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Etiological Diagnosis of Chronic Pelvic Pain in Patients Submitted to Laparoscopic Surgery
Andrea Prestes Nácul, Sergio Galbinski, Gyana Antoni, Lutero Jung
Fêmina Hospital - Conceição Hospital Group - Videoendoscopic Service
ABSTRACT
Objective: The goal of this study was to identify the etiological diagnosis of CPP and profile of patients submitted
to laparoscopic surgery in a public hospital. Patients and Methods: the research to place at the Division of
Laparoscopic Surgery of Hospital Fêmina at Porto Alegre _ Brazil from September 2006 to August 2007. The study population
included female patients submitted to laparoscopy for Chronic Pelvic Pain (CPP) from September 2006 to August 2007. The
study evaluated the laparoscopic surgery results for CPP, the anathomo-pathological exams and the CPP protocol filled
up during appointments before laparoscopy. Results: Thirty-six patients were submitted to laparoscopy. Fifty percent of
the patients reported cyclical pain and ninety five percent of the patients had dysmenorrheal and dyspareunia
complaint. History of Sexually Transmitted Disease (STD) or PID was present in 43% and 48% of the cases, respectively. The
most common contraceptive method used was oral contraceptive by 55,6% of the patients, followed by tubal ligation
and condoms , both with 11% rate. Anamnesis revealed 8,3% of obesity, 22% of tobacco users and 6% suffer from
depression. Almost half of the patients revealed familial history of endometriosis (47%), wherein 37% of patients with
endometriosis diagnosis from laparoscopy had a positive familial history of the disease. Physical examination revealed abdominal
scar in 53% of the patients, pain during palpation in 67%, and pain at uterine cervix mobilization in 80%. At laparoscopy
we observed high prevalence of endometriosis as a cause of Chronic Pelvic Pain (58,3%). From all patients with
endometriosis diagnosis, 50% were classified as stage I, and 50% as stage IV.
Discussion: More than a half of the patients with
CPP presented endometriosis diagnosis. We observed an expressive percentage of patients with mild endometriosis.
In these cases pain could be justified by the production of local inflammatory factors in atypical lesions that are
active biologically. In accordance with the literature there is no correlation between pain due to endometriosis and the stage
of the disease.
Key words: chronic pelvic pain; endometriosis; laparoscopy.
Bras. J. Video-Sur, 2008, v. 1, n. 1: 013-019
| Accepted after revision: February, 13, 2008. |
INTRODUCTION
 |
hronic Pelvic Pain (CPP) is defined as an
intermittent or constant pelvic pain, localized
to the anatomic pelvis, including the abdominal wall
level or bellow the belly button, lumbosacral region,
and the buttocks. The intermittent CPP is a cyclic
and recurrent pain of at least six months in duration
and it is associated with pain less periods without
pain. However, the constant CPP is a non-cyclic
and recurrent pelvic pain of at least six or more
months. The great severity of CPP may lead to quality of
life changes, habits modifications, activities limitations
and require a medical evaluation. It is important
to emphasize that pelvic pain is a symptom, not
a diagnosis. An investigation of pelvic pain etiology
is essential for determining an appropriate treatment.
CPP is an important and common condition in women, in United States the prevalence rates
of CPP range from 3,8% to 15% in women from 15 to 73 years old). There is an estimative that CPP
is responsible for 10% of referrals to
gynecologists, 12% of all hysterectomies procedures and 40%
of gynecological diagnostic laparoscopy. The CPP expenses are significant for the healthcare
system, it requires several visits to primary care
and gynecological emergencies, it also increase
the number of surgeries and the diagnostic tests
are not conclusive for diagnosis and treatment as
well. We should also consider the patient's quality of
life implications, which usually compromise young women at working-age.
The objective of this study was to identify the etiological diagnostic of CPP in patients submitted
to laparoscopic surgery, as well as to investigate
these patients profile.
MATERIAL AND METHODS
The study population included female patients submitted to laparoscopy for Chronic Pelvic
Pain (CPP) from September 2006 to August 2007. An informed consent was obtained from all
participants for this study. It was excluded from the study
patients with CPP and diagnosis etiology whose
symptoms improvement were observed after primary
care treatment and also patients at appointments
for evaluations for laparoscopy.
The study evaluated the laparoscopic surgery results for CPP, the pathological exams and the
CPP protocol filled up during appointments before laparoscopy.
