New Insights Into the Old Problem of Chronic Pelvic Pain By Donald P. Goldstein, Corrine deCholnoky, John M. Leventhal, and S. Jean Emans Boston, Massachusetts 9 Between July, 1974 and February, 1979, 109 adolescent girls, ranging in age from 101/2 to 19 yr, with unexplained chronic pelvic pain, underwent diagnostic laparoscopy. Endometriosis was the most common finding occurring in 49 patients (45%), followed by postoperative adhesions in 17 patients (16%) and congenital abnormalities of the uterus in 10 patients (9%). Other important causes were chronic pelvic inflammatory disease with peritubal and periovarian adhesions in 9%, chronic hemoperitoneum in 5%, functional ovarian cysts in 5%, and uterine serositis in 2%. No pathology could be seen in 10 patients (9%). Analysis of the presenting symptoms and physical findings revealed in most instances that the presence of significant pelvic pathology as a cause of the chronic pelvic pain was predictable and had been previously misdiagnosed. Intraoperative and postoperative management of the major problems encountered stress the importance of conservative surgery and the need for long-term follow-up. INDEX WORDS: Chronic pelvic pain; laparoscopy.
R O N I C PELVIC PAIN is a frequent C Hcomplaint of adult women and can arise from a number of pelvic and lower abdominal structures.' This problem is also one of the common reasons why adolescents seek gynecologic consultation. The use of the laparoscope for evaluating undiagnosed pelvic complaints in adolescent females now provides a means of making a definitive diagnosis and, at times, permits correction of the abnormality encountered without resorting to a major abdominal operation. 2 The purpose of this report is to describe the presenting clinical features and the laparoscopic findings in a group of 109 adolescent girls who presented with chronic pelvic pain, to outline optimal treatment for the management of the most common conditions encountered, and to emphasize the importance of proper long-term gynecologic care of patients in this age group in order to preserve future reproductive function and reduce gynecologic symptomatology. MATERIALS AND METHODS Between July, 1974 and February, 1979, 109 adolescent girls between the ages of 10V2 and 19 were admitted to the
Journal of Pediatric Surgery, Vol. 14, No. 6 (December),1979
Gynecology Service, Children's Hospital Medical Center for evaluation of chronic pelvic pain. The criterion for admission was at least three separate visits to the Emergency Room, pediatrician, and/or gynecologist because of this complaint without a definite diagnosis being made. Table 1 summarizes the presenting symptoms. The duration of symptoms ranged from 3 mo to 3 yr, and consisted for the most part of intermittent sharp or dull pain unrelated to bowel and bladder function. In 29 patients (27%), the pain was sufficiently severe and persistent to prevent normal scholastic or extracurricular activities. In the remaining patients, the pain was regarded as tolerable but required medication. Twenty-six (24%) of the patients had a history of previous abdominal operations for a wide variety of conditions (Table 2). Forty-nine patients had previously undergone thorough evaluation of the gastrointestinal and/or urinary tract. Psychiatric evaluation had been suggested in 19 instances. Table 3 summarizes the physical findings preoperatively. Pelvic examination revealed tenderness with or without nodularity in 71 patients (65%). A distinct mass was palpable in 21 patients (19%). Twenty-five patients (23%) had no significant physical findings despite multiple examinations. Laboratory studies including a complete blood count, urinalysis, erythrocyte sedimentation rate, and cervical and urethral cultures were carried out in each patient on admission to rule out acute and chronic pelvic inflammatory disease. Diagnostic laparoscopy was performed under general endotracheal anesthesia using the 7-ram Storz laparoscope. Pneumoperitoneum was accomplished with a 15-gauge Verres needle. When manipulation of the pelvic organs was required for improved visualization a second puncture site was established in the right lower quadrant and a probe or forceps introduced. Previous pelvic or abdominal surgery was not considered to be a contraindication to laparoscopy and no special precautions were taken in these patients. All patients were prepared for possible electrocoagulation with a grounding plate under the buttock. In order to facilitate manipulation of the uterus a Valtchev~ uterine mobilizer was attached to the cervix prior to pneumoperitoneum.
