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Pain in gynecology. Pain syndrome in gynecology

The problem of chronic pelvic pain in women of reproductive age occupies a special place in gynecology. Almost half of the patients who contact the specialists of the Department of Gynecology and Oncogynecology of the EMC have complaints of chronic pelvic pain - long-term discomfort in the lower abdomen, in the area below the navel. Long-term, despite the fact that conventional painkillers are ineffective, pelvic pain changes the psyche and behavior of women, reduces ability to work and quality of life.

The pain can be constant or periodic, even paroxysmal, can be cyclical or not at all related to the menstrual cycle. Pain impulses arising in the genital organs and surrounding tissues as a result of irritation of nerve endings are transmitted to the central nervous system, which in most women is accompanied by general weakness, irritability, anxiety, excitability, emotional lability, attention disorders, memory loss, and sleep disturbances.

Chronic pelvic pain is characterized by:

    constant pain in the lower abdomen and lower back of varying intensity and nature (pulling, dull, burning, etc.), prone to irradiation lasting more than 6 months;

    periodic exacerbations - pain crises that occur due to cooling, overwork, stress, etc.;

    psycho-emotional disorders, manifested by insomnia, irritability, disability, anxiety and depression, decreased sexual function up to a complete lack of interest and sexual response;

    absence or insignificant effect from conventional therapy with painkillers and antispasmodics.

In some cases, it is not possible to identify its causes even with an in-depth examination - this is the so-called “unexplained” pain. For such patients, the route along the “triangle” - gynecologist-urologist-neurologist - becomes familiar, and pain and fear force them to contact an oncologist. Often, for years, these patients are treated for “inflammation of the uterus and appendages” with large doses of antibacterial drugs, and such irrational treatment further aggravates the situation.

In many gynecological diseases, pain is one of the most common symptoms. External genital endometriosis, adhesions in the pelvic cavity, chronic inflammatory diseases of the internal genital organs, internal endometriosis of the uterine body, Allen-Masters syndrome, tuberculosis of the genital organs, uterine fibroids, benign and malignant ovarian tumors, malignant neoplasms of the body and cervix, developmental anomalies genital organs with impaired outflow of menstrual blood - this is not a complete list of diseases and conditions that may be accompanied by chronic pelvic pain.

The most common misconceptions about chronic pelvic pain

The causes of chronic pelvic pain in women can only be gynecological diseases

In fact, chronic pelvic pain can cause diseases of the musculoskeletal system (osteochondrosis of the spine, myofascial syndromes, arthrosis of the sacrococcygeal joint, primary tumors of the pelvic bones, metastases in the pelvic bones and spine, bone forms of tuberculosis, pathology of the symphysis), retroperitoneal neoplasms, diseases of the peripheral nervous system (plexitis), diseases of the gastrointestinal tract (chronic colitis, irritable bowel syndrome, ulcerative colitis, proctitis, adhesive disease), diseases of the urinary system (chronic cystitis, urolithiasis, pelvic location of the kidney, prolapse of the kidney), diseases vessels (varicose veins of the small pelvis). The causes of chronic pain syndrome can also be mental illness (abdominal epileptic seizures, depressive syndrome, schizophrenia).

Pain is usually caused by one factor, which can be eliminated to relieve pain.

In fact, in most gynecological diseases, the origin of pain is caused by several irritants at once, and it is often impossible to isolate the leading factor. With uterine fibroids, pain can be caused by an enlargement of this organ, disruption of its blood supply and contractility of the uterine muscle, deformation of the uterine cavity by nodes, compression by the enlarged uterus or individual nodes of neighboring organs - the intestines, urinary tract, nerve plexuses, blood vessels.

With ovarian tumors and cysts, the tissue and ligament of the ovaries are stretched (up to torsion), the maturation of follicles is disrupted, micro-tears with inflammation and the formation of adhesions are possible, compression of neighboring organs by cysts

Pelvic pain is characteristic of malformations of the genitals (normal or closed functioning uterus with aplasia of the cervix or vagina, rudimentary uterine horn, closed cavity of a bicornuate or double uterus) and other conditions accompanied by impaired outflow of menstrual blood (intrauterine synechiae, stenosis of the cervical canal or cicatricial changes vagina). In these cases, the occurrence of pain is caused by stretching of closed cavities with blood and irritation of the peritoneum by almost constant hemoperitoneum, inflammation, and adhesions. Incorrect positions of the internal genital organs (curvature of the uterus, prolapse, prolapse) also cause pelvic pain.

As a rule, most patients have a combined gynecological pathology, and each of the diseases can be the cause of pain. External endometriosis often accompanies any other gynecological disease, and uterine fibroids are combined with internal endometriosis of the uterine body. Prolapse of the uterus affected by fibroids or adenomyosis is common. The presence of combined gynecological and extragenital pathology (hernias, diseases of the gastrointestinal tract, urinary tract, spinal osteochondrosis) can significantly complicate the determination of the true cause of pain.

Periodic pain in women is normal

This myth has been common since the 19th century. Doctors then attributed menstrual pain to the instability and delicacy of women’s physiology and believed that pain during menstruation was the norm, which is very characteristic of the female body. Another “cause” of pain in women during menstruation is, as some believe, a low pain threshold.

In fact, many women and girls experience pain during their periods. However, severe pain that disrupts the usual lifestyle and level of activity cannot be the norm, and usually they are based on some disease, for example, endometriosis, a hormonal-dependent disease in which the lining of the uterus (endometrium) grows in other parts of the body. This is the third most common gynecological disease after uterine fibroids and various inflammatory processes in the genitals.

Therefore, every woman with severe pain during menstruation should be fully examined to identify its cause.

Early identification of the causes of pain determines the success of treatment. To identify possible causes of pelvic pain, we work in a single team with doctors of other specialties - general surgeons, oncologists, urologists, neurologists, psychologists.