During investigations when etiology was identify patients were treated and if pain
improvement was observed they were referred back to
primary care and excluded from the study. Patients
with symptoms not suggestive of gynecologic
etiologies (such as gastrointestinal, urologic, musculoskeletal
and psychiatric causes) were referred to
specialists' evaluation and were also excluded from the
study. Endometriosis severity was identified
during laparoscopy and was assessed by revised
American Fertility Society classification (1985). Data
were analyzed by SPSS 11.0 for Windows.
RESULTS
A total of 77 patients were evaluated from September 2006 to August 2007. Thirty six patients were submitted to laparoscopy, 8 patients were not submitted to surgery for different causes such as improvement of the symptoms after antibiotics treatment for Pelvic Inflammatory Disease (PID), oral contraceptives and anti-inflammatory drugs for mild to moderate endometriosis, morbid obesity, diagnostic of herniated disk, hemorrhagic cyst as well as acute appendicitis. Of the total number of patients evaluated 33 were excluded because they did not fulfill the protocol at the end of the study. Table 1 shows the clinical profile of the patients submitted to laparoscopy.
 |
Fifty percent of the patients reported cyclical pain or its exacerbation during menstrual phase.
Ninety five percent of the patients had dysmenorrheal
and dyspareunia complaint. Urinary and
gastrointestinal symptoms were present in 33% and 39% of the
cases, respectively. Frequency of Sexually
Transmitted Disease (STD) or PID was present in 43% and
48% of the cases, respectively. The most common contraceptive method used was oral contraceptive
by 55.6% of the patients, followed by tubal ligation
and condoms, both with 11% rate. The results are in
Figure 1.
 |
Figure 1: Contraceptive methods of patients with CPP
submitted to laparoscopy at Fêmina Hospital. |
Anamnesis revealed 8.3% of obesity, 22% of tobacco users and 6% suffer from depression.
Alcohol and drug use were denied by 100% of the
patients. Familial history revealed a high prevalence
of endometriosis (47%), wherein 37% of patients
with endometriosis diagnosis from laparoscopy had
a positive familial history of the disease. Data are
in Figure 2.
 |
Figure 2: Familial history of gynecological pathologies in
patients submitted to laparoscopy at Fêmina Hospital. |
Physical examination revealed abdominal scar in 53% of the patients, pain during palpation in
67%, RVF uterus in 28%, and pain at uterine
cervix mobilization in 80%, deeply infiltrating nodules in
13%, utero-sacral ligaments inspissation in 13% and
adnexal volume enlargement in 32%.
Laboratory tests revealed negative
uroculture in 96.7% and negative FPE (Feces Parasitologic Examination) in 100% of the cases.
In regard to Chlamydia trachomatis IIF (indirect immunofluorescence), we obtained IgG titer equal
or superior to 1:64 in 58.8% or IgM negative in 100%
of the cases. Uterus ultrasound detected myomatosis
in 18%, adenomyosis in 36,6%, endometrial
pathology in 7% and previous hysterectomy in 3.6%.
Concerning adnexa of uterus, ecography showed cysts in
14.8%, ovarian tumor in 11.1%, hydrosalpinx in 7.4%
and endometrioma in 3.7%.
At laparoscopy we observed high prevalence of endometriosis as a cause of Chronic Pelvic
Pain. Results are in Figure 3. From all patients
with endometriosis diagnosis, 50% were classified as
stage I, and 50% as stage IV.
 |
Figure 3: Etiological diagnosis in patients submitted to
laparoscopy for CPP at Fêmina Hospital. |
DISCUSSION
Thirty-six out of the 77 patients who filled up the study protocol underwent laparoscopy.
The predominant etiological diagnostic was
endometriosis in 58.3% of the cases followed by laparoscopy
without abnormalities in 16.7% and pelvic adhesion in
13.9%. It is important to emphasize that 37% of the
patients with endometriosis diagnosis presented positive
familial history of the disease. Endometriosis was
assessed according to the revised American Fertility
Society classification system score, where 50% were
classified as stage I, and 50% as stage IV.
