Unexpected causes of gynecological pelvic pain.

RS was a 34-year-old patient, para 3+0, with children aged 18, 13, and 11. The middle child was born by cesarean delivery. Her main problem was right iliac fossa pain for 6 weeks: she was regularly menstruating and serum B-HCG was negative in 2 tests 1 week apart. Ultrasound scanning was performed and showed a complex swelling, partly cystic and partly solid in the right adnexa extending to the Pouch of Douglas. The lesion measured 6 cm x 3 cm x 5 cm. Thinking that this was probably inflammation, her family physician started her on broad-spectrum antibiotics for 2 weeks; despite that, the pain did not improve, nor did the ultrasound findings. A vaginal examination revealed a right adnexal swelling that extended to the Pouch of Douglas. The patient consented to operative laparoscopy, which showed a clinical picture consistent with an old right fallopian tube ectopic pregnancy. Laparoscopic right salpingectomy was performed as outpatient surgery. Histological examination of the removed specimen showed necrotic chorionic villi consistent with an old right fallopian tube ectopic pregnancy. The patient became pregnant 6 months later and had a spontaneous vaginal delivery, and then she requested a sterilization procedure.

Laparoscopic appendectomy is being increasingly performed by gynecologists experienced at complicated operative laparoscopy. 1 Stool analysis was not performed preoperatively in this case because this investigation is not routinely done in pelvic pain in teenagers, especially when the patient had no suggestive symptoms like anal and or vaginal itching. The incidence of appendicitis and helminths infestation is higher in children than in teenagers. 2 However, histological examination of the removed appendix is usually the key to the diagnosis in these situations. Mullerian tube anomalies are unusual. 3 They are least expected in parous women, especially when the patient's pelvis had been examined during cesarean delivery, as in this case. Unfortunately, magnetic resonance imaging (MRI) was not done, 4 , 5 and ultrasound scanning during her last pregnancy gave no suggestion of genital anomaly. Laparoscopy is a valuable tool to diagnose and treat the condition. During the initial laparoscopic hysterectomy, the rudimentary uterus was missed, and, therefore, not removed. However, in this case, the patient was obese ((body mass index = 37) with relatively dense retroperitoneal fat layers, and the rudimentary uterus was retroperitoneal. In general, if you do not specifically look for something, you will not find it. Vesicovaginal fistula commonly results from obstetric and gynecological surgery. 6 – 9 In this case, the vaginal pack and urinary catheter were removed 24 hours following surgery, and that was followed by dribbling of urine from the vagina, raising clinical suspicion of urinary fistula. During the successful surgical repair of the fistula, a Graviguard intrauterine contraceptive device was accidentally found. Herniation of omentum, intestines, or both, through laparoscopic trocar incisions of 10-mm diameter or more have been reported especially in the midline, if the fascia was not carefully sutured. 10 Herniation at 5-mm laparoscopic port sites is rare. 11 , 12 Therefore, most surgeons do not routinely close 5-mm post sites, believing that such fascial defects are not large enough to create a significant risk of hernia formation, thus not justifying the extra time and effort needed to close them. However, one has to remember that repetitive motions in different directions in laparoscopic surgery may cause the 5-mm defect to enlarge significantly, allowing a hernia to develop. 13 In this case, herniation and adhesions of the omentum and a small part of a loop of small intestine were unexpected. The condition was successfully treated under laparoscopic guidance. Round ligament leiomyomata are rather uncommon. They may mimic other mass lesions in this vicinity including ovarian masses (as in this patient), adenopathy, and inguinal hernias. Magnetic resonance imaging and computed tomography are more accurate than ultrasound scanning in localizing and defining the lesions. 14 , 15 However, ultrasound scanning is more widely available and less costly to perform. The first step in the diagnosis of ectopic pregnancy is demonstration of pregnancy by means of a widely available and sensitive qualitative test for the beta-subunit of human chorionic gonadotropin (beta hCG). A negative pregnancy test will generally be used to exclude ectopic pregnancy. 16 However, this is the second case of histo-logically confirmed ectopic pregnancy, reported by the same authors. 17 Serum beta-hCG was 1 U/L, a value less than the lower limit of detecting the highly sensitive qualitative serum test whereby the pregnancy test was negative and the clinical diagnosis of ectopic pregnancy was correctly made, based on other features.

We believe that regular review of unusual and unexpected presentations are important facets of quality assurance and the adoption and maintenance of a healthy system of constructive self-criticism. Clinicians should always endeavor to exchange their experience for the benefit of our patients and the profession in general. 18