History, exam offer best clues to pelvic pain origin. (Laparoscopy Ineffective for DX).

MONTREAL -- Laparoscopy is a poor tool for diagnosing the cause of many forms of pelvic pain, failing to identify pathology in up to 40% of patients, Dr. Deborah Metzger said at the 1.1+/- World Congress on Human Reproduction.

"Furthermore, there is another unknown percentage of pelvic pain patients in whom pathology identified at laparoscopy seems unrelated to their pain," she said. "With a thorough history and very detailed physical exam we can diagnose the source of the pain in over 90% of these women who have pain of unknown origin."

Dr. Metzger, a reproductive endocrinologist and medical director of Helena Women's Health Center, a pelvic pain center in San Jose, Calif., said she typically sees patients referred to her who have had an average of four surgeries but no resolution of their pelvic pain.

In her experience, 10% of these patients have evidence of pelvic congestion, 65% have occult inguinal hernias, and 47% have abdominal-wall trigger points.

She asks patients to fill out a 10-page pelvic pain questionnaire that can be downloaded from the International Pelvic Pain Society Web site (www.pelvicpain.org). The questionnaire covers menstrual and obstetrics history; sleep, bladder, and bowel symptoms; and constitutional symptoms such as backache, bloating, and PMS. Patients are asked to rate their gynecologic pain symptoms on a scale from 0 to 10. She and her staff review the completed questionnaire before the patient's appointment.

It's important to attempt to reproduce the patient's pain during the physical exam, Dr. Metzger said.

"Many of these patients have occult inguinal hernias, and this is something that is very underdiagnosed. I have done 550 inguinal hernia repairs since 1994, which says something about how common it is," she said in an interview.