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(Radiology. 2001;219:574.)
© RSNA, 2001

Letters to the Editor

Imaging in Women with Persistent Pelvic Pain

Philip Cook, FRCR* and Martin Quinn, MD, MRCOG{dagger}

Departments of Radiology* and Obstetrics and Gynaecology{dagger}, Royal Cornwall Hospitals NHS Trust, Treliske, Truro, England; e-mail: martin.quinn@hbhc-tr.anglox.nhs.uk

Editor:

The poor diagnostic yield of ultrasonography (US) in young women with persistent pelvic pain and questionable laparoscopic findings is a disappointing though all too frequent outcome, as reported in the August 2000 issue of Radiology (1). Additional magnetic resonance (MR) imaging may, however, be particularly helpful to establish a definitive diagnosis of pelvic allodynic syndromes caused by avulsion of the levator ani muscle at vaginal delivery.

Avulsion of the pubococcygeus muscle from its tendinous origin over the obturator internus muscle on the tendinous arch of the levator ani muscle has been observed on transverse T2-weighted sections in 18 of 26 consecutive patients with persistent pelvic pain and a negative laparoscopic finding. This injury is associated with a prior difficult intrapartum episode, notably, premature or prolonged maternal voluntary efforts. Separation of the muscle from its origin causes disruption of the pelvic nerves as they enter the pelvis on its surface. This denervatory injury sets up the conditions for allodynic syndromes (light touch being perceived as pain) to develop some years after the original intrapartum episode (2).

Young women present with symptom clusters, including pelvic pain, deep dyspareunia, tampon discomfort, urge incontinence, and fecal urgency. The laparoscopic finding is frequently reported as negative. Treatment may include the use of antimuscarinics (tolterodine tartrate [Detrol]; Pharmacia, Bridgewater, NJ) for visceral syndromes or anticonvulsants (gabapentin [Neurontin]; Parke-Davis, Morris Plaines, NJ) for somatic syndromes, though the most urgent requirement is for a prompt and convincing explanation following an appropriate imaging study. Pelvic allodynic syndromes are a particularly common diagnostic problem that cause widespread pain and suffering. Selective MR imaging will free these women from their debilitating, confusing, and embarrassing predicament.

REFERENCES

  1. Harris RD, Holtzman SR, Poppe AM. Clinical outcome in female patients with pelvic pain and normal pelvic US findings. Radiology 2000; 216:440-443.[Abstract/Free Full Text]
  2. Cervero F, Laird JMA. Visceral pain. Lancet 2000; 353:2145-2148.

Dr Harris responds:

Robert D. Harris, MD

Department of Radiology, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756-0001; e-mail: robert.d.harris@hitchcock.org

I thank Drs Cook and Quinn for their interest in our article (1). We agree with their general statement that a substantial proportion of women who have a normal pelvic US finding will not have any abnormal condition documented with further imaging or laparoscopy. However, pelvic US is certainly an excellent screening technique and will show abnormality that causes or contributes to pelvic pain in a certain number of cases, depending on patient population, scanning technique (transabdominal or transvaginal), and equipment used. I find their small series of 26 patients examined with pelvic MR imaging to be intriguing, and I can find no mention of this avulsion injury of the pubococcygeus muscle as a cause of pelvic pain in the literature. I look forward to seeing this work published in a peer-reviewed journal.

REFERENCES

  1. Harris RD, Holtzman SR, Poppe AM. Clinical outcome in female patients with pelvic pain and normal pelvic US findings. Radiology 2000; 216:440-443.




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