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10.1576/toag.12.1.007.27552 http://onlinetog.org

2010;12:712

Review

Review The threshold for

laparoscopy for pelvic pain
Authors Elisenda Laborda / Andrew Clarke / Tyrone Carpenter

Key content:
Detailed history and examination are crucial.
Laparoscopy is readily justifiable in acute pain.
In chronic pelvic pain, the possible benefits and risks associated with
laparoscopy need to be assessed for each woman individually.

Learning objectives:
To outline gynaecological and non-gynaecological reasons for pelvic pain.
To evaluate methods of diagnosis.
To determine the likelihood of laparoscopy being effective in diagnosis and
treatment, and the associated risks in each individual case.

Ethical issues:
The risks of unnecessary and unhelpful surgery should be balanced against the
risks associated with delay and possible misdiagnosis.
Keywords adhesions / endometriosis / irritable bowel syndrome / laparoscopy /
pelvic pain
Please cite this article as: Laborda E, Clarke A, CarpenterT. The threshold for laparoscopy for pelvic pain. The Obstetrician & Gynaecologist 2010;12:712.

Author details
Elisenda Laborda MD MRCOG
Specialist Registrar in Obstetrics and
Gynaecology
Department of Obstetrics and Gynaecology,
Poole Hospital NHS Foundation Trust,
Longfleet Road, Poole, Dorset BH15 2JB, UK

Andrew Clarke BSc MD FRCS

Consultant Surgeon
Department of Surgery, Poole Hospital NHS
Foundation Trust, Poole, UK

2010 Royal College of Obstetricians and Gynaecologists

Tyrone Carpenter BSc MD MRCOG

Consultant Obstetrician and Gynaecologist
Department of Gynaecology, Poole Hospital
NHS Foundation Trust, Poole, UK
Email: tyrone.carpenter@poole.nhs.uk
(corresponding author)

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Introduction
Acute and chronic pelvic pain are two of the most
common presenting complaints in gynaecology.
Despite sharing similar possible aetiologies, they
are usually disparate entities with very different
management approaches. Acute presentations
require urgent investigation and prompt
intervention. Laparoscopy provides the diagnosis
and possible treatment of acute pelvic pain
related to tubo-ovarian pathology; its use is
widely justified in these situations. More difficult
to ascertain is the role of laparoscopy in chronic
pelvic pain (CPP), on account of the
multifactorial origin of this condition.
In the UK, 1 million women have CPP, which
occurs, therefore, as frequently as asthma or
migraine. Chronic pelvic pain represents the
single most common indication for referral to
gynaecology clinics and is the subject of 20% of all
gynaecological consultations.1 It has been estimated
that the prevalence of dyspareunia in the UK is 8%,
dysmenorrhoea 4597% and abdominal pain
2329%.2
Chronic pelvic pain is difficult to define. The
International Association for the Study of Pain
defines CPP without obvious pathology as chronic
or recurrent pelvic pain that has an apparent
gynaecological origin but for which no definitive
lesion or cause is found. This definition is
problematic from a clinical perspective, since it
implies absence of pathology, which excludes pelvic
pain secondary to pathology such as endometriosis
and cases with pelvic pathology that is not necessarily
responsible for the pain. In CPP, as in many other
pain conditions, the relationship of the pain to
observed pathology is often unclear.
Chronic pelvic pain is debilitating and has a huge
socio-economic impact, with a 45% reduction in
work productivity and a 15% increase in time lost
from work among women with the condition.3 It
can be challenging to treat; a multidisciplinary
approach is often required. Several factors have
been identified as predisposing to CPP and
knowledge of these is useful when determining an
individual threshold for laparoscopy. Smoking,
low body mass index, sterilisation, sexual abuse
and psychological symptoms have been associated
with dysmenorrhoea, whereas exercise and oral
contraception have been negatively associated with
the condition. Anxiety, depression, miscarriage,
caesarean section and drug and alcohol misuse are
associated with non-cyclical pelvic pain.4
Several different aetiologies, apart from
gynaecological pathology, need to be considered
when a woman presents with CPP. Detailed history
and examination are important to determine the
nature of the pain and identify the appropriate
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investigations. Laparoscopy is not always the firstline investigation or treatment; careful selection
of cases is essential to minimise unnecessary
intervention and maximise diagnostic accuracy.
To achieve this requires a thorough understanding
of CPP, including all non-gynaecological causes.

