Article four - covering pain from pelvic veins, pain from the appendix, endometriosis, endosalpingiosis, pelvic inflammatory disease (due to infection) and pelvic inflammation without infection.

Pain from pelvic veins - ovarian vein syndrome and pelvic congestion syndrome

Pelvic veins can lead to discomfort and pain in the pelvis, just as enlarged (varicose) veins in the legs can ache and hurt. If the ovarian vein is enlarged then this is known as ovarian vein syndrome (OVS), and if the veins that drain the uterus are affected, it is known as pelvic congestion syndrome (PCS). Both of these conditions are most common in women who have had children and are in their twenties and thirties.

Symptoms

The most frequent symptom is a generalised dull ache felt in one or both sides of the pelvis. It is usually worse after prolonged standing, straining to open bowels or walking, because these activities lead to congestion within the pelvic veins. Sometimes just changing position is enough to bring on the discomfort.

As a period comes closer, the pain worsens and a painful period follows. Painful sexual intercourse (dyspareunia) on deep penetration is very common, as is an ache after sex. Other symptoms include a low backache and, in some women occasional sharp pains.

Lying down reduces the pelvic congestion and improves the pain, just as it does for varicose veins in the legs. Women with pelvic congestion syndrome usually still sleep well.

Causes

In the past, pelvic congestion syndrome was thought to be more common in women who found orgasm difficult. These days few gynaecologists believe this theory. A more likely cause is changes in the ways veins carry blood.

Veins are thin-walled blood vessels that carry blood back from the pelvis to the heart. To help them do this there are valves present inside the veins that permit blood to move forwards but not backwards. This helps the blood to travel back up when women are standing. However, if the valves are not working properly, the blood does not return to the heart as efficiently and it collects in the veins of the pelvis. The pressure from this blood leads to congestion in the pelvic organs and stretches the wall of the vein. The vein becomes enlarged and 'varicose'.

Diagnosis

• A physical examination of the thigh, buttocks or labia may show enlarged veins in these areas as well.
• A doppler ultrasound scan reveals and enlarged vein and poorly functioning valves within the pelvic veins. The left ovarian vein is affected much more frequently than the right.
• A venogram is an X-ray investigation that shows up the position and size of the pelvic veins. It involves having dye injected into the pelvis and an X-ray picture subsequently being taken to show up the dye within the veins. If doppler ultrasound is available a venogram is rarely necessary.
• A laparoscopy may reveal enlarged veins within the pelvis.

Just having enlarged pelvic veins does not mean that they are the reason for the pelvic pain. There may be other causes for the pain such as fibroid pain from uterine fibroids or endometriosis.

An interesting study looked at women who had pelvic pain and an enlarged left ovarian vein, who were already booked for surgery to donate one of their kidneys. During this operation it is normal to divide the ovarian vein. This was an excellent chance to see if dividing the ovarian vein also relieved their pelvic pain. Following the operation, half of the women were better, but half were not. This study suggests that some of the women had discomfort due to their enlarged ovarian vein, but for other women there was another cause for their discomfort.[1]

Treatment

The ideal treatment depends on which veins are varicose and whether these veins are truly the cause of the pelvic discomfort. The options are:

• No treatment. Unless the pain is severe, this may be the preferred option. The enlarged veins may not be the cause of the pain.
• Treat other health problems. By treating other conditions such as heavy periods, emotional distress and premenstrual tension women often find that the pelvic pain improves or becomes easier to live with.
• Surgery to divide (ligate) an enlarged ovarian vein. The ideal surgical procedure depends on which veins are enlarged and whether or not a woman has completed her family. If the ovarian vein is enlarged, it can be divided by removing the ovary on that side, or by dividing the vein and leaving the ovary. Dividing the vein and leaving the ovary is a much more difficult operation.
• Surgery to ligate enlarged pelvic veins. This involves removing the uterus (a hysterectomy). An operation to divide the veins and to leave the uterus is impractical. A hysterectomy will also treat any causes of uterine pain such as fibroids, adenomyosis or fibroid pain and heavy periods (menorrhagia).
• Embolisation of the enlarged vein. A radiologist inserts a small tube through a blood vessel in the groin and passes it through to the enlarged vein. A chemical substance is injected into the vein to embolise (block) it.

Even those women who have a hysterectomy with both ovaries being removed do not always find that their pain resolves completely. There are many unanswered questions about pelvic congestion syndrome and the ideal way to manage the discomfort and hurt that it causes. All the above procedures carry risks, so they should be discussed carefully with your gynaecologist.

