15 patients in whom a pelvic mass was detected by ultrasound, only five were confirmed by laparoscopy.l
578
DONALD PETER GOLDSTEIN
No specific rules can be given regarding radiologic exams. It is certainly not advisable to submit all these teenagers to pelvic radiation without clinical indications. Gastrointestinal, urologic, and orthopedic studies should be ordered on the basis of the diagnostic impression after a thorough history and physical and laboratory workup are completed.
LAPAROSCOPY
Laparoscopy is an invaluable tool for the diagnosis of CPP. It can diagnose or confirm the presence of organic disease that cannot be demonstrated by physical, radiologic, and sonographic examination. It allows the gynecologist to obtain appropriate biopsies and to perform some primary therapy such as fulguration of endometriosis, lysis of adhesions, and aspiration of ovarian cysts. Negative findings at laparoscopy may be equally valuable in reassuring the patient that no organic disease is present and helping her to accept the idea that she might have a functional problem that requires medical or emotional treatment. Indications for laparoscopy in the evaluation of adolescents with CPP can be summarized as follows: 1. Dysmenorrhea unresponsive to the usual therapy with prostaglandin inhibitors or ovulation suppression. 2. Confirmation or exclusion of clinically suspected endometriosis, chronic pelvic inflammatory disease, pelvic adhesions, appendiceal fecaliths, ovarian cysts, and pelvic serositis. 3. Evaluation of undiagnosed pain after appropriate workup.
At Boston's Children's Hospital, our experience with laparoscopy in the diagnosis of CPP in adolescent females revealed that between July 1974 and December 1983, 282 patients ranging in age from 9 to 21 years underwent a diagnostic laparoscopy because of chronic pelvic symptoms. 2 Most of these adolescents had been referred to our gynecology service after a negative gastrointestinal and urinary tract workup or because of dysmenorrhea unresponsive to the usual therapy with prostaglandin inhibitors or oral contraceptives. Many of these patients had undergone psychiatric evaluation because of persistent and undiagnosed pain. Cases of chronic pelvic inflammatory disease were not included in the data because this condition usually is suspected on the basis of the past history and the finding of an elevated erythrocyte sedimentation rate. In these patients, a laparoscopy is usually performed to confirm the diagnosis and evaluate its severity rather than to establish the etiology of CPP. All laparoscopies were performed under general endotracheal anesthesia, either on an inpatient or ambulatory basis. A uterine mobilizer was attached to the cervix to permit mobilization of the uterus. Approximately 2 liters of carbon dioxide were used to create a pneumoperitoneum and a 7-mm Wolf or Stortz laparoscope was introduced through an infraumbilical incision. A second trocar site was established in the suprapubic area to allow the utilization of a probe or of a biopsy forceps. Table 5 summarizes the postoperative diagnosis in these patients.
579
ACUTE AND CHRONIC PELVIC PAIN
Table 5. Postoperative Diagnosis in 282 Adolescent Females with Chronic Pelvic Pain* NO. OF PATIENTS (%)
Endometriosis Postoperative adhesions Serositis Ovarian cyst Uterine malformation Otherst No pathology
126 37 15 14 15 4 71
(45%) (13%) (5%) (5%) (5%) (2%) (25%)
*The Children's Hospital, Boston, MA-1974-1983 tIieitis, infarcted hydatid of Morgagni, pelvic congestion
Three quarters of the patients were found to have intrapelvic pathology. Endometriosis was the most common finding, being diagnosed in 45 per cent of cases. In most instances, the disease was mild to moderate, with implants located in the posterior cuI de sac, on the ovaries, and on the lateral pelvic side walls. The next most common finding was postoperative adhesions, which were present in 13 per cent of patients and were, for the most part, secondary to appendectomy or ovarian cystectomy. One of the most puzzling laparoscopic findings was the presence of a pelvic serositis in 5 per cent of the patients. This was characterized by hyperemia and granuloma-like lesions of the pelvic peritoneum and uterine serosa. Peritoneal biopsies revealed the presence of mesothelial hyperplasia with hemosiderin deposits. Peritoneal culture and cytology were normal. The significance of these changes