The aetiology of pelvic pain

Chronic pelvic pain is usually multifactorial in
origin and diagnosis is not always easy. It may not
be associated with any apparent organic pathology
and when pathology is present the symptoms
often correspond poorly with the pathology
identified. The aetiology can be found in the
gynaecological, gastrointestinal, urological,
neurological or musculoskeletal systems.
Cyclical pelvic pain
Gynaecological pelvic pain can be cyclical or
non-cyclical. Cyclical pain is usually related to
the reproductive system and tends to respond to
suppression of ovarian function. Dysmenorrhoea
defines pain related to menses (see Box 1). This can
be primary, where no underlying pathology is
observed. In secondary dysmenorrhoea there is
underlying pathology such as endometriosis,
adenomyosis, adhesions or pelvic infection;
congenital pelvic malformations or cervical stenosis
may also be found. In primary dysmenorrhoea,
examination of the reproductive system is usually
normal. In secondary dysmenorrhea, abnormalities
in the adnexa, uterosacral ligament or uterus size or
mobility may well be identified.
Non-cyclical pelvic pain
See Box 2. Non-cyclical CPP can be secondary to
gynaecological disorders such as adhesions,
subacute or chronic pelvic infection, hydrosalpinges
or tumours, or it can be due to conditions of the
gastrointestinal, urological, neurological or
musculoskeletal systems. Gastrointestinal and
gynaecological diseases can present with similar
characteristics, as the cervix, uterus, adnexa, lower
ileum, sigmoid colon and rectum share a common
innervation (T10L1). It can be difficult clinically to
differentiate pain coming from these organs.
Irritable bowel syndrome
Irritable bowel syndrome (IBS) is defined according
to the Rome III criteria as abdominal pain or
discomfort and at least two of the three following
features: relief on defecation; onset associated with
change in frequency of stool; onset associated with
change in form (appearance) of stool. Symptoms
should be present for a minimum of 3 months and
organic underlying pathology should be excluded.5
Symptoms of IBS often worsen premenstrually
and during menstruation and are correlated
with increased levels of various perimenstrual
symptoms,6 explaining why IBS accounts for
760% of referrals to gynaecologists.7 Up to 35%
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of women with IBS report having CPP; those with

both diagnoses are more likely to have a lifetime
history of dysthymic disorder, current and lifetime
panic disorder, somatisation disorder or childhood
sexual abuse.8 Longtretch et al.9 studied the
relationship between IBS symptoms among
women undergoing laparoscopy for CPP compared
with hysterectomy for CPP; such symptoms were
recorded among 47% of women undergoing
laparoscopy, 39.5% of women undergoing
hysterectomy and 32% of the controls matched for
the hysterectomy group. Women with endometriosis
were more likely to receive a diagnosis of IBS.
Dyspareunia was more common among those
with IBS than those without. Among women who
underwent hysterectomy for pain, at 12-month
follow-up less pain improvement was recorded
among those with IBS and greater improvement
among those without IBS.
Urological causes
Urological causes of pelvic pain include recurrent
urinary tract infection, interstitial cystitis and
urethral syndrome. These usually present with
symptoms of dysuria, frequency and urgency. The
National Institute of Health consensus criteria for
the diagnosis of interstitial cystitis require at least
one of the following: pain on bladder filling relieved
by emptying; pain in the suprapubic, pelvic,
urethral, vaginal or perineal region; glomerulations
(intramucosal bleeds after hydrodistension) on
endoscopy; and decreased compliance on
cystometrogram. Urethral syndrome is a diagnosis
of exclusion and is probably due to subclinical
infection, with chronic inflammation of the
periurethral glands and possible urethral spasticity.
Treatment may involve re-education of the pelvic
floor with biofeedback and antibiotic therapy.
Myofascial pain
A less common but well documented cause of pelvic
pain is myofascial pain with or without underlying
pathology. Myofascial pain can clearly cause
dyspareunia, dyschesia and exacerbation of
dysmenorrhoea, as the pelvic organs and abdominal
and pelvic muscles have similar innervation
(T10S4). The structures involved include the
rectus, iliopsoas, piriformis obturator (T12L4)
and levator ani (S24) muscles. Myofascial pain
usually presents as a dull ache, which is difficult to
localise. Management is multidisciplinary, involving
medication, physiotherapy, trigger point injections,
botulinum toxin injection and psychological
therapy.10
Nerve injury or entrapment
Injury or entrapment of the ilioinguinal nerve (T12,
L1), iliohypogastric nerve (T12, L1) following a
Pfannenstiel incision, genitofemoral nerve (L1, L2)
and pudendal nerve (S24) following lithotomy
position and vaginal surgery, can result in chronic
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2010;12:712

Primary

Secondary

No underlying pathology observed

Underlying pathology present, such

as endometriosis, adenomyosis,
adhesions or pelvic infection; congenital
pelvic malformations or cervical
stenosis may also be found

