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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 14  |  Issue : 4  |  Page : 310-314

Role of laparoscopy in the diagnosis of chronic pelvic pain


Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India

Date of Submission02-Nov-2019
Date of Decision20-Nov-2019
Date of Acceptance05-Dec-2019
Date of Web Publication16-Jul-2020

Correspondence Address:
Dr. Sri Nayana Kolli
PG-3, PG Guest House Hostel, DMIMS Campus, Sawangi Meghe, Wardha - 442 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_172_19

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  Abstract 


Introduction: Chronic pelvic pain (CPP) is noncyclic pain of 6 or more months' duration that localizes to the anatomical pelvis, anterior abdominal at or below the umbilicus, and the lumbosacral and is of sufficient severity to cause functional disability. Lower abdominal pain can be caused by chronic pelvic inflammatory disease, pelvic adhesions, certain ovarian cysts, pelvic vascular congestion, uterine fibroids, and adenomyosis, but pain arising from organs outside the pelvis may also radiate to the lower abdomen. Only 20%–25% of patients respond to conservative management. When such treatment fails, a diagnostic laparoscopy is usually performed. Aim: We aim to study the role of laparoscopy in the diagnosis of CPP. Objective: The objective was (1) to evaluate the causes of CPP by diagnostic laparoscopy and (2) to compare the clinical finding and ultrasound findings with laparoscopic findings. Materials and Methods: The present study includes fifty patients presented with lower abdominal pain of at least 6-month duration. A detailed history was taken about the pattern of the pain and its association with other problems. Gynecological examination included inspection of the vulva and perineum, speculum examination of the cervix and vagina, bimanual examination to assess the shape, size, direction, mobility of the uterus and adnexa, mass and tenderness of the urethra, vaginal fornix and cervical motion tenderness. The patients were further evaluated by ultrasound examination (transvaginal and abdominal) and diagnostic laparoscopy. Results: Most of the women were of the mean age group of 29.30 years. The pain was most commonly associated with dysmenorrhea in 76% of the patients. Nine patients out of 26 who showed normal findings on bimanual examination revealed abnormal findings on laparoscopy. Five patients out of 22 who showed normal findings on ultrasonography showed abnormal findings on laparoscopy. Conclusion: Laparoscopy is a gold standard tool in the evaluation of women with CPP because diagnosis and treatment can be done in the same sitting.

Keywords: Chronic pelvic pain, laparoscopy, uterine fibroids and adenomyosis


How to cite this article:
Agrawal M, Kolli SN. Role of laparoscopy in the diagnosis of chronic pelvic pain. J Datta Meghe Inst Med Sci Univ 2019;14:310-4

How to cite this URL:
Agrawal M, Kolli SN. Role of laparoscopy in the diagnosis of chronic pelvic pain. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2020 Aug 4];14:310-4. Available from: http://www.journaldmims.com/text.asp?2019/14/4/310/289842




  Introduction Top


Chronic pelvic pain (CPP) is noncyclic pain of 6 or more months' duration that localizes to the anatomical pelvis, anterior abdominal at or below the umbilicus, and the lumbosacral and is of sufficient severity to cause functional disability or lead to medical care.[1],[2] The most common symptoms are dysmenorrhea, mid-cycle pain, premenstrual tension syndrome, and endometriosis. Lower abdominal pain can be caused by chronic pelvic inflammatory disease (PID), pelvic adhesions, certain ovarian cysts, pelvic vascular congestion, loose support of the uterus, uterine fibroids, adenomyosis, but pain arising from organs outside the pelvis may also radiate to the lower abdomen.

CPP is the most common presenting symptom of all the women referred to a gynecology clinic. It accounts about 20% of all gynecological outpatients' appointments and 5% of all new gynecological appointments.[3],[4],[5] The main problem related to pelvic pain is the difficulty in making a definite diagnosis as the abdominal and pelvic viscera share similar nerves so the close proximity, exact location of the pain is difficult to assess, and the pain within these organs is felt as pelvic pain.[6] Only 20%–25% of the patients respond to conservative management.[7] When such treatment fails, a diagnostic laparoscopy is usually performed.

