**8. Pelvic endometriosis**

Fibroids are usually not painful. Acute pain may arise under certain circumstances, such as torsion of pedunculated fibroids, degeneration (especially red degeneration), associated endometriosis/adenomyosis, and/or expulsion of pedunculated submucous fibroids through the cervix [32]. Fibroid also rarely causes acute pain when it outgrows its blood supply, thereby causing necrosis. Spasmodic dysmenorrhoea may result when expulsion of a pedunculated submucous fibroid stimulates uterine contraction [32]. Sarcomatous change, which occurs in 0.1-0.5% of cases [31], can result in pain as well. There is the need to look out for other co-

With respect to the treatment of fibroids the factor considered in this section is the pain, therefore the patient has to be thoroughly evaluated; history, examination, and investigations. Pain is generally managed with the use of analgesics, ranging from acetaminophen (parace‐ tamol) to non-steroidal anti-inflammatory drugs and opioids. Definitive treatment would require surgery if analgesics alone, sometimes with antibiotics in cases associated with infection, fail to alleviate the symptoms. There is usually no room for use of medical treatment

Definitive surgical modalities for management of uterine fibroids include myomectomy, which leaves behind a functional uterus and thus preserving fertility, and hysterectomy, which is desirable for patients over 40 years of age and those not desirous of future fertility. Both procedures can be carried out via the abdominal route, vaginal route, or even laparoscopically. Hysteroscopic myomectomy is indicated for submucous fibroids complicated by abnormal bleeding with pain. Robotic surgery is employed in high technology medical facilities,

Pelvic inflammatory disease (PID) is a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, oophoritis or tuboovarian abscess and pelvic peritonitis/cellulitis. Sexually transmitted organisms, particularly Neisseria gonorrhoeae and Chlamydia trachomatis, are implicated in many cases. Organisms

There is a worldwide increase in the incidence of PID, and it is the most common infectious disease that affects young women and accounts for a significant percentage of the morbidity that is associated with sexually transmitted diseases (STDs). Although it does not usually constitute an emergency in the sense that immediate treatment is life-saving, urgent treatment is required to minimize the effect of the disease on subsequent fertility and reduces the risk of sequelae such as ectopic pregnancy and chronic pelvic pain. This applies to both mild and

The diagnosis of PID is usually based on clinical features although clinical diagnosis is usually imprecise, and many cases of PID go unrecognized or are subclinical. These patients are usually young, sexually active, and complain of abdominal pain, with or without fever

of the vaginal flora however also cause PID, which is often polymicrobial.

morbid conditions in cases of fibroids associated with pains.

40 Contemporary Gynecologic Practice

options for fibroids presenting with acute abdomen or severe pains.

especially in countries with advanced healthcare systems.

**7. Acute Pelvic Inflammatory Disease**

severe disease.

Endometriosis is the presence of endometrial stroma and glands outside of the uterine cavity. The pelvis is the commonest site, with the reproductive organs the most frequently affected [34]. The most common symptoms related to it are dysmenorrhoea, dyspareunia and low back pain which worsen during menstruation, and subfertility. It is a leading cause of disability in women of reproductive age, and the pain may be mild, or it may be severe enough to negatively affect health-related quality of life.

Endometriosis remains a difficult clinical problem and quite a number of patients are often referred to other specialists before seeing the gynaecologist [35]. Painful symptoms, especially when cyclical, may be caused by endometriosis, and it is the underlying cause of pelvic pain in 15% of cases [36]. The exact prevalence is unknown because surgery and/or histology is required for its diagnosis, but estimates of 3-10% of women in the reproductive age group, and 25-35% of infertile women have been made [37].

The symptoms of endometriosis and the laparoscopic findings do not always correlate [38]. The focus during management should be on the illness rather than the disease. There is no place for medical treatment of endometriosis with drugs in infertile women desirous of having babies [39]. Surgery can be done via laparotomy or laparoscopy [40, 41]. Analgesics are often required for symptomatic relief of pain. Unlike infection, endometriosis does not damage the luminal epithelium of the fallopian tube, and thus conservative surgery is more likely to be successful in restoring normal anatomic relations. However, endometriosis is also a well known cause of frozen pelvis.
