Page 26 - World Journal of Laparoscopic Surgery

Laparoscopy as a Diagnostic Tool in the Evaluation of Chronic Pelvic Pain in Women

laparoscopically assessed 1629 patients with chronic pelvic ovarian venography and transuterine retrograde venography
pain and detected abnormal pathology in 76% and a normal is thus required. However, decreasing the intra-abdominal
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pelvic examination in 24% of the patients. Mara et al performed pressure and gradually placing the patient in reverse
480 laparoscopies in patients with chronic pelvic pain and Trendelenburg position can demonstrate pelvic varicosities
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pathology was detected in 82.3%. Swanton et al did when diagnostic laparoscopy is performed. The prevalence
laparoscopy with conscious pain mapping in 39 women and of pelvic varicosities in the broad ligament is reported as 7.3%. 9
identified the cause of pain in 35 (90%) women and none in 4
(10%) women. LAPAROSCOPY AND OVARIAN CYSTS
Thus, the use of laparoscopy allows the detection of Ovarian cysts rarely cause chronic pelvic pain as most are
potentially treatable pathology not detected or detectable by hemorrhagic and corpus luteal or follicle cysts and are cyclical
other types of evaluation such as ultrasonography, imaging and are usually asymptomatic and when they do cause
studies, endoscopy, and laboratory studies. symptoms they are usually acute. However, ovarian cysts which
are associated with endometriosis, residual ovarian syndrome
LAPAROSCOPY AND PELVIC ADHESIONS or ovarian retention syndrome are associated with chronic pelvic
Adhesions are among the most common organic findings noted pain. Swanton et al detected trapped ovary in 7.7% of patients
at the time of diagnostic laparoscopy performed for the undergoing laparoscopy. 7
evaluation of chronic pelvic pain. They form after trauma to the
visceral and parietal peritoneum and thus can be secondary to LAPAROSCOPY AND FIBROIDS
surgery, infection and endometriosis. Between 70-85% are Leiomyomas are the most common tumors found in the female
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thought to occur after surgery. Cheong et al in 2006 reported genital tract. Almost one of four women have palpable fibroids
that endometriosis was a typical finding in 24% of patients with by the time she reaches the 4th decade of life. The incidence of
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chronic pelvic pain. Drozgyik et al in 2007 performed small nonpalpable tumors discovered by endovaginal
laparoscopy on 1061 patients with chronic pelvic pain and found ultrasonography examination or laparoscopy is even higher.
that the most common cause was pelvic adhesions, which Uterine fibroids have been detected in 5.2 to 8.9% in women
detected in 32.5% patients. 9 who have undergone laparoscopy for chronic pelvic pain. 7,9

LAPAROSCOPY AND ENDOMETRIOSIS
DISCUSSION
Sampson in 1921, defined endometriosis as “presence of ectopic The results of research on chronic pelvic pain must be reviewed
endometrial tissue which possesses the histological structure carefully before the data can be generalized to primary care
and function of the uterine mucosa”, and still remains the populations. Few studies have evaluated patients with chronic
accepted definition. Thus, endometriosis is a histological pelvic pain who present to family physicians. Much of the
diagnosis and thus a tissue specimen is required. Thus research has been performed on well-delineated referral
laparoscopy is essential in the diagnosis of endometriosis, and populations; in women who were treated by gynecologists, in
an exploratory laparotomy is not warranted until the symptoms women who were treated in clinics for chronic pain in general or
are extreme or laparoscopy is not available. chronic pelvic pain specifically and in women with chronic pelvic
Endometriosis is also a common diagnosis in patients pain that persisted despite hysterectomy. Women with chronic
evaluated for chronic pelvic pain using diagnostic laparoscopy. pelvic pain responsive to simpler and less invasive treatment
The prevalence of endometriosis that was detected in seldom have been participants in these studies. Chronic pelvic
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laparoscopy is 20.4 to 22.3%. Some studies report confirmation pain has a myriad of possible causes, most with very little
of suspected endometriosis during diagnostic laparoscopy in correlation between clinical evidence and the extent of disease
78 to 84% of patients. 10,11 Based on several randomized control and the quality, quantity or appearance of pain. Often, the
trails, endometriosis appears to be responsible for chronic pelvic woman with chronic pelvic pain has seen several physicians,
pain in more than half of confirmed cases. 12
has used alternative methods of care, may have already had a
hysterectomy, may have used narcotics for pain relief and usually
LAPAROSCOPY AND PELVIC CONGESTION
has multiple other complaints that span several organ systems,
Pelvic congestion is associated with pelvic varicosities and it is including dyspareunia, anorgasmy, postcoital pain,
often found in women with chronic pelvic pain in whom no disturbances in menstrual cycle, backache, nausea, malaise,
other obvious cause of their pelvic pain can be found. However diarrhea, headaches and vertigo.
laparoscopy is not the recommended method for making the Psychological evaluation is necessary in the initial evaluation
diagnosis of pelvic congestion syndrome and thus retrograde and treatment of all women with chronic pelvic pain. Even when

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