Chronic Pelvic Pain

Chronic Pelvic Pain

Introduction

Background

Chronic pelvic pain (CPP) is a common problem and presents a major challenge to health care providers because of its unclear etiology, complex natural history, and poor response to therapy.

Chronic pelvic pain is poorly understood and, consequently, poorly managed. This condition is best managed using a multidisciplinary approach. Management requires good integration and knowledge of all pelvic organ systems and other systems including musculoskeletal, neurologic, and psychiatric systems.

A significant number of these patients may have various associated problems, including bladder or bowel dysfunction, sexual dysfunction, and other systemic or constitutional symptoms. Other associated problems, such as depression, anxiety, and drug addiction, may also coexist.

In the United States, estimated direct medical costs for outpatient visits for chronic pelvic pain (women aged 18-50 y) is approximately $881.5 million per year.¹

Pathophysiology

The pathophysiology of chronic pelvic pain is complex and multifactorial. It remains unclear.

Frequency

United States

Chronic pelvic pain is a common problem. It affects approximately 1 in 7 women.¹ In one study of reproductive-aged women in primary care practices, the reported prevalence rate of pelvic pain was 39%.² Of all referrals to gynecologists, 10% are for pelvic pain.³

International

A similar prevalence of chronic pelvic pain has been described in other countries.⁴

Mortality/Morbidity

As with other chronic pain, chronic pelvic pain may lead to prolonged suffering, marital and family problems, loss of employment or disability, and various adverse medical reactions from lifelong therapy.

Race

In one study, blacks had a higher incidence of pelvic pain.²

Sex

Chronic pelvic pain is most common among reproductive-aged women. Common causes of chronic pelvic pain in men include chronic (nonbacterial) prostatitis, chronic orchalgia, and prostatodynia.

Age

Chronic pelvic pain is most common among reproductive-aged women, especially those aged 26-30 years.²

Clinical

History

The proposed definition of chronic pelvic pain (CPP) is nonmenstrual pain of 3 months duration or longer that localizes to the anatomic pelvis and is severe enough to cause functional disability and require medical or surgical treatment. Most authorities agree that patients should be diagnosed with chronic pelvic pain if they have pain primarily located in the pelvis for more than 3-6 months duration.

Patient history is important in cases of chronic pelvic pain. Because of the complex etiology and, often, the presence of associated disorders, a general approach with a thorough history that directs further evaluation and appropriate consultations is needed.⁵ Perform a detailed review of systems, including reproductive, GI, musculoskeletal, urologic, and neuropsychiatric. As needed, ask specific questions, especially if the patient has an associated disorder. A thorough past history is also important to avoid repeating invasive and expensive procedures.

• Focus history on characterizing the patient's pain, which can lead to appropriate diagnostic and therapeutic plans.
  • Location of pain: The location of pain is an important part of the history. Ask the patient to describe the pain location and type on a pain diagram (anteroposterior and lateral view of human picture).
  • Precipitating factors: Ask questions about factors that provoke or intensify pain. This may provide clues for possible etiologies or associated disorders. For example, in pelvic congestion syndrome, pain is related to posture and is worse at the end of day. In endometriosis, pain is commonly reported during or after intercourse.
  • Alleviating factors: Alleviating factors may be present. For example, rest may decrease pain of musculoskeletal or adnexal origin.
  • Quality of pain: Various terms can be used to describe the quality of pain. Such terms include throbbing, pounding, shooting, pricking, boring, stabbing, lancinating, sharp cutting, lacerating, pressing, cramping, crushing, pulling, pinching, stinging, burning, splitting, penetrating, piercing, squeezing, and dull aching.
  • Pain distribution: Spreading or radiation of pain is also important in the evaluation of neuropathic pain.
  • Severity or intensity of pain: Use some type of rating system to evaluate pain severity or intensity with a degree of objectivity and reproducibility. Different types of pain scales may be used. Numerical scales are more useful and reliable. The visual analog scale is one of the commonly used numerical scales.
• Obtain a history specific to different systems and disorders.
  • Gynecologic and obstetric
    • For example, excessive bleeding with menses suggests uterine leiomyomas or adenomyosis. History of previous surgery may suggest intra-abdominal or pelvic adhesions. Patients with cervical stenosis usually have a history of chronic cervical infection or treatment with cryosurgery/laser surgery/loop excision or endometrial resection. Having multiple sexual partners is a risk factor for pelvic inflammatory disease.
    • Women with adenomyosis have higher levels of dysmenorrhea, pelvic pain, depression, and endometriosis than women with fibroids. Women undergoing hysterectomy with a histologic diagnosis of adenomyosis have a distinct symptomatology and medical history compared with women with leiomyomas.⁶
  • Urologic: A detailed history to evaluate the urological system is important. For example, as compared to patients with pelvic pain, patients with interstitial cystitis report urgency and increased frequency of urination as the most distressing features.
  • Gastrointestinal: For example, deflecting sigmoid adhesions are common in women with chronic pelvic pain and frequently are associated with GI symptoms.
  • Musculoskeletal: History of vaginal delivery with prolonged second-stage episiotomies or tears may suggest pelvic floor relaxation disorder.
  • Neurologic: Constant burning pain is a common complaint in patients with pudendal neuralgia. Patients may report dysesthesia and vulvodynia but usually not dyspareunia.
  • Psychologic: A good psychosocial or psychosexual history is needed when organic diseases are excluded, or coexisting psychiatric disorders are suggested. Obtain sufficient history to evaluate depression, anxiety disorder, somatization, physical or sexual abuse, drug abuse or dependence, and family problems, marital problems, or sexual problems.⁷ Sexual abuse occurring before age 15 years is associated with later development of chronic pelvic pain.⁸ Somatization is a common associated psychologic disorder in women with chronic pelvic pain. Somatization scales can be used for evaluation.