From the Gynecology Division, Department o f Surgery and the Adolescent Unit, Department o f Medicine, Children's Hospital Medical Center and the Department o f Obstetrics and Gynecology and Pediatrics, Harvard Medical School, Boston, Mass. Presented before the lOth Annual Meeting of the American Pediatric Surgical Association, Los Angeles, California, March 25 28, 1979. Address reprint requests to Donald P. Goldstein, M.D., New England Trophoblastic Disease Center. 245 Pond Avenue. Brookline, Mass. 02146 ~ 1979 by Grune & Stranon, Inc. 0022-3468/79/1406~)008501.00/0
675
676
GOLDSTEIN ET AL,
Table 1. Presenting Symptoms in 109 Adolescent Females With Chronic Pelvic Pain No. of Patients Pain Cyclic Acyclic Dyspareunia Vaginal discharge Bladder symptoms Abnormal vaginal bleeding Bowel symptoms
63 46 27 13 12 11 6
Percent 58 42 25 12 11 10 5
RESULTS
The findings at laparoscopy are summarized in Table 4, The most common condition encountered was endometriosis, which was noted in 49 patients (45%) ranging in age from 10I/2 to 19. Retrospective analysis of the symptoms in this group revealed that their pain was both cyclic and acyclic and occurred at any time of the menstrual cycle. On examination nodularity was found in only 11 patients (22%) although tenderness was elicited in 37 patients (76%). Tenderness was more likely demonstrated if pelvic examination was performed during the late luteal phase of the menstrual cycle. When this condition was found, a biopsy of one of the most characteristic-appearing implants was obtained and the extent of disease determined. If only a few implants were present on the pelvic peritoneum (Kistner Stage I) 3 fulguration was performed followed by anterior fixation of the uterus by round ligament suspension. 4 When the disease appeared to be more extensive, particularly when the ovaries were involved, pseudopregnancy was induced. PriTable 2. Antecedent Abdominal Surgery in 26 Adolescent Females W i t h Chronic Pelvic Pain Previous Surgery Appendectomy only Inflamed--8 Normal--2 Ovarian cystectomy With inflamed appendix--2 With normal appendix--7 Nonpelvic laparotomy Ureteroneocystotomy Ileal bladder Bowel resection Removal of ruptured spleen Total
Table 3. Physical Findings in 109 Adolescent Females W i t h Chronic Pelvic Pain
No. of Patients
Percent
10
38
9
35
3 1 1 1 1 26
11 4 4 4 4 1O0
Tenderness Localized Diffuse Cul-de-sac nodularity Mass Adnexal thickening Fixed retroversion No specific abnormalities
No. of Patients
Percent
71 40 31 32 21 19 13 25
65 56 44 29 19 17 12 23
mary operation was limited to those patients with extensive adhesions, endometriomas, and other manifestations of advanced disease (Table 5). Postoperative adhesions were seen in 17 patients (16%). They involved the ovary and the tube in 8 patients, omentum to abdominal wall in 4 patients, and omentum to uterus in 5 patients. Analysis of the symptoms in these patients revealed that the pain was generally acyclic, aggravated by sexual relations and physical activity, and relieved by rest. On examination adnexal thickening and cul-de-sac or adnexal tenderness and nodularity were noted in 15 of the 17 patients (88%). When periovarian and peritubal adhesions were present, the most likely explanation of the pain appeared to be tension on the adhesions that generally involved the pelvic sidewall or sacrum. When possible, adhesions were lysed using the operating scissors with electrocoagulation of the raw edges and anterior fixation of the uterus to prevent reoccurrence. Otherwise conservative laparotomy was performed. When retroversion was present, uterine suspension was carried out. Table 6 summarizes the surgical procedures performed in this group. Table 4. Laparoscopic Findings in 109 Adolescent Females With Chronic Pelvic Pain Findings Endometriosis Postoperative adhesions Uterine anomalies Chronic pelvic inflammatory disease Chronic hemoperitoneum Functional ovarian cysts (6 cm) Serositis No pathology seen Totals
No. of Patients
Percent
49 17 10
45 16 9
9 6
9 5
5 3 10 109
5 2 9 1O0
CHRONIC PELVIC PAIN
677
Table 5. Surgical T r e a t m e n t in 49 Adolescent Females With Endometriosis No. of Patients
Percent
20
41
Operative
16
33
Laparotomy
13
26
Operation Laparoscopy Diagnostic only
Uterine anomalies were encountered in 10 patients (9%). The types of anomalies encountered are listed in Table 7. All had obstructed menstruation that had not been diagnosed preoperatively, although in three cases the diagnosis was suspected because of the presence of a tender mass lateral to the uterus and a history of cyclic pain that coincided with menses. Eight of the ten patients were demonstrated to have ipsilateral renal tract anomalies, usually renal agenesis. One of these patients was also found to have contralateral ureteral obstruction with hydronephrosis. All ten patients subsequently underwent correction of the defect. In seven patients pelvic endometriosis presumably secondary to reflex was also noted and required excision and long-term treatment. Evidence of adhesions of the type commonly associated with chronic pelvic inflammatory disease was observed in nine instances despite preoperative screening that revealed normal sedimentation rates and negative cervical cultures. Pain in these cases was generally acyclic but not noticeably aggravated by either sexual activity or physical activity. Adnexal thickening with or without tenderness was noted in 6 of the 9 patients. In most instances the source of the pain was thought to be duc to either mild subacute or chronic salpingitis or bilateral pelvic adhesions. Three of these patients were treated with long-term antibiotics even though aerobic and anaerobic cultures of the fluid aspirated from the cul-de-sac were negative. Four patients were treated by conservative laparotomy and one required a hysterectomy (Table 8). Table 6. Surgical Treatment in 17 Adolescent Females With Postoperative Adhesions Operation
Operative Laparotomy
No, of Patients
Anomaly Bicornis unicollis with unilateral obstruction
4
Didelphis with unilateral obstruction Septus duplex with unilateral obstruction
3 2
Duplex with unilateral obstruction Total
1 10
