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Pelvic pain can be the presenting feature of many gynecological conditions. It might be caused by:

  • Urinary tract infections
  • Pelvic inflammatory disease
  • Endometriosis
  • Torsion of ovaries or cysts
  • Fibroids
Urinary tract infections

Lower urinary tract infections cause painful urination, lower abdominal pain, fever, hesitancy and frequent urination. A full urine report will provide clues towards the diagnosis; >10 epithelial cells, few red blood cells and organisms. Good fluid intake, antibiotics and supportive treatment will provide rapid relief.

Pelvic inflammatory disease

Pelvic inflammation is commonly caused by ascending infections from the vagina, cervix and uterus. It is common among sexually active women. Candida, Trichomonas and Chlamydia are a few common causative organisms. Pelvic inflammatory disease presents with vaginal discharge, lower abdominal pain, frequent urination, the feeling of imminent defecation and deep pain during sex.

An ultrasound examination may show a thin fluid film in the pelvis (specifically the pouch of Douglas). A swab taken from the vagina and cervix may give clues towards the causative organism of the ascending infection. Antibiotics and pain killers are the mainstay of management.

Endometriosis

Endometriosis is the presence of endometrial tissue in places other than the normal uterine cavity. These tissues are under the control of the hypothalamus-pituitary-ovarian hormonal axis. These abnormally located tissues undergo all the cyclical changes of a normal endometrium seen during a menstrual cycle.

These cyclical changes give rise to cyclical symptoms of endometriosis.

Irregular menstruation, deep pelvic pain during sex, heavy bleeding or scanty bleeding are the principal clinical features of endometriosis.

The pain of endometriosis is characteristic, and slowly increases in intensity till it peaks around day 2 of menstruation and outlasts bleeding.

According to the distribution of ectopic (out of place) endometrial tissue, additional clinical features may manifest themselves. Cyclical, menstruation related bladder symptoms, blood in urine, blood in stools, feeling of imminent defecation, backache, blood in sputum and even eye pain may occur.

Due to frequent inflammation of pelvic tissue, adhesions are very common. Endometriosis may cause subfertility. Impaired ovulation, inflammatory mediators (chemicals that can harm living tissues and cells), and adhesions interfering with rhythmic contraction of the Fallopian tubes are implicated.

Endometriosis is classified according to the distribution of ectopic endometrial tissue, There are four stages of endometriosis.

Stage I endometriosis is restricted to surface lesions with minimal adhesions. Stage 2 has deeper adhesions on top of stage 1. Presence of endometrial deposits on the ovary elevates to stage 3 and extensive adhesion in the presence of large deposits characterizes stage 4.

Gynecologists would do full blood count to identify anemia and signs of infections. A CA-125 level below 200 is a common finding in endometriosis patients. An ultrasound scan of the abdomen may show adenomyosis (presence of endometrial tissue inside the uterine muscle layer), fluid in the pouch of Douglas and distorted anatomy due to adhesions.

A diagnostic laparoscopy, diathermization of endometrial deposits and separation of adhesions is the definite method of diagnosis and treatment.

Apart from surgery there are many medical treatment options as well. Oral contraceptive pills regulate menstruation and reduce pain. Danazol and progesterones inhibit endometrial growth. GnRH agonists (Lupride) act by inhibiting the pulsatile secretion of same hormone by the pituitary gland.

Torsion of ovaries or cysts

The torsion of an ovary or cyst is a gynecological surgical emergency. Patients present with sudden-onset severe lower abdominal pain. No menstrual abnormalities are part of clinical history, and a urine HCG test will be negative.

Surgery is the only option and it should be immediate.

Fibroids

Fibroids during pregnancy sometimes present with pain due to a phenomenon called "red degeneration". A myomectomy is the definitive treatment method, but these fibroids are left undisturbed during pregnancy.

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