This information aims to explain the role of appendicitis in persistent pelvic pain, its association with other pelvic pain conditions and its management. The information is intended for those who may have appendicitis.
The appendix is a small pouch 5-10 cm long attached to the large bowel. It is located on the lower right hand side of the abdomen. The appendix has no known function in humans.
What is appendicitis and what causes it ?
Appendicitis is a painful swelling of the appendix. It is not clear what the causes of this are but it is thought to occur when something, possibly a small piece of faeces, blocks the entrance to the appendix allowing bacteria to grow in the appendix. This increases the pressure in the appendix and leads to inflammation.
Several studies suggest that disease of the appendix may be a significant cause of persistent pelvic pain (Agarwala 2003, Jarrell 2005). Appendicitis may be overlooked and is difficult to diagnose particularly in premenopausal women as menstruation symptoms may overlap with the symptoms of appendicitis and pelvic infection ( Gaitan 2011). Endometriosis or other conditions can affect an otherwise normal appendix producing cyclical or constant lower right sided abdominal pain. Appendicitis may be suspected in those with endometriosis who have abdominal/pelvic pain on the lower right side (Gustofsen 2006, Lyons 2011). This may apply to up to 20% of women undergoing laparoscopic treatment for endometriosis (Harris 2001,Berker 2005).
Who is affected ?
Appendicitis is common affecting around 7% of people in the UK at some point in their life. It can affect men,women or children of any age. It is more common in men than in women and in people between 10 and 20 years old.
What are the symptoms ?
The symptoms include :
- - pain in the abdomen - this may start in the centre and move to the lower right hand side.
- - pressing on the appendix area, coughing or walking, may all make the pain worse
- - a high temperature
- - feeling sick or vomiting
- - constipation or diarrhoea
- - loss of appetite.
If you are older you may not have these symptoms or they may be less obvious. These symptoms are not always due to appendicitis but if you have them or they suddenly get worse, you should seek medical advice immediately.
There is no single test used to diagnose appendicitis. However, to help make a diagnosis,you may have some tests including:
an ultrasound scan
a CT scan
Ultrasound is generally the first investigation to be carried out for persistent abdominal/pelvic pain. However, those performing these scans need to be familiar with non gynaecological causes of abdominal/pelvic pain. CT scans have generally been used more frequently in gastro-enterology but may be used less frequently now due to attempts to reduce exposure to radiation as well as costs ( Baltarowich 2012). However, in our experience, these investigations may not detect an abnormal appendix.
If your doctor thinks you have appendicitis, you will normally be advised to have your appendix removed ( appendectomy ) straight away to prevent it from bursting. The latter is a medical emergency.
Treatment of appendicitis
Antibiotics are not generally successful in treating appendicitis mainly due to the high rate of recurrence ( Vons 2011, Wilms 2011, Mason 2012 ). A multi centre trial is currently underway in uncomplicated acute appendicitis comparing antibiotic therapy with appendectomy (Paaianen 2013). It will be several years before the results of this are known but it is unlikely to change the management of complex ongoing appendicitis.
Removal of the appendix (appendectomy) is the usual treatment for a diseased appendix. Laparoscopic (keyhole) surgery is being increasingly used for emergency appendectomy even when the appendix has perforated. In the UK it is generally carried out by a general surgeon. In clinical settings where the surgical expertise and equipment is available and affordable, it is recommended that laparoscopy is carried out for appendectomy in all patients with suspected appendicitis unless laparoscopy itself is contraindicated or not feasible (Popovic 2004, Sauerland 2010). It has been suggested that laparoscopic appendectomy should be included in training programmes in gynaecology (Kumar 2002). This would enable a diseased appendix to be removed alongside gynaecological disease such as endometriosis during the same procedure thus avoiding multiple unnecessary procedures for patients (Wie 2008) and reducing the cost of multiple surgeries to the health service. If you have endometriosis, a right sided endometrioma and lower right sided pain or a tubo ovarian abscess and you are having a laparoscopy, we suggest that you discuss with your doctor a joint procedure with a general surgeon and a gynaecologist. You may need referral to a specialist centre.
Your surgeon should do a biopsy of the removed appendix and other tissue that is suspected to be abnormal.
Some studies have shown that some women with persistent pelvic pain and no proven disease pathology had significant relief of pain by having diagnostic laparoscopy with removal of the appendix ( Agarwala 2003, Lal 2013). However surgeons generally advise against removing a normal appendix as the operation itself carries a small risk of complications and can be associated with the development of adhesions.
Hernando G Gaitán, Ludovic Reveiz, Cindy Farquhar, Laparoscopy for the management of acute lower abdominal pain in women of childbearing age. Cochrane Menstrual Disorders and Subfertility Group 2011 Jan
Jarrell J, Vilos G, Allaire C SOGC Consensus Guideline for the management of chronic pelvic pain Part two, 2005
Paajanen H1, Grönroos JM, Rautio T, Nordström P, Aarnio M, Rantanen T, Hurme S, Dean K, Jartti A, Mecklin JP, Sand J, Salminen P. A prospective randomized controlled multicenter trial comparing antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis (APPAC trial BMC Surg. 2013 Feb
Stefan Sauerland, Thomas Jaschinski,Edmund AM Neugebauer. Laparoscopic versus open surgery for suspected appendicitis Editorial Group: Cochrane Colorectal cancer Group. OCT 2010
Issue date: March 2014
Review date: March 2017