Chronic Pelvic Pain, Hernias and the General Surgeon

Slowly, ever so slowly, the concept of a multidisciplinary approach to disease management has gained credibility in the medical community. Over the past several decades, it has become common for surgeons, gynecologists, oncologists, radiation therapists and other physicians to be involved in the management of malignant disease.

But this instance of disease-specific interaction is only a small portion of the vast potential for good that a multi-disciplinary approach can bring to surgical disorders. Knowledge gained in one specialty is yet painfully slow to diffuse to other pertinent specialties.

A case in point is the “disease” chronic pelvic pain: disease defined as “any deviation from or interruption of the normal structure or function of any part, organ, or system of the body that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown.”¹ Three main dimensions characterize chronic pelvic pain and include: 1) duration–any type of pelvic pain lasting six months or longer; 2) anatomic–pelvic pain defined by physical findings at laparoscopy; and 3) affective/behavioral–pain accompanied by significantly altered physical activity such as work, recreation, and sex, and changes in mood related to the chronic pain.² Most standard laboratory tests in this group of patients, including the complete blood count, barium enema, ultrasound and CT scan, are typically within normal limits.

For a long time, surgeons have dealt superficially with chronic pelvic pain patients. With no classical indication for operative intervention, general surgeons have been only too grateful to refer these patients to gynecologists.

Frequently referred to as “woman trouble,” chronic pelvic pain has often defied even intensive efforts to determine its cause. Rather than probe the problem of chronic pelvic pain in females, some surgeons have avoided it, neglected it and, ultimately, trivialized it. Chronic pelvic pain, however, is a real entity and is now understood to have a multifactorial etiology. It has been estimated that 7-60% of patients with chronic pelvic pain have a gastrointestinal etiology for their discomfort.³

Information and data concerning chronic pelvic pain and associated diseases have been slow to come together. For example, Black reported that 39 cases of sciatic hernia had been described in the world literature up to 1958.⁴ Sciatic hernia would, therefore, appear to be a very rare hernia. Miklos et al, however, reported that of 1100 female patients who required surgical exploration for chronic pelvic pain, 20 patients were found to have a sciatic hernia⁵—an incidence of sciatic hernia in this patient population of 1.8%. Perhaps sciatic hernia is more common than previously realized.

Obturator hernia, another rare hernia, traverses the obturator canal to create symptoms. These hernias are rarely palpable and are usually not visualized. There were 475 cases of obturator hernia reported in the medical literature up to 1960.⁶ Gray and Skandalakis suggested that an obturator hernia begins with a “pilot tag” of preperitoneal tissue and fat entering into the obturator canal. This first stage is followed by a second stage in which a dimple appears over the opening of the obturator canal. The third stage of obturator hernia is characterized by symptoms of partial to complete incarceration of bowel into the obturator hernia.⁶ Interestingly, Singer et al, in a small series, reported that obturator “pilot tags” were observed in 64% of female cadavers examined.⁷

Also of interest is that 1996 epidemiological data suggested that femoral hernias were repaired at an incidence of approximately 3.4% of all groin hernias.⁸ A laparoscopic approach to groin hernia, however, has demonstrated that femoral hernias are encountered more frequently than noted in traditional literature.⁹ The true incidence of femoral hernia may be double that suggested from data derived from the open anterior repair experience. Occult femoral hernia may thus represent an instance of “missed” hernia and another potential cause of chronic pelvic pain.

What these bits and pieces of information scattered amongst several specialties suggest is that chronic pelvic pain can be due to several etiologies including gynecological, gastrointestinal, or structural abnormalities. These etiologies in many instances are unsuspected and, consequently, under or undiagnosed.

General surgeons, with their broad interest in hernia, have a unique opportunity to collaborate with gynecologists and reexamine the problem of chronic pelvic pain in females. Laparoscopic access can visualize not only the abdominal and pelvic walls but also the entire myopectineal orifice of Fruchaud. In this way, a thorough examination of those potential areas for lower abdominal hernia can be conducted. The sites that serve as a conduit for femoral, obturator, sciatic and contralateral inguinal hernia can be evaluated and treated laparoscopically. Adhesions can be lysed, and quite possibly the bête noire of “missed” hernia reduced.

It is likely that many sufferers of chronic pelvic pain have a legitimate, correctable problem that can respond to general surgical or gynecologic intervention. All surgeons involved in the management of chronic abdominal pain should consider laparoscopic evaluation and the possibility of occult hernia in their work-up of patients with this malady.