This document discusses gynecological causes of chronic pelvic pain. It outlines three main causes: 1) pelvic adhesive disease which can form from prior surgery or infections and cause pain by distorting anatomy or stretching tissues, 2) ovarian remnant syndrome where remnants of excised ovaries are left behind and can cause pain, and 3) pelvic congestion syndrome where incompetent valves in ovarian or pelvic veins cause retrograde blood flow, dilatation, and pain. Diagnosis involves laparoscopy, imaging, or labs while treatment options include adhesiolysis, further surgery to remove remnants, and ovarian vein embolization or ligation.

1. Gynecological causes
of chronic pelvic pain
By TEMESGEN GIRMA(C1)
SPHMMC, Addis Ababa, Ethiopia
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2. Pathophysiology
• The pathophysiology of CPP is unclear in
many patients and may have a significant
association with neuropathic pain.
• Potential gynecologic sources of chronic pain
include
1. Pelvic adhesive disease,
2. Ovarian remnant & retention
syndrome, and
3. Pelvic congestion syndrome
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3. 1. Pelvic Adhesions
• Adhesions are fibrous connections between
opposing organ surfaces or between an organ and
abdominal wall, at sites where there should be no
connection. They vary in vascularity and thickness.
• Filmy adhesions
• Dense adhesions
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4. Common Risks for adhesions
• Prior surgery,
• Prior intra abdominal infection
• Endometriosis
• Inflammation from radiation
• Chemical irritation
• Foreign body reaction
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5. • Adhesions are common, and in laparoscopies
performed for CPP, they are found in approximately
one quarter of cases (Howard, 1993). However, not
all adhesive disease creates pain.
• For example, Thornton and associates (1997) found
no relationship between pelvic pain and women
with intra abdominal adhesions.
5
Cont…

6. Pathophysiology
• Intraperitoneal adhesions are believed to cause
pain when they distort normal anatomy or when
movement stretches the peritoneum or organ
serosa.
• Adhesions that had a relationship to the
peritoneum had a high association with pain.
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7. Diagnosis
• Laparascopy
• Sonography
Treatment
• Adhesiolysis ,but
appropriate steps
should be taken to
minimize
reformation

8. 2. Ovarian Remnant Syndrome &
Ovarian Retention Syndrome
• Ovarian remnant syndrome (ORS) is a group of
symptoms(pelvic pain, pelvic mass, dyspareunia,
absence of menopause) which arises from a
remnants of an excised ovary.
• ORS is very rare but is most likely to occur among
patients who have had imprecise or incomplete
surgery to remove one or both ovaries.
• Ovarian retention syndrome involves symptoms
stemming from an ovary intentionally left at the time
of previous gynecologic surgery.
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9. • Women with symptomatic ovarian remnants most
typically complain of chronic
or cyclic pain or dyspareunia. The onset of
symptoms is variable and may begin years following
surgery.
• Risks
Adhesions…… limit Visualization
Anatomic variations
Intraoperative bleeding
Poor surgical techniques….imprecise choice of
surgical site
9
Cont…

10. Diagnosis
• Diagnostic laparascopy
• Clinically
• Laboratory( FSH &
estrdiol)
Treatment
• Therapeutic laparoscopy
or laparotomy(incase of
ureteral adhesion )
• Hormonal therapy
(GnRH agonists,
progesterone)

11. 3. Pelvic Congestion Syndrome
• Pelvic Congestion Syndrome is a group of
symptoms characterized by chronic pelvic
ache, pressure, and heaviness due to a
retrograde blood flow through incompetent
valves of ovarian or pelvic veins.
• The Cause of pain
• Increased dilatation,
• Concomitant stasis, and
• Release of local nociceptive mediators.
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12. Pathophysiology
• A mechanical dilatation
• An ovarian hormonal dysfunction, or
• Both
• Higher rates of ovarian varicosities and pelvic
congestion syndrome are noted in parous women.
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13. Diagnosis
• Hx & P/Ex
• Pelvic venography G
Treatment
• Hormonal
• Ovarian vein
embolization(95%
pain improvement)
or ligation, and
• Hysterectomy with
(BSO),

14. Thank you !