Obstetrics and Gynecology

Chronic Pelvic Pain

Chronic Pelvic Pain

1. What every clinician should know

Chronic pelvic pain epidemiology and definition

Up to 20% of all women in the reproductive age group experience chronic pelvic pain. Because every patient experiences pain in a unique manner, the astute clinician must be vigilant to listen and watch for subtle clues.

Pain can be unpleasant sensory or emotional sensations, which may or may not be associated with identifiable tissue damage. Both physical and psychological causes are possible; the intricate interplay between the mind and body must always be a consideration.

Six months of symptoms is commonly used to define this condition, but the approach to the patient should not be dependent on a time limit. Similarly, the location of symptoms is usually focused on the pelvis, abdomen below the umbilicus, low back, and/or buttocks region.

It is recognized that the physical examination does not necessarily reflect the presence or absence of a pathologic disease process.

Pelvic pain can develop in women of all ages with certain conditions being more likely at various time of life.

Endometriosis is more likely to cause pain during the reproductive years.

Symptoms that vary in relation to the menstrual cycle suggest a hormonally driven condition, but can also reflect the impact that hormones have on nongynecologic disorders.

Demographic data of women with pain do not differ significantly from those without pain.

Because of the range of conditions that can contribute to chronic pelvic pain in any given patient, each individual is best evaluated using an organized approach that covers the entire spectrum of likely possibilities.

It is tempting for patients and physicians alike to assume that pain presenting in this region is gynecologic, but to do so potentially exclude finding common causes of nongynecologic pelvic pain and also leads to unnecessary gynecologic interventions. Because the patient may have a preconceived thought that "female problems" is the problem, and because previous physicians may have reinforced the presumption that a gynecologic etiology is present, the astute clinician, already well-versed in gynecologic disease processes, is well-served to assume the presence of a nongynecologic cause of pain "until proven otherwise.

This prevents the premature narrowing of the differential diagnosis (see below) and facilitates thorough investigation.

Since gynecologic causes of pelvic pain are often best treated with surgery, first ruling out nongynecologic conditions helps to avoid the risks and complications of such invasive interventions.

A simplified approach to the many possible causes of pelvic pain includes two major categories: Gynecologic and Nongynecologic. The latter conditions, many of which are not always identified and treated by the gynecologist, can be remembered using the mnemonic "GUMP." This includes etiologies of pelvic pain which are loosely, but conveniently grouped as gastrointestinal (G), urinary (U), musculoskeletal (M), and psychiatric (P).

The history in patients with chronic pelvic pain must include a focus on the possible presence of painful intercourse.Dyspareunia is often the presenting complaint within a constellation of other symptoms and may occur in up to 20% of the female population. In some cases, it is the only pain-related complaint. A history of recurrent dyspareunia suggests a likely pelvic cause for the pain whereas the absence thereof must bring that possibility into question.Specifically, deep-thrust dyspareunia (sometimes referred to as "bump" dyspareunia) may well be associated with pathology in the pelvic structures. Pain on initial penile insertion should suggest an alternative etiology with vulvar vestibulitis (vestibulodynia) being the most commonly overlooked.

The physical examination should be comprehensive and methodical in order to identify both gynecologic as well as non-gynecologic conditions. Specifically, the patient should be asked to point to the location of her pain. Palpation, both superficial and deep, of the specified location can help differentiate muscular pain from intraperitoneal conditions.The abdominal wall can be tensed by raising the head off the table and/or raising both legs without bending the knees. Such evocative maneuvers may identify more superficial sources of pain such as trigger points of the abdominal wall.

The pelvic examination should be conducted with each component being treated as a separate evaluation.

  • Q-tip palpation of the vestibule may recreate the dyspareunia that the patient describes.

  • An index finger examination of the vagina may prove more useful in identifying specific sites of pain.

  • Palpation of the pelvic floor and vaginal sidewalls can find muscular pain.

  • Rotating the finger 180 degrees to palpate the urethra and bladder base is useful in identifying a urinary source of pain.

  • Cervical motion tenderness has historically been used to help identify adnexal pathology.

  • In the absence of a uterus, vaginal cuff tenderness may identify the cuff itself as a potential source of pain.

  • Uterine tenderness with bimanual palpation is particularly useful if the pain elicited recreates the chief complaint.