When chronic pelvic inflammatory disease was encountered manipulation of the reproductive organs was reduced to a minimum and antibiotic therapy was started intraoperatively in order to reduce the likelihood of an acute flare-up of the disease. Evidence of old and fresh intraperitoneal bleeding was noted in six patients. In all instances, the pain was acyclic and aggravated by physical activity. These patients were all diffusely tender on pelvic examination. One patient with bleeding from a corpus luteum was tender locally in the region of the ovary preoperatively. No bleeding site was found in two instances despite careful inspection of the pelvic contents. Treatment consisted of fulgeration of the bleeding point where noted, followed by pelvic irrigation; ovulation was suppressed for three months with cyclic oral progestational agents. Ovarian cysts were encountered in five patients. No typical symptoms were discernable in this group and physical examination was normal. The cysts were all functional rather than neoplastic, and ranged in size from 3 to 6 cm. Pain appeared to be due to intermittent torsion without strangulation. Puncture aspiration was carried out in all instances followed by three months of cyclic oral progestational therapy for ovarian suppression. Inflammation of the uterine serosa was observed in three patients. Aerobic and anaerobic cultures of the cul-de-sac fluid were negaTable 8. Surgical Treatment in Nine Adolescent Females W i t h Chronic Pelvic Inflammatory Disease Operation
No. of Patients
Percent
Laparoscopy
2
12
8 7
47 41
Operative Laparotomy Hysterectomy
Laparoscopy Diagnostic only
Table 7. Types of Uterine Anomalies Encountered in 10 Adolescent Females W i t h Chronic Pelvic Pain
Diagnostic only
No. of Patients
Percent
3
33
1 4
11 44
1
11
678
GOLDSTEIN ET AL.
Table 9. Results of Treatment in 109 Adolescent Females With Chronic Pelvic Pain Outcome
Number of Patients
Improved
Percent
Recurrence
Percent
Endometriosis Postoperative adhesions
49
35
71
14
29
17
15
88
2
Uterine anomalies
10
10
1O0
Conditions
--
Chronic PID
9
5
56
4
Chronic hemoperitoneum
6
5
83
1
Functional ovarian cysts
5
5
100
Serositis No pathology Totals
12 --
--
44 17 --
3
2
67
1
13
10
6
60
4
40
109
83
76
26
24
tive, No other associated abnormalities were observed. The cause for the inflammatory process was not known. Treatment consisted of either long-term antibiotocs, analgesics, or the use of prostaglandin inhibitors. No definite cause for chronic pelvic pain was detectable in the remaining 10 patients except for an appendolith in 1 patient who was treated with appendectomy. No additional surgery was performed in the remaining patients. The results of treatment are summarized in Table 9. Follow-up has been completed on all 109 patients for periods of 1 to 51 mo (as of February, 1979). During this time, 26 patients (24%) developed recurrent pelvic pain sufficient to require additional treatment, either medical or surgical. DISCUSSION
This study confirms previous observations that laparoscopy is a valuable diagnostic procedure in the evaluation of otherwise unexplained chronic pelvic pain in adolescent females, j Furthermore, a number of the conditions encountered were found to be amenable to surgical correction by an extension of the laparoscopic operation, thus obviating the need for laparotomy that is associated with significantly more morbidity and prolonged convalescence. Endometriosis was the most common condition encountered in this group of adolescents despite the fact that none of them had been menstruating for longer than 7 yr. The youngest patient was aged 101/z and her menarche had occurred at age 10. This finding lends further credance to the embryonic cell rest theory of the origin of this disease. In many instances, the implants did not appear to be typical of these we are accustomed to seeing in adults in that they were not well circumscribed and lacked
surrounding fibrosis. For this reason, biopsy confirmation should always be obtained. This lack of local reaction is probably a reflection of the very early phase of the disease and certainly accounts for the fact that on preoperative pelvic examination tenderness was elicited in approximately 76% of the patients while nodularity was noted in only 22%. The importance of finding early endometriosis in this age group lies not only in the relief of symptoms afforded the patient by treatment, but in the devastating effect that this disease can have on reproductive function if it is allowed to progress unabated. In light of the frequency of this condition in adolescent females with chronic pelvic pain, pediatricians as well as gynecologists must include this entity in their differential diagnosis. The history and physical examination are of prime importance in the correct diagnosis of this condition at any age. Certainly, the adolescent female who has been menstruating for 6 mo or more, who reports cyclic pelvic pain occurring just prior to or at the onset of menses, and who has tenderness with or without nodularity on pelvic examination, fits the classic description. 5 The next most common cause of chronic pelvic pain in this series was postoperative adhesions. The gratifying response to correction is not surprising in light of our experience with operative laparoscopy in adult women. 6 The use of round ligament suspension via the laparoscopy adds another dimension to therapy by bringing the adnexae out of the cul-de-sac following lysis and fulguration while reperitonealization is taking place. This raises the larger question of whether surgeons should undertake to resect small functional cysts of the ovary when encountered as an incidental finding at laparotomy performed for
CHRONIC PELVIC PAIN
679
conditions unrelated to the female genital tract. Nine of the 26 patients in this series who had undergone antecedant abdominal surgery had functional cysts removed incidentally. This additional procedure does not appear to be justified unless there is the strong suspicion that a tumor is present, particularly in view of the fact that cysts of this type and size are almost always physiologic in this age group. In fact, it is worth emphasizing that careless handling of adnexae under any circumstances is to be condemned because of the strong possibility that damage will result and infertility problems ensue. Perhaps the most important lesson to be learned from this study is that unexplained chronic pelvic pain in adolescent females is
usually a symptom of some significant pelvic pathology and requires prompt and thorough attention. The physician who cares for adolescent females must take this symptom seriously and investigate it thoroughly. A careful pelvic and rectovaginal examination, appropriate laboratory studies, and diagnostic laparoscopy are indicated. This may create a problem for the physician who may need to perform a pelvic examination on a virginal adolescent whose mother is anxious about her daughter undergoing this type of procedure. Educating the patient and her mother regarding the benefits to be gained by such exams and a gentle approach is usually rewarded with a cooperative patient and parent as well as a more accurate diagnosis.
