History

Fact Explanation
Intermittent or constant pain felt in the lower abdomen or pelvis for more than six months Increased nociceptor stimulation by the locally released inflammatory cytokines leads to perception of pain. In case of non-nociceptive chronic pain, it is considered neuropathic or psychogenic. Nerve damage following surgery,trauma, inflammation,fibrosis or infection may contribute to this pain.Persistent pain may lead to changes within the central nervous system, which may magnify the original signal.[1][2]
Pain associated with menstruation Endometriosis and/or adenomyosis can cause intermittent pelvic pain due to pelvic congestion close to menstruation.[1][2][3]
Deep dysperunia Presence of pelvic adhesions or pelvic infections can cause pelvic pain during sexual intercourse[1][3][4]
Pain associated with defaecation Irritable bowel syndrome can cause chronic intermittent pelvic pain associated with bowel motion.[1][3][4]
Pain associated with urination Due to painful bladder syndrome or interstitial cystitis bladder becomes sensitive and easily irritated causing chronic pelvic pain associated with urination.[1][4][7]
Post-coital bleedind Pelvic pain associated with post coital bleeding can occur in patients who have cervical cancer. [4]
Perimenopausal irregular bleeding This symptom associated with pelvic pain may be a feature of endometrial cancer[4]
Postmenopausal vaginal bleeding This symptom also may be associated with endometrial cancer.[4]
Unexplained weight loss This symptom together with chronic pelvic pain may be the first presentation of a gynecological malignancy.[4]
History of physical or sexual abuse Some patients with a history of physical or sexual abuse may experience psychogenic chronic pelvic pain.[4][5][6]
History of pelvic surgery Pelvic surgery may leave behind scar tissue and adhesions with other organs which may cause pain particularly on organ distension or stretching.Dense vascular adhesions may cause chronic pelvic pain.[1][2][4]
History of pelvic infections or sexually transmitted infections Chronic changes following pelvic inflammatory disease occur in about one-third of women and can cause chronic pelvic pain. The reason for this is not clearly known, but is probably because of permanent damage to the uterus, ovaries, and fallopian tubes.[1][3][4]
Use of an intrauterine device Presence of an intrauterine device produce localized endometrial ulceration, inflammation and endometrial prostaglandin release which stimulates local pain sensitive nerve endings leading to pelvic pain[4][8]
History of pelvic irradiation Adhesions (abnormal tissue that causes internal organs or structures, such as the ovaries and fallopian tubes, to adhere to one another) which can occur following pelvic irradiation can cause chronic pelvic pain.[1][4]
References
  1. VERCELLINI P, Somigliana E, Viganò P, Abbiati A, Barbara G, Fedele L.Chronic pelvic pain in women: etiology, pathogenesis and diagnostic approach. Gynecol Endocrinol. 2009 Mar; 25(3):149-58 [viewed 2 April 2014] doi:10.1080/09513590802549858.
  2. Royal College of Obstetricians and Gynaecologists. Guideline No. 41: The initial management of chronic pelvic pain. London, U.K.:RCOG;2005.
  3. HOWARD FM. Chronic pelvic pain. Obstet Gynecol. 2003;101(3):594–611.
  4. ORTIZ David D. et al. chronic Pelvic Pain in Women. Am Fam Physician. 2008 Jun 1;77(11):1535-1542. [viewed on 2 April 2014]. Available from: http://www.aafp.org/afp/2008/0601/p1535.html
  5. WALLING MK, Reiter RC, O'Hara MW, Milburn AK, Lilly G, Vincent SD. Abuse history and chronic pain in women: I. Prevalences of sexual abuse and physical abuse.Obstet Gynecol. 1994 Aug; 84(2):193-9.
  6. LAMPE A, Sölder E, Ennemoser A, Schubert C, Rumpold G, Söllner W.Chronic pelvic pain and previous sexual abuse.Obstet Gynecol. 2000 Dec;96(6):929-33.
  7. STANFORD EJ, Dell JR, Parsons CL. The emerging presence of interstitial cystitis in gynecologic patients with chronic pelvic pain. Urology 2007; 69:53.
  8. J Reprod Med. 1978 Mar;20(3):167-74.Pelvic pain and the IUD.J Reprod Med. 1978 Mar;20(3):167-74.