  • The interpretation of any finding of tenderness on bimanual examination should factor in the anatomic reality that the abdominal wall is also being palpated during this maneuver.

  • Although not always the case, identifying tenderness with the physical examination that recreates the patient's pain is a strong indicator that the anatomic source of the pain is the organ being palpated or manipulated.

  • The connection between the history of pain and the physical finding of tenderness can serve as a useful guide to the clinician considering surgery as a therapeutic option.

Astute clinicians are commonly faced with the dilemma of "lumping or splitting" the symptoms of patients with chronic pelvic pain, i.e., they are challenged to determine whether a single condition is causing the pain (lumping) or if there are several diagnoses which account for the overall pain experience (splitting).

Since it is not uncommon for a complex interplay of different processes to be occurring, the physician should remain open to the possibility that the diagnosis and treatment for a patient might go beyond the first identified disease state.

Of equal importance is the sharing of this clinical management approach with the patient and her family so that everyone involved has realistic expectations.

2. Diagnosis and differential diagnosis

Common Gynecologic Conditions

  1. Endometriosis

    • Historical clues- infertility, dysmenorrhea, constant pain, deep-thrust dyspareunia

    • Physical exam clues- cervical motion tenderness (cmt), adnexal tenderness, uterosacral nodularity

    • Useful labs- none

    • Useful imaging- none

    • Confirmatory procedure- laparoscopy with biopsy

  2. Adenomyosis

    • Historical clues- multigravidity, menorrhagia, dysmenorrhea, deep-thrust dyspareunia

    • Physical exam clues- slightly enlarged, tender, boggy uterus

    • Useful labs- none

    • Useful imaging- none (MRI is utilized by some)

    • Confirmatory procedure- pathologic evaluation of hysterectomy specimen (transmural biopsy advocated by some)

  3. Chronic Pelvic Inflammatory Disease (PID)

    • Historical clues- acute episodes of PID, other STDs, deep-thrust dyspareunia

    • Physical exam clues- cmt, adnexal tenderness

    • Useful labs- none

    • Useful imaging- none

    • Confirmatory procedure: laparoscopy

  4. Pelvic adhesions

    • Historical clues- PID, endometriosis, pelvic surgery, deep-thrust dyspareunia

    • Physical exam clues- cmt, adnexal tenderness

    • Useful labs- none

    • Useful imaging- none

    • Confirmatory procedure: laparoscopy

  5. Leiomyomata Uteri

    • Historical clues- menorrhagia, metrorrhagia, pelvic heaviness, deep-thrust dyspareunia

    • Physical exam clues- irregular and/or enlarged uterus; tenderness recreates chief complaint

    • Useful labs- none

    • Useful imaging- pelvic ultrasound

    • Confirmatory procedure- none needed

  6. Adnexal Mass (including functional ovarian cyst, ovarian neoplasm, para-ovarian cyst, hydrosalpinx)

    • Historical clues- intermittent pain, irregular menses, deep-thrust dyspareunia

    • Physical exam clues- nontender uterus, tender adnexa, palpable mass

    • Useful labs- none

    • Useful imaging- pelvic ultrasound

    • Confirmatory procedure- none needed

  7. Pelvic Congestion Syndrome

    • Historical clues- multigravidity, central pelvic aching pain, deep-thrust dyspareunia

    • Physical exam clues- nonspecific tenderness on bimanual

    • Useful labs- none

    • Useful imaging- venography, MRI, pelvic ultrasound

    • Confirmatory procedure- diagnostic laparoscopy, imaging studies

  8. Vulvar vestibulitis/vestibulodynia

    • Historical clues- chronic vaginal infections, entrance dyspareunia, difficulty inserting tampon, voiding dysfunction

    • Physical exam clues- tender Bartholin's and Skene's duct to Q-tip palpation

    • Useful labs- none (vaginal and urinary cultures nondiagnostic)

    • Useful imaging- none

    • Confirmatory procedure- physical exam recreates symptoms

Common Nongynecologic conditions

  1. Gastrointestinal Conditions (particularly chronic constipation and irritable bowel syndrome [IBS])

    • Historical clues- pains worsened with constipation, diarrhea or associated with bowel movements, (Rome criteria for IBS)