Laparoscopy is a useful tool for the diagnosis and treatment of conditions associated with CPP.[8]

Laparoscopy for CPP is based on the “see and fight” principle.[9] It enables the direct inspection of intra-abdominal organs, facilitates biopsy and cultures, and makes therapeutic intervention possible. Laparoscopy in CPP can reveal findings that cannot be detected clinically, so it can be treated and diagnosed at the same sitting.[10] This study was undertaken to evaluate the role of diagnostic laparoscopy in CPP.

Aim and objectives

Aim

We aim to study the role of laparoscopy in the diagnosis of CPP.

Objective

  • To evaluate the causes of CPP by diagnostic laparoscopy.
  • To compare the clinical finding and ultrasound findings with laparoscopic findings.
  • To evaluate the treatment strategy based on the laparoscopic findings.



  Materials and Methods Top


Setting

The present study was conducted in the Department of Obstetrics and Gynecology at Acharya Vinoba Bhave Rural Hospital (AVBRH), Sawangi (Meghe), Wardha.

Type of study – prospective interventional study

Sample size

By using purposive sampling, fifty patients were included in the study.

The results were compiled and analyzed with software statistics SPSS22.0 version (South Wacker Drive, Chicago, Illinois USA) and test of correlation was applied.

Study duration

This study was performed for 1 year at the Department of Obstetrics and Gynecology, AVBRH hospital, DMIMSU, Wardha, after approval from the institutional ethics committee.

Inclusion criteria

  • Women presenting with lower abdominal pain of at least 6-month duration.
  • Women age group between 20 and 50 years.


Exclusion criteria

  • Patients with nongynecological etiology
  • Women not giving consent.


Ethical clearance

Ethical clearance was obtained from the Institutional Ethical Committee of JNMC, Sawangi (Meghe), Wardha, on 20nd Jan 2019. With ethical clearance no DMIMS(DU)/IEC/2019-20/338.

Method

Patients attending the gynecologic outpatient department were evaluated with detailed history. A detailed history was taken about the pattern of the pain and its association with other problems. These may include psychological, bladder, and bowel symptoms and the effects of movement and posture on the pain. Physical examination including general physical examination, systemic examination, and abdominal examination was done. Gynecological examination included inspection of the vulva and perineum, speculum examination of cervix and vagina, bimanual examination to assess the shape, size, direction, mobility of the uterus and adnexa, mass and tenderness of the urethra, vaginal fornix and cervical motion tenderness. Investigations including complete blood count, urine routine, and microscopic urine culture were done wherever required.

After taking history, clinical examination and routine investigations of blood, urine, and stool were done. Pap's smears were taken on a routine basis.

The patients were further evaluated by ultrasound examination (transvaginal and abdominal) and diagnostic laparoscopy.

Laparoscopy was performed under general anesthesia. A 10-mm Karl Storz 30° angle double port laparoscope was used. Carbon dioxide pneumoperitoneum was accomplished with a 15-gauge Veress needle. When manipulation of the pelvic organs was required for improved visualization, a second puncture site was established lateral to the left rectus muscle under vision taking care to avoid injury to the inferior epigastric artery. A third port was established similarly on the right side whenever an operative procedure is undertaken such as fulguration, adhesiolysis, and cyst wall puncture. Under surface of the liver and diaphragm was always inspected for adhesions before completing the procedure.


  Observation and Results Top


Bimanual pelvic examination findings were normal in 52% of the patients. Fornix tenderness is the most common abnormal finding (16%), followed by bulky uterus (12%), adnexal mass (10%), and retroverted uterus (10%)

Ultrasonography (USG) findings were normal in 44% of the patients. PID was the most common abnormal finding (24%), followed by ovarian cyst (14%), fibroid (12%), tubo-ovarian mass (6%).

Laparoscopic findings were normal in only 34% of the patients. Adhesions were the most common abnormal findings (18%), followed by pelvic congestion/ Fear of Children (FOC) (16%), fibroid (14%), chocolate cyst/endometriosis/hydrosalpinx (6%), and genital tuberculosis/chocolate cyst (4%).