To treat chronic pelvic pain, EMC gynecological surgeons use an approach based on reducing the invasiveness of surgical intervention, avoiding unnecessary radicalism, and wait-and-see tactics for certain diseases of the genital area.

Laparoscopy and hysteroscopy provide us with unique diagnostic and therapeutic opportunities, which allow us to identify and eliminate possible causes of pain that are not diagnosed by other examination methods: endometriosis of the pelvic peritoneum, adhesions, anatomical disorders - hernias, peritoneal defects (Allen-Masters syndrome).

From the patient’s point of view, laparoscopic intervention, unlike laparotomy, is not perceived as a “big and difficult” operation, and the absence of intense and prolonged postoperative pain associated with the surgical wound of the anterior abdominal wall eliminates the aggravation of the original pain due to the layering of operating rooms on them . And finally, early activation and return to physical activity, virtually no cosmetic defects also contribute to rapid recovery.

The scope of surgical intervention is selected by EMC gynecologists depending on the patient’s age, her plans for childbearing, the severity of the detected pathology, and the severity of pain. In young women, organ-sparing operations are performed, warning patients about the likelihood of recurrence of diseases such as endometriosis and uterine fibroids. For patients of older age groups with adenomyosis, multiple uterine fibroids, accompanied by severe pain, bleeding and leading to anemia, tumor growth and its significant size, dysfunction of neighboring organs, radical operations involving removal of the uterus are indicated, which we perform by laparoscopy or from a vaginal approach .

In cases of prolapse and prolapse of the pelvic organs, accompanied by pelvic pain, EMC gynecologists use surgical correction technologies that are fundamentally different from each other, depending on the age of the patient, allowing them to effectively eliminate gynecological pathology and restore impaired pelvic anatomy. For varicose veins of the pelvic vessels, we perform laparoscopic ligation of the ovarian veins, which is highly effective against pelvic pain due to congestion in the pelvic veins, without having a negative effect on ovarian function.

The effectiveness of surgical interventions performed by specialists from the Department of Gynecology and Oncogynecology of the EMC varies from 60 to 95%, which indicates the effectiveness of the treatment and the high level of training of specialists whose experience allows them to take on even the most complex cases.

The work of the EMC Gynecology and Oncogynecology Clinic is built in accordance with the protocols of evidence-based medicine practiced in the USA and Western European countries. The EMC clinic is one of the few in Moscow whose level of medical services meets international standards.

The Clinic's doctors work under the guidance of an experienced gynecological oncologist and obstetrician-gynecologist, certified by the US National Board Certified in Obstetrics-Gynecology and Oncogynecology, as well as certified in Russia in Obstetrics-Gynecology and Oncology.

Pain below the lower back in women requires differential diagnosis between diseases of the pelvis (adnexitis, vaginitis, salpingitis) and pathology of the lumbar spine (intervertebral hernia, scoliosis, osteochondrosis). The symptom appears at least once in a lifetime in the fair sex.

The pain can be of a different nature and localized on the right or left with the same frequency. It all depends on the causative factor of the pathology.

Causes of lower back pain in women

They can be classified as follows:

Acute lumbago (lumbago) is a response to hypothermia or high stress; Lumbodynia – aching chronic pain during prolonged sedentary work or constant stress on the spine; Lumboischialgia is pain radiating to the leg. May be a sign of a herniated disc. It requires immediate treatment.

Aching pain in the lower back in women usually does not cause serious concern if it is not a symptom of chronic infectious diseases in the pelvis. When pain syndrome is provoked by a pathology of the spinal column, it is a consequence of compression of the spinal nerves by an intervertebral hernia or an unstable vertebra (for example, due to torsion or rotation).


Provoking factors for pain below the lower back

A woman who has not done physical labor for a long time suddenly goes out into the garden and begins weeding the beds or planting some plants. Such work is associated with frequent bending and overwork: it is quite natural that after it the lower back will hurt due to the unpreparedness of the skeletal muscles for intense physical activity.

The same sensations can be experienced by athletes who overload themselves with training, or who are new to fitness.

But not only an excess of active movements causes the female lower back to suffer from pain, but also their obvious lack. A sedentary lifestyle associated with working in a sedentary position (for example, at a computer) also leads to lower back pain in women. This especially often happens to those who do not know how to sit correctly and do not monitor their posture.

The same harmless reasons include improper lifting of weights, uneven load when carrying them, as well as hypothermia. It is very easy to get a cold in the lower back - a small draft or too light clothes in extreme cold - and problems in the back will certainly make themselves felt.

Gynecological problems

Severe lower back pain, which gynecology describes with particular care, often occurs due to infectious diseases of the reproductive system.

During menstruation, many women experience pain in the lower abdomen and lower back. At this time, the concentration of so-called pain mediators – prostaglandins – increases. Very often pregnant women experience the same pain. The fetus is constantly growing and the woman’s ability to bear stress decreases. In addition, actively produced progesterone weakens joints and ligaments.

In the first trimester of pregnancy, there is often a threat of detachment of the fertilized egg, which is sometimes manifested by brown discharge and nagging pain in the lower back. These same symptoms can be ominous signs of diseases such as cervical cancer, pelvic infections (including sexually transmitted infections).

Causes lower back pain in women and endometritis (inflammation of the uterine mucosa). All these facts are a reason to urgently consult a doctor. Characteristic pain will be present when a woman has certain pathological conditions, such as uterine prolapse or prolapse.

The normal location of the uterus is the central part of the small pelvis, in which the distances from the pubis and sacrum are the same. It should also be equally distant from the side walls of the pelvis. When this distance changes to one side, the woman may feel pain below the lower back.

Normally, the uterus is slightly tilted forward towards the abdominal wall and upward. When the angle between the cervix and the body of the uterus changes, the uterus is said to be inverted. It can occur from inflammatory and adhesive processes, from fibroids and ovarian tumors.

Pain in the lower back after childbirth is common.

