Chronic pelvic pain

Published on 09/03/2015 by admin

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Last modified 22/04/2025

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Chapter 16 Chronic pelvic pain

Michael Flynn

Pelvic pain is the commonest indication for laparoscopy. This is pain present for at least 6 months severe enough to interfere with normal daily activities.

Physiology and innervation

Pain

• Somatic innervation from the vulva, perineum and lower vagina is via the pudendal nerve (S2–S4).
• Visceral innervation from the uterus, tubes, ovaries and visceral peritoneum is via the autonomic nervous system (T10–L1).
• The assessment of pelvic pain requires a detailed pain history and system review.

Origin

• gynaecological
• gastrointestinal
• urological
• musculoskeletal
• neurological

Viscera

• Viscera are not sensitive to thermal and tactile sensation.
• Pain is poorly localised.
• Pain is referred from the overlying peritoneum via dermatomes of the same nerve root.

Stimuli that produce pain

• distension/contraction of an organ
• stretching of organ capsule
• irritation of the parietal peritoneum
• ischaemic tissues
• inflammation, neoplasia or fibrosis stimulating nerves

Examination

• General examination: look for signs of malignancy, lymphadenopathy, oedema.
• Abdominal palpation: feel for masses, ascites, organomegaly.
• Vaginal speculum examination:

• check for discharge
• cervical pathology
• bimanual examination: check uterine size and position, adnexal pathology, cervical motion pain, pouch of Douglas
• uterosacral ligament nodularity, thickening or tenderness
• rectal examination for masses
• lumbosacral and hip joints

• Assess anatomical locations of tenderness and correlate these with areas of pain.

Gynaecological causes of pelvic pain

• cyclical: dysmenorrhoea, ovulation pain, endometriosis, adenomyosis (some aetiologies of pelvic pain can be exacerbated during menses (irritable bowel syndrome and interstitial cystitis))
• chronic pelvic inflammatory disease
• polycystic ovarian syndrome
• residual ovary, ovarian remnant syndrome
• neoplasia
• pelvic venous congestion
• levator muscle spasm
• pelvic adhesions

Non-gynaecological causes of pelvic pain

• gastrointestinal tract

• diverticulitis, malignancy, obstruction
• inflammatory bowel disease, irritable bowel syndrome

• urinary tract

• calculus, infection, retention, malignancy
• interstitial cystitis (painful bladder)

• musculoskeletal

• osteoarthritis
• prolapsed disc
• fibromyalgia
• myofascial pain
• peripartum musculoskeletal pain

Clinical presentation

Cyclical

Dysmenorrhoea is severe in 5% of women and is often associated with endometriosis, adenomyosis.

Ovulation

• Acute onset of lower abdominal pain is followed by a dull ache for several hours.
• The pain corresponds to the luteinising hormone (LH) peak (1 day before ovulation).
• The pain is due to prostaglandin F2 causing contractility of ovarian perifollicular smooth muscle.

Pelvic inflammatory disease

• Only about 60% can be correctly diagnosed on history alone.
• The gold standard for diagnosis is by laparoscopy.
• Long-term sequelae include chronic infection, pelvic pain, dyspareunia, menstrual changes, infertility and ectopic pregnancy.

Endometriosis

• associated with dysmenorrhoea, dyspareunia and chronic pain

Neoplasia

• benign: degenerating fibroid, ovarian cyst complications
• malignant: weight loss, nausea, abdominal/pelvic pain, ascites, lymphadenopathy, irregular mass in pelvis

Pelvic venous congestion

• has been implicated as a cause of pelvic pain
• may be due to oestrogen causing dilatation of the thin-walled, unsupported pelvic veins

Residual ovary syndrome

• occurs in about 3%–4% of ovaries not removed during hysterectomy
• 75% of patients present with chronic pelvic pain and dyspareunia

Polycystic ovarian syndrome

• pelvic pain/discomfort may be a presenting complaint

Uterovaginal prolapse

• dull ache, dragging lump in vagina

Gastrointestinal

• change in bowel habit, rectal bleeding

Urinary

• infection, calculus causing dysuria, loin pain

Musculoskeletal

• low back ache of musculoskeletal origin, radiating commonly to lower limbs and not abdomen or pelvis

Investigation for pelvic pain

Laparoscopy

• the most informative investigation for chronic pelvic pain

Radiology

• ultrasound scan of the pelvis
• X-ray of lumbosacral spine and hip joints
• other imaging (e.g. upper gastrointestinal series, barium enema, renal tract) if indicated

Others

• mid-stream urine
• Chlamydia
• pelvic congestion is difficult to diagnose

Treatment

Identify specific cause if evident and treat appropriately. The management of women with normal laparoscopy and other investigations is especially difficult.

Treatment of chronic pelvic pain

• pharmacological

• non-steroidal anti-inflammatories
• oral contraceptive pill
• gonadotrophin-releasing hormone (GnRH) agonist

• physiotherapy
• psychological: pain clinics and management
• pain assessment forms may benefit in long-term management

Further reading

Gambone J.C., Mittman B.S., Munro M.G., et al. Consensus statement for the management of chronic pelvic pain and endometriosis: proceedings of an expert-panel consensus process. Fertility and Sterility. 2002;78:961-972.

Gelbaya T.A., El-Halwagy H.E. Chronic pelvic pain in women. Obstetric and Gynecological Survey. 2001;56:757-764.

Howard F.M. Chronic pelvic pain. Obstetrics and Gynecology. 2003;101:594-611.

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