Chronic Pelvic Pain in Women

209 Pages·1981·6.042 MB·English

by  Marcel Renaer M. D., Ph. D., F. R. C. O. G., a. e. (auth.), Marcel Renaer M. D., Ph. D., F. R. C. O. G., a. e. (eds.)

Chronic Pelvic Pain
in Women
Edited by M. Renaer
With 22 Figures and 10 Tables
Springer-Verlag
Berlin Heidelberg New York 1981
Marcel Renaer, M. D., Ph. D., F. R. C. O. G., a. e.
Professor and Head
Department of Obstetrics and Gynecology
A. Z. St. Rafael, Kapucijnenvoer 33
3000 Leuven, Belgium
ISBN- 13 :978-3-642-67970-4 e-ISBN-13 :978-3-642-67968-1
DOl: 10.1007/978-3-642-67968-1
Library of Congress Cataloging in Publication Data. Main entry under title:
Chronic pelvic pain in women. Bibliography: p. Includes index. 1. Pelvis-Dis
eases. 2. Abdominal pain. 3. Backache. 4. Generative organs, Female-Diseases. I.
Renaer, M. [DNLM: 1. Female. 2. Pain. 3. Pelvis. WE 750C557j RG482.C47
617'.5581-326
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© by Springer-Verlag Berlin Heidelberg 1981
Softcover reprint of the hardcover 1s t edition 1981
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Preface
The number of studies on chronic and recurrent pain bears no relation to the
frequency of these complaints in gynecologic practice, nor to the clinical and
scientific problems that still need solving in this area.
Several factors stand in the way of progress in this field, such as the strongly
subjective nature of the complaints, the frequent lack of correlation between
them and objective findings, and the complexity of the psychosomatic interac
tions involved.
Although progress in our knowledge has been much slower than we would have
wished, and although we are well aware of these many gaps, it was considered
useful to gather in a book what we think we have learned during 3 decades of
active interest in pain patients and pain problems in gynecologic practice and 12
years of supervision of a pain clinic in the Department of Obstetrics and
Gynecology of Leuven University.
As there are many differences between acute pain - clinical as well as experi
mental - on the one hand and chronic pain symptoms on the other, it was felt
preferable to limit the scope of this book essentially to chronic and recurrent
pain in gynecologic practice.
When presented with a complaint of lower abdominal and/or low back pain, the
gynecologist should constantly be on the lookout for nongynecologic causes, of
which the most frequent will be either gastroenterologic or orthopedic and
sometimes urologic. I have been fortunate in obtaining the collaboration of Dr.
N. C. Hightower of the Department of Gastroenterology and Dr. J. W. Roberts
of the Department of General Surgery of the Scott and White Clinic (Temple,
Texas, United States), who wrote the extensive review on lower abdominal pain
of enterocolic origin. Professor E. Morscher, Professor of Orthopedic Surgery of
Basel University (Switzerland), has been kind enough to contribute the chapter
on diagnosis and treatment of the orthopedic causes of low back pain. Dr.
R. Vereecken, Associate Professor of Urology at Leuven University (Belgium),
wrote the survey of the urologic causes of lower abdominal and low back pain
and Dr. H. Adriaensen and Prof. J. Gybels (Leuven) the chapter on pain due to
gynecologic tumors.
Because of the ubiquity of psychological influences in pain problems, psycholog
ical evaluation of the complaints and of the patient's personality should go hand
in hand with somatic exploration, which should not just be left to another
specialist. Difficult diagnostic and therapeutic problems are so frequently
encountered as to regularly necessitate the help of a psychiatrist interested in
the psychopathology of everyday life. We have been happy to enjoy, ever since
the start of our gynecologic pain clinic, the close collaboration of a psychiatrist
in our department. His domain and that of his collaborators - initially
psychosomatic gynecology - has steadily expanded and now encompasses
(besides marriage and family problems) requests for adoption, for donor insemi
nation, for surgical sterilization, and for abortion. With this experience as a
background, our colleague, Prof. P. Nijs (Leuven) kindly undertook to write the
chapter on the psychological aspects of chronic pain complaints.