    • Physical exam clues- lower abdomen possibly distended

    • Useful labs- none

    • Useful imaging- none

    • Useful consultants- gastroenterologist

  2. Urinary Conditions (particularly interstitial cystitis [IC])

    • Historical clues- pain improves with voiding, dysuria, frequency, urgency, nocturia

    • Physical exam clues- tender urethra and/or bladder

    • Useful labs- urine culture

    • Useful imaging- none

    • Useful consultants- urogynecologist or urologist

  3. Musculoskeletal Conditions- particularly trigger point or musculoskeletal dysfunction (including fibromyalgia)

    • Historical clues- negative gynecologic work-up, symptoms change with postural changes, previous trauma

    • Physical exam clues- localized tenderness of muscles to palpation

    • Useful labs- none

    • Useful imaging- none

    • Useful consultants- physical therapist (particularly with orthopedic expertise and/or manual therapy skills)

  4. Psychiatric Conditions- (particularly depression or sexual abuse victim)

    • Historical clues- anhedonia, change in diet and/or sleep; history of being touched inappropriately

    • Physical exam clues- none

    • Useful labs- none

    • Useful imaging- none

    • Useful consultants- mental health provider, e.g. psychiatrist, clinical psychologist, licensed social worker

3. Management

Gynecologic conditions

Endometriosis - Even though the diagnosis is made only with direct visualization (and, ideally histologically with a biopsy), management of the pain associated with endometriosis is often medical.

If the diagnosis is confirmed at the time of laparoscopy, removal or ablation of visible endometriosis is expected to be beneficial. Since endometriosis is stimulated by ongoing hormonal stimulation, consideration must be given to medical suppression of the disease with a variety of possible treatments. These include oral contraceptives (possibly administering the pills continuously without placebo pills or pill-free days to render a patient amenorrheic), progestational agents, e.g. medroxyprogesterone acetate, norethindrone, megesterol acetate, GnRH agonists, and danazol.

Although not ideal, circumstances may warrant one or more of the medications being administered empirically for presumed endometriosis, i.e. without visual confirmation. Often the use of medical treatment must be balanced against the patient's desire to conceive, which would rule out the use of hormonal treatment.

If oral contraceptives are used, it should be noted that it is possible that a formulation with one type of progestin may be more effective than another for a particular patient.

Surgical treatment often is required for cases unresponsive to medical therapy. Even in younger patients, if the endometriosis is extensive, removal of the affected organ may be necessary with the extirpative procedure of hysterectomy with bilateral salpingo-oophorectomy considered to be definitive surgical management. By removing the ovaries, it is generally assumed that future endometriosis-related symptoms have been eliminated.

Although rare, recurrent endometriosis after bilateral oophorectomy has been reported, likely related to estrogen replacement therapy.

Adenomyosis - Although histologically similar to endometriosis, this condition (formerly referred to as endometriosis interna) does not respond to hormonal suppression.

Surgical management is still considered the appropriate definitive treatment. Short of removal of the uterus, treatment options are limited to symptomatic management, e.g. analgesics for the dysmenorrhea and hormonal ablation of menorrhagia.

Chronic PID - Once this diagnosis is established, the pain is assumed to be due to the residua of recurrent inflammation and anatomic distortion, including tubo-ovarian abscesses, hydrosalpinges, and pelvic adhesions.

Although antibiotics are useful in acute episodes, they have no efficacy in these cases. Surgical management is necessary, sometimes by normalizing anatomy (lysis of adhesions, tubal reconstructive surgery, etc.) and sometimes by removing diseased tissue. As with endometriosis, hysterectomy with bilateral salpingo-oophorectomy may be necessary even though preserving ovarian function in a young woman is ideal.

Unless there is documented evidence of this condition, the most appropriate initial surgical intervention is likely to be diagnostic laparoscopy with possible lysis of adhesions instead of extirpative surgery which is reserved for those patients whose symptoms persist despite laparoscopy.

Pelvic adhesions - Because there is no medical treatment for symptomatic pelvic adhesions, patients who are felt to have pain due to adhesions and their physicians are faced with the conundrum of whether to perform a surgical procedure to perform adhesiolysis, which can, itself, create new adhesions. It is for this reason that management of pelvic adhesions begins with prevention.

