Chronic Pelvic Pain

CHRONIC PELVIC PAIN

Chronic pelvic pain is a common disorder that repre-sents significant disability and utilization of resources. Estimates suggest that 15% to 20% of women aged 18 to 50 years have chronic pelvic pain that lasts longer than 1 year. Although there is no generally accepted definition of chronic pelvic pain, one proposed definition is noncyclic painlasting for more than 6 months that localizes to the anatomic pelvis, anterior abdominal wall at or below the umbilicus, the lumbosacral back, or the buttocks and is of sufficient severity to cause functional disability or lead to medical care. Chronicpelvic pain may be caused by diseases of the reproduc-tive, genitourinary, and gastrointestinal tracts (Box 30.2 and Table 30.2). Other potential somatic sources of pain include the pelvic bones, ligaments, muscles, and fascia. Sometimes there is no clear etiology for the pain.

Assessment

The successful evaluation and treatment of chronic pelvic pain requires time and a patient, caring physician. The taking of the history and physical examination is a time in which the physician may both gather information and establish a trusting rapport. Effective management of this disease is dependent on a good doctor–patient relation-ship, and the therapeutic effects of the relationship itself should not be overlooked.

As with the evaluation of any pain, attention must be paid to the description and timing of the symptoms in-volved. The history should include a thorough medical, surgical, menstrual, and sexual history. Inquiries should be made into the patient’s home and work status, social his-tory, and family history (past and present). The patient should be questioned about sleep disturbances and other signs of depression, as well as a past history of physical and sexual abuse. 

Box 30.2

Gynecologic Conditions That May Cause or Exacerbate Chronic Pelvic Pain, by Level of Evidence

Level A*

·               Endometriosis^†

·               Gynecologic malignancies (especially late stage)

·               Ovarian retention syndrome (residual ovary syndrome)

·               Ovarian remnant syndrome

·               Pelvic congestion syndrome

·               Pelvic inflammatory disease^†

·               Tuberculous salpingitis

Level B^‡

·               Adhesions^†

·               Benign cystic mesothelioma

·               Leiomyomata^†

·               Postoperative peritoneal cysts

Level C^§

·               Adenomyosis

·               Atypical dysmenorrhea or ovulatory pain

·               Adnexal cysts (nonendometriotic)

·               Cervical stenosis

·               Chronic ectopic pregnancy

·               Chronic endometritis

·               Endometrial or cervical polyps

·               Endosalpingiosis

·               Intrauterine contraceptive device

·               Ovarian ovulatory pain

·               Residual accessory ovary

·               Symptomatic pelvic relaxation (genital prolapse)

*Level A: good and consistent scientific evidence of causal relationship to chronic pelvic pain.

^†Diagnosis frequently reported in published series of women with chronic pelvic pain. 

^‡Level B: limited or inconsistent scientific evidence of causal relationship to chronic pelvic pain. 

^§Level C: causal relationship to chronic pelvic pain based on expert opinions. 

From American College of Obstetricians and Gynecologists. Chronic pelvic pain. ACOG Practice Bulletin No. 51. ObstetGynecol. 2004;103(3):589–605.

Studies have found a significant correlation between a history of abuse and chronic pain. If a history of abuse is obtained, the patient should also be screened for any current physical or sexual abuse.

Physical examination of patients with chronic pain is directed toward uncovering possible causative pathologies. The patient should be asked to indicate the location of the pain as a guide to further evaluation and to provide some indication of the character of the pain. If the pain is local-ized, the patient will point to a specific location with a single finger; if the pain is diffuse, the patient will use a sweeping motion of the whole hand. Maneuvers that du-plicate the patient’s complaint should be noted, but undue discomfort should be avoided to minimize guarding, which would limit a thorough examination.

Many of the same conditions that cause secondary dys-menorrhea may cause chronic pain states. As in the evaluationof patients with dysmenorrhea, cervical cultures should be obtained if infection is suspected. For most patients, a reasonably accurate differential diagnosis can be established through the history and physical examination. The wide range of differential diagnoses possible in chronic pelvic pain lends itself to a multidisciplinary approach, which might include psychiatric evaluation or testing. Consultation with social workers, physical therapists, gastroenterologists, anesthesiologists, orthopaedists, and others should be con-sidered. The use of imaging technologies or laparoscopy may also be required to determine a diagnosis. However, in approximately one-third of patients with chronic pelvic pain who undergo laparoscopic evaluation, no identifi-able cause is found. However, two-thirds of these patients have potential causes identified where none was apparent before laparoscopy.

The evaluation should begin with the presumption that there is an organic cause for the pain. Even in patients with obvious psychosocial stress, organic pathology can and does occur. Only when other reasonable causes have been ruled out should psychiatric diagnoses such as som-atization, depression, or sleep and personality disorders be entertained.

Conditions That Increase the Risk of Chronic Pelvic Pain

Common disorders in women with chronic pelvic pain are pelvic inflammatory disease, irritable bowel syndrome, interstitial cystitis, endometriosis, and adhesions. However, it is sometimes difficult to pinpoint a specific cause of chronic pelvic pain, and many women with chronic pelvic pain have more than 1 disease that might lead to pain.

Pelvic Inflammatory Disease

Approximately 18% to 35% of women who have had pelvic inflammatory disease will develop chronic pelvic pain. Theexact mechanism is unknown, but may involve chronic inflammation, adhesive disease, and the coexistence of psychosocial factors.

IRRITABLE BOWEL SYNDROME

Irritable bowel syndrome (IBS) occurs in 50% to 80%of women with chronic pelvic pain.  

The diagnosis of IBS is defined by the Rome II criteria: abdominopelvic pain for 12 weeks (not necessarily consecutive) in the preced-ing 12 months that cannot be explained by known disease, having at least two of the following features: (1) relieved with defecation, (2) onset associated with a change in the frequency of bowel movements (diarrhea or constipation), or (3) onset associated with a change in the form of stool (loose, watery, with mucus, or pellet-like). IBS is often usefully subcategorized for purposes of treatment depend-ing on the predominant complaint: pain, diarrhea, con-stipation, or alternating constipation and diarrhea. The pathophysiology of the syndrome is not clearly identi-fied, but factors proposed to be involved include altered bowel motility, visceral hypersensitivity, psychosocial factors (especially stress), an imbalance of neurotransmit-ters (especially serotonin), and infection (often indolent or subclinical). A history of childhood sexual or physical abuse is highly correlated with the severity of symptoms experienced by those with IBS.

INTERSTITIAL CYSTITIS

Interstitial cystitis is a chronic inflammatory condition ofthe bladder that is often characterized by pelvic pain, uri-nary urgency and frequency, and dyspareunia. The pro-posed etiology is a disruption of the glycosaminoglycan layer that normally coats the mucosa of the bladder. The interstitial cystitis symptom index predicts the diagnosis of interstitial cystitis and may be used to help determine whether cystoscopy is indicated. Further evaluation can be done with bladder distention with water or intravesical potassium sensitivity testing.