Patient Information

Pelvic Pain of Gastrointestinal Origin

The ability to tell pelvic pain due to gastrointestinal disease apart from other sources of chronic pelvic pain is a challenging and complex problem for surgeons, gynecologists, gastroenterologists and general practitioners. Understanding the differences between the sources of pain has important implications for the approach to diagnosis and treatment as well as the prognosis for the patient.

The history and physical exam are essential and should include screening for symptoms such as any link with diet, (ie irritable bowel syndrome- see below,) change in bowel habits, bleeding or pain on bowel movement. The nature of the pain including the location, quality, length of time, frequency, areas the pain spreads to and triggering or relieving factors should be noted. The physical exam may indicate findings that suggest a gastrointestinal cause for pelvic pain.

Cramping, intermittent pain that suggests bowel obstruction should be evaluated immediately. 

The appropriate use of diagnostic tests will assess most gastrointestinal causes of chronic pelvic pain. Appropriate consultation between gynaecologist, colorectal surgeon, gastroenterologist and members of the pain management team will often lead to effective treatment of the disorder.   

Rapkin AJ, Mayer EA Gastroenterologic causes of  chronic pelvic pain. Obstet Gynecol Clin North 1993

Adhesions

Adhesions can occur as a result of several bowel conditions and as a result of surgery. They can cause pain, infertility and small bowel obstruction. We are carrying out a survey about adhesions Click here   For further information about adhesions Click here

Appendicitis

Appendicitis is often overlooked and is difficult to diagnose. Incomplete obstruction and inflammatory changes of the appendix  (ie Crohn’s disease,endometriosis or recurrent appendicitis ) may present with intermittent chronic pelvic pain. Pelvic abscess formation may also lead to chronic pain and be difficult to distinguish from pelvic inflammatory disease. A CT scan or ultrasound can be used to assess this possibility. Surgical management is generally recommended with drainage of the abscess and removal of the appendix if possible.

Calder JD,Gajraj H. Recent advances in the diagnosis and treatment of acute appendicitis. Br J Hosp Med 1995

Colorectal Cancer

Most gastrointestinal cancers are associated with a change in bowel habits (ie constipation or diarrhoea) but other symptoms include intermittent obstruction, bleeding, nausea or vomiting and cramping lower abdominal pain. The majority of cancers are adenocarcinoma which are more common in older patients, but can occur at any age. A family history of colon polyps or colon cancer should indicate a thorough evaluation to rule out cancer as a cause of chronic pelvic pain. A good physical exam including a rectal exam should be carried out. Diagnosis is usually confirmed endoscopically with a biopsy. The management depends on the size, location and extension of the tumour. Surgical resection is possible in nearly all cases. Advanced tumours are treated with chemotherapy, radiotherapy and surgery. Patients with a history of colon polyps or cancer in the past should be followed up regularly.          

Stevenson GW Radiology and endoscopy in the pretreatment diagnostic management of  colorectal cancer. Cancer 1993 

Crohn’s Disease (Inflammatory Bowel Disease )

The symptoms include pain which may be either intermittent or cramping or continuous. A temperature is common and suggests perforation with fistula or abscess formation. 

Inflammation may be associated with chronic pain in the pelvis. It can originate from inflamed bowel or from complications of inflammation such as obstruction, perforation, fistula or abscess formation. Symptoms include bloating and may be similar to the symptoms of irritable bowel syndrome but they tend to be much more severe and disabling. Pelvic symptoms such as cramping/pressure in the pelvis may be associated with even a small amount of inflammation. Diagnostic studies such as barium enema are helpful to identify complications of Crohn’s disease. CT scan is useful to identify an abscess and will usually localize an inflamed bowel. Colonoscopy can be useful to judge the extent and severity of chronic disease. Proctoscopy can be performed easily to detect anal disease and assess the colon. The advantage of these procedures is that a diagnostic biopsy can be taken. Treatment of Crohn’s disease is usually medical with antiiflammatory and immunosuppressive medications. Surgery is generally carried out for complications of the disease, such as  hemorrage, perforation, stricture, obstruction or fistula.