Abnormalities in the adnexa, uterosacral

ligament or uterus size or mobility may
be identified

Review

Box 1

Characteristics of dysmenorrhoea

Examination of the reproductive system

is usually normal

Affected system

Examples of disorders

Gynaecological

Adhesions

Box 2

Summary of causes of non-cyclical

chronic pelvic pain

Subacute or chronic pelvic infection

Hydrosalpinges
Tumours
Gastrointestinal
Urological

Irritable bowel syndrome

Recurrent urinary tract infection
Interstitial cystitis
Urethral syndrome

Neurological

Nerve injury or entrapment following

lithotomy position and vaginal surgery

Musculoskeletal

Myofascial pain with or without

underlying pathology

lower abdominal or pelvic pain. These usually

present as stabbing, sharp pains occurring with
movement and they tend to be relieved by
infiltration of local anaesthetic into the tender
point. Women with this condition may have
experienced a recent significant change in weight
and/or have undertaken new physical activity.

Clinical history and

examination for chronic
pelvic pain
A detailed pain anamnesis, with full gynaecological,
obstetric, medical and surgical histories, is required
to identify the likely causes of CPP. It is important
to be aware of the chronology of the pain, including
the starting point, duration, predisposing factors
and the womans perception of what the cause of
her pain could be. The nature, type, location,
intensity and radiation of the pain, aggravating
and alleviating factors and impact on social, work
and family life should be noted. Women with
endometriosis, for example, are more likely to
report their pain as throbbing and to experience
dyschesia. One should enquire about any associated
somatic symptoms related to the genitourinary
tract and gastrointestinal, musculoskeletal and
nervous systems as well as any previous therapies
and investigations. Any psychological conditions,
past or present, should be noted.
Examination should include assessment of the
general condition, body mass index, posture,
movement and anxiety level. Abdominal and
gynaecological examinations should be performed.
It is useful to start the vaginal examination using
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only one finger to assess any tenderness of the

urethra, bladder base, pelvic floor muscles,
piriformis, obturator internus, cervix and
uterosacral ligaments. Bimanual examination
should be carried out to assess the size, axis and
mobility of the uterus and presence of any palpable
mass or nodules in the rectovaginal septum or
uterosacral ligament, as well as tender points.

The role of laparoscopy

Laparoscopy is established as the preferred surgical
technique to treat endometriosis, endometriomas
and adhesions in the presence of known disease
identified by either previous laparoscopy or
ultrasound evidence of endometriomas. Equally,
the role of laparoscopy in the acute setting is well
established; the question that remains unclear is, at
what stage in the investigation of CPP is laparoscopy
indicated? The problem is that reliable diagnosis of
the two most frequently encountered abnormalities,
endometriosis and adhesions, is very difficult
without laparoscopy. Ultrasound is very accurate
in the identification of endometriomas11 but not
of peritoneal disease. Some authors have found
ultrasound effective in defining pelvic adhesions,12
but such diagnostic accuracy is not possible in the
general clinical setting. Magnetic resonance imaging
(MRI) may be useful in assessing deeply invasive
endometriosis but it cannot be used to record
peritoneal lesions 4 mm in diameter.2,13 Finally,
despite much research, no serum markers have
shown adequate sensitivity and specificity to be of
clinical use.

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percentage with observed pathology seems to be

significantly increased (78% showed some
pathology, 40% had endometriosis) compared
with adults (60% in that study showed some
pathology). It is important to bear in mind,
however, that 2829% of asymptomatic women
will be found to have pelvic abnormalities1,15 at the
time of laparoscopy.
Of those women with pathology identified at
laparoscopy, the majority will have pelvic adhesions
affecting the genital tract and bowel (3855%) and
often endometriosis (2945%).1416 Other possible
diagnoses include non-endometriotic cysts,
hydrosalpinges, hernias, pelvic congestion and
postoperative peritoneal cysts.
The role of adhesions in CPP is still controversial,
with contradictory data. It is accepted that intraabdominal adhesions can cause small bowel
obstruction and infertility. However, it is common
to find adhesions at laparoscopy among women
without pelvic pain, even with evidence of nerve
fibres within the adhesion. Interestingly, adhesions
are not usually described as a cause of pain in men.
A review of adhesiolysis did not show it to be of
benefit other than among women with extensive
adhesions,17 although some studies reported a
50% rate of improvement in CPP 612 months
after adhesiolysis.18

More than 40% of gynaecological laparoscopies are

performed for CPP. To minimise unnecessary
intervention, a detailed clinical history, examination
and non-invasive investigations are essential.
History taking should include particular attention
to symptoms suggestive of the non-gynaecological
disorders outlined earlier. Bowel symptoms
suggestive of IBS should receive prompt appropriate
treatment first, to assess the effect on symptoms.
Likewise, symptoms suggestive of interstitial
cystitis or urethral syndrome indicate urological
referral. Clinical examination is useful but not
wholly reliable: 75% of cases of CPP with normal
bimanual examination show abnormal findings at
laparoscopy and 11% of cases with abnormal
bimanual examination feature no pathology at
laparoscopy.14 Thus it is clear that women with
abnormal clinical findings should probably
proceed straight to laparoscopy, whereas normal
findings on clinical examination are of little use in
diagnosis.