REFERENCES 1. Anteby EL: Value of laparoscopy in acute pelvic pain. Ann Surg 181:484-491, 1974 2. Cognat M, Rosenberg D, David L, et al: Laparoscopy in infants and adolescents. Obstet Gynecol 42:515 521, 1973 3. Kistner R, Siegler AM, Behrman S J: A proposed classification for patients with endometriosis--Related to infertility. Fertil Steril 28:1008 1011, 1972
4. Mann WT, Stenger VG: Uterine suspension through laparoscope. Obstet Gynecol 57:563-566, 1978 5. Bullock JL, Massey FM, Gambrell RD: Symptomatic teenagers A reappraisal. Obstet Gynecol 43:896 900, 1973 6. Lindberg WI, Wall JE, Mathews JE: Laparoseopy in evaluation of pelvic pain. Obstet Gynecol 42:872-876, 1973
Discussion L. L. Leape (Boston): 1 was impressed that almost half of the patients had that diagnosis. 1 was also impressed that only ten of the examinations were normal. We haven't fared that well in laparoscopies for chronic abdominal pain. Only a third of those patients proved to have any pathology. Can you tell us what the long-term results were in terms of correction of symptoms? Unfortunately, you sometimes find pathology that you can correct but the patient continues to have pain. This is particularly true with paraovarian cysts which may not be of clinical significance. Finally, I would like to ask the authors two other questions. Can you enlighten us nongynecologists as to what are the rationale and results of suspension of the uterus? You mention that removal of ovarian cysts may cause adhesions and pain. Are you implying that they should not be removed, and if not, what do you recommend for treatment of the ovarian cysts that is seen at laparoscopy or at laparotomy? S. Kleinhaus (New York): We have had considerable experience with laparoscopy in
adolescent patients. Between 1973 and 1976, laparoscopy was performed on 50 girls aged 12 to 18 yr old for evaluation of abdominal pain severe enough to warrant hospitalization. In nine patients, a pelvic mass was suspected on physical examination or ultrasonography. Twenty-three patients had histories of previous episodes of salphingitis, but negative cultures at time of admission. Eighteen patients had no significant past medical history and normal physical findings. Laparoscopy established a diagnosis in 28 of 50 patients, and in the 32 patients in whom a specific preoperative diagnosis was entertained, laparoscopy proved it to be incorrect in 15. In all cases where laparoscopy resulted in specific treatment, the symptoms were relieved. There was no morbidity or mortality. There were two major differences between our series and the series presented this morning. First, the distribution of patients in the author's series shows a surprisingly small number of patients with PID, and second, all the laparoscopies are done by pediatric surgeons.
680
M. J. Warden (Los Angeles): Chronic pelvic pain has been around a long, long time. The operation of uterine suspension has been around a long, long time. But several years ago I thought that the operation had been abandoned. I seem to remember some official report that really declared it as a nonessential, unnecessary operation. There is some resurgence for it, and as Dr. Leape asked, what is the indication? S. J. Dickinson (New York): I was particularly impressed by the 29 patients with previous surgery. Residents, unless restrained, will pull on tubes and ovaries with a Babcock. For years ! have been emphasizing to them, leave it alone. We treat testes with exquisite care during the course of a hernia operation. What we tend to let our residents do to ovaries is appalling. I'd like to see that 29 number quoted widely. D. P. Goldstein (closure): l find ultrasound to be generally unreliable with regard to smaller ovarian masses. The ovary is a cystic structure, it goes through a phase and a cycle. Our ultrasound people at Children's (Boston) are very conscientious and sincere, but very often if I can't feel a pelvic mass I don't consider it significant. We, too, have run into the situation where we have patients who have been in the emergency room with a label of chronic PID who,
GOLDSTEIN ET AL.
when we laparoscoped, do not have any pelvic adhesions consistent with PID. We have found a number of these patients have endometriosis. It's been called the Boston disease. Nonetheless we have pathologic confirmation in the vast majority of our patients. ! would suggest perhaps that it's going unrecognized in other areas. We have a recurrence rate of about 25%. That means that the patient's symptoms recurred after completion of initial therapy whether that therapy was medical, such as for endometriosisor or surgical, via laparoscopy or laparotomy. Anterior fixation of the uterus because a patient has retroversion is not considered good gynecologic care. But fixation of the uterus anteriorly in a patient on whom you performed pelvic surgery, for example, adnexal surgery and infertility work or endometriosis is considered good pelvic surgery. Therefore, when we perform lysis of adhesions we do try to get the adnexa out of the cul-de-sac by performing uterine suspension. With regard to management of ovarian cysts, all the smaller cysts that we consider physiologic are puncture aspirated and ovaries are suppressed with cyclic progestational agents. Sometimes if they are very small or they are corpeus luteum cysts, they are just left alone. It depends upon the size and the symptoms.