Some patients demonstrated symptoms improvement during primary care or a diagnosis
of nongynecologic etiology; therefore they were
not submitted to surgical procedures. Pain
improvement after antibiotic treatment was associated to
PID etiology that was not previously investigated
or appropriately treated. Up to one-third of the
patients with Pelvic Inflammatory Disease can complain
of CPP. Prescription of anti-inflammatory drugs and
oral contraceptives for mild to moderate
endometriosis presented symptoms improvement in patients
that were not submitted to videosurgery. It is also
described symptoms alleviation when oral contraceptives
were prescribed in combination with 30 to 35µg
of etinilestradiol for 6 to 12 months. However,
this treatment presents recurrence of 17 to 18% in
the first year and an annual recurrence of 5 to
10%; therefore, it does not represent a definitive
treatment. Medroxyprogesterone acetate (150 mg)
prescribed every three months is also effective for pain
treatment associated with endometriosis, however it is not
an appropriate treatment to infertile women because
it incited prolonged amenorrhea and anovulation, and
it will be necessary a variable period of time to
reestablish ovulation after treatment interruption.
The average age of menarche is about 12 and half years old, and this is the period for pain
symptoms onset, it is also possible that endometriosis
affects adolescent patients after menacme. Since the
80s, diagnosis including laparoscopy and
aggressive treatment in adolescents with severe
dismenorrhoea and CPP are being considered. Nowadays it
is observed mild to moderate endometriosis in adolescents; therefore laparoscopy at this age
should be performed with caution. Pain management is
the main objective when treating adolescents.
Less than one-fourth of the patients with CPP complained about infertility. Frequently
association between infertility and endometriosis is
accepted. Many times infertility occurs because of an
anatomic distortion of the pelvis mainly in more advanced
stages; however, endometriosis may affect fertility
because it is well known the association with a high level
of cytokines including tumor necrosis factors.
These inflammatory mediators may alter intratubal or
intra-uterine peritoneal environment, and may
adversely affect fertilization, initial development and
embryo implantation.
Non-cyclic pain results of 50% are above literature data that varies from 4% to 43.4%. The
high incidence of dysmenorrhoea and dyspareunia is relevant, as these symptoms are strongly
associated with endometriosis, infections and pelvic
adhesions. Dyspareunia complaints should always be
questioned during evaluations for Chronic Pelvic Pain, because
it determines a strong suspicious of gynecologic pathology. Dysmenorrheal results of 95% is
according to literature studies which ranges from 1.7% to
97%; however dyspareunia is above literature data
which ranges from 1.3% to 45.7%.
It was observed some cases of obesity including morbid obesity cases leading
laparoscopy surgery impossible to perform due to the
increased risk of anesthesiologic complications. These
patients were referred to bariatric surgery and
nutrition services. Obesity is also an important risk of
factor for pain, especially because of musculoskeletal
and articular alterations.
Urinary and gastrointestinal symptoms are important because a great number of patients
with CPP may be diagnosed with interstitial cystitis
and irritable bowel syndrome; therefore, referral to
a specialist may be necessary. Interstitial cystitis is
more frequent in women than in men and the
autoimmune etiology is the most accepted. In one study of
45 women with CPP, 38% were diagnosed with
interstitial cystitis. The characteristics symptoms are
suprapubic pain that can be associated with chronic pain
of gynecological origin. Irritable bowel syndrome is
a common cause of lower abdominal pain, and can be responsible for many gynecological referrals for
pelvic pain. A study of 987 women with CPP in 8 years
of follow up reported 35% incidence of irritable
bowel syndrome. In this study the syndrome risk
factors included age greater or equal 40, muscle lumbar
pain, depression, history of physical abuse and 6 to 8
painful sites at physical examination.
Frequency of sexually transmitted diseases or pelvic inflammatory pain was higher in the
past, 43% and 48%, respectively. This is an
evidence of unprotected intercourse, which bring
up discussion towards HIV exposition, greater incidence of cervix carcinoma and
reproductive problems in the future.
Laboratory tests using IIF revealed in the majority of cases positive results for
Chlamydia trachomatis for IgG, with titer equal or superior to
1:64 and no positive results for IgM. Chronical
salpingo-oophoritis by Chlamydia follows an acute infection;
in addition it is associated with deceitful symptoms
that can be misunderstood as endometriosis symptoms
as well as a risk of infertility besides a greater
susceptible risk for tubal pregnancy.
Pain is usually long-term. A great number of patients had already had medical evaluation
and previous treatment; therefore they were at
evaluation exhausted and anxious for an effective treatment.
