The causal role of adhesions in the genesis of pelvic pain is uncertain, and surgery will lead to further adhesion formation and perhaps organ injury. Therefore, lysis is not recommended unless there is intermittent partial bowel obstruction or infertility. Although some observational studies showed that laparoscopic lysis of adhesions can alleviate chronic pelvic pain, randomized controlled trials have not revealed any long-term benefit. If surgery is performed, barrier materials such as oxidized regenerated cellulose or hyaluronic acid with carboxymethylcellulose can be used for prevention of adhesion re-formation. Repeated surgical procedures for lysis of adhesions are not indicated.
Pelvic Congestion Pelvic congestion syndrome involves congestion or dilation of uterine and/or ovarian venous plexuses (93–97). First proposed in the 1950s, this condition was a suggested result of emotional stress that could lead to smooth muscle spasm and congestion of ovarian and uterine pelvic venous plexuses. A subsequent blind study was undertaken to compare results of transuterine venography in patients with unexplained CPP and negative laparoscopy with controls (97). This study demonstrated that women with CPP had a larger mean ovarian vein diameter, delayed disappearance of contrast medium, and greater ovarian plexus congestion compared to controls. The existence of this condition is controversial.
Pelvic congestion affects women of reproductive age. Typical symptoms include bilateral lower abdominal and back pain that is increased with standing for long periods, secondary dysmenorrhea, dyspareunia, abnormal uterine bleeding, chronic fatigue, and irritable bowel symptoms (97). Pain usually begins with ovulation and lasts until the end of menses. The uterus is often bulky, and the ovaries are enlarged with multiple functional cysts. The uterus, parametria, and uterosacral ligaments are tender.
Transuterine venography is the primary method for diagnosis, although other modalities, such as pelvic ultrasound, magnetic resonance imaging, and laparoscopy, may disclose varicosities (93). Because of the cost and possible side effects of treatment, further management should be based on related symptoms and not simply on the presence of varicosities.
Treatment of suspected pelvic congestion ranges from the less invasive hormonal suppression and cognitive behavioral pain management to the more invasive ovarian vein embolization or hysterectomy and salpingo-oophorectomy (93–97). Low-estrogen, progestin-dominant continuous oral contraceptives, high-dose progestins, and GnRH analogues often provide pain relief (94). Hormonal suppression should be the initial mode of treatment for women with suspected pelvic congestion. Medroxyprogesterone acetate, 30 mg daily, is useful (95). A multidisciplinary approach incorporating psychotherapy, behavioral pain management, or both is highly recommended. Percutaneous transcatheter embolization can be considered for women who do not respond to medical or hormonal therapy (96,97). Technically more invasive, transcatheter embolotherapy selectively catheterizes the ovarian and internal iliac veins, followed by contrast venography and embolization. This treatment showed some promise in small uncontrolled studies, but larger randomized controlled trials are necessary to validate its benefits. For women who have completed their childbearing, hysterectomy with oophorectomy is a reasonable option if multidisciplinary management has failed (97).
Patients with salpingo-oophoritis usually present with symptoms and signs of acute infection. Atypical or partially treated infection may not be associated with fever or peritoneal signs. Subacute or atypical salpingo-oophoritis is often a sequel of chlamydia or mycoplasma infection. Abdominal tenderness, cervical motion, and bilateral adnexal tenderness are typical of pelvic infection (see Chapter 18).