Examination

Fact Explanation
Lack of uterus mobility on bimanual examination Due to presence of endometriosis or pelvic adhesions. [1][2]
Nodularity or masses on abdominal, bimanual pelvic and/or rectal examination Presence of adenomyosis, endometriosis, malignancy, tumors can give rise to this sign.[1][2]
Pain on palpation of outer back and outer pelvis Due to presence of abdominal/pelvic wall source of pain, trigger points.[1][2]
Point tenderness of vagina, vulva, or bladder Adhesions, endometriosis, nerve entrapment, trigger points, vulvar vestibulitis can cause this sign.[2]
Tenderness in sacroiliac joints or the symphysis pubis Occurs when the pain is musculoskeletal in origin.[1]
References
  1. Royal College of Obstetricians and Gynaecologists. Guideline No. 41: The initial management of chronic pelvic pain. London, U.K.:RCOG;2005.
  2. ORITZ David D et al. chronic Pelvic Pain in Women. Am Fam Physician. 2008 Jun 1;77(11):1535-1542. [viewed on 2 April 2014]. Available from: http://www.aafp.org/afp/2008/0601/p1535.html

Differential Diagnoses

Fact Explanation
Endometriosis Will cause pelvic pain which varies markedly over the hormonal changes of the menstrual cycle[1][3][4][7]
Pelvic inflammatory disease Chronic changes following pelvic inflammatory disease can cause chronic pelvic pain[1][2][3]
Pelvic adhesions Dense vascular adhesions may cause chronic pelvic pain[1][8]
Gynecological malignancies May present with chronic pelvic pain and red flag symptoms, such as unexplained weight loss, perimenopausal irregular bleeding, postmenopausal vaginal bleeding, or postcoital bleeding etc.[2][3][4]
Adenomyosis Can cause pelvic pain which shows marked variation over the menstrual cycle[1][4][7]
Inflammatory bowel disease Can also cause chronic pelvic pain[2][3]
Irritable bowel syndrome Symptoms suggestive of IBS or are often present in women with chronic pelvic pain. This may be the primary cause of chronic pelvic pain, a component of chronic pelvic pain or a secondary effect caused by efferent neurological dysfunction due to presence of chronic pain.[1][9]
Diverticulitis Presents as chronic pelvic pain[2][3]
Painful bladder syndrome Can cause chronic pelvic pain due to increased sensitivity and irritability of bladder[2][3][4]
Interstitial cystitis Symptoms suggestive interstitial cystitis are often present in women with chronic pelvic pain.[2][4][6]
Pelvic floor dysfunction Symptoms of pelvic floor dysfunction include pelvic pain, pain with urination, difficulty urinating, constipation, pain with intercourse, or frequent/urgent urination[2][3][4]
Abdominal migraines Can also cause chronic pelvic pain[3][4]
Depression Can present with somatic symptoms such as chronic pelvic pain[1][3]
Neurologic dysfunction Can modify perception of pain and lead to chronic pelvic pain[1][3]
Somatization Patients with this disorder may present with recurrent episodes of chronic pelvic pain despite there are no proven physical cause that may lead to pelvic pain[3][4]
References
  1. Royal College of Obstetricians and Gynaecologists. Guideline No. 41: The initial management of chronic pelvic pain. London, U.K.:RCOG;2005.
  2. VERCELLINI P, Somigliana E, Viganò P, Abbiati A, Barbara G, Fedele L.Chronic pelvic pain in women: etiology, pathogenesis and diagnostic approach.Gynecol Endocrinol. 2009 Mar; 25(3):149-58. [viewed 2 April 2014] doi:10.1080/09513590802549858.
  3. ORITZ David D et al. chronic Pelvic Pain in Women. Am Fam Physician. 2008 Jun 1;77(11):1535-1542. [viewed on 2 April 2014]. Available from: http://www.aafp.org/afp/2008/0601/p1535.html
  4. HOWARD FM. Chronic pelvic pain. Obstet Gynecol. 2003;101(3):594–611.
  5. RACKOW BW, Novi JM, Arya LA, Pfeifer SM.Interstitial cystitis is an etiology of chronic pelvic pain in young women.J Pediatr Adolesc Gynecol. 2009 Jun; 22(3):181-5.
  6. STANFORD EJ, Koziol J, Feng A.The prevalence of interstitial cystitis, endometriosis, adhesions, and vulvar pain in women with chronic pelvic pain. J Minim Invasive Gynecol. 2005 Jan-Feb; 12(1):43-9.
  7. SCIALLI AR. Evaluating chronic pelvic pain. A consensus recommendation.Pelvic Pain Expert Working Group. J Reprod Med 1999;44:945–52.
  8. SWANK DJ,Swank-Bordewijk SC,HopWC,Van ErpWF,Janssen IM,Bonjer HJ,et al.Laparoscopic adhesiolysisin patients with chronic abdominal pain: a blinded randomised controlled multi-centre trial.Lancet 2003;361:1247–51
  9. TACHAWIWAK K, Cheewadhanaraks S.Prevalence of irritable bowel syndrome among patients with mild-moderate and severe chronic pelvic pain. J Med Assoc Thai. 2012 Oct;95(10):1257-60.

