Pelvic pain: Chronic

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Chapter 27 PELVIC PAIN: CHRONIC

Chronic pelvic pain is defined as noncyclic pelvic pain that has lasted 6 or more months. The additional requirement of severity enough to cause functional disability or to necessitate medical or surgical treatment is often used in the definition. Pelvic pain may refer to pain that localizes to the pelvis, lower abdominal wall, lower back, or buttocks. About 15% to 20% of 18- to 50-year-old women suffer from chronic pelvic pain.

The most common causes of chronic pelvic pain are endometriosis, interstitial cystitis, adhesions, and irritable bowel syndrome. In addition, there is a strong association between chronic pelvic pain and a history of physical or sexual abuse.

The cause of chronic pelvic pain is often not discernible even after thorough evaluation. In addition, there may be several associated conditions that contribute to the pelvic pain. Disorders of the reproductive tract, gastrointestinal system, urologic organs, musculoskeletal system, and neurologic system, as well as psychologic factors, may be associated with chronic pelvic pain in women. On occasion, only one of these disorders is present, and treatment is curative. More often, however, the pain is associated with several diagnoses, and a number of contributing factors necessitate evaluation and treatment.

Causes of Chronic Pelvic Pain

Gastrointestinal

Chronic intermittent bowel obstruction

Diverticular disease

Inflammatory bowel disease

Irritable bowel syndrome

Gynecologic

Musculoskeletal

Miscellaneous

Key Historical Features

✓ Location, timing, and quality of pain

✓ Associated fever, chills, or night sweats, which may indicate infection or cancer

✓ Associated weight loss, which may indicate cancer

✓ Associated increased abdominal girth, which may indicate a mass or ascites

✓ History of physical or sexual abuse

✓ Medical history

• Especially interstitial cystitis, irritable bowel syndrome, pelvic inflammatory disease, or endometriosis

✓ Surgical history

✓ Obstetric and gynecologic history

• Previous pregnancies

• History of infertility, which may indicate endometriosis or chronic pelvic inflammatory disease

• Menstrual symptoms and associated pain

• Pain associated with intercourse

• History of sexually transmitted diseases or pelvic inflammatory disease

• Birth control method

✓ Prior gynecologic surgeries

✓ Social history

• Alcohol or drug abuse

• Tobacco use

✓ Review of systems, especially the following:

• Gastrointestinal symptoms

— Symptoms suggestive of irritable bowel syndrome such as constipation or diarrhea or both, abdominal distension, relief of pain with bowel movements, or mucus in bowel movements

— Rectal bleeding

• Urologic symptoms

— Dysuria, urinary urgency, or frequency, which may indicate interstitial cystitis or infection

— Hematuria, which may indicate bladder neoplasm or infection

— A history of recurrent urinary tract infections associated with negative culture results, which may indicate interstitial cystitis

✓ Psychologic

• History of depression or symptoms of depression

Suggested Work-Up

The work-up of patients with chronic pelvic pain should be guided by the history and physical examination:

Urine pregnancy test or serum β–human chorionic gonadotropin	To rule out pregnancy
Transvaginal pelvic ultrasonography	To evaluate for pelvic masses
Pap smear	To evaluate for cervical dysplasia
Swab/culture for Neisseria gonorrhoeae and Chlamydia organisms	To evaluate for pelvic inflammatory disease
Urinalysis and urine culture	To evaluate for microscopic hematuria and urinary infections
Complete blood cell count	To evaluate for infection

Additional Work-Up

Depending on the history and physical examination, as well as findings from the initial evaluation, a more extensive workup may be warranted:

Computed tomographic (CT) scan of abdomen and pelvis	To further evaluate abnormal findings on pelvic ultrasonography or examination
Laparoscopy	To evaluate for endometriosis, adhesions, or pelvic masses or neoplasms
Cystoscopy	To evaluate for interstitial cystitis if symptoms are suggestive of this diagnosis and to evaluate for bladder neoplasms if microscopic hematuria is present
Intravesical potassium sensitivity test	If interstitial cystitis is suspected
Flexible sigmoidoscopy or colonoscopy	To evaluate for colonic neoplasms
Magnetic resonance imaging (MRI) of spine	If disease of the spine is suspected

FURTHER READING

ACOG Committee on Practice Bulletins–Gynecology. ACOG Practice Bulletin No. 51. Chronic pelvic pain. Obstet Gynecol. 2004;103:589-605.

Bordman R, Jackson B. Below the belt: approach to chronic pelvic pain. Can Fam Physician. 2006;52:1556-1562.

Gunter J. Chronic pelvic pain: an integrated approach to diagnosis and treatment. Obstet Gynecol Surv. 2003;58:615-623.

Howard FM. Chronic pelvic pain. Obstet Gynecol. 2003;101:594-611.

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