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 consensus on the contribution of adhesions to pelvic pain. Methods: Impressions about the role of adhesion location, extent, and severity of pelvic pain, were surveyed among 13 gynaecological surgeons. They were asked whether adhesions covering specific organs to a varying extent would 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 recommend surgery to reduce pelvic pain. Results: Women with dense vascular adhesions covering all of the uterus but not the bowel or adnexal structures were thought to have a 49 ± 9% likelihood of having pelvic pain; this fell to a 34 ± 7% and 18 ± 5% likelihood of pain if 60% or 20%, respectively, of the uterus was involved with adhesions. Similar observations were made for adhesions involving the posterior cul-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 involvement of both tubes and ovaries with dense, vascular adhesions were thought to 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%, respectively. In contrast, filmy adhesions to both tubes and ovaries, were thought to cause pain in 46 ± 9%, 26 ± 5%, and 13 ± 3% of women, respectively, 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 100% of both ovaries and tubes. Surgeons were only slightly less likely to recommend surgery for pain relief for adhesions involving either both tubes or both ovaries or for pain associated with unilateral tubal and ovarian adhesions. 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 surface, surgery was recommended by 42%, 58%, 83% and 92% of surgeons, respectively. Posterior cul-de-sac involvement resulted in recommendation of surgery by 50%, 83%, 92%, and 100% of surgeons, respectively; however, for corresponding amounts of anterior cul-de-sac adhesions, surgery was recommended by only 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 thought to provide the potential for pain relief.