Pelvic adhesions and pelvic pain: opinions on cause and effect relationship and when to surgically intervene

Objective In the absence of definitive data, we sought to determine the con sensus on the contribution of adhesions to pelvic pain. Methods Impressions about the role of adhesion location, extent, and severi ty of pelvic pain, were surveyed among 13 gynaecological surgeons. They wer e asked whether adhesions covering specific organs to a varying extent woul d be likely to cause pain significant enough to require pain medication, or to lead a woman to alter her normal activities, and when they would recomm end surgery to reduce pelvic pain. Results Women with dense vascular adhesions covering all of the uterus but not die bowel or adnexal structures were thought to have a 49 +/-9% likelih ood of having pelvic pain; this fell to a 34 +/-7%and 18 +/-5% likelihood o f pain if 60% or 20%, respectively, of the uterus was involved with adhesio ns. Similar observations were made for adhesions involving die posterior cu l-de-sac and large bowel. However, adhesions involving the anterior cul-de- sac were thought to be less likely to cause pain. Women with total involvem ent of both tubes and ovaries with dense, vascular adhesions were thought t o be 60 +/-9% likely to have pelvic pain; reduction in extent of adhesions to 50% or 25% reduced the prediction of pain to 38 +/-5% and 21 +/-3%, resp ectively. In contrast, filmy adhesions to both tubes and ovaries, were thou ght to cause pain in 46 +/-9%, 26 +/-5%, and 13 +/-3% of women, respectivel y, according to extent. Half the surgeons said they would recommend surgery for patients with pain and dense adhesions involving 15% of both tubes and ovaries; 10 recommended surgery if it was known that adhesions involved 10 0% of both ovaries and tubes. Surgeons were only slightly less likely to re commend surgery for pain relief for adhesions involving either both tubes o r both ovaries or for pain associated with unilateral tubal and ovarian adh esions. For bilateral tube and ovary adhesions, surgery was equally likely to be recommended for relief of pain when adhesions were cohesive and dense ; for adhesions which were filmy, surgery was less likely to be recommended . For dense adhesions involving 20%, 40%, 60%, and 80% of the uterine surfa ce, surgery was recommended by 42%,58%,83% and 92% of surgeons, respectivel y. Posterior cul-de-sac involvement resulted in recommendation of surgery b y 50%, 83%, 92%, and 100% of surgeons, respectively; however, for correspon ding amounts of anterior cul-de-sac adhesions, surgery was recommended by o nly 17%, 33%, 67%, and 75% of surgeons. Conclusions (1) Adhesions are frequently considered to be a cause of pelvic pain; (2) the likelihood of discomfort is related to location, extent, and to a lesser degree, the severity of adhesions, and (3) adhesiolysis is tho ught to provide the potential for pain relief.