remains unclear. It may represent the appearance of very early endometriosis, a reaction to repeated hemoperitoneum secondary to leaking corpus luteum or hemoperitoneum, a viral infection, or an incidental finding. These patients are very difficult to treat. Owing to the small number of cases, no uniform therapy has emerged. Some patients respond to therapy with long-term prostaglandin inhibitors, others to ovulation suppression, and others to steroids. Long-term followup will better define this entity. A few patients with this finding have since developed endometriosis, confirmed at subsequent laparoscopy. Other findings included ovarian cysts, uterine malformations of the obstructive type, and cases of ileitis, infarcted hydatid of Morgagni, and pelvic congestion. No organic disease was documented in 25 per cent of the patients. In this group, pain was attributed to functional bowel disease or to psychogeniC factors. Despite apparently normal bowel function, many teenagers with CPP improve when placed on a regimen of stool softeners and increased dietary fiber and fluid intake. The value of a negative laparoscopy should not be underestimated. In many instances, the assurance that their pelvic structures are normal is sufficient to improve the symptoms in these adolescents. Goldstein et al. reported that 74 per cent of these patients were symptomatically improved after negative laparoscopy findings. 2 In a small number of these teenagers, adjunctive psychologic or behavioral modification therapy is necessary. For the years 1980 to 1983, the results were broken down into age
580
DONALD PETER GOLDSTEIN
Table 6. Age-related Incidence of Laparoscopic Findings in 129 Adolescent Females with Chronic Pelvic Pain*
Endometriosis Postoperative adhesions Serositis Ovarian cyst Uterine malformation Others No pathology
AGE
AGE
AGE
AGE
AGE
11-13
14-15
16-17
16-19
20-21
NO. OF PTS. (%)
NO. OF PTS. (%)
NO. OF PTS. (%)
NO. OF PTS. (%)
NO. OF PTS. (%)
2 (12%) 1 (6%) 5 (29%) 2 (12%) 1 (6%) 0(0%) 6 (35%)
9 (28%) 4 (13%) 4 (13%) 2 (6%) 0(0%) 1 (3%) 12 (37%)
21 (40%) 7 (13%) 0(0%) 3 (5%) 1 (2%) 2 (4%) 19 (36%)
17 (45%) 5 (13%) 2 (5%) 2 (5%) 0(0%) 1 (3%) 11 (29%)
7 (54%) 2 (15%) 0(0%) 0(0%) 1 (8%) 0(0%) 3 (23%)
*The Children's Hospital, Boston, MA-1980-1983
groups (Table 6). It is interesting to note that the incidence of endometriosis among adolescents complaining of CPP increases progressively with age, from 12 per cent in the 11- to 13-year-old group to 54 per cent in patients aged 20 and 21 years. Pelvic serositis, on the other hand, was encountered mostly in the 11- to 15-year-old group. Other findings remained fairly constant in all age groups.
SUMMARY Acute and chronic pelvic pain in the adolescent patient needs to be taken seriously. In most cases, an underlying cause can be identified. Under no circumstances should the label of psychogenic pain be offered on these teenagers without a prior negative laparoscopy. Adequate diagnosis and early therapy are essential to improve the quality of life and preserve the reproductive prognosis in these young patients.
REFERENCES 1. Gidwani GP: Laparoscopy for diagnosis of chronic pelvic pain. Transitions: Dec, 1981 2. Goldstein DP, DeCholnoky C, Emans SJ et al: Laparoscopy in the diagnosis and management of pelvic pain in adolescents. J Reprod Med 24:251, 1980 3. Guzenski G: A new approach to chronic pelvic pain. The Female Patient. 8:32-43, 1983 25 Sunset Street Boston, MA 02120
0031-3955/89 $0.00
+ .20
Acute and Chronic Pelvic Pain
Donald Peter Goldstein, MD*
Acute and chronic pelvic pain accounts for a substantial number of office and emergency department consultations for the gynecologists who deal with the adolescent age group. The reasons are twofold: first, there is a tendency to attribute all pain "below the umbilicus" in perimenarchal and postmenarchal females to a gynecologic etiology; second, most physicians are reluctant to perform a pelvic examination in the young patient. The differential diagnosis of pelvic pain, in fact, includes a wide variety of gynecologic, non gynecologic, and functional or psychosomatic causes. The purpose of this article is to suggest an efficient approach to this common and challenging problem.
ACUTE PELVIC PAIN Acute pelvic pain necessitates aggressive management because of the intensity of symptoms and the possibility that a potentially life-threatening condition may exist.
