PELVIC PAIN AND ITS CLINICAL FEATURES

There are many reasons for a female patient to have pelvic pain. There are primarily two categories of pelvic discomfort.

1. Visceral pain 

—Results from stimulation of the nerves innervating the splanchnic organs. 

—The Character of pain: Pain is vague, dull, and poorly localized.

2. Somatic pain 

—Results from stimulation of the peripheral somatic nerves. The pain is dermatomal or localized. 

—The character of Pain: Sharp pain typically affects the epidermis, a muscle, or the parietal peritoneum.

CLINICAL FEATURES: When attempting to determine the source of the pain, it can be useful to be aware of the four different patterns of pelvic discomfort.

1. Mild visceral pain results from visceral inflammation due to infection or distention. Causes include the following:

a) Pelvic inflammatory disease (PID) is characterized by vague lower abdominal pain and diffuses cervical, uterine, and adnexal tenderness.

b) Early appendicitis is characterized by diffuse abdominal pain, primarily epigastric or periumbilical, with right lower quadrant tenderness on direct palpation. Symptoms include fever, nausea, and anorexia, usually evolving over 24 to 48 hours.

c) Vaginitis or cervicitis can cause diffuse, lower abdominal pain focused around the suprapubic region. Tenderness is appreciated on vaginal and cervical examination with no adnexal findings. Other symptoms include vaginal discharge, dyspareunia, and dysuria.

d) Urinary tract infection is characterized by suprapubic fullness and crampy pain, possibly referred to the flanks. Patients may describe dysuria or hematuria associated with painful, burning urethral irritation.

e) Ovarian cyst symptoms usually occur around midcycle or during the postovulatory phase. Fluid engorgement and distention cause dull, constant, achy pain in the lower abdominal adnexal region. Adnexal tenderness may be noted around the affected ovary.

f) Early ectopic pregnancy: Distention at the site of implantation, nebulous lower abdomen pain, and/or adnexal tenderness are symptoms brought on by the expanding trophoblast. Vaginal bleeding and a positive pregnancy test are further results.

g) Menstrual cramps are vague, cramping, sometimes sharp pains, lasting several days before to several days after the cycle begins. This is a diagnosis of exclusion.

h) Uterine fibroids are associated with pubic pressure, pain, dysmenorrhea, or menorrhagia. Uterine tenderness may be noted, and fibroids may be palpable.

i) Endometriosis: Ectopic endometrial tissue growth can result in a dull, ongoing pain that gets worse at the end of the menstrual cycle as a result of hormonal changes and tissue breakdown. As the lesions "slough," creating local inflammation, pain may become more intense during menstruation. Without cervical motion tenderness, the exam may detect adnexal or cul-de-sac tenderness. In the emergency room (ED), endometriosis is a diagnosis of exclusion that is often made only after laparoscopic surgery.

j) Dysmenorrhea is cyclic, painful menstruation thought to be mediated by prostaglandins. The patient may describe a dull, progressive pelvic ache that radiates to her back or thighs.

2. Severe visceral pain is an intense, restless pain often associated with nausea and vomiting. Underlying causes include severe infection, inflammation, obstruction, and visceral ischemia.

a) Ovarian torsion is characterized by sudden, severe pain that is out of proportion to the concomitant adnexal tenderness. Symptoms usually occur around midcycle and can also occur in pregnant patients. The patient may have a history of ovarian cysts.

b) Nephrolithiasis is characterized by colicky, intermittent, restless pain that usually begins in the flank but may progress or radiate to the lower quadrant, suprapubic, and groin regions. Associated nausea, vomiting, and hematuria are possible. The examination may reveal flank and/or lower quadrant tenderness without peritoneal signs.

c) Bowel obstruction is associated with diffuse, crampy pain, bloating, nausea, and vomiting. An examination may reveal a distended abdomen, decreased or high-pitched bowel sounds, and diffuse tenderness without peritoneal signs. Inability to pass stool or flatus should alert the physician to this diagnosis. Previous abdominal surgery, hernia, or cancer are risk factors.

3. Visceral pain progressing to somatic pain: Progressive irritation of the nearby peritoneum results from organ inflammation. Localized, somatic pain may be caused by an irritated parietal peritoneum.

a)Appendicitis: Parietal peritoneal inflammation may be brought on by the rupture or progression of appendiceal inflammation. The patient reports generalized, crampy pain that gradually narrows in on the right lower quadrant. There is a sharper, more powerful, and more concentrated tenderness there. While appendicitis still occurs during pregnancy, the position of the pain and tenderness may change as a result of uterine displacement.

b) Complicated PID: Local peritonitis can result from salpingeal infection spreading to the parietal peritoneum. As a result of diaphragmatic irritation, gonococcal or chlamydial seeding of the Glisson capsule (in the liver) can cause significant right upper quadrant discomfort and tenderness as well as right pleuritic chest pain (Fitz-Hugh-Curtis syndrome).

c) Advanced ectopic pregnancy: Hemorrhage can happen as trophoblastic tissue erodes the implantation site, leading to diffuse peritonitis, shock, progressive adnexal and cul-de-sac soreness, abdominal distention, and local peritoneal pain.

4. Sudden somatic pain: Diffuse peritonitis can develop from parietal peritoneal inflammation brought on by blood, cystic fluid, pus, urine, or faeces. This inflammation can cause excruciating local abdominal discomfort.

a) Ruptured ectopic pregnancy: Small quantities of bleeding can cause localised, abrupt, intense stomach discomfort and tenderness. The peritoneum becomes diffusely implicated as the bleeding progresses, leading to substantial peritoneal abnormalities during an examination.

b) Ruptured ovarian cyst: Cyst rupture causes fluid or blood to leak onto the parietal peritoneum next to it, resulting in abrupt, severe, unilateral, and potentially diffuse adnexal discomfort and tenderness.

— Follicular cysts rupture midcycle; rupture is associated with ovulatory pain (mittelschmerz).

— Luteal cysts rupture late in the menstrual cycle and may be associated with significant hemorrhage and shock.