Introduction:
Pelvic pain is localized to the pelvis below the umbilicus and is usually caused by pelvic organs, bones, muscles, nerves, joints, or blood vessels. It can be classified as acute or chronic. The American College of Obstetrics and Gynecologists describes chronic pelvic pain (CPP) as an ache in the pelvic area that lasts for six months or longer and results in functional or psychological disability which requires intervention and treatment. Chronic pelvic pain can be constant or intermittent and associated with menstruation (dysmenorrhea).
How Is Pelvic Pain Diagnosed?
1. Pelvic Examination: The expert does this to reveal any signs of infection, abnormal growths, or tense pelvic floor muscles and areas of tenderness.
2. Laboratory Tests: This involves blood-related tests like blood cell counts and urinalysis to inspect for a urinary tract infection to rule out infections like chlamydia or gonorrhea, or inflammation.
3. Ultrasound: Utilizing high-frequency sound waves to create precise images of structures within the body and help to detect masses or cysts in the uterus, ovaries, or fallopian tubes.
4. Other Imaging Tests: To help detect abnormal structures or growths with:
- Abdominal X-rays.
- Computed tomography (CT) scans.
- Magnetic resonance imaging (MRI).
5. Diagnostic Laparoscopy (DL): Diagnostic laparoscopy delivers a comprehensive examination of the abdominal cavity and is considered the gold standard in diagnosing and managing chronic pelvic pain (CPP). Advances in non-invasive diagnostic and imaging techniques like 3D ultrasonography and magnetic resonance neurography (MRN) have evolved into a second-line diagnostic and treatment modality. However, it can only be detected in intraperitoneal pathologies.
What Are the Surgical Interventions for Chronic Pelvic Pain?
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Resection of vulvar or vestibular tissue for human papillomavirus (HPV).
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Cervical dilation for cervix stenosis.
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Hysteroscopic resection for submucous or intracavitary myomas or polyps.
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Myomectomy (myolysis) for intramural, subserosal, and pedunculated myomas.
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Adhesiolysis is the lysis for all thick adhesions in areas with pain, like peritubular, periovarian, and bowel adhesions.
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Ovarian treatment for symptomatic ovarian pain.
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Appendectomy for chronic appendicitis.
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Trigger point injection treatment for myofascial pelvic pain and abdominal muscle dysfunction.
What Are the Common Surgical Approaches for Pelvic Pain?
Some of the commonly employed surgical approaches are as follows:
1. Laparoscopic Method:
The first explanation of laparoscopic hysterectomy was in 1989. However, laparoscopic surgery has acquired popularity over the last decade. It has replaced laparotomy, particularly in treating benign gynecological illnesses, with the advantage of returning patients to their normal movements, shorter hospital stays, and rarer wound infections. In addition, it is associated with reduced blood loss and decreased postoperative pain. Laparoscopic surgery can be accomplished using conventional techniques or robotic platforms.
2. Robot-Assisted Laparoscopic Surgery:
Robot-assisted laparoscopic instruments permit a wrist-like motion for basic techniques, such as suturing, enabling a high-resolution, three-dimensional view of the pelvis area and a smoother surgical field compared to conventional laparoscopy. In addition, the procedure is done under general anesthesia. Thus, better visualization of smaller pelvic spaces allows effortless access, better dissection, and diminished blood loss.
3. Laparoscopic Surgery:
In laparoscopic surgery, the surgeon inserts a slender viewing instrument called a laparoscope via a small incision around the umbilicus and inserts a tool to remove endometrial tissue via either one or more different small incisions according to the requirement. Laparoscopy is considered a minimally invasive surgery that is indicated in the following cases:
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Ovarian cysts.
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Fibroids (fibrous overgrowth in the uterus wall).
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Endometrial implants.
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Endometriosis (tissue lining of the uterus grows outside the uterus).
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Prolapsed organs (falling or bulging of the body part).
During a laparoscopy, a surgeon uses a narrow scope with the smallest lamp at the tip inserted into a small incision in the abdomen to examine and remove endometrial implants, fibroids, endometriosis, or pelvic inflammatory disease and operate on prolapsed organs. This surgery is done under general anesthesia.
4. Myomectomy
Myomectomy includes removing the fibroids, relieving the pain they cause. There are three types of procedures: hysteroscopy, laparoscopy, and laparotomy.
- Hysteroscopy: A thin, lighted scope is inserted via the vagina to remove fibroids inside the uterus.
- Laparoscopy: Surgical instruments are inserted via incisions in the abdomen to remove fibroids that grow outside the uterus. As myomectomy preserves the uterus, this method is the most acceptable treatment for women who desire a child.
5. Vaginal Surgery
In this procedure, the surgeon can replace the prolapsed or dropped organ in its actual location by accessing through the vagina, performed with general or spinal anesthesia. After this surgery, some limitations are to be observed, such as lifting, exercise, and sexual activity that should be ceased for up to six weeks.
6. Hysterectomy
Hysterectomy is the surgical extraction of the uterus. When it includes ovary removal, it is termed an oophorectomy, and if it involves the fallopian tubes, it is called a salpingectomy. It is indicated as a last-resort treatment for pelvic pain. It is mostly conducted in women with severe adenomyosis (tissue lining of the uterus grows into the muscular wall), endometriosis (tissue lining that grows outside the uterus), or fibroids and women who like to terminate the possibility of pregnancy. Hysterectomy can be performed with laparoscopy, robotic laparoscopy, or open surgery implicating a large abdominal incision.
What Are the Complications Related To Surgical Interventions for Chronic Pelvic Pain?
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Postoperative bleeding and the potential need for a blood transfusion.
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Infection.
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Hernia (bulging of the organ through the abdominal wall opening).
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Risk of damage to internal structures, such as bladder, blood vessels, bowel, stomach, and ureter.
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Abdominal inflammation or infection.
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Blood clots.
Conclusion:
Chronic pelvic pain is the clinical presentation of underlying issues with the pelvis, such as musculature, urological, or gynecological. Ruling out the cause is the basic aim of any treatment. With the application of all the advanced laparoscopic modalities, it is easy to rule out etiology. Around 80 % of women with chronic pelvic pain (CPP) have reported a significant reduction in pain. With proper follow-up, one can achieve a pain-free life with the best outcome after the surgical resolution of the cause. Even when all laparoscopic techniques are used, 20 % of patients still have poor outcomes. These patients have also been found to be frequently depressed. It makes no difference to them whether the pain is a contributory factor to depression or the depression has led to a heightened sense of pain. Both women who react to surgical intervention and those who do not may benefit from selective referrals to an integrated pain center with psychologic counseling and the prudent prescription of antidepressants.