The cause is weakened muscles of the anterior abdominal wall or injury received during childbirth - rupture of the pelvic floor muscles. With such pathologies, nagging pain appears in the lower abdomen, lower back and sacrum, frequent urination, and constipation.

The weakening of the ligamentous apparatus that develops with these pathologies may be associated with congenital characteristics or be the result of several births. When the uterus is bent, women complain of pain below the lower back (in the sacrum) and in the lower abdomen. They can also occur during sexual intercourse and during menstruation. In such cases, infertility or problems with bearing a child are often observed.

The cause of severe lower back pain in women can be serious diseases that require emergency intervention by gynecologists. This could be an ectopic pregnancy, rupture of an ovary or cyst, or its torsion.

Lower back pain in women with endometriosis

As endometrial cells grow, they can spread to the ovaries, the outer surface of the uterus, the intestines and the pelvic mucosa. This pathology requires mandatory treatment.

Pain below the lower back in women can be caused by endometriosis - excessive growth of the epithelium outside the uterus. With pathology, the inner layer of the organ is non-functional. It is actively growing, complicating the functionality of the reproductive sphere of the fair half.

The pathology very often leads to infertility, since in the initial stages it does not manifest clinical symptoms. Women attribute isolated pain in the lower back to hormonal imbalances or to the approach of menstruation. As a result, the disease progresses.

The danger of this condition is that pathological cells begin to grow in other organs. At the same time, other symptoms appear: coughing up blood, pain in the head (with brain damage), constipation.

Of course, you should not get used to pain in the lower back. They are a sign of serious diseases that lead to disability.

Every woman has experienced lower back pain at least once in her life. Even a girl who seems absolutely healthy at first glance sometimes has pain or shooting pains in her lower back. There are many reasons why lower back pain occurs in women: from uncomfortable sitting in one position and walking in high heels to serious gynecological diseases. If the attack happened once, then there is no reason to worry, but if the problem does not go away for several days or weeks, then you should not delay going to the doctor.

What kind of pain occurs in the lower back in women?

Lumbago is an acute lumbar lumbago that occurs as a result of increased stress or after hypothermia.
Lumbodynia is a constant dull pain acquired as a result of sedentary work or from regular stress on the back.
Lumboischialgia - pain radiating to the leg, is the main symptom of a vertebral hernia. Requires immediate medical attention.

Causes of pathology

As soon as the summer season opens, women rush to their gardens: weed, dig, plant. All these procedures involve frequent bending. Obviously, by the end of the day, a tired summer resident will complain of lower back pain. This happens because unprepared muscles have been subjected to sudden and excessive stress. Both athletes who train mercilessly before competitions and newcomers to the gym suffer the same lumbar pain.

But the lower back can bother you not only after vigorous physical activity, but also with a sedentary lifestyle and sedentary work. All this is aggravated by the incorrect posture in which office employees can sit for hours. The cause may also be a mattress that is too soft: in this case, the body takes an unnatural position during sleep, the spine is bent, and the muscles suffer.

If you lift weights incorrectly and unevenly distribute the load in your hands (for example, heavy bags), you may feel pain in the lower back. Women with small children, who are forced to carry the baby in their arms throughout the day, often experience back pain for this very reason.

Gynecological problems

In gynecology, a special place is given to lower back pain, as it is a sign of many infectious diseases. During pregnancy, progesterone, produced in large quantities, weakens joints and ligaments, and the constantly growing fetus puts pressure on the muscles and organs of the pelvis, which causes pain below the lower back. Women in the first trimester have a high risk of natural termination of pregnancy or miscarriage. The first signs of what has happened are brown discharge and discomfort in the lumbar region. These same symptoms may also indicate other serious health problems, such as cervical cancer and sexually transmitted diseases. The endometrium is inflamed, the uterus has dropped or even prolapsed - these are just some of the many possible answers to the question “why does the lower back hurt in women?”

A disease such as endometriosis, characterized by the spread of endometrial tissue outside the uterus, leads to its dysfunction, in other words, to infertility. At the early stage of development of this pathology, there are practically no symptoms. That is why a single pain below the lower back in women is attributed to hormonal disorders or premenstrual syndrome, thereby allowing the disease to progress.

Why does the lower back pull? Reasons

In women (and men too), pain of this kind may indicate simple fatigue. But most often it signals the development of a serious illness.

1. Renal colic. They are accompanied by acute and very severe pain in the lumbar region, but, as a rule, only on one side. A person suffers from intense pain. Before the onset of such powerful spasms, patients complain that their lower back is pulling. Women experience fever, discomfort in the perineal area, rapid heartbeat, urination and nausea.

2. Pyelonephritis. Going to the toilet becomes more frequent and painful, and lower back pain can be described as dull and aching.

3. Osteochondrosis and osteoarthrosis. These diseases are widespread among older people, and they are characterized by nagging pain on both sides of the lower back, which intensifies with any load. With sudden movements there is a risk of pinching the nerve, so you should be careful with bending and turning.

4. Gynecological pathologies. They are accompanied by nagging pain that intensifies during menstruation.

5. Spondyloarthropathy. Most often occurs in young people. The peculiarity of the disease is that all discomfort worsens at rest, and with any activity it decreases. The pain is shallow but widespread.

6. Malignant tumors. They cause severe, deep pain that does not go away for more than a day, even when changing position.

7. Tuberculosis and osteomyelitis of the spine. With these diseases, the lower back ache for a long time. If the pain does not go away, then after a day signs of poisoning of the body are observed.

There are many reasons why lower back pain occurs in women. In order to eliminate them, you need to see a doctor, get tested and undergo the required treatment.

Problems with internal organs

Sometimes there is pain and burning in the lower back in women. Similar sensations can be caused by diseases of the gastrointestinal tract, kidneys, nerve endings, and spine. The cause of burning is most often urolithiasis. An unpleasant feeling is caused by sand and stones located in the ureters. When moving, they irritate the epithelium layer, it becomes inflamed. If these lumps are no more than 5 mm in diameter, they come out on their own and do not pose a strong danger, but if they are large, they can clog the outlet channels of the ureters, increase the pressure in the kidney and even cause its death. A rare, but still common case is when lumbar pain is caused by a stomach or intestinal ulcer.

