(Professor and Head, Department of Obstetrics and Gynecology, Seth G S Medical College & K E M Hospital, Mumbai, India.)
Pelvic tenderness in a woman can be caused by a number of conditions, like acute pelvic infection, endometriosis and torsion of adnexal structures. It is conventionally evaluated by an algorithmic approach, the final investigation being a laparoscopy. We encounter some cases in which no cause is found after extensive evaluation, including a laparoscopy as the final diagnostic case. An innovative approach was used in one case recently, which helped avoid an unnecessary laparoscopy.
Pelvic tenderness is caused by inflammation of pelvic structures, which may be an infection like acute salpingo-oophoritis, pelvic peritonitis and pelvic cellulitis, or endometriosis or acute torsion of normal adnexa or adnexal mass like an ovarian tumor, or acute hemorrhage as from an ectopic pregnancy or corpus luteum hematoma. The diagnosis can usually be made by history, clinical examination, laboratory tests, imaging and if required, a laparoscopy. Sometimes no cause can be found despite all tests being done. A simple test is described to differentiate a vaginal pain due to hyperesthesia, so that an unnecessary laparoscopy was avoided.
A 45 year old woman, para 2 living 2, presented with a complaint of something coming out per vaginum. Her menstrual cycles were regular, every 28-30 days, mildly painful and with moderate flow for 3-4 days. Her sexual history were normal. There was no dyspareunia. Her medical and surgical history was not contributory. She had two normal vaginal deliveries in the past. Her general and systemic examination revealed no abnormality. Abdominal examination findings were normal. A speculum examination showed healthy cervix and vagina, a moderate rectocele of right lateral type and a lax perineum. A bimanual examination showed lateral forniceal tenderness, a normal sized retroverted uterus, and no pelvic masses. The sensation over the remaining vagina was normal. A diagnosis of a rectocele, perineal laxity and possibly pelvic inflammatory disease was made. She was prescribed, as per national policy a combination of doxycycline 100 mg q12 and metronidazole 500 mg q12h PO for 14 days and cefixime 400 qd PO once. Her hemogram, plasma sugar levels, liver and renal function tests, and pelvic ultrasonography were normal. She was reassessed after 2 weeks. Her lateral vaginal forniceal tenderness was still the same as at the time of the first visit. It was deemed essential to diagnose and treat the condition causing pelvic tenderness before surgical repair of the rectocele and perineal laxity. So a cervical swab was sentr for microbiologic study. It showed no growth. The last step in evaluation as per our algorithm was to perform a laparoscopy to diagnose the cause of the pelvic tenderness. But the patient was reluctant to undergo such a procedure, as she had no related symptoms like pelvic pain and dyspareunia. Even we felt that pelvic tenderness in the absence of any symptoms and positive results of laboratory tests and imaging, it might not be any serious condition. So 2% lignocaine jelly was applied to her vagina and the bimanual pelvic examination was repeated after 5 minutes. She had no lateral forniceal tenderness at this time. A diagnosis of lateral forniceal hyperesthesia was made. A posterior colpoperineorrhaphy was done. The patient made an uneventful recovery and was found to be well at the time of follow up examinations after 15 days and one month.
Pelvic tenderness is a sign, which is often elicited in patients with pelvic pain. It may be due to the following conditions.[1-5]
- Pelvic inflammatory disease: acute salpingo-oophoritis, pelvic peritonitis, pelvic cellulitis.
- Pelvic endometriosis.
- Tubal ectopic pregnancy.
- Torsion of adnexal structures: normal adnexa, ovarian tumor.
- Corpus luteum hematoma.
In the case presented here, the patient had tenderness on palpation of lateral vaginal fornix, without undue pressure. There was no positive history or examination finding other han the tenderness, and haematological, biochemical, microbiological tests and ultrasonography were negative. It could not be put off as functional, as it was a distinctly positive clinical sign, the mechanism and importance of which was not known to the patient, who did not have any medical background. Ignoring it was not acceptable, as an underlying disease could progress if left untreated. The lignocaine application test was thought of to differentiate vaginal surface pain and pelvic pain, akin to differentiating between abdominal wall tenderness and intraabdominal tenderness. Lignocaine application anesthetized her vagina and the pain disappeared, while a pelvic tender area would have continued to remain tender.
No treatment was offered to the woman for her vaginal lateral forniceal tenderness because she had no disease that required treatment. It was explained as forniceal hyperesthesia, somewhat akin to hyperesthesia experience by a uncircumscribed male over glans penis. It goes away as he adjusts to it. Since the woman was unlikely to experience such tenderness again unlike the male in the example given, except when she would undergo another bimanual pelvic examination, she needed no treatment.
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- Engeler D. S., Baranowski A. P., Dinis-Oliveira P., et al. The 2013 EAU guidelines on chronic pelvic pain: Is management of chronic pelvic pain a habit, a philosophy, or a science? 10 years of development. European Urology. 2013;64(3):431–439.
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- Sorrells ML, Snyder JL, Reiss MD, Eden C, Milos MF, Wilcox N, et al. Fine-touch pressure thresholds in the adult penis. BJU Int. 2007;99(4):864-9.
Parulekar SV. Pseudopelvic Tenderness. JPGO 2019. Vol 6 No. 3. Available from: https://www.jpgo.org/2019/03/pseudopelvic-tenderness.html