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Diagnosis of Chronic pelvic pain cause

As stated repeatedly above, an accurate detailed history is absolutely crucial as a first step in reaching a diagnosis.

Once the history is concluded, the doctor might have some idea as to what might be the underlying cause. At this point, a careful targeted physical examination follows. In case of a suspected gynaecological problem, an abdominal and vaginal examination will be necessary. This gives vital clues as to whether the doctor’s impression formed from the history might be correct.

If the history was pointing towards a possible musculoskeletal problem, examination manoeuvres such as demonstration of the ‘Psoas sign’; ‘Patrick Test’; ‘Betty manoeuvre’ and others may have to be carried out.

Tests performed in chronic pelvic pain:

There are many tests available. It is important for the tests to be targeted rather than random. Tests offered will therefore depend on the history and examination findings.

Imaging investigations:

§ When pelvic pathology such as a pelvic mass or pathological cyst from endometriosis etc is suspected, an ultrasound scan can be quite useful. It is important to be aware that a scan cannot confirm a diagnosis of endometriosis. It is merely suggestive

§ MRI and CT scan can also be used to get a clearer picture but for gynaecological pain problems, their use is rather limited.

§ Plain X-ray. This may be called upon when there is a suspicion of a musculoskeletal pathology, either arising from the spine or the hip joints.

§ Hysterosalpingography (HSG): This is mainly used in fertility investigations as it helps assess the shape of the uterine cavity and patency of the fallopian tubes. However, it can also play a role in evaluation of possible chronic pelvic inflammatory disease as a cause of pelvic pain.

§ Barium enema: Used in suspected bowel problems

Blood tests

§ Hormone assay is regarded as a baseline test rather than diagnostic.

§ CA-125 test: This biomarker is more famous for screening for possible ovarian malignancy. In actual fact it is a chemical of low specificity which can also be raised, albeit modestly, in conditions such as active endometriosis, fibroids and chronic pelvic inflammation.

§ Renal function tests

§ Liver function tests: These could be abnormal in such conditions as pelvic abscess

§ Chlamydia serology: A blood test which is useful in establishing possible long-standing undiagnosed Chlamydia infection which could have led to pelvic adhesions and pain.

Microbiology studies

§ Vaginal and cervical swabs for possible infection

§ Urine test for possible urinary tract infection

Again, this list is not exhaustive but these are the commonest tests usually performed in a bid to reach a diagnosis.

Invasive investigations for chronic pelvic pain

Laparoscopy is the commonest surgical diagnostic procedure employed in chronic pelvic pain. It is performed under a general anaesthetic and will normally last no more than 15 – 20 minutes. It allows for direct magnified visualisation of all the pelvic cavity and organs. Conditions such as endometriosis, ovarian cysts, fibroids, pelvic varicosities and congestion and pelvic adhesions are confirmed via laparoscopy. They are also conclusively ruled out via the same procedure.

It is estimated that around 40% of diagnostic laparoscopic procedures will be negative. In other words; no pathological condition will be identified.

Treatment for pelvic pain

At risk of stating the obvious, definitive treatment depends on the cause. It is therefore quite important to get the diagnosis right. That is where the real challenges lies.

Many gynaecologists will tell you of the common refrain in their clinics where they patiently try to explain to their patient of the things they may need to do to get to the bottom of the problem. “I just want this pain gone, I’ve had enough!” the patient shoots back. That is completely understandable. There are few things more frustrating than ongoing pain that appears to defy anything thrown at it and that threatens to take over one’s life. Unfortunately, the reality is that in many cases of chronic pelvic pain, no specific underlying pathology is identifiable. It follows, therefore, that only non-specific remedial measures such as regular strong pain-killers can be instituted.

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Last update: August 28, 2012

Betty manoeuvre (for piriformis syndrome): When abduction of the thigh against resistance is requested, the patient will report pain.

Straight-leg raising test (possible herniated disc, radiculopathy).

Psoas sign: If pain is elicited during flexion of hip against resistance, this may suggest dysfunction of the psoas muscles or fascia.

          Faber test (flexion in abduction and external rotation) for hip evaluation.