Pain from the appendix

Appendicitis is an acute illness that comes on quickly. It causes people to become ill in a day or a few days. The symptoms are fever, pain in the right lower abdomen, loss of appetite, nausea and vomiting. Acute appendicitis requires an emergency operation to remove the inflamed appendix.

However, some doctors believe that the appendix can cause chronic (long-term) pain without ever developing into acute appendicitis. This is something that doctors disagree about. Some believe that it can, but most believe that unless the appendix is infected, it does not cause pain.

An American study looked at 300 women who had chronic pain in the right lower abdomen, with no abnormality found during a laparoscopy and a normal-looking appendix removed[2]. Out of these women, 10% found that their pain had resolved after surgery. Of course this meant that 90% of the women were no better. Would their pain have gone away even without surgery, or did taking out the normal-looking appendix actually cure the pain. It is difficult to know.

Certainly if an appendix is affected by abnormalities that can be seen, such as endometriosis, then it is best removed.

Symptoms

If the appendix does cause symptoms then some doctors believe that it causes chronic right sided lower abdominal or pelvic discomfort.

What is the appendix?

The appendix is part of the bowel. It is a small hollow tube, which is closed at one end and opening into an important section of the large intestine (colon) called the caecum at the other end. The appendix is usually about the same size and shape as a woman’s little finger. If the appendix becomes blocked and infected with bacteria, the result is acute appendicitis. Acute appendicitis is not a cause of long-term pain.

Treatment

No useful role has been found for the appendix in humans, so if it causes problems, it can be removed. This can nearly always be carried out via a laparoscope.

Treating acute appendicitis or removing an appendix that lies in a difficult position requires a bowel surgeon, but in other situations a gynaecologist who is skilled at laparoscopic surgery may be able to remove the appendix.

Removing the appendix usually goes smoothly but complications can happen, and many gynaecologists are not trained in this type of surgery. Therefore removing an appendix laparoscopically is only performed by gynaecologists in women whose symptoms fit with appendix pain, or in women where abnormalities of the appendix (such as endometriosis) are seen at surgery.

Endometriosis

see this article: Endometriosis 

Endosalpingiosis (serous change)

Sometimes a gynaecologist will remove a white lesion that is thought to be endometriosis, but when the piece of tissue is examined histologically by a pathologist it is found to be endosalpingiosis.

Endosalpingiosis is tissue that looks like the lining of the fallopian tube, whereas endometriosis is tissue that looks like the endometrium of the uterus.

The two conditions are similar, but definitely not the same. Endosalpingiosis can only be diagnosed during a laparoscopy, or open surgery on the pelvis. It may look like endometriosis, but when examined under a microscope looks different.

Doctors debate whether or not endosalpingiosis causes pain or not.

A German study investigated over 1000 women who had had a laparoscopy during one year. The medical researchers found endosalpingiosis in 7% of these women. It was just as common in those women who had pelvic pain as those who did not have pelvic pain[3].

However many gynaecologists have treated women whose pain has improved after removal of Endosalpingiosis. Some gynaecologists speculate that tiny areas of endosalpingiosis are normal and painless, whilst larger areas may be painful. There is still a lot to learn about this condition.

Pelvic inflammatory disease (pelvic infection)

It is normal for women to have bacteria present in the cervix and vagina, but not in the uterus, fallopian tubes, around the ovaries or in the pelvic or abdominal cavity. A pelvic infection means that these one or more of these areas have become infected. The infection may be acute, meaning that it has come on quickly and has only been present for a short time, or chronic meaning that it has been present for some time. Some women have repeated acute infections and never recover completely between episodes of infection.

There may be a mixture of bacteria present. Some are transmitted sexually, such as chlamydia or gonorrhoea, while others are simply the normal bacteria which live in our bowel and vagina all the time.

Symptoms

An acute pelvic infection can lead to a variety of symptoms. Some women become sick and unwell quite rapidly. They develop a high temperature, severe pain across both sides of the lower abdomen and may vomit. They look unwell. There may be an increase in the vaginal discharge or abnormal vaginal bleeding. Other women have mild pelvic discomfort, but often nothing severe enough for them to see a doctor. This type of infection may go unrecognised and undiagnosed for some time. Some infections, classically those caused by chlamydia, can be asymptomatic (have no symptoms) and can silently lead to infertility.

Over time the infection can damage the fallopian tubes and cause adhesions. If the fallopian tubes become blocked, they fill with fluid and enlarge. This is known medically as a hydrosalpinx. Infection and adhesions around the fallopian tube and ovary on one side may occasionally form a tender infected mass which becomes an abscess. These long-term problems often cause chronic pelvic pain.

Some women only discover that they have had a pelvic infection in the past when they undergo a laparoscopy as an investigation for infertility problems. The infection can lead to blocked fallopian tubes.