R O N I C PELVIC PAIN is a frequent C Hcomplaint of adult women and can arise from a number of pelvic and lower abdominal structures.' This problem is also one of the common reasons why adolescents seek gynecologic consultation. The use of the laparoscope for evaluating undiagnosed pelvic complaints in adolescent females now provides a means of making a definitive diagnosis and, at times, permits correction of the abnormality encountered without resorting to a major abdominal operation. 2 The purpose of this report is to describe the presenting clinical features and the laparoscopic findings in a group of 109 adolescent girls who presented with chronic pelvic pain, to outline optimal treatment for the management of the most common conditions encountered, and to emphasize the importance of proper long-term gynecologic care of patients in this age group in order to preserve future reproductive function and reduce gynecologic symptomatology. MATERIALS AND METHODS Between July, 1974 and February, 1979, 109 adolescent girls between the ages of 10V2 and 19 were admitted to the
Journal of Pediatric Surgery, Vol. 14, No. 6 (December),1979
Gynecology Service, Children's Hospital Medical Center for evaluation of chronic pelvic pain. The criterion for admission was at least three separate visits to the Emergency Room, pediatrician, and/or gynecologist because of this complaint without a definite diagnosis being made. Table 1 summarizes the presenting symptoms. The duration of symptoms ranged from 3 mo to 3 yr, and consisted for the most part of intermittent sharp or dull pain unrelated to bowel and bladder function. In 29 patients (27%), the pain was sufficiently severe and persistent to prevent normal scholastic or extracurricular activities. In the remaining patients, the pain was regarded as tolerable but required medication. Twenty-six (24%) of the patients had a history of previous abdominal operations for a wide variety of conditions (Table 2). Forty-nine patients had previously undergone thorough evaluation of the gastrointestinal and/or urinary tract. Psychiatric evaluation had been suggested in 19 instances. Table 3 summarizes the physical findings preoperatively. Pelvic examination revealed tenderness with or without nodularity in 71 patients (65%). A distinct mass was palpable in 21 patients (19%). Twenty-five patients (23%) had no significant physical findings despite multiple examinations. Laboratory studies including a complete blood count, urinalysis, erythrocyte sedimentation rate, and cervical and urethral cultures were carried out in each patient on admission to rule out acute and chronic pelvic inflammatory disease. Diagnostic laparoscopy was performed under general endotracheal anesthesia using the 7-ram Storz laparoscope. Pneumoperitoneum was accomplished with a 15-gauge Verres needle. When manipulation of the pelvic organs was required for improved visualization a second puncture site was established in the right lower quadrant and a probe or forceps introduced. Previous pelvic or abdominal surgery was not considered to be a contraindication to laparoscopy and no special precautions were taken in these patients. All patients were prepared for possible electrocoagulation with a grounding plate under the buttock. In order to facilitate manipulation of the uterus a Valtchev~ uterine mobilizer was attached to the cervix prior to pneumoperitoneum.
From the Gynecology Division, Department o f Surgery and the Adolescent Unit, Department o f Medicine, Children's Hospital Medical Center and the Department o f Obstetrics and Gynecology and Pediatrics, Harvard Medical School, Boston, Mass. Presented before the lOth Annual Meeting of the American Pediatric Surgical Association, Los Angeles, California, March 25 28, 1979. Address reprint requests to Donald P. Goldstein, M.D., New England Trophoblastic Disease Center. 245 Pond Avenue. Brookline, Mass. 02146 ~ 1979 by Grune & Stranon, Inc. 0022-3468/79/1406~)008501.00/0
675
676
GOLDSTEIN ET AL,
Table 1. Presenting Symptoms in 109 Adolescent Females With Chronic Pelvic Pain No. of Patients Pain Cyclic Acyclic Dyspareunia Vaginal discharge Bladder symptoms Abnormal vaginal bleeding Bowel symptoms
63 46 27 13 12 11 6
Percent 58 42 25 12 11 10 5
RESULTS
The findings at laparoscopy are summarized in Table 4, The most common condition encountered was endometriosis, which was noted in 49 patients (45%) ranging in age from 10I/2 to 19. Retrospective analysis of the symptoms in this group revealed that their pain was both cyclic and acyclic and occurred at any time of the menstrual cycle. On examination nodularity was found in only 11 patients (22%) although tenderness was elicited in 37 patients (76%). Tenderness was more likely demonstrated if pelvic examination was performed during the late luteal phase of the menstrual cycle. When this condition was found, a biopsy of one of the most characteristic-appearing implants was obtained and the extent of disease determined. If only a few implants were present on the pelvic peritoneum (Kistner Stage I) 3 fulguration was performed followed by anterior fixation of the uterus by round ligament suspension. 4 When the disease appeared to be more extensive, particularly when the ovaries were involved, pseudopregnancy was induced. PriTable 2. Antecedent Abdominal Surgery in 26 Adolescent Females W i t h Chronic Pelvic Pain Previous Surgery Appendectomy only Inflamed--8 Normal--2 Ovarian cystectomy With inflamed appendix--2 With normal appendix--7 Nonpelvic laparotomy Ureteroneocystotomy Ileal bladder Bowel resection Removal of ruptured spleen Total
Table 3. Physical Findings in 109 Adolescent Females W i t h Chronic Pelvic Pain