While comparing bimanual pelvic examination with gold standard laparoscopic findings, sensitivity was 72.73%, specificity was 100%, positive predictive value was 100%, negative predictive value was 65.38%, and accuracy was 82%.

While comparing USG findings with the gold standard laparoscopic findings, sensitivity was 84.85%, specificity was 100%, positive predictive value was 100%, negative predictive value was 77.27%, and accuracy was 90% [Table 1], [Table 2], [Table 3], [Table 4] and [Graph 1], [Graph 2], [Graph 3], [Graph 4].
Table 1: Distribution of women according to the findings on bimanual pelvic examination

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Table 2: Distribution of women according to ultrasonography findings

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Table 3: Distribution of women according to laparoscopic findings

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Table 4: Sensitivity and specificity of bimanual pelvic examination and ultrasonography findings in relation to laparoscopic findings

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  Discussion Top


The aim of this study was to describe the various causes of CPP as observed on laparoscopy and to compare the clinical diagnosis with the laparoscopic diagnosis. Fifty patients were selected conveniently, and the diagnosis was made both clinically and laparoscopically.

The mean age of the present study was 29.30 ± 5.46 years which was comparable to the study by Surajeetboruah et al. (30.72 ± 6.12 years), Rawat et al.(30 years), and Bajracharya et al. (33 years).

On clinical examination, forniceal tenderness/fullness was present in 16% of the patients which is comparable to a study by Shripadhebbar et al.(15.1%) and 34.1% in a study of Shahlabaloch et al. On laparoscopy, pelvic adhesions were found in 18% of the patients, it is comparable to 12% in Krolikowshi et al., 48% in carter and 40% by Newham et al., 33.17% in SR Menon et al. pelvic congestion in 16% as compared to 15.79% in Bajracharya et al., 20% in Sharma D et al., 18.6% in Shripadhebbar et al., 8% in Rawat et al. fibroid uterus in 14% as compared to 14.75% in Surajeetboruah et al., 13% in Kamilyagourisankar et al., 3.63% in Pushpa Bhatia et al., endometriosis in 6% as compared to 9.52% in Menon et al., 41.31% in Surajeetboruah et al., 25% in Kamilyagourisankar et al.

The sensitivity of clinical and USG examination to find the etiology of CPP in the present study was 72.73% and 84.85%, respectively, comparable to Kamilyagourisankar et al. with 71.6% and 82.4%, respectively.

The negative predictive value of clinical examination in the present study was 65.38% comparable to 42.8% reported by Ozaksit et al.[11] The negative predictive value of USG was 72.27% comparable to 66.7% reported by Kamilyagourisankar et al.

Thirty-four percent of the patients showed normal findings on laparoscopy comparable to 35% negative laparoscopies reported by a study conducted by Howard F. M. at the University of Rochester School of Medicine and Dentistry[12] and 34.1% reported by a study conducted by Shahlabaloch et al., 26% in Kamilya Gourisankar et al., 13% in Rawat et al., and 10% in Syedashaistawaheed et al.

Laparoscopy is also called minimally invasive surgery. Various small operative procedures can be done from laparoscope. Laparoscopy surgery causes reduced pain and short recovery time. In the present study, adhesiolysis, endometriotic cyst removal, ovarian cystectomy, and hydrosalpinx removal were done as treatment in necessary diagnosed cases.[13] Other studies have also shown almost similar results and interesting findings.[14],[15],[16],[17],[18],[19],[20]


  Conclusion Top


The present study had been done to evaluate the role of laparoscopy in the diagnosis and treatment of CPP.

Our study concludes that laparoscopy is an excellent tool in the evaluation of women with CPP because diagnosis and often treatment can be accomplished in one sitting, without subjecting them to exploratory laparotomy.

The predictive values of abnormal clinical and USG findings are high, but the sensitivity of these two is low in comparison to that of laparoscopic evaluation.