Investigations - for Diagnosis

Fact Explanation
Diagnostic laparoscopy This is the test capable of reliably diagnosing peritoneal endometriosis and adhesion. It can also detect any pelvic masses[1][2][3]
Transvaginal scanning (TVS) Done to identify and assess adnexal masses. Also a useful test to diagnose adenomyosis.[1][2]
Magnetic resonance imaging (MRI) A useful test to diagnose adenomyosis.[1][2]
Gonorrhea/chlamydia testing/ Screening for sexually transmitted infections Done if there is any suspicion of pelvic inflammatory disease[1][2][3]
Urine full report and urine culture Done if there is suspicion of bladder malignancy and urinary tract infection[1][2]
References
  1. Royal College of Obstetricians and Gynaecologists. Guideline No. 41: The initial management of chronic pelvic pain. London, U.K.:RCOG;2005.
  2. ORITZ David D et al. chronic Pelvic Pain in Women. Am Fam Physician. 2008 Jun 1;77(11):1535-1542. [viewed on 2 April 2014]. Available from: http://www.aafp.org/afp/2008/0601/p1535.html
  3. VERCELLINI P, Somigliana E, Viganò P, Abbiati A, Barbara G, Fedele L.Chronic pelvic pain in women: etiology, pathogenesis and diagnostic approach. Gynecol Endocrinol. 2009 Mar; 25(3):149-58. [viewed 2 April 2014] doi:10.1080/09513590802549858.

Investigations - Fitness for Management

Fact Explanation
Complete blood count analysis Can indicate presence of Infection, systemic illness, or malignancy[1]
References
  1. ORITZ David D et al. Chronic Pelvic Pain in Women. Am Fam Physician. 2008 Jun 1;77(11):1535-1542. [viewed on 2 April 2014]. Available from: http://www.aafp.org/afp/2008/0601/p1535.html

Investigations - Screening/Staging

Fact Explanation
CA125 Done if ovarian cancer is suspected. Particularly in women over the age of 50 years[1]
References
  1. Royal College of Obstetricians and Gynaecologists. Guideline No. 41: The initial management of chronic pelvic pain. London, U.K.:RCOG;2005.

Management - General Measures

Fact Explanation
Maintain good posture Reduces chronic pelvic pain of musculoskeletal origin.[1][2]
Pelvic floor excercise Helps in patients with pelvic floor dysfunction.[1][3]
Nutrition therapy Vitamin B1 and magnesium has shown to reduce dysmenorrhoea.[1][3]
Psychological councelling Cognitive behavioral therapy has been found to be helpful in many people with chronic pain.Relaxation techniques can relieve musculoskeletal tension.[2]
References
  1. ACOG Committee on Practice Bulletins–Gynecology. ACOG Practice Bulletin No. 51. Chronic pelvic pain. Obstet Gynecol. 2004;103(3):589–605.
  2. ORITZ David D et al. chronic Pelvic Pain in Women. Am Fam Physician. 2008 Jun 1;77(11):1535-1542. [viewed on 2 April 2014]. Available from: http://www.aafp.org/afp/2008/0601/p1535.html
  3. Royal College of Obstetricians and Gynaecologists. Guideline No. 41: The initial management of chronic pelvic pain. London, U.K.:RCOG;2005.

Management - Specific Treatments

Fact Explanation
Medical therapy Should offer appropriate analgesia to control the pain.Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of 3–6 months before having a diagnostic laparoscopy. Women with IBS should be offered a trial of antispasmodics.[1][2]
Surgical management Lysis of severe adhesions has been shown to benefit patients with chronic pelvic pain.[3] Total abdominal hysterectomy has shown some benefit in some studies.[4] pelvic pain that does not respond to any other therapy may respond to surgery involving cutting or destroying nerves so that pain signal are not transmitted.[5]
Neuro-modulation therapy Uncontrolled studies of sacral nerve stimulation in women with chronic pelvic pain have shown some benefit.[1][6] Some benefit in using percutaneous tibial nerve stimulation to treat chronic pelvic pain has also been shown.[1][7]
References
  1. ORITZ David D. Chronic Pelvic Pain in Women. Am Fam Physician. 2008 Jun 1;77(11):1535-1542. [viewed on 2 April 2014]. Available from: http://www.aafp.org/afp/2008/0601/p1535.html
  2. Royal College of Obstetricians and Gynaecologists. Guideline No. 41: The initial management of chronic pelvic pain. London, U.K.:RCOG;2005.
  3. STONES RW, Mountfield J. Interventions for treating chronic pelvic pain in women. Cochrane Database Syst Rev. 2000;(4):CD000387.
  4. KJERULFF KH, Langenberg PW, Rhodes JC, Harvey LA, Guzinski GM, Stolley PD. Effectiveness of hysterectomy. Obstet Gynecol. 2000;95(3):319–326.
  5. ACOG Committee on Practice Bulletins–Gynecology. ACOG Practice Bulletin No. 51. Chronic pelvic pain. Obstet Gynecol. 2004;103(3):589–605.
  6. ABOSEIF S, Tamaddon K, Chalfin S, Freedman S, Kaptein J. Sacral neuromodulation as an effective treatment for refractory pelvic floor dysfunction. Urology. 2002;60(1):52–56.
  7. KIM SW, Paick JS, Ku JH. Percutaneous posterior tibial nerve stimulation in patients with chronic pelvic pain: a preliminary study. Urol Int. 2007;78(1):58–62.