Farmer RG et al Clinical patterns in Crohn’s disease: a statistical study of 615 cases. Gastroenterology 1975  

Diverticulitis

The incidence of this disease increases with age. It is often related to decreased stool volume secondary to low diet fibre and an increase in pressure that leads to the formation of diverticuli of the bowel. Infection of the diverticuli make patients susceptible to an ongoing inflammatory process with microabscesses with abdominal pain. The pain is usually on the lower left side with involvement of the sigmoid colon although inflammation can occur anywhere that diverticuli are present. Pain in this area that is linked with a temperature or raised white blood cell count should lead to a suspicion of sigmoid diverticultis.  A CT scan can define diverticular disease and its complications. CT or ultrasound can be useful in guiding  drainage of abscesses.  The management varies according to the severity of symptoms , coexisting diseases and immune system competency. It includes antimicrobial therapy, bowel rest, intravenous fluids, antibiotics, (including enterococcus, gram negative and anaerobic bacteria). Patients who do nor respond within the first 72 hours should undergo further evaluation to rule out abscess that may require drainage. If symptoms worsen surgical intervention is needed. Surgery is often required even in patients who avoid emergency surgery.   

Freeman SR , McNally PR. Diverticulitis. Med Clin North Am 1993

Ulcerative Colitis (Inflammatory bowel disease )

This is a chronic inflammatory condition that most commonly involves the rectum. A history of intermittent cramping lower abdominal pain and diarrhea containing blood, especially in a younger patient is suggestive of ulcerative colitis. Weight loss and a mucous discharge are other symptoms linked with this disease. Diagnosis can usually be made by sigmoidoscopy although infectious causes of colitis should be ruled out with stool cultures. It is usually treated with a combination of corticosteroids or nonsteroidal medications. There is a risk of colorectal cancer with this condition over time. Patients with long-standing disease should be evaluated for colorectal cancer. There are surgical options for complicated or refractory ulcerative colitis which result in cure of the disease.

Langholz E et al Colorectal cancer risk and mortality in patients with ulcerative colitis Gastroenterology 1992

Hernia

Hernias in the pelvic or perineal area are unusual but they may cause intermittent lower abdominal or pelvic pain. Obturator hernias are a rare but potentially serious cause of chronic pelvic pain that is difficult to diagnose. The symptoms of small bowel obstruction may be the presenting symptoms for these hernias. They may be detected using a CT scan or herniography. The management is generally surgical. As with all hernias the bowel should be assessed for any obstruction. These hernias may be suspected in patients with severe or recurrent symptoms.

Yip AW et al Obturator hernia: a continuing diagnostic challenge Surgery 1993 

Irritable Bowel Syndrome (IBS) See below.

Intestinal Endometriosis

The symptoms here may include abdominal pain, constipation or diarrhea, low back pain and painful intercourse. They may not vary with menstrual periods. Partial obstruction due to adhesions or scarring from endometriosis may lead to worsening abdominal pain and constipation. Diagnosis is suspected by a patient’s history and physical exam. On rectovaginal examination there may be tender nodules in the Pouch of Douglas (cul-de-sac) indicative of endometriosis. Bowel involvement is often inferred from gastrointestinal symptoms. Endoscopy with biopsy is useful to make the diagnosis and helps rule out carcinoma. If endometriosis is found incidentally during a laparotomy and there are no symptoms it is not necessary to remove it. However, if the lesions are symptomatic a combination of medical and surgical treatments can be used depending on the extent of involvement and the severity of the symptoms. Endometriosis of the appendix is a frequent location for intestinal endometriosis. This may require removal of the appendix.

