Chronic Pelvic Pain

Aka: Chronic Pelvic Pain, Chronic Pelvic Pain in Women, Chronic Pelvic Pain History, Chronic Pelvic Pain Exam

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II. Definition

  1. Persistent, noncyclic pain for at least 6 months
  2. Severe enough to cause functional Disability
  3. Localized to Pelvis, sub-umbilical anterior abdominal wall or buttocks

III. Epidemiology

  1. Prevalence: 3-4% in U.K. studies up to 15% in U.S. studies
  2. Zondervan (1999) Br J Obstet Gynaecol 106(11):1149-55 [PubMed]
  3. Mathias (1996) Obstet Gynecol 87(3): 321-7 [PubMed]

IV. Pathophysiology: Models (analogous conditions)

  1. Chronic regional pain syndrome
    1. Neuromuscular-psychosocial disorder similar to Reflex Sympathetic Dystrophy
  2. Functional somatic pain syndrome
    1. Similar to Irritable Bowel Syndrome or non-specific Fatigue
  3. Associated factors
    1. Hyperesthesia or Allodynia (pain from non-painful stimulation such as light touch)
    2. Pelvic Floor Dysfunction

V. Causes

  1. Idiopathic in up to 60% of cases
  2. See Chronic Pelvic Pain Causes
  3. See Acute Pelvic Pain Causes
  4. See Acute Abdominal Pain Causes

VI. Symptoms: Red Flags

  1. Unexplained Weight Loss, pelvic mass or postmenopausal onset
    1. Genitourinary cancer
  2. Hematochezia
    1. Inflammatory Bowel Disease
    2. Gastrointestinal Tract malignancy
  3. Hematuria
    1. Interstitial Cystitis
    2. Urinary tract malignancy
  4. Perimenopausal or Postmenopausal irregular bleeding
    1. Endometrial Cancer
  5. Postcoital bleeding
    1. Cervical Cancer
    2. Sexually Transmitted Infection (STI) such as chlamydia Cervicitis
    3. Pregnancy

VII. History

  1. See Red Flags as above
  2. Pain History
    1. Localization and radiation
    2. Palliative and provocative factors
    3. Quality, intensity and duration
      1. Crampy pain
        1. Inflammatory Bowel Disease
        2. Irritable Bowel Syndrome
      2. Hot, burning or electric-shock Sensation
        1. Nerve entrapment
    4. Changes in pain over time
      1. Pain associated with Menses
        1. Endometriosis
        2. Adenomyosis
      2. Pain not associated with Menses
        1. Pelvic adhesions
        2. Initerstitial cystitis
        3. Irritable Bowel Syndrome
        4. Abdominal Wall Pain
  3. Associated Symptoms
    1. Menstrual Cycle
      1. Abnormal Bleeding (Menorrhagia, Metrorrhagia)
      2. Painful Menses (Dysmenorrhea)
    2. Altered bowel habits (Constipation, Diarrhea)
    3. Altered Bladder habits
      1. Dysuria, Urinary Frequency
        1. Urinary Tract Infection
        2. Urethritis (e.g. Chlamydia or other STI)
      2. Urinary urge
        1. Interstitial Cystitis
        2. Urethral syndrome
    4. Sexual intercourse (Dyspareunia)
    5. Exercise (e.g. Abdominal Wall Pain)
    6. Back, joint or Muscle pain (Myofascial Pain)
  4. Pelvic adhesion risks
    1. Pelvic surgery
    2. Pelvic infection
    3. Intrauterine Device usage
  5. Previous evaluation and treatment by other providers
  6. Psychiatric History
    1. Mood changes and how quickly
    2. Physical functioning in work and activities
    3. Family Roles and Responsibilities with recent changes
    4. Sexual Dysfunction
    5. Sexual abuse or physical abuse history (commonly associated)
    6. Posttraumatic Stress Disorder
    7. Efforts to cope with pain (Relaxation or Exercise)
    8. Patient and Families' interpretation of pain
  7. Associated Conditions (one or more present in 50% of cases)
    1. Irritable Bowel Syndrome
    2. Interstitial Cystitis (often accompanies Endometriosis)
    3. Endometriosis
    4. Pelvic adhesions

VIII. Exam: Neurologic

  1. Stance and gait
  2. Posture
  3. Sitting position

IX. Exam: Abdominal

  1. Palpate anterior wall for nodularity or point tenderness
    1. Palpation of Urethra and Bladder trigone
    2. Chronic Urethritis or trigonitis
      1. Frequency, urgency, Dysuria without bacteruria
  2. Musculoskeletal
    1. Focal tenderness and Trigger Points
      1. Palpate with single finger (e.g. index finger) or cotton swab for Allodynia
    2. Carnett's Sign Positive
      1. Abdominal Muscle wall source
  3. Post-surgical neuromas
    1. Entrapment in Suture with lateral Pfannenstiel
      1. Ilioinguinal Nerve
      2. Iliohypogastric Nerve
  4. Hernia
    1. Umbilical Hernia
    2. Inguinal Hernia
    3. Incisional Hernia
    4. Femoral Hernia
    5. Spigelian Hernia (Lateral margin of rectus)
  5. Meralgia Paresthetica
  6. Piriformis Syndrome
  7. Psoas inflammation from pelvic inflammation
    1. See Psoas Sign