DIFFERENTIAL DIAGNOSIS
The differential diagnosis of acute pelvic pain in adolescents is summarized in Table 1. The gynecologic causes can be divided into three categories: infection, rupture, and torsion. In general, symptoms associated with infection usually develop progressively over a few days. In cases of rupture or torsion, pain occurs suddenly and the patient can most often tell precisely at what time symptoms began. Nongynecologic etiologies involve mainly the digestive or the urinary tract.
*Assistant
Clinical Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Harvard Medical School; Chief, Division of Gynecology, Department of Surgery, The Children's Hospital, Boston, Massachusetts
Pediatric Clinics of North America-Vol. 36, No.3, June 1989
573
574
DONALD PETER GOLDSTEIN
HISTORY AND PHYSICAL EXAMINATION
The history should define, as exactly as possible, the sequence of events, the pain location and its radiation, and associated gastrointestinal, urinary tract, and systemic symptoms. A careful menstrual, contraceptive, and sexual history is also mandatory. A complete physical examination should, of course, be performed. Special attention is paid to the abdomen to localize the pain, define the presence of and identifY peritoneal signs and evidence of bowel obstruction. A pelvic exam must be performed on every patient to determine the uterine size, shape and symmetry, the presence of adnexal or cervical tenderness, and to identifY adnexal masses or thickening. A rectoabdominal examination in the lithotomy position is adequate when the hymen is "tight."
DIAGNOSTIC STUDIES
The basic laboratory workup should include a complete blood count with differential, an erythrocyte sedimentation rate, a complete urinalysis, a urine culture, a pregnancy test, and a cervical culture for gonococcus and chlamydia. The finding of a high white count or sedimentation rate suggests the presence of either an infectious or inflammatory process, or the presence of ischemia, usually secondary to adnexal torsion or bowel obstruction. Hemoglobin and hematocrit are usually poor indicators of bleeding because in acute hemorrhage hemodilution may not have occurred. Depending on the type of pregnancy test used, it should be remembered that a negative result does not always rule out early intrauterine or an ectopic pregnancy. A pelvic ultrasound may be valuable to confirm the presence of a mass when the pelvic examination is not completely satisfactory, to identifY the presence of free fluid in the cuI de sac, and to localize a suspected pregnancy.
MANAGEMENT
After these first steps have been taken, all patients fall into one of the following clinical categories: 1. There is a definite surgical emergency that necessitates immediate attention. In this situation, the suspected diagnosis is usually an acute hemoperitoneum, a ruptured tubo-ovarian abscess, an acute or ruptured appendicitis, or some other gastrointestinal surgical emergency. 2. The patient is suffering from a medical condition and adequate treatment is started (e.g., urinary tract infection, gastroenteritis, pelvic inflammatory disease, etc). 3. The problem needs further investigation (e.g., urinary calculi). 4. The condition remains undiagnosed and the question usually is "Does this patient have PID, an ectopic pregnancy, appendicitis, or a ruptured or torsioned ovarian cyst?"
575
ACUTE AND CHRONIC PELVIC PAIN
Table 1. Differential Diagnosis of Acute Pelvic Pain in Adolescent Females Nongynecologic Causes Gastrointestinal Appendicitis Meckel's diverticulitis Gastroenteritis Mesenteric adenitis Intestinal obstruction Urinary Cystitis Pyelonephritis Calculi
Gynecologic Causes Infection Pelvic inflammatory disease Rupture Follicular cyst Corpus luteum cyst Endometrioma Tumor Torsion Ovarian cyst Tube Hydatid of Morgagni
At this point, laparoscopy becomes an invaluable diagnostic tool. The potential risk of a surgical diagnostic procedure remains a concern for many physicians. In fact, a laparoscopy provides an immediate diagnosis that allows for appropriate medical or surgical treatment. It is also more cost effective to perform an immediate laparoscopy than to subject the patient to a long period of inpatient observation during which a surgical catastrophe, such as a ruptured appendicitis or ectopic pregnancy, remains a possibility. In cases of ruptured ovarian cysts or hemorrhagic corpus luteum, in which there is no more active bleeding, it is possible to aspirate free blood and clots and ensure hemostasis by fulguration of bleeders. This technique may save the patient several days of agonizing pain and usually allows her to be discharged within 12 hours of the procedure. In our judgment, the advantages of laparoscopy certainly outweigh the minimal surgical risk in these generally healthy teenagers, particularly where appendicitis is a real possibility. Table 2 summarizes the principallaparoscopic diagnosis in 121 patients ages 11 to 17 who presented at Boston Children's Hospital with acute abdominal pain between 1980 and 1986. In general, the most common cause of pain was due to some complication of an ovarian cyst. It is of interest that the causes of acute abdominal pain in the adolescent do not appear to be age related (Table 3).