VI Preface
To all these collaborators I extend my heartfelt thanks for the time and energy
they invested in the preparation of their contributions.
It is fitting that I express my gratitude to those who initiated me in the problems
of chronic pain in gynecology, in particular, Prof. R. Schockaert and Prof.
J. A. Schockaert (Leuven), Prof. James Young, British Postgraduate Medical
School (Hammersmith, London), and Prof. H. C. Taylor (Columbia Presbyte
rian Medical Center, New York).
I wish to thank Dr. Phil. Guy A. J. Tops (Universitaire Faculteiten St. Ignatius
Antwerpen), who did the linguistic correction of the texts contributed by the
Belgian authors. Bernard Shaw would certainly have agreed that writing a book
in English with such competent and devoted help is an excellent means of
improving one's English.
I also wish to acknowledge my indebtedness to Mrs. Chr. Nijs-Taels, to Mrs.
M. Bogaerts-De Messemaecker, and to Mrs. Van Hulst-Toremans for the
countless secretarial tasks involved in preparing the manuscript.
My wife will surely be more relieved than anyone else now that "the deed is
done."
M.Renaer
Contents
1 Introduction . . . . . . . . . 1
1.1 Frequency of Chronic Pain 1
1.2 Frequent Incorrect Diagnoses 1
1.3 Two-Staged Clinical Investigation of Chronic Pain Syndromes 2
2 Anatomy and Physiology of Gynecologic Pain 4
2.1 Innervation. . . . . . . . . . . . . . . . . 4
2.2 Central Pathways and Modulating Influences 4
2.3 Sensitivity of the Genital Organs ...... 8
3 General Characteristics of Chronic Pain of Gynecologic Origin 9
3.1 Most Frequent Localizations .............. 10
3.2 Radiation or Spread of Pain . . . . . . . . . . . . . . . . . . 12
3.3 Time-Intensity Relationship During the Menstrual Cycle . . . 13
3.4 Hyperalgesia of the Abdominal Wall and of Back in Chronic
Pain Syndromes . 13
3.5 Other Useful Data . . . . . . . . . . . . . . . . . . . . . . . 14
4 Examination of Patients with Chronic Pain Syndromes 15
4.1 The Patient and Her Complaints. . . . . . . . . . . 15
4.2 Clinical Examination and Some Special Explorations 16
4.2.1 History ofthe Present Disorder 16
4.2.2 Somatic Examination 17
4.2.3 Some Special Explorations 18
4.3 Gynecologic Laparoscopy 18
4.3.1 Systematic Visual Exploration of the Pelvis 19
4.3.2 Indications................. 22
4.3.3 COntraindications............. 22
4.4 Interpretation of Data: Some Causes of Diagnostic Errors 23
5 Psychological Aspects of the Pain Experience (P. Nijs) . . . . 24
5.1 General Considerations . . . . . . . . . . . . . . . . . . . 24
5.2 Behavioral Patterns of Patients with Acute and Chronic Pain 25
5.3 Presentation of the Pain Complaint ........... 26
5.3.1 Verbal Presentation . . . . . . . . . . . . . . . . . . . 26
5.3.2 Indications Suggesting Psychogenic Components in Pain
Complaints ....................... 26
5.3.3 Main Psychopathologic Syndromes Inducing or Accompanying
Gynecologic Pain Complaints . . . . . . . . . . . . . . . . .. 29
VIII Contents
6 Genital Prolapse and Retroversion of the Uterus 31
6.1 Genital Prolapse . . . . . . . . . . . . . . . 31
6.1.2 Pain Mechanisms ............. . 32
6.2 Retroversion and Retroflexion of the Uterus 33
