Chronic Pelvic Pain

1. See Also
   1. Chronic Pelvic Pain Causes
   2. Suprapubic Abdominal Pain
   3. Acute Pelvic Pain
   4. Acute Abdominal Pain
   5. Chronic Pelvic Pain in Men
   6. Pelvic Nerve Innervation
2. Epidemiology
   1. Prevalence: 3-4% in U.K. studies up to 15% in U.S. studies
   2. Zondervan (1999) Br J Obstet Gynaecol 106(11):1149-55
   3. Mathias (1996) Obstet Gynecol 87(3): 321-7
3. Causes
   1. Idiopathic in up to 60% of cases
   2. See Chronic Pelvic Pain Causes
   3. See Acute Pelvic Pain Causes
   4. See Acute Abdominal Pain Causes
4. Definition
   1. Noncyclic pain for at least 6 months
   2. Severe enough to cause functional Disability
   3. Localized to Pelvis, sub-umbilical anterior abdominal wall or buttocks
5. Symptoms: Red Flags
   1. Unexplained weight loss
   2. Hematochezia
   3. Perimenopausal or Postmenopausal irregular bleeding
   4. Postcoital bleeding
6. History
   1. Pain History
      1. Localization and radiation
      2. Quality, intensity and duration
      3. Palliative and provocative factors
      4. Changes in pain over time
   2. Associated Symptoms
      1. Menstrual Cycle
         1. Abnormal bleeding (Menorrhagia, Metrorrhagia)
         2. Painful Menses (Dysmenorrhea)
      2. Altered bowel habits (Constipation, Diarrhea)
      3. Altered Bladder habits (Dysuria, urinary urgency, urinary frequency)
      4. Sexual intercourse (Dyspareunia)
      5. Exercise (e.g. Abdominal Wall Pain)
      6. Back, joint or muscle pain (myofascial pain)
   3. Pelvic adhesion risks
      1. Pelvic surgery
      2. Pelvic infection
      3. Intrauterine Device usage
   4. Previous evaluation and treatment by other providers
   5. Psychiatric History
      1. Mood changes and how quickly
      2. Physical functioning in work and activities
      3. Family Roles and Responsibilities with recent changes
      4. Sexual dysfunction
      5. Sexual abuse or physical abuse history (commonly associated)
      6. Efforts to cope with pain (Relaxation or Exercise)
      7. Patient and Families' interpretation of pain
7. Exam: General
   1. Neurologic
      1. Stance and gait
      2. Posture
      3. Sitting position
   2. Abdominal exam
      1. Palpate anterior wall for nodularity or point tenderness
         1. Palpation of Urethra and Bladder trigone
         2. Chronic Urethritis or trigonitis
            1. Frequency, urgency, Dysuria without bacteruria
      2. Musculoskeletal
         1. Focal tenderness and Trigger Points
         2. Carnett's Sign Positive
      3. Post-surgical neuromas
         1. Entrapment in Suture with lateral Pfannenstiel
            1. Ilioinguinal Nerve
            2. Iliohypogastric Nerve
      4. Hernia
         1. Umbilical Hernia
         2. Inguinal Hernia
         3. Incisional Hernia
         4. Femoral Hernia
         5. Spigelian Hernia (Lateral margin of rectus)
      5. Meralgia Paresthetica
      6. Piriformis Syndrome
      7. Psoas inflammation from pelvic inflammation
         1. See Psoas Sign
8. Exam: Pelvic Exam
   1. Vulvitis and vestibulitis provocative factors
      1. Touch vulva and distal vagina with moistened cotton tip swab
      2. Acetic acid
   2. Digital vaginal exam with 1 finger
      1. Patient contracts and relaxes intermittently
      2. Same type of pain as with intercourse?
      3. Press at pelvic floor (levator plate palpation)
         1. Pelvic floor tension myalgia increases during day
   3. Bimanual Exam
      1. Cul-de-sac palpation for nodularity or masses
      2. Cervical Motion Tenderness for Cervicitis
         1. Mild
            1. Endometriosis
            2. Adhesions
         2. Severe
            1. Pelvic Inflammatory Disease (PID)
      3. Retroverted Uterus associated conditions
         1. Endometriosis
         2. Pelvic adhesions
         3. Low Back Pain at menstruation
         4. Dyspareunia
         5. Pain elicited with palpation of fundus
      4. Ovarian pain (difficult to localize)
   4. Rectovaginal exam
      1. Evaluate for nodularity, posterior uterine masses, pelvic floor tenderness
   5. Signs of Pelvic Relaxation
      1. Organ prolapse (e.g. Cystocele, Uterocele, Rectocele)
9. Labs
   1. Urine Pregnancy Test (bHCG)
   2. Urinalysis and Urine Culture
   3. Erythrocyte Sedimentation Rate
   4. Chlamydia Test
   5. Gonorrhea Test
10. Imaging
    1. First-line: Pelvic Ultrasound
    2. Second-line tests: Pelvic CT or Pelvic MRI (Limited usefulness)
11. Diagnostics
    1. Endoscopic studies may be useful in some cases
       1. Cystoscopy
       2. Colonoscopy
    2. Laparoscopy
       1. Endometriosis
       2. Lysis of adhesions
12. Management
    1. See Chronic Pelvic Pain Management
13. References
    1. Steege (1993) Chronic Pelvic Pain ACOG Video
    2. Howard (2003) Obstet Gynecol 101:594-611
    3. Ortiz (2008) Am Fam Physician 77:1535-42
    4. Zondervan (2001) Am J Obstet Gynecol 184:1149-55