Journal of Surgical Oncology 7:249-254 (1975)

Pelvic Neoplasms Causing Pain ....................................................................................... ....................................................................................... GLENN W. GEELHOED, M.D., and ALFRED S. KETCHAM,” M.D. The following is a discussion of dyspareunia and its role as an aid to diagnosing pelvic neoplasms. The great majority of cases of dyspareunia are psychosomatic in origin, and in a large proportion of the remaining cases, painful coitus is an indicator of benign problems. Nevertheless, painful coitus is a symptom which requires careful pelvic examination to rule out the possibility of pelvic neoplasm and to discover treatable causes of dyspareunia.

.......................................................................................... .......................................................................................... KEY WORDS: pelvic pain; coital pain; cancer, symptoms; early diagnosis of pelvic cancer

Dyspareunia appears to be an unusual complaint in patients with pelvic neoplasms. A retrospective review of the recorded medical history of over 500 patients admitted to the Surgery Branch, National Cancer Institute with the proven diagnosis of advanced carcinoma of the uterus or vagina revealed that only two patients spontaneously complained of painful intercourse. However, it was unusual to find any evidence in the chart that a question had been asked of the patient that might have evoked such a discussion. Certainly the typical woman with a recently diagnosed cancer has other anxieties to bring to the attention of the physician taking the history, who may be preoccupied by other matters as well. The physician may fail to specifically discuss dyspareunia with a gynecologic cancer patient because of her immediate worries of more significance than the discussion of compatibility of sexual relations. Prospective appraisal of the association of dyspareunia and pelvic neoplasms is unrevealing when dealing with patients with the more common neoplasms of the uterus. In contrast, a carcinoma of the vagina is more often than not associated with painful intercourse, and the frequency of dyspareunia with ovarian carcinoma is midway between that for vaginal and uterine malignancies. Confusing responses can be “prompted” by the doctor in questions relating to sexual relations. There are those women who, when faced with the diagnosis of cancer, choose to establish some degree of blame for this distressing circumstance by recalling that their sexual relations had been less than satisfactory in the recent past. For such an individual the explanation of the cause for this change in sexual relations can be whatever the questioner elicits from the patient or whatever she thinks the doctor wants to hear - the most common being pain. From the Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, *University of Miami School of Medicine, Miami, Florida.

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@ 1975 Alan R. Liss, Inc., 150 Fifth Avenue, New York, N.Y. 10011

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It has also been found that when a complaint of dyspareunia is elicited, many other questions must be considered; the most important is the association of pain with positions in the sexual act itself. Vaginal lesions are symptomatic regardless of the positional relationship to the sexual act. Ovarian lesions cause discomfort in direct relation to coital position. Figure 1 illustrates the anatomic positions of the neoplasms causing pain at different phases in the coital act. The great majority of cases of dyspareunia are psychosomatic in origin (1-1 1) and in a large proportion of the remaining cases, painful coitus is an indicator of benign problems. These benign causes can be divided into two categories: inflammatory (such as chronic cervicitis, cervical erosion, pelvic inflammatory disease) and pelvic relaxation (such as the relaxed pelvic floor of grand multiparity). Nonetheless, painful coitus is a symptom which requires careful pelvic examination to rule out the possibility of pelvic neoplasms and to discover treatable causes of dyspareunia. A negative pelvic examination would be the mandatory and important first finding before proceeding to study what might be other causes of the discomfort. The common physical cause of coital pain is uterine descensus. As already mentioned, the majority of physical causes of dyspareunia are benign. Cervical prolapse is a frequent cause of descensus, as are the other clinical conditions grouped under relaxed pelvic floor. However, mass lesions and neoplasms that exert downward pressure within the pelvis can also lead to uterine descensus, expressed symptomatically by the patient as painful coitus. Of lesions lower in the female genitourinary tract, vulvar and vaginal cancers can cause irritation or pain on penetration. Malignant change in genital mucosa can lead to loss oflubricating secretions (Fig. 2). Lesions of bladder and urethra as well as the rectum and anus can also cause pain during coitus. Of the most common female genital malignancies, carcinoma of the cervix can present with abnormalities first noted during intercourse; however, this usually presents as postcoital spotting. Fear of causing a repetition of the bleeding incident can be reported by the patient as pain. Anxiety concerning bleeding after intercourse is a more frequent complaint than actual pain during the sexual act. Later stage advanced lesions of the uterine cervix that have considerable mass can cause dyspareunia, as well as descensus of the cervix itself (Fig. 3). T h s would be a late stage for detection of cancer of the cervix, for a sexually active female should have noted other abnormalities prior to the descensus, such as abnormal bleeding. Pelvic or peritoneal malignancies, through their mass or ascites, can exert abdominal pressure on the female genitalia and cause dyspareunia. Painful coitus may signal the presence of ovarian or uterine malignancy in the pelvis or malignant masses in the abdominal cavity (Table I). Mobile pedunculated masses such as dermoid cysts of the ovary or, in some cases, the uterus may be mobile enough to fall back in the cul-de-sac and can also cause pain during intercourse. A mobile mass that falls into the cul-de-sac during intercourse causes pain of an acute episodic nature, particularly in association with deep or forceful penetration. Detailed information must be elicited from the history to suggest to the examining physician what the cause of painful coitus might be. There are many possible causes for painful penetration. For example, it may be caused by sustained deep pelvic dysesthesias; this pain is quite different from acute pain that occurs only episodically and in certain positions in later stages of the coital act. By asking the appropriate questions, the physician may focus on the source of the problem in the lower genital tract, the cervix, the internal genitalia (including the uterus and adnexal structures) or locate secondary problems in