Table 2. Principal Laparoscopic Diagnoses in 121 Adolescent Females 11 to 17 Years old with Acute Pelvic Pain*
Ovarian cyst Acute PID Adnexal torsion Endometriosis Ectopic pregnancy Appendicitis No pathology
PATIENTS
PERCENT
47 21 9 6 4 13 21
39 17 8
*The Children's Hospital, Boston, MA-1980-1986
5 3 11 17
576
DONALD PETER GOLDSTEIN
Table 3. Age-related Prevalence of Principal Laparoscopic Findings in 121 Adolescent Females 11 to 17 Years old with Acute Pelvic Pain*
Ovarian cyst Acute PID Adnexal torsion Endometriosis Ectopic pregnancy Appendicitis No pathology Total
AGE 11-13
AGE 14-15
AGE 16-17
Patients (%)
Patients (%)
Patients (%)
12 (50) 4 (17) 0(0) 0(0) 0(0) 3 (13) 5 (20) 24 (20)
16 (35) 7 (16) 7 (16) 2 (4) 3 (7) 4 (9) 6 (13) 45 (37)
19 10 2 4 1 6 10 52
(37) (19) (4) (7) (2) (12) (19) (43)
*The Children's Hospital, Boston, MA-1980-1986
CHRONIC PELVIC PAIN Chronic pelvic pain (CPP) in adolescents is a common complaint and source of frustration for the patient, her parents, and her physician. CPP can be defined as 3 months or more of constant or intermittent, cyclic or acyclic pelvic pain, which has necessitated at least three separate visits to a physician without a definite diagnosis. Symptoms can be characterized by dull or severe pain, dysmenorrhea, dyspareunia, or vaginal pain. Very often these teenagers have been absent from school frequently, have seen several physicians, have undergone several radiologic examinations, and have tried a variety of analgesics without success. Many have already been referred for psychologic or psychiatric evaluation. Guzenski3 has drawn an excellent picture of the CPP patient with whom it is sometimes difficult to deal. After having been told, often more than once, that nothing is wrong with her, she may come to you with a considerable amount of anger, frustration, or desperation. It is therefore important to assure her that all efforts will be made to sort out her problem and that she will not be abandoned or her symptoms discussed as merely psychosomatic. DIFFERENTIAL DIAGNOSIS
Table 4 summarizes the differential diagnosis of CPP in adolescent females. It includes many organ systems that can be responsible for pelvic symptoms either directly or by referred pain, as well as those of functional or psychogenic etiology. An efficient approach to the problem depends on taking a thorough history and performing an adequate physical examination as well as the judicious use of diagnostic studies. HISTORY AND PHYSICAL EXAMINATION
It is essential to review the complete history of the problem, including description, location and radiation of the pain, exacerbating and relieving
577
ACUTE AND CHRONIC PELVIC PAIN
Table 4. Differential Diagnosis of Chronic Pelvic Pain in Adolescent Females Gynecologic Causes Dysmenorrhea (primary, secondary) MiUelschmertz Endometriosis Chronic pelvic inflammatory disease Ovarian cyst Genital tract malformations Pelvic congestion Pelvic serositis Gastrointestinal Causes Constipation, bowel spasms Appendiceal fecaliths Bowel inflammatory diseases Dietary intolerance (lactose)
Urinary Causes Urinary tract infection Hydronephrosis Urethral stricture Urethral caruncle Urinary retention Orthopedic Causes Lordosis, kyphosis, scoliosis Herniation of intervertebral disk Adhesions Postoperative Post pelvic infection Psychogenic
factors, association with the menstrual cycle or with gastrointestinal, urinary, and musculoskeletal symptoms. The past medical and surgical history also may provide a clue. All prior diagnostic procedures and trials of treatment should be recorded and, when possible, old medical records obtained. The familial and social history, as well as the association of the pain episodes with stressful events, should be detailed. A complete physical examination should be performed, the abdomen being carefully palpated in search of any masses, tender areas, and organomegaly. Special care should be taken to differentiate deep pain from abdominal wall tenderness, especially in patients who have undergone prior surgeries in which adhesions to the abdominal wall scar may be present. A skeletal assessment to identify any orthopedic abnormality that may be the cause of referred pelvic pain or associated with a congenital reproductive tract anomaly is also of great importance. A speculum examination should be performed to identifY any vaginal or cervical anomaly and obtain cultures and cytology specimens. The bimanual rectovaginal/abdominal palpation evaluates the pelvic structures and localizes tender areas. The posterior cuI de sac should also be assessed for pain and nodularity. DIAGNOSTIC STUDIES