6.2.1 Which Symptoms May Be Caused by Mobile Retroversion? 33
6.2.2 Treatment of Mobile Retroversion 36
6.2.3 Fixed Retroversion 37
7 Parietal Pain . . . . . . . . . . . . . . . . . . . . . . 38
7.1 Possible Causes of Pain Arising in the Abdominal Wall 38
7.1.1 Posterior Columns and Posterior Horns 38
7.1.2 Posterior Roots and Spinal Ganglia ......... . 38
7.1.3 Peripheral Nerves .................. . 41
7.2 Meaning of Parietal Tenderness in Chronic Abdominal Pain
Syndromes .......................... . 41
7.3 Characteristics of Parietal Pain Due to Irritation of Peripheral
Nerves ofthe Abdominal Wall . . . . . . . . . . . . . . 42
7.4 Some Examples of Parietal Pain in Gynecologic Practice 42
7.4.1 Pain Due to Irritation of the Posterior Roots and Ganglia 42
7.4.2 Pain Due to Irritation of Peripheral Nerves ...... . 44
7.5 Some Examples of Abdominal Parietal Pain in Obstetric
Practice ......................... . 46
8 Dysmenorrhea 47
8.1 Incidence 48
8.2 Classification 48
8.3 Primary Dysmenorrhea 48
8.3.1 Clinical Characteristics 48
8.3.2 Pathophysiology . . . . 49
8.3.3 Pathogenesis of Primary Dysmenorrhea 52
8.3.4 Management . . . . . . . 55
8.4 Secondary Dysmenorrhea 58
8.4.1 Endometriosis 58
8.4.2 Adenomyosis ..... . 58
8.4.3 Fibroids ........ . 60
8.4.4 Obstructive Dysmenorrhea 60
8.4.5 Psychogenic Dysmenorrhea 62
9 Midcycle Pain . . 65
9.1 Severe Form . . . 66
9.2 Less Severe Forms 66
9.3 Pathogenesis 67
9.4 Treatment .... 68
Contents IX
10 Premenstrual Tension 68
10.1 Symptoms 69
10.1.1 Signs ..... . 69
10.1.2 Prevalence . . . 69
10.1.3 Pathophysiology 70
10.2 Pathogenesis . . 70
10.2.1 Premenstrual Tension and Personality 70
10.2.2 Hyperestrogenism or Deficient Luteal Function? 72
10.2.3 Hyperaldosteronism? ... 72
10.2.4 Does Prolactin Playa Role? 73
10.3 Treatment .... 73
10.3.1 C1eneralRemarks 73
10.3.2 Drug Treatment . 74
11 Endometriosis 77
11.1 Incidence 77
11.2 Diagnosis 78
Spontaneous Pain 78
11.3 Various Pain Localizations in Endometriosis 79
11.3.1 Visceral Pain . . . . . 80
11.3.2 Parietal Pain . . . . . . 80
11.3.3 Referred Pain of Visceral Origin; Somatic Pain Radiations 80
11.4 Mechanism of Pain Due to Endometriosis 81
11.4.1 Pain Mechanism .. .. 81
11.4.2 Why Do Some Lesions Remain Painless? 82
11.4.3 How to Know Whether a Pain Symptom Is Due to
Endometriosis . . . . . . 82
11.5 Acute Pain Syndromes Due to Endometriosis 83
11.5.1 Intestinal Stenosis and Obstruction . . 83
11.5.2 Acute Pain Without Rupture of an Endometriotic Cyst 83
11.5.3 Acute Pain Syndromes Due to Rupture of an Endometriotic
Cyst ... . . . 83
11.5.4 Pseudoappendicitis 84
11.5.5 Pseudoinflammatory Variety 84
11.6 Management of Endometriosis 85
12 Chronic Pelvic Inflammatory Disease ......... . 89
12.1 Chronic Parametritis Due to a Chronic Cervical Infection 89
12.2 Chronic Salpingo-Oophoritis ............. . 90
12.2.1 Tuberculous Salpingitis ................ . 90
12.2.2 Sequelae of Acute PID or "Chronic Salpingo-Oophoritis" 92
12.2.3 Subacute and Recurrent Salpingo-Oophoritis . . . . . . . 94
X Contents
13 Ovarian Pain 97
13.1 Ovarian Cysts 97
13.1.1 Follicle Cysts 97
13.1.2 Lutein Cysts . 97