Another cause of burning can be diseases of the pelvic organs (fibroids, endometritis). Symptoms indicating the presence of pathology do not appear, unfortunately, in the initial stages. Uterine fibroids cause dull pain in the lower back and abdomen.

Problems with the spine and peripheral nerves

Osteochondrosis and herniated discs cause a burning sensation in the lower back. This is explained by the fact that these diseases affect the radicular nerves. Overgrowth of bone tissue between the joints, disc deformation due to herniation puts pressure on the nerve processes, causing inflammation and loss of sensitivity.

Painful sensations when carrying a baby appear due to changes in the body and hormonal changes, as well as due to softening of joints, ligaments and muscles.

Treatment

It is not enough to know why women have lower back pain; one must also be able to eliminate such discomfort. If we are talking about sensations caused by physical factors, then you need to take a horizontal position on a flat surface and relax your body. The position can be any, the main thing is to feel that the pain subsides. An excellent way to relieve tension from the lumbar region is to lie on your back and raise your legs at a right angle to your body. No sudden movements! You should also get up slowly: first roll over on your side, then get on all fours. If the pain does not go away completely, you will have to take pills to relieve the attack.

To prevent pregnancy from being marred by lumbar burning, doctors recommend wearing a bandage, strengthening your back muscles, and monitoring your gait and weight gain.

An excellent solution to the problem is massage. It promotes relaxation, relieves muscle spasms, and improves blood circulation. To achieve greater effect, you can use special gels and ointments for rubbing.

Pregnant women should trust their body only to an experienced specialist who knows how to help and not harm.

If pain appears after an injury or fall, you should immediately call a doctor. For chronic lumbar burning sensations, you should undergo a full examination by contacting a gynecologist, orthopedist, cardiologist, infectious disease specialist, or urologist.

Traditional medicine can also give some good advice. So, to alleviate the condition, it is recommended to take a bath with mustard or hay dust, or make a compress from pre-heated sand. That is, therapy is based on heating the affected area. However, before using traditional methods, it is necessary to find out why women have lower back pain. For example, in almost 90% of cases, for pregnant women or those suffering from cancer, hot baths and heating are contraindicated.

Instead of a conclusion

Pain never occurs out of nowhere. At its first manifestations, it is necessary to contact a specialist. Then there is a chance to nip the disease in the bud, preventing it from developing.

Pain and its causes in alphabetical order:

gynecological pain

Gynecological pain may be of a different nature. First of all, gynecological pain can be acute or chronic.

What diseases cause gynecological pain:

Acute gynecological pain is sudden, severe pain that lasts several hours or days. Acute pain may be accompanied by fever, nausea, vomiting, intestinal problems, severe weakness and malaise. In cases of acute pain, especially in combination with the complaints described above, it is necessary to urgently consult a gynecologist. Acute pain manifests itself in almost any inflammatory disease of the uterus and appendages, ectopic pregnancy, torsion or rupture of an ovarian cyst, as well as a number of other conditions that require immediate help.

The symptom of chronic gynecological pain is understood as periodically recurring or constant pain in the lower abdomen for several months or even years. The causes of chronic gynecological pain differ significantly from the causes of acute pain, which is why they are identified as a separate concept. Chronic gynecological pain is extremely common - in every sixth woman. Pain is relatively rarely caused by any one cause, but more often by a combination of various factors. Therefore, diagnostic and therapeutic methods are very diverse. There are also cases when obvious causes of pain cannot be identified, but even for such cases a specific treatment strategy has been developed, which requires mutual understanding and cooperation between the doctor and the patient.

The main causes of gynecological pain:
- Endometriosis.
- Features of the anatomical structure of the genital organs, hormonal imbalances.
- Vulvodynia (pain in the perineum and vaginal opening).
- Chronic inflammation of the genital organs.
- Formations (benign and malignant) of the uterus and ovaries.
- Prolapse of the uterus and vaginal walls (pelvic organ prolapse).

Which doctors should you contact if gynecological pain occurs:

Are you experiencing gynecological pain? Do you want to know more detailed information or do you need an inspection? You can make an appointment with a doctor Eurolab always at your service! The best doctors will examine you, study external signs and help you identify the disease by symptoms, advise you and provide the necessary assistance. You can also call a doctor at home. Clinic Eurolab open for you around the clock.

How to contact the clinic:
Phone number of our clinic in Kyiv: (+38 044) 206-20-00 (multi-channel). The clinic secretary will select a convenient day and time for you to visit the doctor. Our coordinates and directions are indicated. Look in more detail about all the clinic’s services on it.

(+38 044) 206-20-00

If you have previously performed any research, Be sure to take their results to a doctor for consultation. If the studies have not been performed, we will do everything necessary in our clinic or with our colleagues in other clinics.

Do you have gynecological pain? It is necessary to take a very careful approach to your overall health. People don't pay enough attention symptoms of diseases and do not realize that these diseases can be life-threatening. There are many diseases that at first do not manifest themselves in our body, but in the end it turns out that, unfortunately, it is too late to treat them. Each disease has its own specific signs, characteristic external manifestations - the so-called symptoms of the disease. Identifying symptoms is the first step in diagnosing diseases in general. To do this, you just need to do it several times a year. be examined by a doctor, in order not only to prevent a terrible disease, but also to maintain a healthy spirit in the body and the organism as a whole.

If you want to ask a doctor a question, use the online consultation section, perhaps you will find answers to your questions there and read self care tips. If you are interested in reviews about clinics and doctors, try to find the information you need on. Also register on the medical portal Eurolab to be constantly aware of the latest news and information updates on the site, which will be automatically sent to you by email.

