Chronic pelvic pain is a syndrome of pain arising from one or more pelvic organs, and can include any one or all pelvic viscera or muscles.
A methodical, complete, criteria-based history is required to determine how many and which organ systems are involved and to uncover comorbid psychiatric conditions, particularly depression or a history of abuse.
The physical examination must be methodical and complete, searching for point tenderness in all individual pelvic muscles and organs, specifically including the vestibule, levator ani muscles, bladder, cervix and uterus, adnexa, and lower abdominal wall.
Diagnostic tests are determined by the organ systems generating pain and may include urinalysis with culture, pelvic ultrasound, cystoscopy with hydrodistension, and diagnostic laparoscopy.
Because chronic pain is sometimes a disorder of pain perception, minimal if any pathological change may be found.
Treatment is targeted at each organ system involved in pain production. Global pain in all organs or refusal of non-narcotic management may represent drug-seeking behaviour.
Complications are inherent to all treatments, which frequently include surgery.
Chronic pelvic pain is inconsistently defined, but the American College of Obstetricians and Gynecologists recommended definition is "pain symptoms perceived to originate from pelvic organs/structures typically lasting more than 6 months. It is often associated with negative cognitive, behavioural, sexual and emotional consequences as well as with symptoms suggestive of lower urinary tract, sexual, bowel, pelvic floor, myofascial, or gynaecological dysfunction".
Patients typically present with at least two of several common pain-related diagnoses: interstitial cystitis, irritable bowel syndrome, fibromyalgia, levator ani syndrome (pelvic floor tension myalgia), endometriosis, adenomyosis, leiomyoma, or vulvodynia. Common comorbid conditions include depression, anxiety, and traumatic stress disorder.
History and exam
Key diagnostic factors
- presence of risk factors
- abdominal trigger points
- levator ani tenderness
- cervical motion tenderness
- uterine tenderness
- abdominal tenderness
- vestibular tenderness
- rectal tenderness
- adnexal tenderness
- bladder tenderness
- urethral tenderness
Other diagnostic factors
- abdominal pain
- incomplete voiding
- low back pain
- sexual abuse
- pelvic inflammatory disease
- anxiety or depression
- drug or alcohol abuse
- previous caesarean section
1st investigations to order
- urine culture
- cervical swab
- pelvic ultrasound
- alkalinised lidocaine instillation into bladder
Investigations to consider
- pelvic CT
- pelvic MRI
- laparoscopic biopsy
- cystoscopy with hydrodistension
fibromyalgia or levator ani syndrome
- Chronic pelvic inflammatory disease
- Diagnosis and treatment of interstitial cystitis/bladder pain syndrome
- Reducing sexually transmitted infections
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