Up to 22% of asymptomatic women and up to

2945% of women with pelvic pain may be found
to have endometriosis. Laparoscopy is the gold
standard investigation for diagnosis, having a
positive predictive value of 93.3%, sensitivity of
69.9%, negative predictive value of 41.9% and
specificity of 83.1% in predicting endometriosis,
according to a recent study that analysed the
relationship between visual findings and histological
diagnosis.19 Interestingly, approximately 25% of the
lesions categorised as atypical in appearance by the
surgeon were confirmed to be endometriosis after
histological assessment. This would suggest that,
when excising endometriosis, all atypical lesions
should also be excised, together with red and
black endometriosis.14,15 In a similar study,20 only
54% of the lesions suspected to be endometriosis
were confirmed by histology. All of the red lesions
in the study, 92% of black lesions and 31% of
white lesions turned out to be endometriosis. By
location, the most accurate diagnosis was of
endometriosis on the parietal peritoneum (100%),
followed by the ovarian fossa (67%), uterosacral
and broad ligaments (60%) and ovarian surface
(48%).

Several studies have reached similar conclusions,

i.e. that approximately 20% of women with CPP
have normal pelvic anatomy and 6080% have some
pathology. Among symptomatic adolescents, the

Although the accurate diagnosis of endometriosis

is somewhat complicated by the need for an invasive
procedure, to an extent this is offset by the ability to
treat the condition simultaneously. In all but severe
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disease, one can offer optimal excisional surgery at

the time. This is without doubt advantageous
among women with associated subfertility21 and
endometriomas22 and is probably the treatment
of choice for women with pain only. When
endometriosis is excised for pelvic pain, the
reduction in pain and the improvement in quality
of life persist for up to 5 years. Reported recurrence
rates are 21.5% at 2 years and 4050% at 5 years.23
The probability of requiring further surgery after
resection of endometriosis has been reported as
36%.24 The return of the pain is not always associated
with clinical evidence of recurrence. Laparoscopic
excisional techniques for the treatment of
endometriomas seem to be superior to drainage
and ablation with regard to recurrence, return of
pain and, among previously subfertile women,
subsequent spontaneous pregnancy.25

Conclusion

One should also remember that pelvic pain can

be managed conservatively as well as surgically.
Treatments include simple analgesics as well as
hormonal therapies involving estrogens,
progestogens and gonadotrophin-releasing
hormone (GnRH) analogues. The latter down
regulate ovarian function by direct effect on the
pituitary gland and reduce the growth of
endometrial cells26 and several inflammatory
molecules in the peritoneal cavity.27

References

Clinicians should be able to give information about

success rates and risks of all possible treatments, to
allow women to take an informed decision regarding
their treatment. According to RCOG guidelines
laparoscopy has both serious and frequent risks.28
Serious risks are uncommon (2/1000) but can have
serious consequences. They include: damage to the
bowel, bladder, ureters or major blood vessels that
would require immediate repair by laparoscopy or
laparotomy; failure to gain entry to the abdominal
cavity and to complete the intended procedure;
hernia at the site of entry; and death (38/100 000).
Frequent risks that should be mentioned are wound
bruising, gaping and infection and shoulder-tip pain.
These risks are increased with obesity, significant
pathology, previous surgery and pre-existing
medical conditions.
The clinical threshold for laparoscopy should be
individualised for each woman according to her
fertility needs, previous treatments, symptom
severity, quality of life and particular wishes.
Despite the increased risks associated with
surgical options, Ballard et al.29 showed that some
women may benefit from knowing the exact
pelvic pathology, as this may target the treatment
more appropriately for them and also reassure
them by excluding malignancy. The exact role of
laparoscopy in CPP is thus difficult to standardise
because of its complex and diverse aetiology and
the limited data available.
2010 Royal College of Obstetricians and Gynaecologists

Review

Laparoscopy is readily justifiable in acute pain

situations where imaging techniques suggest the
presence of tubo-ovarian pathology. It is more
difficult to determine an appropriate threshold for
women with CPP and the risks needs to be assessed
for each person individually.
Detailed history and examination are crucial in
identifying cases with gynaecological pathology
and thereby minimising unnecessary intervention.
Women with symptoms suggestive of bowel or
urological disease should be referred to the
appropriate specialty or treated empirically before
undertaking laparoscopy. On the other hand, there
should probably be a lower threshold for
adolescents and for women with abnormal
clinical findings.

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