The symptom chart is for educational purposes only. Do not self-medicate; For all questions regarding the definition of the disease and methods of its treatment, consult your doctor. EUROLAB is not responsible for the consequences caused by the use of information posted on the portal.

If you are interested in any other symptoms of diseases and types of pain, or you have any other questions or suggestions, write to us, we will definitely try to help you.

For gynecological diseases, along with pain in the lower abdomen, lumbosacral pain is characteristic. This applies to pathologies such as displacement, prolapse and prolapse of the genital organs, inflammatory processes, tumors, especially those moving to the back wall of the pelvis or metastasizing to the sacrum, and menstrual cycle disorders. Pain usually occurs due to increased blood supply to the pelvic organs and intoxication.

Sexual dissatisfaction in women it causes irritability, headaches, pain in the sacrum, and a feeling of heaviness in the lower abdomen. Unresolved rushes of blood to the genitals lead to congestion in the pelvis with subsequent morphological (swelling, enlarged uterus) and functional (increased secretion, menstrual irregularities) changes.

Incorrect positions of the uterus. Normally, in women, the uterus is located in the center of the small pelvis at an equal distance from the pubis and sacrum, as well as from the side walls of the pelvis. The fundus of the uterus does not extend beyond the plane of the entrance to the pelvis. Happens quite often prolapse and prolapse of the uterus and vagina when the uterus and vaginal walls move downward. The main reasons for this are weakening of the muscles of the anterior abdominal wall, disruption of the integrity of the pelvic floor muscles, often resulting from birth trauma (perineal rupture), age-related atrophy of the uterus, ligaments and pelvic floor muscles. In nulliparous women, genital prolapse is extremely rare. With prolapse and prolapse of the uterus and vagina, women complain of a feeling of heaviness and pain in the lumbar region and sacrum, nagging pain in the lower abdomen, urination disturbance (frequent, painful urination, urinary incontinence under stress, for example, when coughing, laughing), difficulty in defecation ( constipation), sensation of the presence of a foreign body in the genital opening, difficulty walking.

The uterus is normally inclined slightly anteriorly, its bottom is directed towards the anterior abdominal wall, that is, anteriorly and upward, which doctors call anteversion (anteversio). An obtuse angle open anteriorly is formed between the body of the uterus and the cervix - anteflexio. Changes in the characteristics of the angle between the neck and the body are called changes in position. This can happen when:

  • weakening of the ligamentous apparatus of the uterus (congenital feature or the result of multiple births);
  • tumors of the ovaries and fallopian tubes, uterine fibroids;
  • inflammatory and adhesive processes in the pelvis (with inflammation of the uterine appendages, located on the side and somewhat posterior to the uterus, fusions of the uterus with the posterior wall of the pelvis are formed).

A sharper inclination of the uterine body anteriorly, at which the angle between the cervix and the body becomes acute, is called hyperanteflexia. The posterior inclination of the uterine body is called retroversion, while the neck forms an angle with it, open posteriorly, - retroflexion. In everyday life, this is more often called a bend of the uterus. Women with a bent uterus may experience pain in the lumbosacral region and lower abdomen, pain during sexual intercourse and during menstruation, increased frequency and pain of urination, and constipation. There may be problems with conception and pregnancy. Sometimes the listed anomalies are asymptomatic.

Tumors of the uterus. Uterine fibroids- a benign tumor arising from muscle tissue. It can be asymptomatic, or it can cause pain, bleeding, dysfunction of neighboring organs, and infertility. The pain can be constant or during menstruation, it can be localized in the lower abdomen, in the lower back, and in case of complications - throughout the entire abdomen.

Cancer of the uterus usually develops in women over 50 years of age, nulliparous or nulliparous. It is manifested by uterine bleeding, discharge streaked with blood or the type of meat slop, pain and a feeling of heaviness in the lower abdomen.

N. Romanovskaya

“Back pain and pain due to gynecological diseases” and other articles from the section

Pelvic pain is a feeling of discomfort in the lower abdomen: below the navel, above and medial to the inguinal ligaments, behind the pubis and in the lumbosacral region. Chronic pelvic pain syndrome is a long-term (over 6 months), difficult-to-control pelvic pain that disorganizes the central mechanisms of regulation of the most important functions of the human body, changes the psyche and behavior of a person and disrupts his social adaptation.

SYNONYMS OF CHRONIC PELVIC PAIN

Pelvic pain syndrome, pelvic neurosis, autonomic pelvic ganglioneuritis, psychosomatic pelvic congestion.

EPIDEMIOLOGY OF PELVIC PAIN

According to WHO, every fifth person in the world suffers from chronic pain caused by diseases of various organs and systems. Over 60% of women annually seek help from an obstetrician-gynecologist specifically due to pelvic pain. Chronic pelvic pain is much more often a symptom of gynecological (73.1%) or extragenital diseases (21.9%) than of various types of mental disorders (1.1%). Just as rarely, it has an independent nosological or syndromic significance (1.5%).

CLASSIFICATION OF CHRONIC PELVIC PAIN

According to its manifestations, chronic pelvic pain can be divided as follows:

● pelvic pain itself - pain in the lower abdomen, groin areas, lower back, which worries the patient almost constantly and intensifies on certain days of the menstrual cycle, with hypothermia, prolonged static load, etc.;
● dysmenorrhea - painful menstruation;
● deep dyspareunia - painful sexual intercourse with deep penetration.