Occasionally, there is pain and tenderness over the liver in the right upper quadrant of the abdomen. This is due to adhesions around the liver as is known medically as Fitz-Hugh-Curtis syndrome.

Prevention of pelvic infections

• Practising safer sexual practices such as using barrier contraception methods (condoms and diaphragms) decrease the risk of contracting the sexually transmitted infections that commonly lead to pelvic infections.
• Vaginal douching should be avoided.

Diagnosis

• A physical examination by a doctor may show tender areas on both sides of the lower abdomen, an increased vaginal discharge and tenderness on vaginal examination when the cervix is moved from side to side. Occasionally a hydrosalpinx or abscess near an ovary is found
• Swabs taken from the cervix may show infection with gonorrhoea or chlamydia. These days a urine sample can be used to check for chlamydia as well. In order to do this the laboratory needs to examine the first few drops of urine passed in the morning, rather than the mid-stream urine sample that is used to check for a urinary tract infection.
• Blood tests for white blood cells, ESR and CRP (C-reactive protein) may show raised levels. These tests indicate infection or inflammation anywhere in the body.
• An ultrasound may be normal, but may show a dilated fallopian tube, ovarian abscess or ovarian cyst.
• A laparoscopy. This is the most reliable investigation. In the case of a pelvic infection, it shows red inflamed pelvic organs, sometimes pus and occasionally a hydrosalpinx or abscess if they are present.

Treatment

The treatment for a pelvic infection is antibiotics. The choice of antibiotic will depend on how unwell you are, the local prescribing policy (decided on local known antibiotic data), the type of bacteria identified, and whether or not hospital admission is necessary. Most women have more than one type of bacteria causing their infection, so they require more than one antibiotic. The antibiotic prescription may include:

• One antibiotic for a group of bacteria that include chlamydia (as well as similar bacteria that are not sexually transmitted)
• One antibiotic for anaerobic bacteria – these are bacteria that do not need oxygen to grow - , plus
• One antibiotic for other bacteria

Your partner may need antibiotics as well. If so it is important that you both take the antibiotics at the same time, to prevent re-infection.

Women who are very unwell are admitted to hospital for intravenous antibiotics. It is important that the infection is treated. The longer that it is present, the more damage it can cause and the more likely the pain can become chronic, and the greater the risk of infertility.

Read more: Pelvic inflammatory disease

Pelvic Inflammation – without infection

Sometimes tissue that resembles endometriosis at laparoscopy, is discovered to be ‘inflamed tissue’ when it is removed and examined with a microscope. Recent medical research suggests that this may be an autoimmune condition[4]. Autoimmune conditions are those in which the body makes antibodies against its own cells, which can then lead to inflammation and tissue damage.

Symptoms

These vary, but most women experience sharp stabbing pains, worse before periods. Other symptoms include tiredness, dyspareunia (painful sex) and over-sensitive skin.

Diagnosis

• Tissue biopsied during a laparoscopy shows chronic (long-term) inflammation
• Blood tests reveal inflammation within the body somewhere – the ESR and C-reactive protein (CRP) are often raised.
• Blood tests for auto-immune antibodies, such as anti-nuclear antibodies, thyroid antibodies, rheumatoid factor and others.

Treatment

Excision of the affected area may be sufficient

Anti-inflammatory medications

Auto-immune medications. These drugs are usually used to treat conditions such as rheumatoid arthritis or systemic lupus erythematosis (SLE or ‘lupus’). Examples include: methotrexate or hydroxychloroquine.

If you are concerned about the possibility of pelvic inflammation due to auto-immune disease then I suggest that you discuss the above reference (ref [4]) with your doctor or gynaecologist.

References:

[1] Ovarian Varices in Healthy Female Kidney Donors: Incidence, Morbidity, and Clinical Outcome Alexander Belenky1, Gabriel Bartal2, Eli Atar1, Maya Cohen1 and Gil N. Bachar1 Am J Roentgenol, 179 (3), 2002 Sep, pp. 625-7

[2] Laparoscopic appendectomy. Neena N Agarwala and C Y CY Liu J Am Assoc Gynecol Laparosc 10(2):166-8 (2003) PMID 12732765

[3] Endosalpingiosis in laparoscopy. Hesseling MH, De Wilde RL. J Am Assoc Gynecol Laparosc. 2000 May;7(2):215-9. PMID: 10806265

[4] Thomson JC. Redwine DB. Chronic pelvic pain associated with autoimmunity and systemic and peritoneal inflammation and treatment with immune modification. Journal of Reproductive Medicine. 50(10):745-58, 2005 Oct.