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Management of pelvic pain after negative diagnostic laparoscopy

10/1/2018 - Michael Breen, MD, FACOG

Mentor: Amy Young, MD, FACOG.

Editor: Abimbola Famuyide, MBBS.

Although considered gold standard in investigating acute or chronic pelvic pain, diagnostic laparoscopy may not demonstrate any causative factors in 30-50% of patients, leading to considerable disappointment.  When endometriosis is not detected by gross inspection and or by biopsy, alternative etiologies should be considered. Often, multiple etiologies are culpable; hence evaluation should be aimed at identifying contributory factors rather than focusing on a single diagnosis as the cause of pelvic pain.

A thorough history should be elicited for characteristics of the pain (type, site, duration, and referral), association with bowel, urinary symptoms and impact of physical activity and posture. Evaluation should include abdominal and pelvic examination with careful palpation for focal muscle tenderness (levator ani, obturator internus, and piriformis), inguinal and femoral hernia orifices, sacroiliac joints, pubic symphysis and lumbosacral vertebrae. Hernias may be diagnosed by palpating a cough impulse during physical examination; inguinal ultrasonography (with cough stress test) may also aid diagnosis. Treatment is surgical repair with or without supporting mesh.

Musculoskeletal source of pain is often overlooked, for example, myofascial pain (trigger points), pelvic floor myalgia, hernias, degenerative disc disease and nerve entrapment syndromes. In one study, abdominal wall pain (AWP) was diagnosed in 67% of patients with chronic pelvic pain (CPP) and AWP patients were more likely to require opioids or pain adjuvants than women without abdominal wall pain. Diagnosis of AWP is aided by Carnett’s test. Carnett’s test is performed by having the patient tense her abdominal wall; unchanged or worsening abdominal wall tenderness (positive test) is diagnostic of abdominal wall pain. Once hernias are excluded, injecting the muscle with a local anesthetic with or without corticosteroids is both diagnostic and therapeutic.

Pelvic floor myalgia (non-relaxing pelvic floor dysfunction) is a common cause of CPP and is characterized by pelvic pain worsened by prolonged sitting or standing, or physical activity including sexual intercourse. Pain is minimal in the morning and worsens as the day progresses and is often associated with defecatory dysfunction or urinary urgency.  One prospective magnetic resonance imaging (MRI) study identified levator ani injury in 77% of patients with pelvic pain after negative laparoscopy compared to 4% of pain free controls. Careful digital palpation may show exquisite tenderness of levator ani, obturator internus and or pyriformis muscles. Anorectal manometry with balloon expulsion may help confirm defecatory disorders and urodynamic testing may be appropriate in evaluating urinary symptoms. Early referral for physical therapy is important with 60-80% of patients reporting marked or complete relief.

Adenomyosis is common in women of reproductive age group and is often indistinguishable from endometriosis with features including cyclic pelvic pain, severe dysmenorrhea, and deep dyspareunia. Unlike endometriosis, heavy menstrual bleeding may be a prominent symptom. Pelvic examination may demonstrate a globally enlarged and tender uterus and 2D ultrasonography may show characteristic features including heterogenous myometrial echo texture, myometrial cysts, indistinct endometrial-myometrial border and presence of diffuse myometrial vascularity. Both 3D ultrasonography and MRI imaging can be diagnostic if the initial results are inconclusive. Effective treatment options include oral contraceptive pills, levonorgestrel intrauterine systems and uterine artery embolization.

Depression, sleep disorders and psychological issues are often associated with CPP and may be the result of the pain rather than causative factors. Conversely, a significant proportion of women with chronic pelvic pain may have histories of sexual or physical abuse and in particular child abuse that may provoke pain somatization. Use of abuse screening questions may be helpful because patients do not generally associate history of abuse with current pain syndrome.  When appropriate, referral to a mental health professional should be considered. 

Other etiologies that must be considered include urethral syndrome, vulvodynia, irritable bowel syndrome, chronic appendicitis, central sensitization syndrome, pelvic neuropathies and constipation. The complex nature of managing pelvic pain after negative laparoscopy may be best addressed in a center by a specialized multidisciplinary team including gynecologist, psychiatrist and/or psychologist, pelvic floor physical therapist, social worker, pain management specialist, and other subspecialists.

     

Further Reading:

Royal College of Obstetricians and Gynaecologists, Guidelines Committee of the Royal College of Obstetricians and Gynaecologists. The initial management of chronic pelvic pain. Green-top Guideline No. 41, May 2012. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_41.pdf

Faubion SS, Shuster LT, Bharucha AE. Recognition and management of nonrelaxing pelvic floor dysfunction. Mayo Clin Proc. 2012 Feb;87(2):187-93. doi: 10.1016/j.mayocp.2011.09.004.

 

Initial Approval May 2018

 

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