No. of Patients
Percent
10
38
9
35
3 1 1 1 1 26
11 4 4 4 4 1O0
Tenderness Localized Diffuse Cul-de-sac nodularity Mass Adnexal thickening Fixed retroversion No specific abnormalities
No. of Patients
Percent
71 40 31 32 21 19 13 25
65 56 44 29 19 17 12 23
mary operation was limited to those patients with extensive adhesions, endometriomas, and other manifestations of advanced disease (Table 5). Postoperative adhesions were seen in 17 patients (16%). They involved the ovary and the tube in 8 patients, omentum to abdominal wall in 4 patients, and omentum to uterus in 5 patients. Analysis of the symptoms in these patients revealed that the pain was generally acyclic, aggravated by sexual relations and physical activity, and relieved by rest. On examination adnexal thickening and cul-de-sac or adnexal tenderness and nodularity were noted in 15 of the 17 patients (88%). When periovarian and peritubal adhesions were present, the most likely explanation of the pain appeared to be tension on the adhesions that generally involved the pelvic sidewall or sacrum. When possible, adhesions were lysed using the operating scissors with electrocoagulation of the raw edges and anterior fixation of the uterus to prevent reoccurrence. Otherwise conservative laparotomy was performed. When retroversion was present, uterine suspension was carried out. Table 6 summarizes the surgical procedures performed in this group. Table 4. Laparoscopic Findings in 109 Adolescent Females With Chronic Pelvic Pain Findings Endometriosis Postoperative adhesions Uterine anomalies Chronic pelvic inflammatory disease Chronic hemoperitoneum Functional ovarian cysts (6 cm) Serositis No pathology seen Totals
No. of Patients
Percent
49 17 10
45 16 9
9 6
9 5
5 3 10 109
5 2 9 1O0
CHRONIC PELVIC PAIN
677
Table 5. Surgical T r e a t m e n t in 49 Adolescent Females With Endometriosis No. of Patients
Percent
20
41
Operative
16
33
Laparotomy
13
26
Operation Laparoscopy Diagnostic only
Uterine anomalies were encountered in 10 patients (9%). The types of anomalies encountered are listed in Table 7. All had obstructed menstruation that had not been diagnosed preoperatively, although in three cases the diagnosis was suspected because of the presence of a tender mass lateral to the uterus and a history of cyclic pain that coincided with menses. Eight of the ten patients were demonstrated to have ipsilateral renal tract anomalies, usually renal agenesis. One of these patients was also found to have contralateral ureteral obstruction with hydronephrosis. All ten patients subsequently underwent correction of the defect. In seven patients pelvic endometriosis presumably secondary to reflex was also noted and required excision and long-term treatment. Evidence of adhesions of the type commonly associated with chronic pelvic inflammatory disease was observed in nine instances despite preoperative screening that revealed normal sedimentation rates and negative cervical cultures. Pain in these cases was generally acyclic but not noticeably aggravated by either sexual activity or physical activity. Adnexal thickening with or without tenderness was noted in 6 of the 9 patients. In most instances the source of the pain was thought to be duc to either mild subacute or chronic salpingitis or bilateral pelvic adhesions. Three of these patients were treated with long-term antibiotics even though aerobic and anaerobic cultures of the fluid aspirated from the cul-de-sac were negative. Four patients were treated by conservative laparotomy and one required a hysterectomy (Table 8). Table 6. Surgical Treatment in 17 Adolescent Females With Postoperative Adhesions Operation
Operative Laparotomy
No, of Patients
Anomaly Bicornis unicollis with unilateral obstruction
4
Didelphis with unilateral obstruction Septus duplex with unilateral obstruction
3 2
Duplex with unilateral obstruction Total
1 10
When chronic pelvic inflammatory disease was encountered manipulation of the reproductive organs was reduced to a minimum and antibiotic therapy was started intraoperatively in order to reduce the likelihood of an acute flare-up of the disease. Evidence of old and fresh intraperitoneal bleeding was noted in six patients. In all instances, the pain was acyclic and aggravated by physical activity. These patients were all diffusely tender on pelvic examination. One patient with bleeding from a corpus luteum was tender locally in the region of the ovary preoperatively. No bleeding site was found in two instances despite careful inspection of the pelvic contents. Treatment consisted of fulgeration of the bleeding point where noted, followed by pelvic irrigation; ovulation was suppressed for three months with cyclic oral progestational agents. Ovarian cysts were encountered in five patients. No typical symptoms were discernable in this group and physical examination was normal. The cysts were all functional rather than neoplastic, and ranged in size from 3 to 6 cm. Pain appeared to be due to intermittent torsion without strangulation. Puncture aspiration was carried out in all instances followed by three months of cyclic oral progestational therapy for ovarian suppression. Inflammation of the uterine serosa was observed in three patients. Aerobic and anaerobic cultures of the cul-de-sac fluid were negaTable 8. Surgical Treatment in Nine Adolescent Females W i t h Chronic Pelvic Inflammatory Disease Operation
No. of Patients
Percent
Laparoscopy
2
12
8 7
47 41
Operative Laparotomy Hysterectomy
Laparoscopy Diagnostic only
Table 7. Types of Uterine Anomalies Encountered in 10 Adolescent Females W i t h Chronic Pelvic Pain
Diagnostic only
No. of Patients
Percent
3
33
1 4
11 44
1
11
678
GOLDSTEIN ET AL.
