Enigmatic pelvic pain.

Field: Medicine (Health Sciences)

Enigmatic pelvic painLast year in Britain over 10 000 women had diagnostic laparoscopies for lower abdominal painl-a statistic which emphasises both the frequency of this symptom and the difficulty of making a clinical diagnosis.The many possible organic causes of pelvic pain2 include bowel disorders such as diverticulitis and appendicitis, urinary tract infection, and gynaecological disease such as salpingitis or endometriosis.Abnormalities of the lumbar spine may also cause pain in the pelvis.All too often, however, no disease can be found in the pelvic organs or the spine, and indeed when the pain is of long standing a specific diagnosis can be made in only a minority of cases.2In the remainder the complaint of pain in normal pelvic organs may have several diagnostic labels, including "congestive dysmenorrhoea" or "pelvic sympathetic syndrome," and it has recently3 been given the more charismatic name of "enigmatic pelvic pain."Women with this syndrome3-5 have usually borne children and are always premenopausal.They have a dull ache in the suprapubic area or in one or both iliac fossae, and pain may be referred to the inner thighs.The pain is at its worst before a menstrual period, and there is often deep dyspareunia, which may persist during the day after intercourse.There may be leucorrhoea, menorrhagia, or irritability of the bladder, but bowel dysfunction is infrequent-a finding which helps differentiate the pain from colon spasm.Why should pain occur in an apparently.normalpelvis?Over the years many reasons have been suggested, from sexual frustration to neuralgia.'"Probably the syndrome has several causes.One theory which has recently been re-examined3 5 is that there is a vascular disturbance producing "congestion" of the pelvic organs.Changes in pelvic blood flow occur during sexual arousal and other emotional disturbances.4During pregnancy uterine blood flow increases tenfold to around 500 ml minute at term," and perhaps in some women the blood flow remains at a higher level after pregnancy despite involution of the uterus-though how this would cause pain is unexplained.A study5 of women with pelvic pain and vulval varicosities has shown that such patients may also have pelvic varicosities.In most patients, however, vulval venography is not practicable, and until we have a convenient method of measuring pelvic blood flow the concept of "congestion" will remain ill defined.Patients with unexplained pelvic pain are usually anxious, and the syndrome may be a stress disorder.:'In one psychiatric © BRITISH MEDICAL JOURNAL 1978.All reproduction riglhts reserved.survey4 of women with pelvic congestion most were found to be "psychologically ill" and almost all had had their first symptoms during a time of stress.A recent British study9 of women undergoing laparoscopy for pelvic pain compared those with demonstrable disease to those with normal pelvic organs: patients in the latter group were significantly more neurotic and had less satisfactory sex lives.Perhaps sexual frustration may indeed cause congestion of the pelvic organs, but anxiety and depression may also result from persisting pain which doctors dismiss as imaginary.5Though the problem is common, treating these unfortunate women remains as enigmatic as their pain.It has even been