Hence, laparoscopy is the gold standard in diagnosing the etiology of CPP and treating the cause in the same sitting if required.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Howard FM. The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol 2000;14:467-94.  Back to cited text no. 1
    
2.
Papathanasiou K, Papageorgiou C, Panidis D, Mantalenakis S. Our experience in laparoscopic diagnosis and management in women with chronic pelvic pain. Clin Exp Obstet Gynecol 1999;26:190-2.  Back to cited text no. 2
    
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Morris M, O'Niell D. Outpatient Gynaecology. BMJ 1958;2:1038.  Back to cited text no. 3
    
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Howard FM. The role of laparoscopy in chronic pelvic pain: Promise and pitfalls. Obstet Gynecol Surv 1993;48:357-87.  Back to cited text no. 4
    
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Shripad H, ChanderC. Role of laparoscopy in evaluation of chronic pelvic pain. J Min Access Surg 2008; 1:116-20.  Back to cited text no. 5
    
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Stones RW. Chronic pelvic pain. In: Personal Assessment in Continuing Education. Review No. 97/01. London: Royal College of Obstetrician and Gynaecologist; 1997.  Back to cited text no. 6
    
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Henzl MR. Dysmenorrhoea: Achievements and challenge. Sex Med Today. 1985;9:812.  Back to cited text no. 7
    
8.
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9.
Demir F, Ozcimen EE, Oral HB. The role of gynecological, urological, and psychiatric factors in chronic pelvic pain. Arch Gynecol Obstet 2012;286:1215-20.  Back to cited text no. 9
    
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Renaer M. Chronic pelvic pain in women, p l. New York: Springer-Verlag; 1981.  Back to cited text no. 10
    
11.
Ozaksit G, Caglar T, Zorlu CG, Cobanoglu O, Cicek N, Batioglu S, et al. Chronic pelvic pain in adolescent women. Diagnostic laparoscopy and ultrasonography. J Reprod Med 1995;40:500-2.  Back to cited text no. 11
    
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Howard FM. The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol 2000;14:467-94.  Back to cited text no. 12
    
13.
Demir F, Ozcimen EE, Oral HB. The role of gynecological, urological, and psychiatric factors in chronic pelvic pain. Arch Gynecol Obstet 2012;286:1215-20.  Back to cited text no. 13
    
14.
Gogate A, Brabin L, Nicholas S, Gogate S, Gaonkar T, Naidu A, et al. Risk factors for laparoscopically confirmed pelvic inflammatory disease: Findings from Mumbai (Bombay), India. Sex Transm Infect 1998;74:426-32.  Back to cited text no. 14
    
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Eftekhar M, Pourmasumi S, Motamed Zadeh L. Coexisting pelvic tuberculosis and endometriosis presenting in an infertile woman: Report of a rare case. Iran J Reprod Med 2014;12:439-41.  Back to cited text no. 15
    
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Yeola ME, Gode D, Bora AK. Diagnostic Laparoscopy as an Effective Tool in Evaluation of Intra-Abdominal Malignancies. World J Laparosc Surg 2018;11:68-75. Available from: https://doi.org/10.5005/jp-journals-10033-1338. [Last accessed on 2019 Oct 22].  Back to cited text no. 16
    
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Yeola ME, Gode D, Bora AK. Evaluation of Abdominal Malignancies by Minimal Access Surgery: Our Experience in a Rural Setup in Central India. World J Laparosc Surg 2018;11:115-20. Available from: https://doi.org/10.5005/jp-journals-10033-1350. [Last accessed on 2019 Oct 22].  Back to cited text no. 17
    
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Swarnkar M, Agrawal A. Kimura's Disease. Formos J Surg 2018;51: 26-8. Available from: https://doi.org/10.4103/fjs.fjs_56_17. [Last accessed on 2019 Oct 22].  Back to cited text no. 18
    
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Jagati A, Chaudhary R, Rathod S, Madke B, Baxi K, Kasundra D. Preparation of Platelet-Rich Fibrin Membrane over Scaffold of Collagen Sheet, Its Advantages over Compression Method: A Novel and Simple Technique. J Cutan Aesthet Surg 2019;12:174-8. Available from:https://doi.org/10.4103/2543-1854.267617. [Last accessed on 2019 Oct 22].  Back to cited text no. 20
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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