The minimal laboratory workup in these patients consists of a complete blood count with differential and erythrocytic sedimentation rate, a urinalysis and culture, and cervical cultures for gonococcus and chlamydia. Other hematologic and biochemical studies are ordered, depending on clinical indications. Pelvic ultrasonography may be useful to define a mass, provide information about a suspected genital tract malformation, and to screen patients in whom a satisfactory pelvic examination is impossible. Routine sonography in every patient is probably not advisable. In a study of 96 adolescents evaluated for CPP at The Cleveland Clinic, Gidwani reported that of 15 patients in whom a pelvic mass was detected by ultrasound, only five were confirmed by laparoscopy.l
578
DONALD PETER GOLDSTEIN
No specific rules can be given regarding radiologic exams. It is certainly not advisable to submit all these teenagers to pelvic radiation without clinical indications. Gastrointestinal, urologic, and orthopedic studies should be ordered on the basis of the diagnostic impression after a thorough history and physical and laboratory workup are completed.
LAPAROSCOPY
Laparoscopy is an invaluable tool for the diagnosis of CPP. It can diagnose or confirm the presence of organic disease that cannot be demonstrated by physical, radiologic, and sonographic examination. It allows the gynecologist to obtain appropriate biopsies and to perform some primary therapy such as fulguration of endometriosis, lysis of adhesions, and aspiration of ovarian cysts. Negative findings at laparoscopy may be equally valuable in reassuring the patient that no organic disease is present and helping her to accept the idea that she might have a functional problem that requires medical or emotional treatment. Indications for laparoscopy in the evaluation of adolescents with CPP can be summarized as follows: 1. Dysmenorrhea unresponsive to the usual therapy with prostaglandin inhibitors or ovulation suppression. 2. Confirmation or exclusion of clinically suspected endometriosis, chronic pelvic inflammatory disease, pelvic adhesions, appendiceal fecaliths, ovarian cysts, and pelvic serositis. 3. Evaluation of undiagnosed pain after appropriate workup.
At Boston's Children's Hospital, our experience with laparoscopy in the diagnosis of CPP in adolescent females revealed that between July 1974 and December 1983, 282 patients ranging in age from 9 to 21 years underwent a diagnostic laparoscopy because of chronic pelvic symptoms. 2 Most of these adolescents had been referred to our gynecology service after a negative gastrointestinal and urinary tract workup or because of dysmenorrhea unresponsive to the usual therapy with prostaglandin inhibitors or oral contraceptives. Many of these patients had undergone psychiatric evaluation because of persistent and undiagnosed pain. Cases of chronic pelvic inflammatory disease were not included in the data because this condition usually is suspected on the basis of the past history and the finding of an elevated erythrocyte sedimentation rate. In these patients, a laparoscopy is usually performed to confirm the diagnosis and evaluate its severity rather than to establish the etiology of CPP. All laparoscopies were performed under general endotracheal anesthesia, either on an inpatient or ambulatory basis. A uterine mobilizer was attached to the cervix to permit mobilization of the uterus. Approximately 2 liters of carbon dioxide were used to create a pneumoperitoneum and a 7-mm Wolf or Stortz laparoscope was introduced through an infraumbilical incision. A second trocar site was established in the suprapubic area to allow the utilization of a probe or of a biopsy forceps. Table 5 summarizes the postoperative diagnosis in these patients.