13.1.3 Endometriotic Cysts 98
13.1.4 "Sclerocystic Ovaritis" 98
13.1.5 Recurrent Functional Ovarian Cysts 99
13.2 Ovarian Remnant Syndrome 99
13.3 Residual Ovary Syndrome . . . . . 100
13.4 Chronic Oophoritis and Perioophoritis 100
13.5 Ovarian Dyspareunia ...... . 100
13.6 Ovarian Tumors . . . . . . . . . . 101
13.7 Some Rare Causes of Ovarian Pain 101
14 Dyspareunia ....... 102
14.1 Varieties of Dyspareunia 103
14.2 Superficial Dyspareunia 103
14.2.1 Tender Episiotomy Scars 104
14.2.2 Posterior Repair Scars 104
14.2.3 Senile Atrophy 105
14.2.4 Perineal Endometriosis 105
14.3 Vaginal Dyspareunia 105
Psychogenic Dyspareunia 107
14.4 Deep Dyspareunia . . 107
14.5 Psychological Factors 109
15 Acute and Chronic Lower Abdominal Pain of Enterocolic
Origin (N. C. Hightower and J. W. Roberts) 110
15.1 Innervation and Visceral Sensations 111
15.1.1 Innervation ........... . 111
15.1.2 Visceral Sensations ....... . 112
15.2 General Considerations of Enterocolic Pain 113
15.2.1 Visceral Pain . 113
15.2.2 Somatic Pain . 114
15.2.3 Referred Pain 115
15.2.4 Shifting Pain . 116
15.3 Abdominal Pain Patterns 117
15.3.1 Location of Pain 117
15.3.2 Duration of Pain . . . . . 118
15.3.3 Quality of Pain . . . . . . 118
15.4 Enterocolic Disorders Causing Lower Abdominal Pain 119
15.4.1 Irritable Bowel Syndrome 119
15.4.2 Infectious Diarrheas . . . . . . . . . . . . . . . . . . 121
Contents XI
15.4.3 Appendicitis ........ . 122
15.4.4 . Diverticulitis . . . . . . . . . 123
15.4.5 Inflammatory Bowel Disease 123
15.4.6 Obstruction . 125
15.4.7 Tumors 128
15.4.8 Pelvic Abscess 129
15.4.9 Hernias 131
15.4.10 Intestinal Ischemia (Abdominal Angina) 134
16 Low Back Pain in Women (E. Morscher) 137
16.1 Introduction............... 137
16.2 Definition of Low Back Pain . . . . . . . 138
16.3 Medicosocial Importance of Low Back Pain 138
16.4 Origin of Low Back Pain. . . . 138
16.5 Investigation of Low Back Pain 139
16.5.1 History ........... 139
16.5.2 P,hysical Examination .... 142
16.5.3 Roentgenologic Investigation 142
16.5.4 Special Investigations .. 144
16.6 Etiology of Low Back Pain 144
16.6.1 Congenital Anomalies . . 144
16.6.2 Growth Disorders . . . . 144
16.6.3 Traumatic Lesions of the Vertebral Column 147
16.6.4 Inflammation 148
16.6.5 Tumors ......... 148
16.6.6 Osteoporosis....... 148
16.6.7 Postdiskectomy Syndrome 149
16.6.8 Degenerative Changes in the Spine 149
16.6.9 Spinal Stenosis . . . . . . . . . . . 150
16.6.10 Pathologic Changes in the Sacroiliac Joints 150
16.6.11 Coccygodynia ............... 151
16.6.12 Pubic Symphysis Pain ........... 151
16.7 General Rules of Treatment and Conduct for Patients with Back
Complaints ........................... 151
17 Chronic Pelvic Pain of Urologic Origin (R. L. Vereecken) 155
17.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . 155
17.2 Recurrent Cystourethritis . . . . . . . . . . . . . . . . 155
17.3 Intractable Suprapubic Pain Due to Infiltrating Bladder
Tumors ...... . 157
17.4 Pelvic Kidney Ectopia . . . . 158
17.5 Nephroptosis ....... . 158
17.6 Ureteral Causes of Pelvic Pain 158
17.6.1 Congenital Ureteral Obstructions 158
17.6.2 Acquired Ureteral Obstructions . 159