Table 9. Results of Treatment in 109 Adolescent Females With Chronic Pelvic Pain Outcome
Number of Patients
Improved
Percent
Recurrence
Percent
Endometriosis Postoperative adhesions
49
35
71
14
29
17
15
88
2
Uterine anomalies
10
10
1O0
Conditions
--
Chronic PID
9
5
56
4
Chronic hemoperitoneum
6
5
83
1
Functional ovarian cysts
5
5
100
Serositis No pathology Totals
12 --
--
44 17 --
3
2
67
1
13
10
6
60
4
40
109
83
76
26
24
tive, No other associated abnormalities were observed. The cause for the inflammatory process was not known. Treatment consisted of either long-term antibiotocs, analgesics, or the use of prostaglandin inhibitors. No definite cause for chronic pelvic pain was detectable in the remaining 10 patients except for an appendolith in 1 patient who was treated with appendectomy. No additional surgery was performed in the remaining patients. The results of treatment are summarized in Table 9. Follow-up has been completed on all 109 patients for periods of 1 to 51 mo (as of February, 1979). During this time, 26 patients (24%) developed recurrent pelvic pain sufficient to require additional treatment, either medical or surgical. DISCUSSION
This study confirms previous observations that laparoscopy is a valuable diagnostic procedure in the evaluation of otherwise unexplained chronic pelvic pain in adolescent females, j Furthermore, a number of the conditions encountered were found to be amenable to surgical correction by an extension of the laparoscopic operation, thus obviating the need for laparotomy that is associated with significantly more morbidity and prolonged convalescence. Endometriosis was the most common condition encountered in this group of adolescents despite the fact that none of them had been menstruating for longer than 7 yr. The youngest patient was aged 101/z and her menarche had occurred at age 10. This finding lends further credance to the embryonic cell rest theory of the origin of this disease. In many instances, the implants did not appear to be typical of these we are accustomed to seeing in adults in that they were not well circumscribed and lacked
surrounding fibrosis. For this reason, biopsy confirmation should always be obtained. This lack of local reaction is probably a reflection of the very early phase of the disease and certainly accounts for the fact that on preoperative pelvic examination tenderness was elicited in approximately 76% of the patients while nodularity was noted in only 22%. The importance of finding early endometriosis in this age group lies not only in the relief of symptoms afforded the patient by treatment, but in the devastating effect that this disease can have on reproductive function if it is allowed to progress unabated. In light of the frequency of this condition in adolescent females with chronic pelvic pain, pediatricians as well as gynecologists must include this entity in their differential diagnosis. The history and physical examination are of prime importance in the correct diagnosis of this condition at any age. Certainly, the adolescent female who has been menstruating for 6 mo or more, who reports cyclic pelvic pain occurring just prior to or at the onset of menses, and who has tenderness with or without nodularity on pelvic examination, fits the classic description. 5 The next most common cause of chronic pelvic pain in this series was postoperative adhesions. The gratifying response to correction is not surprising in light of our experience with operative laparoscopy in adult women. 6 The use of round ligament suspension via the laparoscopy adds another dimension to therapy by bringing the adnexae out of the cul-de-sac following lysis and fulguration while reperitonealization is taking place. This raises the larger question of whether surgeons should undertake to resect small functional cysts of the ovary when encountered as an incidental finding at laparotomy performed for
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conditions unrelated to the female genital tract. Nine of the 26 patients in this series who had undergone antecedant abdominal surgery had functional cysts removed incidentally. This additional procedure does not appear to be justified unless there is the strong suspicion that a tumor is present, particularly in view of the fact that cysts of this type and size are almost always physiologic in this age group. In fact, it is worth emphasizing that careless handling of adnexae under any circumstances is to be condemned because of the strong possibility that damage will result and infertility problems ensue. Perhaps the most important lesson to be learned from this study is that unexplained chronic pelvic pain in adolescent females is
usually a symptom of some significant pelvic pathology and requires prompt and thorough attention. The physician who cares for adolescent females must take this symptom seriously and investigate it thoroughly. A careful pelvic and rectovaginal examination, appropriate laboratory studies, and diagnostic laparoscopy are indicated. This may create a problem for the physician who may need to perform a pelvic examination on a virginal adolescent whose mother is anxious about her daughter undergoing this type of procedure. Educating the patient and her mother regarding the benefits to be gained by such exams and a gentle approach is usually rewarded with a cooperative patient and parent as well as a more accurate diagnosis.