ETIOLOGY OF PELVIC PAIN

The main causes of pain in the lower abdomen:

● gynecological diseases;
● chronic inflammatory diseases of the internal genital organs;
● adhesions as a consequence of a previous inflammatory disease of the genital organs;
● external genital endometriosis;
● internal endometriosis of the uterine body;
● Allen–Masters syndrome;
● genital tuberculosis;
● uterine fibroids;
● BC and malignant ovarian tumors;
● malignant neoplasms of the body and cervix;
● primary algomenorrhea;
● “middle” pain (“Mittelschmerz”);
● abnormal development of the genital organs with impaired outflow of menstrual blood;
● atresia of the cervical canal;
● use of IUD;
● serosocele and adhesions after gynecological operations;
● residual ovarian syndrome;
● gastrointestinal diseases;
● chronic colitis, irritable bowel syndrome, ulcerative colitis;
● diseases of the musculoskeletal system;
● osteochondrosis of the spine;
● Schmorl's hernia;
● coccydynia, arthrosis of the sacrococcygeal joint;
● primary tumors of the pelvic bones;
● metastases to the pelvic bones and spine;
● tuberculosis of the musculoskeletal system;
● symphysiolysis, symphysiopathies;
● retroperitoneal neoplasms, including retroperitoneal ganglioneuroma;
● diseases of the peripheral nervous system;
● plexitis, including solaritis and solaropathy;
● appendicular-genital syndrome;
● proctitis;
● adhesive disease;
● diseases of the urinary system;
● chronic cystitis;
● urolithiasis;
● pelvic dystopia of the kidney, nephroptosis;
● vascular diseases;
● varicose veins of the small pelvis;
● mental illness;
● abdominal seizures of epilepsy;
● depressive syndrome, including schizophrenia;
● “inorganic” pain not associated with mental illness;
● psychogenic pain;
● abdominal form of spasmophilia;
● abdominalgia in patients with hyperventilation syndrome;
● pain for no apparent reason.

MECHANISM OF DEVELOPMENT OF CHRONIC PELVIC PAIN

The main reasons for the formation of chronic pelvic pain syndrome in various gynecological diseases should be considered disorders of regional and intraorgan hemodynamics, impaired tissue respiration with excessive formation of cellular metabolic products, inflammatory, dystrophic and functional changes in the peripheral nervous system of the internal genital organs and autonomic sympathetic ganglia. It is obvious that stabilization and aggravation of pain, i.e. in fact, the formation of pelvic pain syndrome occurs through the interaction of various factors, among which the type of development of a woman’s personality, features of her lifestyle, level of intelligence, etc. are of no small importance.

Pain syndrome, which, as a rule, does not form immediately, but after some (sometimes quite a long) time from the onset of the action of certain damaging factors, apparently goes through certain stages of development. The first stage is called the organ stage, and is characterized by the appearance of local pain in the pelvic area and lower abdomen. Often the pain is combined with dysfunction of the genitals and adjacent organs. These phenomena largely depend on circulatory disorders (hyperemia, blood stagnation, etc.).

The second (superorgan) stage is characterized by the appearance of repercussion (referred) pain in the upper abdomen. In a number of observations, pain sensations finally move to the upper abdomen. Thus, a secondary focus of irritation occurs in one of the paravertebral nodes. When the visible connection between the pain syndrome and the genital apparatus disappears, it is usually very difficult to explain these pains, and this often leads to diagnostic errors.

The third (multisystem) stage of the disease is characterized by the spread of trophic disorders in an ascending direction, with wide involvement of various parts of the nervous system in the pathological process. In this case, as a rule, disturbances of menstrual, secretory and sexual functions, intestinal disorders, and metabolic changes occur. Pelvic pain becomes more intense, making it extremely difficult or almost impossible to diagnose the disease. At this stage, the pathological process acquires a multisystem character, and its nosological specificity finally disappears.

CLINICAL CHARACTERISTICS OF CHRONIC PELVIC PAIN

Pain in the lower abdomen, on the one hand, can be a symptom of any gynecological, somatic or mental disease, on the other hand, it can have a completely independent, nosological significance, and be the most important component of pelvic pain syndrome.

With chronic pelvic pain syndrome of almost any origin, women, as a rule, complain of increased irritability, sleep disturbances, decreased performance, loss of interest in the outside world (“the patient goes into pain”), depressed mood, up to the development of depressive and hypochondriacal reactions, which, in turn, aggravate the pathological pain response. A kind of “vicious circle” is formed: pain - social maladjustment - psycho-emotional disorders - pain. Chronic pain, as a rule, occurs in people of a certain type: hypochondriacal, anxious, suspicious.

DIFFERENTIAL DIAGNOSTIC MEASURES FOR LOWER ABDOMINAL PAIN

ANAMNESIS

A well-collected medical history is of key importance for the differential diagnostic search for the causes of pain in the lower abdomen in women. The history of the present disease, family and social history, as well as detailed information (including data from medical documents) about the state of the main systems of the woman’s body allow us to assume the most likely genesis of the pain syndrome and, based on this, develop an individual examination plan for the patient.

The woman's main complaints should be recorded with particular care. At the same time, complaints, as a rule, are quite varied. Often the patient is not able to accurately indicate the location of the pain, noting a fairly large area: from the hypo to the epigastric region. However, specifying the topography of pain is of fundamental importance.

Pain localized in the midline of the abdomen slightly above the symphysis pubis or directly behind it, are mainly characteristic of chronic inflammatory diseases and tumors of the uterus, bladder, rectum, as well as internal endometriosis of stages II–III of spread. Much less often, such pain occurs with anomalies of the uterus, symphysiolysis, unrecognized umbilical hernias or postoperative hernias of the white line of the abdomen.

Pelvic pain in the right and left iliac regions It is often the main and sometimes the only symptom of chronic inflammation of the uterine appendages, external genital endometriosis, traumatic damage to the broad ligaments of the uterus (Allen-Masters syndrome), benign and malignant tumors of the internal genital organs.

Pain, predominantly projected to the lower quadrants of the abdomen on the right or left, observed in functional or organic diseases of the gastrointestinal tract (nonspecific colitis, irritable bowel syndrome, diverticulosis and diverticulitis, Crohn's disease, atony of the cecum, neoplasms), organs of the urinary system (hydroureteronephrosis, ureterolithiasis, chronic ureteritis, etc.), as well as in cases of retroperitoneal damage lymph nodes (lymphosarcoma, visceral form of lymphogranulomatosis) and diseases of the spleen (chronic myeloid leukemia). In general, to simplify the diagnostic search, we can conditionally assume that pelvic pain localized below the line connecting the iliac spines and the navel, as a rule, indicates diseases of the internal genital organs, and above this line - damage to the intestines, kidneys, etc.