X. Exam: Pelvic Exam

  1. Consider exam with a mirror so that patient may identify areas of pain
  2. Observe for Vulvar Dermatoses
    1. Genital Ulcers
    2. Papulosquamous Vulvar Dermatoses (e.g. Vulvar Lichen Sclerosus et atrophicus, Vulvar Lichen Planus, Contact Dermatitis, Psoriasis)
    3. Bullous Vulvar Dermatoses (e.g. Erythema Multiforme, Bullous Pemphigoid, Pemphigus)
    4. Systemic disease (e.g. Behcet's Disease, Systemic Lupus Erythematosus, Reiter's Syndrome)
  3. Observe for vaginal infection
    1. Vaginitis
    2. Human Papillomavirus
    3. Herpes Simplex Virus
  4. Observe for Vaginal Dryness, abrasions or other Trauma
    1. Vaginal Atrophy or decreased lubrication
    2. Forceful vaginal penetration
  5. Vulvitis and vestibulitis provocative factors
    1. Touch vulva and distal vagina with moistened cotton tip swab
    2. Acetic acid
      1. May also identify lesions such as HPV
  6. Suburethral fullness or tenderness
    1. Urethral Diverticulum
  7. Digital vaginal exam with 1 finger
    1. Patient contracts and relaxes intermittently
    2. Same type of pain as with intercourse?
    3. Press at pelvic floor (levator plate palpation)
      1. Pelvic floor tension myalgia increases during day
  8. Speculum exam
    1. Use a small speculum with adequate lubricant
    2. Obtain KOH and Wet Prep sample
    3. Obtain STD testing for Gonorrhea and Chlamydia
  9. Bimanual Exam
    1. Cul-de-sac and uterosacral palpation for nodularity, tenderness or masses
      1. Endometriosis
      2. Adenomyosis
      3. Cancer
    2. Cervical Motion Tenderness for Cervicitis
      1. Mild
        1. Endometriosis
        2. Adhesions
      2. Severe
        1. Pelvic Inflammatory Disease (PID)
    3. Retroverted Uterus associated conditions
      1. Endometriosis
      2. Pelvic adhesions
      3. Low Back Pain at Menstruation
      4. Dyspareunia
      5. Pain elicited with palpation of fundus
    4. Ovarian pain (difficult to localize)
    5. Pelvic mass
      1. Uterus enlarged, tender or immobility
      2. Adnexal Mass
  10. Rectovaginal exam
    1. Evaluate for nodularity, posterior uterine masses, pelvic floor tenderness
  11. Signs of Pelvic Relaxation
    1. Pelvic Organ Prolapse (e.g. Cystocele, Uterocele, Rectocele)

XI. Labs

  1. Urine Pregnancy Test (bHCG)
  2. Urinalysis and Urine Culture
  3. Erythrocyte Sedimentation Rate
  4. Chlamydia Test
  5. Gonorrhea Test
  6. Complete Blood Count
  7. C-Reactive Protein or Erythrocyte Sedimenation Rate

XII. Imaging

  1. First-line
    1. Transvaginal Pelvic Ultrasound
      1. Pelvic Mass
      2. Adenomyosis
      3. Hydrosalpinx (Pelvic Inflammatory Disease)
  2. Second-line tests
    1. Pelvic CT or Pelvic MRI
      1. Limited usefulness unless defining an abnormal Ultrasound finding

XIII. Diagnostics

  1. Exploratory Laparoscopy (indicated for persistent and severe symptoms and nondiagnostic testing)
    1. Negative or nondiagnostic in 40% of cases
    2. Endometriosis
    3. Diagnosis and lysis of pelvic adhesions
  2. Endoscopic studies may be useful in some cases
    1. Cystoscopy
    2. Colonoscopy

XIV. Evaluation

  1. Quality of Life Scale
  2. Pain Log
    1. Pain episode dates
    2. Pain characteristics and severity
    3. Associated factors (e.g. Menses, mood, bowel or Bladder symptoms, intercourse, Exercise)

XV. Management

  1. See Chronic Pelvic Pain Management

XVI. Resources

  1. International Pelvic Pain Society Evaluation Forms and patient information
    1. http://pelvicpain.org/professional/documents-and-forms.aspx

XVII. References

  1. Steege (1993) Chronic Pelvic Pain ACOG Video
  2. Howard (2003) Obstet Gynecol 101:594-611 [PubMed]
  3. Ortiz (2008) Am Fam Physician 77:1535-42 [PubMed]
  4. Speer (2016) Am Fam Physician 93(5):380-7 [PubMed]
  5. Zondervan (2001) Am J Obstet Gynecol 184:1149-55 [PubMed]

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