REFERENCES 1. Anteby EL: Value of laparoscopy in acute pelvic pain. Ann Surg 181:484-491, 1974 2. Cognat M, Rosenberg D, David L, et al: Laparoscopy in infants and adolescents. Obstet Gynecol 42:515 521, 1973 3. Kistner R, Siegler AM, Behrman S J: A proposed classification for patients with endometriosis--Related to infertility. Fertil Steril 28:1008 1011, 1972
4. Mann WT, Stenger VG: Uterine suspension through laparoscope. Obstet Gynecol 57:563-566, 1978 5. Bullock JL, Massey FM, Gambrell RD: Symptomatic teenagers A reappraisal. Obstet Gynecol 43:896 900, 1973 6. Lindberg WI, Wall JE, Mathews JE: Laparoseopy in evaluation of pelvic pain. Obstet Gynecol 42:872-876, 1973
Discussion L. L. Leape (Boston): 1 was impressed that almost half of the patients had that diagnosis. 1 was also impressed that only ten of the examinations were normal. We haven't fared that well in laparoscopies for chronic abdominal pain. Only a third of those patients proved to have any pathology. Can you tell us what the long-term results were in terms of correction of symptoms? Unfortunately, you sometimes find pathology that you can correct but the patient continues to have pain. This is particularly true with paraovarian cysts which may not be of clinical significance. Finally, I would like to ask the authors two other questions. Can you enlighten us nongynecologists as to what are the rationale and results of suspension of the uterus? You mention that removal of ovarian cysts may cause adhesions and pain. Are you implying that they should not be removed, and if not, what do you recommend for treatment of the ovarian cysts that is seen at laparoscopy or at laparotomy? S. Kleinhaus (New York): We have had considerable experience with laparoscopy in
adolescent patients. Between 1973 and 1976, laparoscopy was performed on 50 girls aged 12 to 18 yr old for evaluation of abdominal pain severe enough to warrant hospitalization. In nine patients, a pelvic mass was suspected on physical examination or ultrasonography. Twenty-three patients had histories of previous episodes of salphingitis, but negative cultures at time of admission. Eighteen patients had no significant past medical history and normal physical findings. Laparoscopy established a diagnosis in 28 of 50 patients, and in the 32 patients in whom a specific preoperative diagnosis was entertained, laparoscopy proved it to be incorrect in 15. In all cases where laparoscopy resulted in specific treatment, the symptoms were relieved. There was no morbidity or mortality. There were two major differences between our series and the series presented this morning. First, the distribution of patients in the author's series shows a surprisingly small number of patients with PID, and second, all the laparoscopies are done by pediatric surgeons.
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M. J. Warden (Los Angeles): Chronic pelvic pain has been around a long, long time. The operation of uterine suspension has been around a long, long time. But several years ago I thought that the operation had been abandoned. I seem to remember some official report that really declared it as a nonessential, unnecessary operation. There is some resurgence for it, and as Dr. Leape asked, what is the indication? S. J. Dickinson (New York): I was particularly impressed by the 29 patients with previous surgery. Residents, unless restrained, will pull on tubes and ovaries with a Babcock. For years ! have been emphasizing to them, leave it alone. We treat testes with exquisite care during the course of a hernia operation. What we tend to let our residents do to ovaries is appalling. I'd like to see that 29 number quoted widely. D. P. Goldstein (closure): l find ultrasound to be generally unreliable with regard to smaller ovarian masses. The ovary is a cystic structure, it goes through a phase and a cycle. Our ultrasound people at Children's (Boston) are very conscientious and sincere, but very often if I can't feel a pelvic mass I don't consider it significant. We, too, have run into the situation where we have patients who have been in the emergency room with a label of chronic PID who,
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when we laparoscoped, do not have any pelvic adhesions consistent with PID. We have found a number of these patients have endometriosis. It's been called the Boston disease. Nonetheless we have pathologic confirmation in the vast majority of our patients. ! would suggest perhaps that it's going unrecognized in other areas. We have a recurrence rate of about 25%. That means that the patient's symptoms recurred after completion of initial therapy whether that therapy was medical, such as for endometriosisor or surgical, via laparoscopy or laparotomy. Anterior fixation of the uterus because a patient has retroversion is not considered good gynecologic care. But fixation of the uterus anteriorly in a patient on whom you performed pelvic surgery, for example, adnexal surgery and infertility work or endometriosis is considered good pelvic surgery. Therefore, when we perform lysis of adhesions we do try to get the adnexa out of the cul-de-sac by performing uterine suspension. With regard to management of ovarian cysts, all the smaller cysts that we consider physiologic are puncture aspirated and ovaries are suppressed with cyclic progestational agents. Sometimes if they are very small or they are corpeus luteum cysts, they are just left alone. It depends upon the size and the symptoms.