Ripps BA, Martin DC Endometriosis and chronic pelvic pain. Obstet Gynecol Clin N Am 1993

Cameron IC et al: Intestinal endometriosis: presentation, investigation, and surgical management. Int J Colorectal Dis 1995       

 Pelvic Floor Dysfunction: Rectal prolapse, proctalgia fugax, coccygodynia

Coccygodynia

The symptoms of Coccygodynia are associated with a sharp or dull perineal pain localized to the coccyx that worsens with sitting. (There are other conditions that worsen with sitting ie pudendal neuralgia, inferior cluneal neuralgia)  A burning sensation with a dull ache and radiation of pain to the buttocks and thighs may be noted with this syndrome. Pressure on the coccyx during rectal exam reproduces the pain. Low pelvic pain and pressure while straining are characteristic of this condition and incontinence is common. A thorough physical exam that includes neurological evaluation as well as evaluation of the lumbosacral plexus should be carried out. Proctosigmoidoscopy, as well as electromyography of the pelvic floor, can be used to assess the pelvic muscles and innervation. Treatment is generally based on the management of incontinence and nonsteroidal antiinflammatory medications should provide relief.

Maigne JY et al Idiopathic coccygodynia.  Spine 1994

Proctalgia Fugax

This condition is more common in women and it usually affects young or middle aged, active professional people. The symptoms are an intermittent muscle spasm type pain that starts suddenly in the perianal region. Diagnosis is based on the patient’s history and physical exam which may show spasm of the levator muscle during an attack. Hot sitz baths , anal massage and occasional enemas may provide some relief. Quinine, calcium channel blockers and muscle relaxants have been used with varying success. Fortunately the symptoms are not usually disabling and they are short lived

Ger GC et al Evaluation and treatment of chronic intractable rectal pain a frustrating endeavour. Dis Colon Rectum  1996 

Rectal Prolapse

The symptoms of this may include pelvic pressure with pain and bleeding. Diagnosis is difficult to make unless there is rectal protusion from the anal canal. Complete rectal prolapse may be apparent on examination and surgical repair with pelvic floor reconstruction is indicated. Incomplete rectal prolapse may be difficult to diagnose since the symptoms include pressure sensation which can be particularly painful after bowel movements but the prolapse is not visible. A defecating proctogram may be required.

Bartolo DC Rectal prolapse Br J Surg 1996     

Irritable Bowel Syndrome (IBS)

Irritable Bowel Syndrome (IBS) is one of the most common gastrointestinal conditions. It affects men and women. However women are more prone to IBS than men. In a study on the impact of IBS on health-related quality of life in France, women reported a significantly poorer quality of life than men. This study showed a link between low quality of life scores and the intensity of pain. (Amouretti M 2006).

Abnormal activity of the bowel muscles and nerves can trigger the intestine to contract abnormally (spasm) which result in combinations of the following symptoms:

• pain
• diarrhoea
• constipation

Gastrointestinal infections, increased sensitivity of the intestine, diet, food intolerance and psychological factors are linked with an increased likelihood of developing IBS. Stress has been shown to play an important role in causing intestinal pain. Many people who develop symptoms of IBS have had stressful experiences in the preceding months.

Symptoms

There is no test for IBS but there are criteria that are used to make a diagnosis. According to NICE Guidance 2008 you should be asked if you have had any of the following symptoms that have lasted for at least 6 months:

- changes in bowel habit (for example diarrhoea or constipation )

-pain or discomfort in the abdomen

- a bloated feeling. If you have any of these, your doctor should conisder assessing you for irritable bowel syndrome. The symptoms that need to be present for a positive diagnosis are either :

- abdominal pain or discomfort that goes away when you empty your bowel

or

-abdominal pain or discomfort with a change in how often you empty your bowel or stools (faeces) that look different from usual. You also need to have two of the following symptoms:

- a change in how you pass stools - for example needing to strain, feeling a sense of "urgency" or feeling that you havn't completely emptied your bowel

-bloating, tension or hardness in your abdomen

-a feeling that your symptoms are worse after eating

-passing of mucus from the rectum

if you have abdominal or discomfort your doctor should ask if the pain is in one area or if it moves around. In IBS the pain does not usually stay in one place. As part of a changing bowel habit you may have accidents that involve a leakage of faeces (faecal incontinence) . There may also be symptoms such as tiredness, nausea, backache and bladder problems - passing urine frequently or urgency. Your doctor should askif you have had any of these symptoms.