Techniques such as achieving meticulous hemostasis, minimizing tissue tension, and using atraumatic tissue handling can reduce the incidence of subsequent adhesions. The use of adhesion barriers has also been found to have a place in the prevention of adhesions. Because therapeutic options to treat this condition are limited, it behooves the clinician to rule out all other reasonable etiologies before making the assumption that adhesions are the cause of pain and embarking on surgery.

Leiomyomata uteri - Fibroids may require treatment for reasons in addition to pain, e.g. infertility, dyspareunia and menorrhagia. As a result, the choice of treatment may well be driven by a complex series of priorities.

Removal of fibroids can be accomplished surgically as a myomectomy or hysterectomy. The choice of the route of surgery (open, vaginal, laparoscopic, robotic) is beyond the scope of this decision, but, assuming all options are available, surgery should generally be reserved as a last resort.

When pain is the issue, the natural role of menopause cannot be minimized. Since fibroids are expected to shrink after the menopause, it is conceivable that symptomatic medical treatment and other temporizing modalities can be used until the menopause. Shrinkage of fibroids can be accomplished with uterine artery embolization, GnRH agonist, and MR-guided ultrasound.

Adnexal Mass (including Adnexal Mass, ovarian neoplasm, para-ovarian cyst, and hydrosalpinx) - The management of pain related to an ovarian enlargement is dependent on the cause of the cyst, i.e., is it a functional ovarian cyst (follicular or corpus luteum) or a neoplasm (such as a mature cystic teratoma, aka dermoid)? In the former case, the cyst may well resolve as the hormones of the reproductive cycle continue to fluctuate, whereas in the latter case, the cyst is expected to persist.

In the absence of an acute episode such as torsion, rupture or hemorrhage, attempted non-surgical management is not unreasonable. If the cyst persists through a cycle or becomes more painful, surgery is indicated, typically using minimally-invasive techniques.

Conservation of the ovary is usually preferred over oophorectomy. Even if a portion of the ovary has to be removed, the remaining normal ovarian tissue should be preserved. Particularly in the reproductive-age woman, incidental removal of the ipsilateral fallopian tube is not recommended unless it is medically necessary or unavoidable.

A para-ovarian cyst, typically a remnant of the Wolffian duct, is often difficult to differentiate from the ovary using imaging studies. It is not responsive to hormonal fluctuation or suppression.

A hydrosalpinx does not change relative to the menstrual cycle or treatment with hormones. It is likely related to previous episodes of PID or, under less common circumstances, manifests distention of the proximal fallopian tube following tubal ligation.

Pelvic Congestion Syndrome - characterized as similar to varicose veins found in the legs, this condition has been described in both ovarian and pelvic vessels.

In light of the ability of interventional radiology to selectively embolize dilated vessels in a minimally-invasive environment, the possibility of this diagnosis being the cause of dull, aching central pelvic pain is gaining broader attention.

The traditional approach of hysterectomy is still a reasonable option, but the treatment for pelvic congestion remains controversial. Neither hysterectomy nor venous embolization should be undertaken without a full work-up for more commonly-encountered conditions.

Vulvar vestibulitis/vestibulodynia - with symptoms described as burning, irritation, and rawness, these women also describe painful entrance dyspareunia, often making coitus impossible. The cause is unknown and there are no proven treatments, although it is not uncommon to find co-existing symptoms of interstitial cystitis, endometriosis, and other pain syndromes. As a result, symptomatic treatment may also include those used to treat other causes of pain.

Specific treatment for isolated cases of vulvar vestibulitis includes the use of topical anesthetic gel or ointment to the vestibule, neuropathic medications, and, if symptoms do not respond to other modalities, surgical excision of the affected area (vestibulectomy with vaginal advancement). Dietary modification, Botox injections, and behavioral therapy have also been described.

Nongynecologic conditions

Gastrointestinal - Irritable bowel syndrome is found in up to 1/3 of the population and is twice as common in women compared to men. Complaints are most commonly diarrhea, constipation, abdominal bloating/distention or a combination thereof.

Initial symptomatic management may well be effective prior to referral to a consultant. Desipramine, hyoscyamine, and dicyclomine have all been reported to be of benefit for both diarrhea and bloating. Diphenoxylate and loperamide are additional treatments commonly used to treat diarrhea. Constipation is managed with dietary fiber, sorbitol, and lactulose among other agents.

