Severe Chronic Pelvic Pain in Women May Be Caused By Ligamentous Laxity in the Posterior Fornix of the Vagina

EDITORIAL COMMENT: We accepted this paper for publication because severe chronic pelvic pain, often with associated secondary dysmenorrhoea and dyspa‐reunia, is a difficult gynaecological problem to deal with, and is not uncommon. The women are usually premenopausal and bimanual palpation of the uterus reproduces the pain they complain of ‐ the uterus seems tender but the explanation could be that described in this paper. In these women the uterus is freely mobile and there is no palpable adnexal pathology, and as noted by the author, laparoscopic findings are normal. It is widely believed that it is the ovaries and not the uterus (or the contents of its supporting ligaments) that are the cause of this syndrome, and when hysterectomy is contemplated, the question of whether to perform bilateral oophorectomy arises. Hysterectomy alone is often curative of pain in these patients (A) but the lesser procedure described here warrants consideration in patients with chronic severe pelvic pain. To establish that the proposed operation is effective, it would be necessary to perform a properly designed blinded randomized controlled trial, with the control women having a ‘placebo’ operation (e.g. anaesthetic/sedation, local analgesia infiltration, incision of vagina without plicating the uterosacral ligaments). We believe that such a trial is feasible. Summary: The aim was to prospectively study the relationship between pelvic pain of otherwise unknown origin and laxity in the posterior vaginal fornix. Twenty‐eight patients with negative laparoscopy findings, lower abdominal pain and laxity in the posterior ligamentous supports of the uterus underwent surgical approximation of their uterosacral ligaments. At 3‐month review, 85% of patients were cured, and at 12 months, 70%. Nonorganic pelvic pain has frequently been attributed to psychological factors. However, the results suggest that this may be a T12‐L1 parasympathetic pain referred to the lower abdomen, perhaps due to the force of gravity stimulating pain nerves unable to be supported by the lax uterosacral ligaments in which they are contained. It was concluded that laxity in the posterior ligaments of the vagina should first be excluded before referring patients with pelvic floor discomfort or pain for psychiatric care.