579
ACUTE AND CHRONIC PELVIC PAIN
Table 5. Postoperative Diagnosis in 282 Adolescent Females with Chronic Pelvic Pain* NO. OF PATIENTS (%)
Endometriosis Postoperative adhesions Serositis Ovarian cyst Uterine malformation Otherst No pathology
126 37 15 14 15 4 71
(45%) (13%) (5%) (5%) (5%) (2%) (25%)
*The Children's Hospital, Boston, MA-1974-1983 tIieitis, infarcted hydatid of Morgagni, pelvic congestion
Three quarters of the patients were found to have intrapelvic pathology. Endometriosis was the most common finding, being diagnosed in 45 per cent of cases. In most instances, the disease was mild to moderate, with implants located in the posterior cuI de sac, on the ovaries, and on the lateral pelvic side walls. The next most common finding was postoperative adhesions, which were present in 13 per cent of patients and were, for the most part, secondary to appendectomy or ovarian cystectomy. One of the most puzzling laparoscopic findings was the presence of a pelvic serositis in 5 per cent of the patients. This was characterized by hyperemia and granuloma-like lesions of the pelvic peritoneum and uterine serosa. Peritoneal biopsies revealed the presence of mesothelial hyperplasia with hemosiderin deposits. Peritoneal culture and cytology were normal. The significance of these changes remains unclear. It may represent the appearance of very early endometriosis, a reaction to repeated hemoperitoneum secondary to leaking corpus luteum or hemoperitoneum, a viral infection, or an incidental finding. These patients are very difficult to treat. Owing to the small number of cases, no uniform therapy has emerged. Some patients respond to therapy with long-term prostaglandin inhibitors, others to ovulation suppression, and others to steroids. Long-term followup will better define this entity. A few patients with this finding have since developed endometriosis, confirmed at subsequent laparoscopy. Other findings included ovarian cysts, uterine malformations of the obstructive type, and cases of ileitis, infarcted hydatid of Morgagni, and pelvic congestion. No organic disease was documented in 25 per cent of the patients. In this group, pain was attributed to functional bowel disease or to psychogeniC factors. Despite apparently normal bowel function, many teenagers with CPP improve when placed on a regimen of stool softeners and increased dietary fiber and fluid intake. The value of a negative laparoscopy should not be underestimated. In many instances, the assurance that their pelvic structures are normal is sufficient to improve the symptoms in these adolescents. Goldstein et al. reported that 74 per cent of these patients were symptomatically improved after negative laparoscopy findings. 2 In a small number of these teenagers, adjunctive psychologic or behavioral modification therapy is necessary. For the years 1980 to 1983, the results were broken down into age
580
DONALD PETER GOLDSTEIN
Table 6. Age-related Incidence of Laparoscopic Findings in 129 Adolescent Females with Chronic Pelvic Pain*
Endometriosis Postoperative adhesions Serositis Ovarian cyst Uterine malformation Others No pathology
AGE
AGE
AGE
AGE
AGE
11-13
14-15
16-17
16-19
20-21
NO. OF PTS. (%)
NO. OF PTS. (%)
NO. OF PTS. (%)
NO. OF PTS. (%)
NO. OF PTS. (%)
2 (12%) 1 (6%) 5 (29%) 2 (12%) 1 (6%) 0(0%) 6 (35%)
9 (28%) 4 (13%) 4 (13%) 2 (6%) 0(0%) 1 (3%) 12 (37%)
21 (40%) 7 (13%) 0(0%) 3 (5%) 1 (2%) 2 (4%) 19 (36%)
17 (45%) 5 (13%) 2 (5%) 2 (5%) 0(0%) 1 (3%) 11 (29%)
7 (54%) 2 (15%) 0(0%) 0(0%) 1 (8%) 0(0%) 3 (23%)
*The Children's Hospital, Boston, MA-1980-1983
groups (Table 6). It is interesting to note that the incidence of endometriosis among adolescents complaining of CPP increases progressively with age, from 12 per cent in the 11- to 13-year-old group to 54 per cent in patients aged 20 and 21 years. Pelvic serositis, on the other hand, was encountered mostly in the 11- to 15-year-old group. Other findings remained fairly constant in all age groups.
SUMMARY Acute and chronic pelvic pain in the adolescent patient needs to be taken seriously. In most cases, an underlying cause can be identified. Under no circumstances should the label of psychogenic pain be offered on these teenagers without a prior negative laparoscopy. Adequate diagnosis and early therapy are essential to improve the quality of life and preserve the reproductive prognosis in these young patients.
REFERENCES 1. Gidwani GP: Laparoscopy for diagnosis of chronic pelvic pain. Transitions: Dec, 1981 2. Goldstein DP, DeCholnoky C, Emans SJ et al: Laparoscopy in the diagnosis and management of pelvic pain in adolescents. J Reprod Med 24:251, 1980 3. Guzenski G: A new approach to chronic pelvic pain. The Female Patient. 8:32-43, 1983 25 Sunset Street Boston, MA 02120