Urinary - interstitial cystitis has no known etiology; as a result, treatment is varied and aimed at symptomatic relief.

The diagnosis is usually based on positive findings at the time of hydrodistention/double-fill cystoscopy.

The procedure itself may prove therapeutic in some cases.

Other treatment modalities include medications (pentosan polysulfate, antihistamines, SSRIs, SNRIs, tricyclic antidepressants, analgesics), biofeedback, neuromodulation, biofeedback, pelvic floor treatment, acupuncture, dietary modification, and bladder washings.

It is common for a patient to require multiple treatments simultaneously to achieve a reasonable quality of life.

Musculoskeletal - trigger points are hyperirritable muscle bundles found throughout the body, but are particularly common in the lower abdominal wall. Injections with a local anesthetic to the sensitive area can be both diagnostic and therapeutic. Treatment modalities typically employed by a physical therapist skilled in the field include massage therapy, dry needling and/or acupuncture. Trigger points may also be found within the pelvic floor musculature and may respond to the same treatment as is used elsewhere.

More widespread muscular pain might be related to fibromyalgia, whose symptoms also include fatigue, sleep disorders, joint stiffness, and cognitive dysfunction. (American College of Rheumatology Diagnostic Criteria)

Treatments include medications (analgesics, antidepressants, anticonvulsants, muscle relaxants, and dopamine agonists), physical therapy, behavioral therapy, and psychiatric/psychologic intervention.

As with other chronic pain conditions, the use of multiple modalities simultaneously may be needed.

Musculoskeletal dysfunction based on postural abnormalities such as leg-length discrepancy, ilial torsion and symptomatic kypho-lordosis can best be managed with physical therapy.

Psychiatric - clinical depression is found in up to half of all patients with chronic pain. Because the two conditions are intimately intertwined, the treatment of one invariably requires the need to evaluate for the other.

Several categories of antidepressants are available, each with several options. Because response to the medication may take as long as four to six weeks, the clinician and patient should not expect a rapid response. No single category of antidepressant has been shown to be more efficacious than the others.

Commonly used choices include tricyclic antidepressants (amitriptyline, nortriptyline, desipramine, imipramine), SSRIs (fluoxetine, paroxetine, sertraline, citalopram, escitalopram, viladozone), and SNRIs (venlafaxine, desvenlafaxine, duloxetine, milnacipran). MAOIs, e.g. phenelzine, are less commonly-used but can be effective in selected cases, particularly in patients with atypical depression.

The treatment of symptoms related to a history of sexual abuse, either as a child or adult, is best handled by those with special training. Because pelvic pain is commonly-found in this group of patients, inquiring of each patient who presents with chronic pelvic pain "Have you ever been touched against your will, either as a child or adult?" is an appropriate step toward identifying this underlying problem.

Because the first step in managing the problem is demystifying and identifying it, merely asking the question is giving the patient permission to respond at a later time that may be more comfortable and non-threatening to her.

4. Complications

Potential complications of the various conditions related to chronic pelvic pain are specific to the underlying etiology. In most cases, the complications are self-limiting because the nature of the disease course is such that evaluation and treatment of the pain is being undertaken before more severe consequences are likely. For example, the pain of endometriosis often leads to its diagnosis and treatment before it creates extensive anatomic distortion which might make infertility even more likely than when no gross anatomic abnormality is seen.

Similarly, adhesions are known to potentially cause bowel obstruction, but if pain is the presenting symptom, prevention of the gastrointestinal complication can be accomplished as an ancillary benefit to the pain relief.

The gynecologic as well as non-gynecologic causes of chronic pelvic pain are rarely the cause of an emergent problem, but, instead, are insidious in their progression if any. Because the symptoms are, by definition, longstanding, timely assessment and intervention is defined with a timeline different from acute disease processes.

Because the treatment modalities are so diverse, their respective complications are idiosyncratic to the therapy initiated. Of greater significance is the risk of ignoring or discounting the complaint. If the clinician chooses to not believe and/or ignore the patient's symptoms, an inevitable alienation occurs, the patient may feel isolated, and further implications for mood disorders are created. It can be therapeutic for the physician to clearly verbalize that the patient's complaints are being taken seriously and will be investigated.

Even though the specific etiology is not identified, having a healthcare advocate is a critical part of the treatment paradigm.