Chronic pelvic pain with an epicenter in the lumbosacral region most often associated with acquired skeletal diseases of traumatic, inflammatory, degenerative or tumor origin. Somewhat less often - with congenital anomalies of its development (cleft vertebral arch, spondylolysis, lumbarization, sacralization, etc.). Pain of similar localization is often observed with dysmenorrhea, including that caused by genital endometriosis. Pain can also occur with so-called sexual neurasthenia, which is often caused by congestive hyperemia of the pelvic organs, for example, under the influence of long-term masturbation or interrupted sexual intercourse (irritation of the visceral nerves). However, unilateral pain in the sacrum in the vast majority of cases argues against its genital origin.

Among the variety of extragenital causes of chronic pain in the lumbosacral region, one cannot fail to mention renal diseases (chronic pyelonephritis, hydronephrosis, nephroptosis), ureteral strictures of traumatic, inflammatory or tumor origin, as well as congenital or acquired diseases of the sigmoid and rectum (sigmatosis, megasigma, enlargement of the rectum, hemorrhoids, etc.).

Pain in the coccyx area- coccydynia is more often a consequence of traumatic damage to the coccyx itself (periostitis, arthritis of the sacrococcygeal joint, ankylosis of the joint, dislocation of the coccyx), less often it is of a reflected nature. In the latter case, coccydynia may be a symptom of parametritis, retrocervical endometriosis or endometriosis of the uterosacral ligaments. Severe pain in the coccyx area is often noted in advanced forms of rectal and cervical cancer.

When conducting a differential diagnostic search, it is also necessary to take into account factors that provoke aggravation of pain symptoms.

In case of diseases of the musculoskeletal system, these are most often static or dynamic physical activity; in case of damage to the urinary system - hypothermia or errors in diet (salty spicy foods, etc.). The last factor is considered decisive in diseases of the gastrointestinal tract.

The appearance or intensification of pain in the second phase of the menstrual cycle, usually 3–7 days before the expected menstruation, traditionally associated with genital endometriosis. Worsening pain symptoms in the second phase of the menstrual cycle can also be one of the most striking clinical manifestations of PMS or pelvic varicose veins. In the latter case, the intensity of pelvic pain depends not only on the day of the menstrual cycle, but also on the time of day: increasing in the evening, it gradually decreases or completely stops after a relatively long rest in a horizontal position.

New or worsening pelvic pain during menstruation- dysmenorrhea is most typical for gynecological diseases, in particular for adenomyosis, primary algodysmenorrhea, abnormalities in the position and development of the uterus, chronic endometritis.

Increase in pain symptoms in the early follicular phase of the menstrual cycle most typical for exacerbation of chronic inflammation of the uterine appendages. As a rule, in parallel with increased pelvic pain, symptoms appear that indicate activation of the inflammatory process (increased body temperature, leucorrhoea, etc.).

Among gynecological diseases accompanied by pain, a special place is occupied by the so-called intermenstrual pain syndrome, or midline pain syndrome. With this syndrome, pain of varying intensity and duration occurs periodically (usually monthly) on the 13th–15th day of the menstrual cycle and is accompanied by severe psychovegetative disorders. Often, intermenstrual pain syndrome is associated with various gynecological diseases (chronic inflammation of the uterus and its appendages, genital endometriosis, functional ovarian cysts, varicose veins of the small pelvis), i.e. has a specific organic basis. However, the debut of pain symptoms and its subsequent stabilization are usually preceded by a variety of stressful situations: from banal hypothermia to severe mental trauma.

Another type, and in some cases an integral component of chronic pelvic pain syndrome, is dyspareunia. Most often, this symptom is observed in patients with external genital endometriosis when heterotopias are located on the uterosacral ligaments or in the retrocervical space. Somewhat less frequently, dyspareunia is detected in cases of fixed retrodeviation of the uterus, chronic salpingoophoritis, and adhesions in the pelvis of almost any origin.

It is necessary to clarify not only the factors that provoke increased pelvic pain, but also to carefully evaluate the effectiveness of previous treatment. Progestogen drugs significantly reduce pelvic pain in genital endometriosis, primary algodismenorrhea, and PMS. Limiting static load can be effective not only for diseases of the musculoskeletal system, but also for varicose veins of the small pelvis, traumatic damage to the broad ligaments of the uterus (Allen-Masters syndrome), and incompetence of the pelvic floor muscles. The use of a course of physiotherapeutic treatment (diadynamic, fluctuating, sinusoidally modulated currents) is most effective in patients with symptoms of chronic pelvic pain of inflammatory origin, including those with concomitant adhesions and hemodynamic disturbances in the pelvic vessels. However, with classic chronic pelvic pain syndrome, physiotherapeutic procedures often have the opposite effect, aggravating the initial pain symptoms.

In everyday practice, when examining this group of patients, visual analogue scales are most widely used, allowing, by comparison, to study the dynamics of a pain symptom in a certain time interval or during any treatment. They also use specially designed questionnaires, with which you can get an idea not only of the intensity of pelvic pain, but also of the degree of subjectivity in its assessment.

PHYSICAL INVESTIGATION

Typically, a physical examination begins with examination and superficial palpation of the abdomen, focusing on the appearance of pain associated with abdominal hyperesthesia. It may depend on various reasons, in particular on organic changes in the skin itself or in the deeper layers of the anterior abdominal wall (neurolipomas, desmoid tumors of the abdominal wall, muscle ruptures, etc.). The easiest way to detect increased sensitivity is by pinching the skin. To study hyperesthesia of the deep layers, you can use the following technique: the doctor places his hand flat on the corresponding area of ​​the abdominal wall, after which he applies light, usually almost painless pressure. Then the patient is asked to quickly raise the upper half of the body. With the contraction of the abdominal muscles occurring at this moment, light hand pressure can cause severe pain.