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Fig. 1. Sagittal view of female pelvis illustrating three neoplastic sites that can produce pain during coitus.

the pelvis or abdominal cavity that have been referred to the pelvis and reflected as symptomatic coital pain. Uterine descensus is a factor associated with neoplasm and benign conditions in the pelvis and abdomen, whereas inflammatory and erosive lesions are more frequent at the levels of introitus and lower genital tract. The patient who presents with painful coitus deserves a careful examination, including a detailed history to pinpoint the possible organic source of her discomfort. Further studies may be indicated by findings on pelvic examination or information obtained about the timing and nature or positional association of her pain. Such discomfort is very distressing and naturally carries a degree of overlying psychosomatic distress. The reluctance of both patient and physician to discuss the details of the sexual

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Fig. 2. A level I pelvic neoplasm: in this case, a vulvar melanoma.

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Fig. 3. The most common level I1 pelvic neoplasm, cervlcal carcinoma. In each of the four stages of this tumor, pelvic pain during coitus can occur.

TABLE I.

Neoplasms that Can Cause Painful Coitus

Lower genital tract Vulvar (Bowen’s disease or epidermoid cancer) Vaginal (squamous or adenocarcinoma, or mucosal melanoma) Carcinoma of cervix Bladder and urethra Rectum and anus Internal genitalia Uterine (adenocarcinoma or myometrial fibroids) Ovarian (germ cell or epithelial) Pedunculated neoplasms (e.g. dermoid) Retroversion of uterus (acquired, neoplasm-induced) Culde-sac space-occupying lesions Metastatic cancer (e.g. Krukenberg tumor, gastric*varies) Pelvis and peritoneum Gastrointestinal (e.g. sigmoid) Hepatic (e.g. ascites) Hematologic (e.g. splenomegaly) Neurogenic (e.g. neurofibroma) Mesenchymal (e.g. sacrococcygeal teratoma)

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act that are found most distressful must be overcome if relief of the symptoms or discovery of their cause is to be achieved. Communication barriers must be broken down across professional roles, gender roles, and dependency transference if the physician’s examination is to be of maximum benefit to the patient. Treatment ranges from reassurance to total pelvic exenteration, depending on the cause of the problem - diagnosis, then, is all important. Reassurance and symptomatic and psychological support for the patient who complains of dyspareunia would be a disservice following anything but the most careful search for a pelvic cause of her discomfort. Equally important in dealing with patients who have developed cancer of the pelvic structures is the reassurance or directional guidance the physician can give in relieving the patient of the anxiety she may have concerning the relationship of past sexual activity and her cancer. Without the assurance that her cancer is unrelated to specific sexual acts, sexual rehabilitation after cancer cure is sometimes never satisfactorily obtained.

REFERENCES 1. Bret, A. J., et al. (1967). Pain in gynecology. Rev. Franc. Gynec. Obstet. 62:315. 2. De Brux, J. A., Bret, J. A., Demay, C . , and Bardiaux, M. (1968). Recurring pelvic peritonitis. A comment on the Allen-Masters syndrome. Amer. Obstet. Gynec. 102:SOl. 3. Douglas, C. P. (197 1). Pelvic pain. “Psychosomatic Medicine in Obstetrics and Gynaecology.” London: 3rd int. Congr., 457. 4. Harlow, R. A. (1969). Dyspareunia. Practitioner 202:393. 5. Jeffcoate, T. N. (1969). Pelvic pain. Brit. Med. J. 3:431. 6. Jeffocate, T. N. (1962). “Principles of Gynaecology,” 2nd ed. London: Butterworths. 7. Landau, M. E. (1960). Dyspareunia. Practitioner 185:238. 8. Lieveaux, A. (1967). Dyspareunia. Apropos of 143 cases. Rev. Franc. Gynecol. 62: 309. 9. Pace, G. (1961). Dyspareunia. Clin. Obstet. Ginec. 63:334. 10. Sinclair, W. Y. (1971). Chronic pelvic pain in young women. “Psychosomatic Medicine in Obstetrics and Gynaecology.” London: 3rd int. Congr., 463. 11. Zapella, R. (1963). Problem of pain in pelvic neoplasms. Quad. Clin. Obstet. Ginec. 18:1556, suppl 1.

Pelvic neoplasms causing pain.

The following is a discussion of dyspareunia and its role as an aid to diagnosing pelvic neoplasms. The great majority of cases of dysparenia are psyc...
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