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A B S T R A C T
Objective
To find out efficacy of laparoscopy in evaluation and treatment of chronic pelvic pain (CPP) ingynecologic patients in terms of arriving at diagnosis. Study design
Place &
Department of Obstetrics and Gynaecology Baqai Medical University Karachi, from July 2006 Duration of
study
Patients and
A total of 30 patients were selected for laparoscopy. Women aged between 20-48 years were Methods
included in the study. Pain level was assessed by interviewing patients. Pain level was rated at ascale of 1 to 10 (1=no pain, 10=severe pain). Activity level was also assessed in a similar manner.
Laparoscopic surgery was designed to restore normal pelvic anatomy. Patients were completelyevaluated for other causes of pain i.e. gastrointestinal, urological, myofacial and musculoskeletalcauses. Patients suitable for medical treatment were put on hormones before and after surgeryand results observed after 1, 3 and 6 months. R e s u l t s
Endometriosis was found in 17 (56.6%) cases. Deep endometriotic lesions were treated byelectrosurgical excision. Lesions on bowel were resected in collaboration with general surgicalcolleagues. Patients who had extensive endometriosis were selected for medical therapy withgonadotropic releasing hormones for 3 months after laparoscopy. Pelvic adhesions distorting thetubes were found in 5 (16.6%) cases. These were treated by sharp dissection. Bowel adhesionand adhesions between appendix and uterus were found in 1 (3%) case. In this case adhesiolysiswas done and appendix was also removed. Two (6.6%) cases had benign ovarian cyst and wereremoved. Two (6.6%) cases had polycystic ovarian disease and drilling was performed. Three(4%) patients had negative laparoscopy and were reevaluated for other causes of CPP. Five(16.6%) cases underwent hysterectomy for persistent pelvic pain 6 months after laparoscopy. Conclusions
Laparoscopy is a useful procedure both in evaluation and treatment of chronic pelvic pain. Key words
Chronic pelvic pain, Laparoscopy, Adhesions, Endometriosis. INTRODUCTION:
Chronic pelvic pain can be defined as the pain that is Department of Obstetrics & Gynaecology non menstrual for more than 3 months duration, localizes to the anatomic pelvis and leads to significant distress and functional disability.1 It is estimated that about 20%of the visits to gynaecologist are for pelvic pain, and one Journal of Surgery Pakistan (International) 13 (4) October - December 2008 out of every seven hysterectomies are performed for this extensive endometriosis were put on gonadotrophic reason.2 The bladder, the intestine and the pelvic organs releasing hormones for 3 months following laparoscopy share similar nerves and our brain may not be able to and about 75% of cases were almost completely free of differentiate pain from one area to another. Because of pain. Pelvic adhesions distorting the tubes were found in close proximity, exact location of pain is difficult to assess, 5 (16.6%) cases. They present with infertility and therefore problem anywhere within these organs felt as dyspareunia. They were treated by sharp dissection.
Bowel adhesions and adhesions between appendix and Laparoscopic treatment helps in relieving chronic pelvic uterus caused severe lower abdominal pain localized to pain. Among the gynaecological causes endometriosis is right lower quadrant of abdomen in 1 (3%) case and treated the most common cause,5 followed by adhesions due to by sharp dissection and appendix was also removed. Two previous surgeries, leiomyomas, bowel adhesions, ovarian (6.6%) cases had benign ovarian cyst removed successfully cyst and appendiceal abnormalities,6 This study was by stripping technique. Two (6.6%) cases had polycystic performed to determine the effectiveness of laparoscopic ovarian syndrome and drilling was performed. Three (10%) surgical therapy for abnormal pelvic finding in women with cases had negative laparoscopy. These patients were reassured and put on OCPS for 3-6 months in order toexclude deep endometriotic lesion missed during PATIENTS AND METHODS:
laparoscopy. Five cases underwent hysterectomy after 6 This study was conducted between July 2006 to July 2008 at Baqai Medical University Karachi. Diagnostic andtherapeutic laparoscopy was performed on 30 women.
The pain level preoperatively reported by the patients was Inclusion criteria were non menstrual pain of 3 months or 9, At one month following surgery it dropped down to 6, at more causing functional disability, history of previous 3 months it dropped to 3 and at 6 months to 1.5. There surgery either obstetrical or gynaecological and pain related were 5 patients who had persistent pain 6 months after to intercourse (dyspareunia). Exclusion criteria was obvious laparoscopy and they underwent hysterectomy. Activity pelvic pathology like malignancy, orthopedic injury, level was 3 preoperatively, 5 at one month , 7.5 after 3 m u s c u l o s k e l e t a l a n d p s y c h o l o g i c a l c a u s e s .
months of surgery and 9 after 6 months of surgery.
Detailed history and physical examination were performed.