Expectant management (which is not in any way similar to ignoring the symptoms), medical management, and surgery may each play a role in these difficult cases. For example, even if the physician does not suspect intra-abdominal pathology, diagnostic laparoscopy to reassure the patient may be necessary prior to implementing other non-surgical treatments with which the patient is less familiar.

5. Prognosis and outcome

As is the case with other chronic conditions, it is less likely that there will be a rapid cure or resolution of pelvic pain than if the problem were acute. This reality should be shared with the patient and her support system at the outset of treatment. Unrealistic expectations on the part of the patient or the provider can undermine the therapeutic partnership needed to maximum success in these cases.

Validating the patient's symptoms is sometimes overlooked, but cannot be emphasized enough.

Making the patient a part of the investigative team improves the prognosis for improvement.

Recognizing the mind/body interplay is sometimes a foreign concept to some patients.

It is helpful to explain that even though eliminating the pain is the ultimate goal, learning to manage the pain within the context of a functional lifestyle may be a more achievable short-term accomplishment.

None of the medical, surgical, or behavioral treatment modalities listed above achieves a 100% success rate. For example, any individual antidepressant is not expected to be efficacious in more than about two-thirds of patients.Changing doses, changing agents within a category, or changing category of antidepressant may be needed to successfully treat the patient. The same is true in other instances also, such as neuropathic medications for vestibulitis or hormonal treatment for endometriosis.

Even surgical removal of the suspected offending organ, e.g. a hysterectomy or oophorectomy or vestibulectomy, is not universally successful. Citing cure rates of any therapeutic intervention for chronic pelvic pain at no greater than 80% is both accurate based on the bulk of scientific literature, and allows the clinician to prepare the patient for less-than-hoped-for outcomes.

If the treatment proves successful, the patient is appreciative and satisfied, whereas if it is not successful, at least she has been forewarned of that possibility. Guaranteeing that a particular treatment will be curative is not in the best interest of either the patient or physician.

6. What is the evidence for specific management and treatment recommendations

Foster, DC. "Oral desipramine and topical lidocaine for vulvodynia: a randomized controlled trial". Obstet Gynecol. vol. 116. 2010. pp. 583-93.

(Desipramine, with or without topical lidocaine, improved symptoms of vuvodyna, but not over placebo.)

Slocumb, JC. "Neurological factors in chronic pelvic pain: trigger points and the abdominal pelvic pain syndrome". Am J Obstet Gynecol. vol. 140. 1984. pp. 536-43.

(Injection of the abdominal wall can resolve pain previously thought to be due to pelvic pathology.)

Ling, FW. "Randomized controlled trial of depot leuprolide in patients with chronic pelvic pain and clinically suspected endometriosis. Pelvic Pain Study Group. ". Obstet Gynecol. vol. 93. 1999. pp. 51-8.

(Treatment for suspected endometriosis can be undertaken without visual confirmation of the disease.)

Peters, AA. "A randomized clinical trial to compare two different approaches in women with chronic pelvic pain". Obstet Gynecol. vol. 77. 1991. pp. 740-4.

(A multi-disciplinary approach to pelvic pain is superior to one that focuses on gynecologic disorders.)

Learman, LA. "Symptom resolution after hysterectomy and alternative treatments for chronic pelvic pain: does depression make a difference?". Am J Obstet Gynecol. vol. 204. 2011. pp. 269.

(The presence of clinical depression should not delay the implementation of other treatment for chronic pelvic pain.)

Longstreth, GF. "Irritable bowel syndrome in women having diagnostic lapaoscoy or hysterectomy. Relation to gynecologic features and outcome". Dig Dis Sci. vol. 35. 1990. pp. 1285.

(There is a high prevalence of IBS symptoms among women undergoing gynecologic surgery for pain.)

Jamieson, DJ, Steege, JF. "The association of sexual abuse with pelvic pain complaints in a primary care population". Am J Obstet Gynecol. vol. 177. 1997. pp. 1408.

(Sexual abuse history and pelvic pain are commonly associated.)

Summitt, RL. "Urogynecologic causes of chronic pelvic pain". Obstet Gynecol Clin North AM. 1993. pp. 20-685.

(The evaluation of pelvic pain in women should include an investigation of potential urologic causes.)

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