To exclude unrecognized inguinal, umbilical or epigastric hernias, the patient is examined both in a standing and lying position. When coughing and straining, you can usually determine the expansion of the hernial orifice or identify increased sensitivity when palpating the corresponding areas of the anterior abdominal wall. The use of special methods of gynecological examination (examination of the external genitalia, examination of the cervix and vagina using speculum, bimanual vaginal and/or rectovaginal examination) allows us to distinguish two main groups of patients.

The first of them consists of women who, already at this stage of examination, can be diagnosed with various gynecological diseases that can, alone or in combination, lead to the emergence and progression of chronic pelvic pain syndrome with the subsequent impact of the algogenic focus on the mental and somatic sphere.

The second group includes patients in whom visually detectable or palpable pathological changes in the external and internal genital organs are absent altogether or are expressed so insignificantly that they are not considered as a cause of chronic pelvic pain. The absence of mental disorders or any extragenital diseases in these women that occur with severe pain symptoms suggests the development of a unique condition in which pain takes on a nosological meaning, i.e. In fact, it becomes a disease itself.

However, this assumption requires mandatory clinical laboratory, instrumental and, in some cases, pathomorphological confirmation.

LABORATORY AND INSTRUMENTAL RESEARCH METHODS

To clarify or verify the genesis of chronic pelvic pain, a complex of clinical laboratory and hardware and instrumental research methods is used, the mandatory components of which are considered to be:

  • laboratory testing for herpetic infection, which is more associated with the development of pelvic ganglioneuritis;
  • Ultrasound of the pelvic organs (screening to exclude organic diseases of the internal genital organs and urinary system);
  • X-ray examination of the lumbosacral spine and pelvic bones;
  • absorption densitometry to exclude osteoporosis;
  • X-ray (irrigoscopy) or endoscopic (sigmoidoscopy, colonoscopy, cystoscopy) examination of the gastrointestinal tract and bladder;
  • laparoscopy.

It is necessary to highlight laparoscopy, emphasizing the validity and feasibility of its implementation for all women suffering from chronic pelvic pain. The reason for this exclusivity is that laparoscopy is considered a necessary step in the diagnosis of peritoneal endometriosis, Allen-Masters syndrome, chronic inflammation of the uterine appendages, adhesions in the abdominal and pelvic cavity, varicose veins of the small pelvis, i.e. those diseases that, according to statistical studies, occupy leading positions in the structure of causes of chronic pelvic pain.

Currently, laparoscopy allows us to identify all the main causes of pain in the pelvis. If the cause of chronic pelvic pain still cannot be identified (in approximately 1.5% of cases), then in relation to such situations, the International Statistical Classification of Diseases, Injuries and Causes of Death (WHO, Geneva, 1997) provides for the classification “pain without visible reasons”, which gives grounds for symptomatic therapy.

TREATMENT OF CHRONIC PELVIC PAIN

The main treatment methods are presented in Table 1

Treatment of patients with chronic pelvic pain requires an integrated approach. Typically, the duration of the pain history is proportional to the number of methods and treatments tried, as well as the patient’s nihilism towards medicine in general and specific doctors in particular. In this regard, it is necessary to involve specialists of various profiles in drawing up a plan for examining and treating the patient: a therapist, a urologist, a neurologist, a physiotherapist and, possibly, a neuropsychiatrist. Collegiality reduces the likelihood of confrontation between the patient and the doctor, and therefore increases the chances of treatment success.

In general, treatment of chronic pelvic pain syndrome should be based on the following basic principles:

  • it is necessary to help the patient understand the cause of the pain and, if possible, specify the factors that lead to exacerbation;
  • It is better to reduce to a rational minimum the number of pharmacological agents used, eliminating unnecessary and ineffective ones. In this case, it is necessary to simplify treatment regimens as much as possible, gradually reducing the doses of drugs to a value where a pronounced beneficial effect can be achieved with minimal side effects;
  • It is necessary to use methods of restorative therapy as early as possible and more widely, aimed at correcting personal factors that interfere with the elimination of pain, increasing the functional capabilities of the female body, and improving the quality of life.

Table 1: Basic principles and methods of treatment for chronic pelvic pain

Type of treatment Goal of treatment Treatment methods
Etiotropic Elimination (cessation of action) of the cause of pain Antibacterial, antiviral, antifungal therapy for chronic inflammatory diseases of the genital organs.
Surgical (traditional, endoscopic) treatment for tumors of the genital organs, adhesions, external and internal endometriosis, developmental anomalies and abnormal positions of the genital organs, etc.
Endovascular and endosurgical treatment of varicose veins of the small pelvis.
Taking NSAIDs and antispasmodics for algodismenorrhea
Pathogenetic Normalization of local biochemical processes in tissues surrounding the pain receptor HRT (hormone therapy for external genital endometriosis)
Antioxidant therapy, vitamin therapy, enzyme therapy.
Physiotherapy (alternating magnetic field, etc.)
Taking NSAIDs for external genital endometriosis and inflammatory diseases of the genital organs.
Taking medications that normalize microcirculation in tissues
Prevention (reduction
intensity) receipts
pathological impulses in the central nervous system		 Blockade, alcoholization of nerve conductors. Elements of neurosurgical interventions (for example, paracervical denervation of the uterus, presacral neurotomy for external endometriosis).

Acupuncture
Restoring the balance of activating and inhibitory processes in the central nervous system, influencing the antinociception system.
Prevention of the development of neurotic reactions, vegetative correction		 Psychotherapy, suggestive therapy.
Sedative therapy.
The use of drugs with a vegetative-corrective effect.
Acupuncture