Location and character of pain, radiation of pain, factors DISCUSSION:
aggravating and relieving pain, association of the pain with Pelvic pain sometimes can be thought of as a puzzle that posture, relation with menstrual periods and sexual requires careful examination.7 There are many different intercourse etc were inquired. Associated symptoms like causes of pelvic pain and some are non-gynaecologic.
nausea, vomiting, constipation, decreased appetite, fatigue Laparoscopy often helps us to establish the cause of pelvic and fever were noted. History of previous surgery, infections, pain and in many cases can be used to treat the cause of obstetrical deliveries, orthopedic injuries and surgery was the pain as well.8 With careful inspection gynaecological problems such as endometriosis, pelvic infection, adhesions,ovarian cysts, inflammation or infection of the appendix, Physical examination was done to find out scar of previous intestine or gallbladder may be detected.9 surgery, any tenderness into this or other areas includingabdomen, pelvis and spine and their characteristics were The common presentation of chronic pelvic pain is acyclic assessed. Pelvic and rectal examination were carried out lower abdominal pain in about 80% of patients, congestive to for any tenderness, growth like fibroid, tubo-ovarian dysmenorrhoea in 26% approximately, pelvic tenderness mass etc. Laboratory investigations including blood CP, in 20% of cases while there is a large percentage of patient ESR, urine DR, x-ray, ultrasound were carried out. A ten with no sign on pelvic examination but positive laparoscopic days course of vibramycin and/or metronidazole was given findings in 61%.10 Studies have shown that 40% of to rule out any chronic pelvic inflammation or urinary laparoscopies and 10-12% of all hysterectomies are done infection. Pain level rated on a scale of 1 to 10 (1=no pain due to chronic pelvic pain which is close to our figures of and 10=severe pain). Patients recorded their pain level before and 1 month, 3 months and 6 months after surgery.
Endometriosis is one of the most prevalent gynaecologicdiagnosis among women with recurrent and progressive RESULTS:
chronic pelvic pain (CPP).12 Patients who underwent Laparoscopic evaluation of 30 patients with chronic pelvic laparoscopy for chronic pelvic pain had biopsy confirmed pain revealed endometriosis in 17 (56.6%) cases. Deep endometriosis as in our study.13 In few patients presenting endometriosis lesions were treated by electrosurgical to gynaecology clinic with history of urinary urgency, excision. Lesions on bowel were resected. Patient with frequency and/or pelvic pain in the absence of UTI are Journal of Surgery Pakistan (International) 13 (4) October- December 2008 Outcome of Laparoscopy in Chronic Pelvic Pain diagnosed as cases of interstitial cystitis.14 Chronic pelvic Carter JE. Laparoscopic treatment of chronic pelvic pain without organic pathology e.g adhesions is found in about 25% of cases.15 We found adhesions distorting tubes in 16.6% cases which is close to the figure by Hebbar of20.9%.16 Stratton P, Sinaii N, Segar d, Koziol D, Wesley R,Zimmer C, Winkel C, Nieman LK. Return of chronic Patient presenting with chronic pelvic pain and negativelaparoscopy were provided an opportunity for treatment pelvic pain from endometriosis after raloxifene with GnRH agonist in our study and endometriosis was treatment. J obstet Gynecol 2008;: 88-96.
found to be the most likely diagnosis missed in suchpatients.17 Ideally all the patients should be completely evaluated by psychological, gastrointestinal, urological, g a s t r o e n t e r o l o g i c a l , g y n a e c o l o g i c a l o r gynaecological, myofascial and musculoskeletal examination Psychological. Int J Colorectal Dis 1997;12:57-62.
to avoid the risk that they may undergo during unnecessaryprocedure.18 Guo SW, Wang Y. The prevalence of endometriosisin women with chronic pelvic pain. Gynecol Obstet Laparoscopic surgical therapy for various causes of chronic pain resulted in improvement in almost 75% of cases inour study. A review of 11 published studies on laparoscopy Howard FM. The role of laparoscopy in chronic and chronic pelvic pain showed that less than 50% of pelvic pain: Promise and pitfalls. Obstet Gynecol women were helped by diagnostic and operativelaparoscopy. This rate of relief is comparable to that achieved with ovarian suppression therapy when clinical suspicionis very high, that endometriosis is related to chronic pelvic Toozs-Hobson P, Bidmead J, Cardozo L. Chronic pain. A diagnostic therapeutic trial of GnRH may be pelvic pain. Br J Obstet Gynecol 1998; 105: 1238.
considered and in fact may be as effective as laparoscopictherapy.19 Demco LA. Effects on negative laparoscopy , Ratein chronic pelvic pain patients using patient Assisted We performed hysterectomy in 5 (16.6%) cases who failed Laparosc. J Surg Laparosc 1997;1: 319-24.
to obtained long term relief of pain with medical therapy.
These women were actually diagnosed with pelvic Chaly A, Chien P. Chronic pelvic pain: Clinical congestion syndrome, although almost 25% of cases dilemma or clinician’s night mare. J Sex Transm revealed adenomyosis which is almost similar to otherstudy.
Berker B. Laparoscopic appendectomy in patients CONCLUSIONS:
with endometriosis J Min Invasive Gynaecol Laparoscopy continues to be a useful tool in the workup and treatment of patients with CPP. Pain and dyspareuniashowed significant improvement after lysis of adhesions.
Agarwala N, Liu CY, Laparoscopic Appendectomy.
In properly selected cases it resulted in significant J Assoc Gynecol Laparoscopist 2003; 10: 166-8.
Steege S, Dodson JF, Hughes WC, Claude L.
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