Musculoskeletal and Myofascial causes
This is one of the mostly
neglected causes of chronic pelvic pain in general practice and gynaecology
clinics. Pain related to the anterior abdominal wall has been known since the
third decade of the last century. The concept of trigger points became more important in recent years. Travell and Simons
wrote an elaborate review in 1983. Trigger
points are taught and tender muscle bands which are usually caused by local
trauma, or persistent muscular spasm. This may result in increased metabolic
activity, with release of certain metabolites that cause local fibrosis [Costello 1998], and shortening of the muscle with loss
of function. Trigger points can be active causing continuous pain on movement, or inactive causing pain only on pressure. They may as well cause muscle
twitching during needling or palpation. Sustained pressure on these points and
massage can allow the muscle to stretch and regain its original length.
Injection of the trigger points with local anaesthetics or phenol may lead to
long lasting relief. In fact one study showed that local injection of 5%
aqueous phenol resulted in complete or good pain relief in 56% of the patients
for 3.5 years [Mehta and Ranger 1971]. All abdominal wall muscles can be involved especially the iliopsoas, rectus abdominus, external and internal
obliques and pyramidalis
The same concepts are valid
for the pelvic muscles which are important for the proper functioning and
integrity of the pelvic viscera. Dysfunction or spasm of these muscles can lead to pelvic pain and other problems. The typical standing and sitting
postures of these patients have been described before. Accordingly, a
gynaecologist involved in the management of patients with chronic pelvic pain
should have enough information to recognise these myofascial problems, and to
refer patients as necessary to the corresponding specialist. Different body
movements and posture can affect pain of musculoskeletal origin. It has also
been described as variable affecting the patient differently at different times
of the day, but does not wake the patient up at night.
Chronic levator ani syndrome
is related to pelvic pain caused, or associated with overactive pelvic muscles
and trigger points. An overactive pelvic muscle can cause continuous afferent
impulses to the dorsal horn and higher centres leading to primary or secondary
hyperalgesia respectively. This can be a protective mechanism following
pelvic viscera or vulval inflammation or dysfunction. Treatment of such
conditions may help with its management. Such spasm may lead to dyspareunia
or pelvic pain which can be intensified by pressure on the affected muscle.
Treatment plans are similar to those applied for anterior abdominal wall
muscles, mainly inactivating the trigger points. Biofeedback by a trained
physiotherapist is very useful to deal with this problem. One exercise to
improve muscular function and coordination is to contract the pelvic muscles
during expiration and relax them with inspiration. On the medical side,
treatment with tricyclic antidepressants may have a good impact on nerve
desensitisation. However, it usually takes long time to resolve as vulvodynia
and the urethral syndrome may be involved. Occasionally, local anaesthetic
injections of the pudendal nerve may be needed to give some relief. Such
nerve block can be done where the nerve hooks around the ischeal spine.
Nerve inflammation and entrapment may follow trauma or previous surgery. This is especially so for the ilioinguinal
and iliohypogastric nerves which are more vulnerable with lower abdominal
incisions. In fact previous surgical procedures were considered as one of the
commonest causes of abdominal wall pain [Stultz P, 1982]. The quality of pain can be
variable, but as for any other neuropathic pain it is typically described as
burning or shooting in nature. Such pain can be relieved by injection of
local anaesthetics or phenol. Depending on the extent of nerve damage, partial
loss of sensation [numbness] may be felt in the involved area.
Inguinal, femoral, spigelian, incisional and
sciatic hernias are not commonly seen in the pelvic pain clinic. Nevertheless,
all patients should be examined for such possibilities. A hernia can show as
a swelling with a positive cough impulse, but occasionally it can be difficult
to diagnose especially in obese patients. Accordingly, the absence of such a
mass or impulse does not exclude the diagnosis. High frequency ultrasound scan
examination of the anterior abdominal wall can show a fascial defect with the
hernia sac protruding through. The exact appearance depends on the
contents of the sac and the amount of air or fluid in case of bowel herniation.
It may be useful to ask the patient to cough or strain during examination.
This allows a better diagnosis of the enlarged hernial sac in doubtful
cases. Such ultrasound examination should be performed in all patients with
anterior abdominal wall mass or positive Carnett’s sign. The differential
diagnosis of anterior abdominal masses should include desmoid tumours and
endometriomas along pervious scars, lipomas, and spontaneous haematomas.
Currently laparoscopic herniorrhaphy with mesh enforcement of the inguinal
canal is becoming popular. This can reduce postoperative complications and
allow early return to work when compared to the open technique. The recurrence rate is thought to be equal after
laparoscopic and open repair. Furthermore, 30% of patients with a unilateral
hernia may develop a hernia on the opposite side in the future.
The neighbouring laparoscopic picture shows a
widely open right internal inguinal ring, with the round ligament seen at its
lower part. Such an open ring puts the patient at risk of developing an
indirect inguinal hernia.
Chronic coccygeal pain
Patients suffering from chronic coccygeal pain usually have their symptoms accentuated when they sit on a firm or hard surface. The condition usually results from severe local
trauma, or mild repetitive injuries to the coccyx. It is usually
diagnosed by digital palpation of the coccyx during vaginal or rectal
examinations. Usually the coccyx can be pushed backwards up to 300, without any significant pain. However, with coccygeal injury or chronic coccygyeal pain, this
will be intolerable and may cause severe pain.
Patients with fibromyalgia may present with
chronic pelvic pain in the gynaecology clinic. They are prone to have other
conditions including depression, irritable bowel syndrome, chronic fatigue
syndrome and somatization [Lane et al, 1991].
Two conditions were set by the American College of Rheumatology before
fibromyalgia could be diagnosed:
- Pain should be felt in all 4 quadrants of the body.
- More than 10 of the 18 possible sites should be tender during
Short leg syndrome
another condition which is rarely seen in the pelvic pain clinic. There are two types, being structural or postural, but both may present with similar symptoms. The full details of this condition is beyond the remit of this manuscript, as its diagnosis and management are outside the gynaecologists domain. Patients should be referred when there is doubt about the diagnosis. The most common causes for the structural type are:
- Congenital causes related to the position of the fetus in the uterus;
- Injuries such as a dislocated hip sustained during delivery;
- Injuries or infection of the leg growth plates during childhood;
- Fractures or dislocations of the lower limb, during adulthood;
- Hip or knee surgery may cause the leg to shrink.
patients stand on the short leg keeping the longer one to the side or in front.
Measuring the inside leg can help in making a
diagnosis in the structural type. Usually there is a shoulder drop on the longer side, lower iliac crest with knee rotation and foot arch drop on the short side. It may lead to exaggerated scoliosis and lower back pain, as well
as deep pelvic pain due to spasm of the pelvic muscles. It can be corrected
with especially made shoes.