RCOG World Congress 2025

SERVICE EVALUATION AUDIT FOR SURGICAL MANAGEMENT OF CHRONIC PELVIC PAIN IN WYE VALLEY NHS TRUST

AIMS AND OBJECTIVES

1.To correlate the presentation of women with chronic pelvic pain with their laparoscopic findings.

2.To identify the causes of chronic pelvic pain.

3.To compare the compliance with RCOG GTG guideline 41 – Management of chronic pelvic pain.

4.To evaluate number of patients who underwent pre-operative imaging

5.To evaluate the post operative management of patients with chronic pelvic pain

AUDITABLE STANDARDS

-Out of all the women presenting with chronic pelvic pain and undergoing diagnostic laparoscopy, almost 33-50% of diagnostic laparoscopies will be negative.

-Offering an imaging modality (USS/MRI) to women presenting with chronic pelvic pain as a part of evaluation before diagnostic laparoscopy – 100%.

-Women with cyclical pain should be offered a therapeutic trial of hormonal treatment for a period of 3–6 months before having a diagnostic laparoscopy - 100%

METHOD

This is a retrospective audit, data of patients who underwent diagnostic laparoscopy in gynaecology for the last two years. Data was extracted from electronic patient record (Maxims).

Data collected from 1st August 2022 to 31st July 2024. Total of 56 patients underwent surgical management.

INCLUSION AND EXCLUSION CRITERIA

All women who underwent diagnostic laparoscopy for pelvic pain from 1st August 2022 to 31st July 2024 were included.

Acute pelvic pain excluded

Pregnant women excluded.

RESULTS

-AGE PREVALANACE – Most common among reproductive age group, especially among 21 – 25 years.

-EXAMINATION FINDINGS - Out of the 56 women, 38 of them had non tender abdomen. Examination in 18 women elicited tenderness (out of the 18 patients who had tender abdomen, only 5 had positive bimanual examination findings).

-PRE OP IMAGING FINDINGS – Imaging was done in 100%, out of which 77% has normal findings. Ovarian cysts was seen in 13% and fibroids in 5% of cases.

- TRIAL OF HORMONAL (MEDICAL) MANAGEMENT - All patients (100%) were offered medical management – hormonal trial for 3-6 months, but only 15 patients (20.5%) accepted hormonal treatment. The remaining declined and requested for surgical management directly.

Patient who had medical management: when they underwent diagnostic laparoscopy – 10 of them had normal findings, 5 had endometriosis seen.

-OPERATIVE FINDINGS - 53% had normal findings, 43% had endometriosis, 1% had fibroid seen and 1% had an ovarian cyst noted.

-ENDOMETRIOSIS – 40% had endometriotic spots in POD, followed by 30% having endometriomas. Almost 40% of them had mild endometriosis, and 10% had severe endometriosis.

-POST OP MANAGEMENT - The 30/56 women, with normal findings in diagnostic laparoscopy, were discharged from gynaecology care. Out of them, 14 were referred to the chronic pain team for further management.

10/56 had mirena coil fitted at the time of laparoscopy, and did not come back with any complaints, which says that the mirena coil is being effective in symptomatic management.

Out of the 24 patients diagnosed with endometriosis, 40% were referred to endometriosis specialised care (Worcester). 33% were treated with zoladex and remaining 25% were treated during the diagnostic laparoscopy itself.

DISCUSSION

Chronic pelvic pain can be defined as an intermittent or constant pain in lower abdomen or pelvis in women, lasting for least 6 months, not occurring exclusively with menstruation or intercourse and not associated with pregnancy. Chronic pelvic pain is presented in women very frequently and may significantly impact women’s ability to function. Hence, aiming for accurate diagnosis and effective management from first presentation can help to reduce disruption of the woman’s life. The causes are endometriosis, adenomyosis, factors affecting central/peripheral nervous system like tumour necrosis factor alpha and chemokines, adhesions, IBS, interstitial cystitis, musculoskeletal, nerve entrapment, psychological and social issues. Imaging such as USS/MRI should be done. If no underlying cause found; diagnostic laparoscopy is gold standard to find any underlying condition. It is second-line investigation if other therapeutic interventions fail (first line – recommended COCP 3-6 months). Interestingly, almost one-third to one-half of diagnostic laparoscopies will be negative.

CONCLUSION FROM THIS STUDY

Almost 53% of patients who underwent diagnostic laparoscopy had normal findings and no interventions required, this is in alliance with the standard RCOG guidelines and the most common age group presenting were from 21 – 25 years. Imaging modality was considered pre operatively in all patients and COCP offered for all, but accepted only in 20%. Interestingly, multi factorial presentation of chronic pelvic pain could not be identified – IBS, bladder pain syndrome, psychological or sexual factors.

RECOMMENDATION

All auditable (RCOG) standards are met

To continue with the good clinical practice

Adequate history probing into all causes of chronic pelvic pain including sexual history and abuse / domestic violence.

RCOG World Congress 2025

Service evaluation audit for surgical management of chronic pelvic pain.

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