if your doctor thinks you may have IBS you should be offered some blood tests. These should check for anaemia and levels of inflammation in the bodyand make sure that you do not have another gut disorder known as coeliac disease

Generally IBS can be managed in primary care. It is important to rule out other illnesses such as cancer or inflammatory bowel disease (IBD) You should be asked if you have, or have had any of the following :

unintentional or unexplained weight loss

bleeding from the rectum

a family history of bowel or ovarian cancer

 If you are aged 60 or over, your doctor should aslo ask if you have had a change in bowel habit that has lasted for more than 6 weeks in which you are producing looser stools or need to empty your bowel more frequently.

Lifestyle and Diet

If you are diagnosed with IBS you should be given advice about physical activity, lifestyle, diet and the medicines you can take to help your symptoms. Your doctor should assess how physically active you are (this may involve using a questionnare). It is important to find time for relaxation and leisure activities that you enjoy.

Your doctor should ask you about diet: the following may help the symptoms:

-Eat regular meals and take time to eat without rushing

-Drink at least 8 cups of fluid a day, especially water or non-caffeinated drinks, for example herbal teas

-Avoid drinking more than 3 cups of tea or coffeee per day

-Cut down on alcohol or fizzy drinks

-Limit high fibre food such as bran, wholemeal bread, brown rice

-Reduce resistant starch which is often found in processed foods.

-Avoid eating more than 3 portions of fresh fruit per day (one portion is 80g)

-If you have diarrhoea, avoid the artificial sweetener sorbitol which is founbd in chewing gum, drimks and in some slimming products

-If you have wind or bloating, it may help to eat oats and linseeds (up to one tablespoon a day )

-If you want to try a probiotic to see if it helps your doctor should advise you to keep taking it for at least 4 weeks and to take the amount recommended by the manufacturer. You should record whether it makes a difference to your symptoms.

If following general advice about diet has not helped, referral to a dietitian may be suggested to try specific exclusion diets. It is important to do such diets only the supervision of a dietitian.

Medicines for IBS

You may be offered an antispasmodic which reduces bowel spasm. If you have diarrhoea loperamide may help. A laxative (but not laculose ) may be prescribed for costipation.

If these do not help, a tricyclic antidepressant (TCA) may be offered at a low dose (between 10 and 30 mg ) because they can help to ease pain. This is a different use from when they are used to treat depression. If a TCA does not help, you may be offered a selective serotonin reuptake inhibitor (SSR). The benefits and possible side effects of these medications should be discussed with you. If you take these your doctor should ask to see you after 4 weeks to check your progress and then every 6 -12 months.

 If after following dietary and lifestyle advice and taking medicines have not helped after a year of treatment , you may be offered a psycholigical therapy such as hypnotherapy, psychological therapy or cognitive behavioural therapy.

Your progress should be monitored by your doctor and you should be asked if you have experienced any new symptomssince your last visit.

Aloe vera should be avoided, you should not be offered lactulose for constipation. Acupuncture or reflexology should not be recommended as treatments for IBS.

Reference:

NICE Guidance - Irritable Bowel Syndrome in Adults - Diagnosis and Management of IBS in primary care. february 2008

A wide range of non-gastrointestinal problems that affect wellbeing are associated with IBS such as gynaecological, urinary and musculoskeletal symptoms. A pelvic mass outside the bowel should be referred to a gynaecologist or a urologist. See guidelines page for further information.In some cases women may have unnecessary surgery in an attempt to improve the symptoms (Longstreth 2007) There are several gynaecological conditions that may cause pain in the lower abdomen and pelvis such as :

• endometriosis
• pelvic inflammatory disease
• mid-cycle pain caused by swelling and rupture of an egg follicle
• cancer of the cervix or ovaries (much less common than IBS)

Reviewed by Pr D Drossman, N.Carolina, USA