In the last decades it has been described a faster etiological diagnosis for pain and a decrease in
the prevalence of endometriosis in advanced stages
during the first laparoscopy evaluation. Endometriosis
for many patients is a chronic and of difficult
treatment disease that affects quality of life and
emotional behavior.
Literature describes up to 46.8% of history of physical or sexual abuse among these patients.
In our clinic we could not successfully obtain history
of physical or sexual abuse. Low incidence of
depression (6%) was reported, and alcohol and drug use
were denied for all patients. We are aware of the
association of CPP with depression and sleep disorders.
We believe that incidence is possible lower because it
was difficult to assess during an appointment
deeper psychological aspects in these patients. In order
to obtain the most trustful results it is necessary
several appointments, privacy, besides a close and
trustworthy doctor-patient relationship.
Familial medical history revealed a high prevalence of endometriosis counting 47% of
the patients, wherein 37% of patients with
endometriosis diagnosis from laparoscopy had a positive
familial history of the disease. Studies of genetic factors
report an increased risk of endometrioses that ranges
from 4.3% to 6.9% among first-degree relatives and
the hereditary pattern is considered multifactorial.
Physical examination depicted previous abdominal scar in more than a half of the
patients proposing a possible discussion about surgery
sequela. Many times abdominal scars are not considered
a postsurgical sequela; hence they are investigated
as CPP.
Our studies revealed similar data to that described in the Brazilian literature for
endometriosis and pelvic adhesions as the main etiological factors
in laparoscopy.
The high prevalence of endometriosis as the most common cause of CPP emphasizes
the importance of an appropriate treatment. Of all
the patients with endometriosis diagnosis, 50%
were classified as stage I, and 50% as stage IV, therefore
it bring up to a discussion about the source of the pain
in these patients. According to the majority of the
studies there is no correlation between the stage of
pelvic pain and endometriosis intensity; thus some
women with diffuse disease did not complain
significantly about pain; however, women with minimal disease
can present severe pain.
Pain is not only caused by severe endometriosis due to pelvic adhesions and
anatomic distortions, but also by inflammatory and
reactionary factors. Significant evidences show
that endometriosis association with subclinical
peritoneal inflammation is comprised of increased
peritoneal fluid volume, increased leukocytes concentration
in the peritoneal fluid (macrophages), elevation
of inflammatory cytokines, growth factors and substances that stimulate angiogenesis. There
is evidence that local inflammation and
prostaglandins secretion are associated with differences
of endometrial aromatase in with women with endometriosis or not. A great number of these
factors are being studied, thus in the future it will be
possible to understand what factors are involved with
etiology of pain in endometriosis in order to suggest a
more adequate treatment.
Normal findings in patients submitted to laparoscopy for CPP should be mention to call
attention to all the factors that may cause relevant pain
should also be considered before an indication to laparoscopy.
It is important to investigate psychologic,
urologic, coloproctologic and orthopedic factors. Opinion
of different specialists in order to help treatment
and diagnosis is important, as well as a
multidisciplinary team to achieve an appropriate follow-up.
Based on the results obtained in our studies an algorithm for the investigation and management
of CPP was developed. (Figure 4)
 |
Figure 4: Algorithm for Management of Chronic Pelvic Pain.
Adaptation of "The initial Management of Chronic Pelvic Pain. Royal College of Obstetricians and Gynaecologists - Guideline No. 41 April, 2005". |
CONCLUSIONS
Laparoscopy has an important role in the CPP investigation, and it can be used as diagnostic or therapeutic tool. Endometriosis is an important cause of Chronic Pelvic Pain. The relationship among severity, appearance and localization of the pain is not evident, as well as it is not established the correlation between the exposition of ectopic endometrium and the beginning of the pain. Further studies to investigate the presence of cytokine and inflammatory components that can explain the relationship between mild endometriosis and pain are still in need.
ACKNOWLEDGEMENT
This study was support by Education and Research Management of Hospital Group Conceição by Fund of Research of the Federal Government.
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Correspondence address:
Andrea Prestes Nácul
Hospital Fêmina - Grupo Hospitalar Conceição
Serviço de Videolaparoscopia
Rua Mostardeiro nº 17, Bairro Moinhos de Vento.
Porto Alegre - RS
Telephone: (51) 33145200 (5281/5290)
Fax: (51) 3227-3346
e-mail: andreanacul@terra.com.br