Physical

Good rapport, tolerance, and an open-minded approach are important in the evaluation of any patient with chronic pain. A thorough systematic examination usually suggests an appropriate diagnosis and therapy.

• Obstetric-gynecologic and other system examinations could be long and stressful. Detailed examination of obstetric-gynecologic and other systems can be performed in different positions. Usually, this includes standing, sitting, supine, and lithotomy positions.
• Lithotomy examination usually includes the following:
  • Visual inspection of the external genitalia
  • Basic sensory testing and evaluation for trigger points
    • A cotton-tipped swab can be used for precise sensory and tender-point evaluation of the vestibule, vaginal cuff, cervical os, paracervical region, and cervical region.
    • Single-digit examinations of the vulva, pubic arch, levator ani coccyx, introitus, urethral, trigonal, cervix, paracervical areas, vaginal fornices, uterus, and adnexa are indicated.
  • Colposcopic evaluation of the vulva and vestibule
  • Sims retractor or single-blade speculum examination of the vagina and pelvic muscles
  • Bimanual pelvic examination
  • Rectovaginal examination
• Perform detailed examinations for other systems (eg, GI, urologic, neurologic, musculoskeletal) as required. For example, gait and posture evaluation, spine examination, and sensory and motor examination are often useful.
  • Betty maneuver (for piriformis syndrome): When abduction of the thigh against resistance is requested, the patient will report pain.
  • Obturator sign (dysfunction of the obturator muscles or fascia)
  • Straight-leg raising test (possible herniated disc, radiculopathy)
  • Psoas sign: If pain is elicited during flexion of hip against resistance, this may suggest dysfunction of the psoas muscles or fascia.
  • Patrick or faber (flexion in abduction and external rotation) test for hip evaluation

Causes

Various reproductive, GI, urologic, and neuromuscular disorders may cause or contribute to chronic pelvic pain. Sometimes, multiple contributing factors may exist in a single patient.

• Extrauterine reproductive disorders
  • Endometriosis
  • Adhesions
  • Adnexal cysts
  • Chronic ectopic pregnancy
  • Chlamydial endometritis or salpingitis
  • Endosalpingiosis
  • Ovarian retention syndrome (residual ovary syndrome)
  • Ovarian remnant syndrome
  • Ovarian dystrophy or ovulatory pain
  • Pelvic congestion syndrome
  • Postoperative peritoneal cysts
  • Residual accessory ovary
  • Subacute salpingo-oophoritis
  • Tuberculous salpingitis
• Uterine reproductive disorders
  • Adenomyosis
  • Chronic endometritis
  • Atypical dysmenorrhea or ovulatory pain
  • Cervical stenosis
  • Endometrial or cervical polyps
  • Leiomyomata
  • Symptomatic pelvic relaxation (genital prolapse)
  • Intrauterine contraceptive device
• Urologic disorders
  • Bladder neoplasm
  • Chronic urinary tract infection
  • Interstitial cystitis
  • Radiation cystitis
  • Recurrent cystitis
  • Recurrent urethritis
  • Urolithiasis
  • Uninhibited bladder contractions (detrusor-sphincter dyssynergia)
  • Urethral diverticulum
  • Chronic urethral syndrome
  • Urethral caruncle
• Musculoskeletal disorders
  • Abdominal wall myofascial pain (trigger points)
  • Compression fracture of lumbar vertebrae
  • Faulty or poor posture
  • Fibromyalgia
  • Mechanical low back pain
  • Chronic coccygeal pain
  • Muscular strains and sprains
  • Pelvic floor myalgia (levator ani spasm)
  • Piriformis syndrome
  • Rectus tendon strain
  • Hernias (eg, obturator, sciatic, inguinal, femoral, spigelian, perineal, umbilical)
• Gastrointestinal disorders
  • Carcinoma of the colon
  • Chronic intermittent bowel obstruction
  • Colitis
  • Chronic constipation
  • Diverticular disease
  • Inflammatory bowel disease
  • Irritable bowel syndrome
• Neurologic disorders
  • Neuralgia/cutaneous nerve entrapment (surgical scar in the lower part of the abdomen; usually iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous nerves)
  • Shingles (herpes zoster infection)
  • Degenerative joint disease
  • Disk herniation
  • Spondylosis
  • Abdominal epilepsy
  • Abdominal migraine
  • Neoplasia of spinal cord or sacral nerve
• Psychologic and other disorders
  • Personality disorders
  • Depression
  • Sleep disorders
  • Sexual and/or physical abuse
• Common causes of chronic pelvic pain in men
  • Chronic (nonbacterial) prostatitis
  • Chronic orchalgia
  • Prostatodynia