All women at some time experience pelvic pain associated with physiological events such as menstruation, ovulation, or sexual intercourse. Only a few women seek medical advice for such pain, yet it is the commonest reason for laparoscopy in Britain. In three quarters of cases no cause is found, but the reason for this is not clear. People’s perception of pain varies, and women with unexplained pelvic pain have often been diagnosed as suffering from psychogenic pain. Certainly, the incidence of anxiety and depression is high in women with unexplained abdominal pain, but in some cases the pain may be due to genuine but unrecognised disease. For example, we and others have reported the consistent finding of pelvic varicosities in women who have often complained of a chronic dull ache in the pelvis. We have called this the pelvic pain syndrome. Many of these women have a history of serious disturbance to their normal emotional development in childhood, which may in some way underlie the subsequent development of varicosities. Whatever the cause, high levels of anxiety or depression certainly increase the severity of their pain. cheap canadian Skelaxin

Thus it is clear that the diagnosis and management of pelvic pain are not as simple as is sometimes believed. Severe pain is not necessarily caused by obvious organic disease just as women who complain little of pain may have serious disease. It therefore pays to investigate the patient fully before making a diagnosis. canadian pharmacy levitra

Classification
Many conditions cause pelvic pain, and a classification is of little practical use other than to remind the clinician of the possibilities to be considered.
Problems of pregnancy—abortion, ectopic pregnancy, round ligament pain, degeneration of fibroids, unexplained uterine pain.
Menstrual cycle—dysmenorrhoea, mittelschmerz.
Infection—pelvic inflammatory disease.
Urinary tract—cystitis, calculus, urethral syndrome.
Large bowel—carcinoma (rare), ulcerative colitis, diverticulitis, irritable bowel syndrome.
Genital tract—torsion, degeneration and haemorrhage into cyst, endometriosis, fibroids, prolapse, pelvic pain syndrome (varicosities).
Musculoskeletal—prolapsed intervertebral disc, spondylolisthesis.

Diagnosis
History—A clear history of the nature of the pain, its site, factors which exacerbate and alleviate it, and its timing should be obtained. Pain caused by bleeding from an ectopic pregnancy or torsion of an ovarian cyst is strikingly different from that due to more chronic conditions. Thus the diagnosis of an acute abdominal incident necessitating immediate laparoscopy is not difficult. Occasionally, however, pelvic pain syndrome may present as severe lower abdominal pain inimicking an acute gynaecological emergency. The longstanding pain of endometriosis, recurrent pelvic inflammatory disease and pelvic varicosities is more difficult to diagnose, although the patient’s history may be helpful. Unpublished data from our studies show that women suffering from pelvic pain syndrome have several symptoms, are more likely to admit to sexual problems which predate the onset of pain, are taking greater quantities of drugs, and have more hospital referrals than patients with proved organic disease. buy Levaquin 500 mg

Site of tenderness in the pelvic pain syndrome, x = the ovarian point, which is located at the junction of the upper and middle thirds of a line drawn from the anterior superior iliac spine to the umbilicus.

Examination—Typically, women with pelvic pain syndrome look unhappy and they often resent questioning. In gynaecological emergencies abdominal examination is helpful when the site of tenderness is localised with or without rebound tenderness. With chronic pain the site of tenderness is more difficult to identify. In pelvic pain syndrome, however, pressure over the ovarian point (see figure) produces pain in the pelvis identical to that of which the patient complains. Pelvic venography shows that the reason for this is probably compression of the ovarian vein over the transverse processes of the lumbar vertebrae, which results in back pressure on the plexus of veins at the hilum of the ovary. Vaginal examination is essential to assess the size of the uterus and to detect pelvic disease. buy omnicef antibiotics

In pelvic pain syndrome the cervix is often blue due to engorgement, and the pelvic organs, particularly one or other of the ovaries, are tender on gentle pressure.

Investigation
Further investigation may not be necessary if the diagnosis is obvious, but increasingly laparoscopy is being used before resorting to laparotomy. This is particularly important with a diagnosis of pelvic inflammatory disease based on clinical findings as it is often disproved on laparoscopy buy canadian Celebrex. Pelvic varicosities with polycystic ovaries may be found in an otherwise normal pelvis. Polycystic ovaries can be confirmed with ultrasound scanning and varicosities in the broad ligament or the infundibulopelvic ligament with venography and ultrasound scanning (Adams J, et al, 24th British Congress of Obstetrics and Gynaecology, 1986).

We have recently described the routine use of Pelvic venography — in women with suspected pelvic pain syndrome. A normal venogram excludes pelvic pain syndrome as a cause of chronic pelvic pain and encourages the doctor to look for another cause. generic Imitrex online

Treatment
The algorithm shows the management of women with pelvic pain. Surgery is increasingly being replaced by medical treatment, even for conditions such as endometriotic “chocolate” cyst of the ovary. The treatment of pelvic pain syndrome is still in its infancy, but the success of non-directive counselling and relaxation training suggests that psychotherapy is likely to remain a cornerstone of treatment. Recentiy preliminary results have suggested that suppression of ovarian activity with medroxyprogesterone acetate (Provera) brings about complete relief of pelvic pain syndrome (Reginald PW, et al, 24th British Congress of Obstetrics and Gynaecology, 1986), but a prospective trial is needed to confirm this. Buy Metaxalone 400 mg

Results of surgery are disappointing. Surgery is also inappropriate in most cases, not only because most sufferers are in their reproductive years but also because removal of any pelvic organ tends to reinforce these women’s feelings of inadequacy. canadian pharmacy Skelaxin