Primary care management of chronic pelvic pain in women

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Chronic pelvic pain in women can arise from many causes and often results in significant declines in function and quality of life. A systematic approach for evaluating patients and initiating a management plan are recommended in the primary care setting. Comprehensive management strategies may include medication, pelvic physical therapy, and behavioral interventions.


  • Diagnosing and managing chronic pelvic pain may be difficult, but patients are often best served when their primary care provider directs a team-based approach to their care.
  • A detailed history, thorough abdominal and pelvic examinations, and targeted testing facilitate the diagnosis.
  • As in other chronic pain syndromes, the goals of therapy should be incremental and meaningful improvements in pain, function, and overall well-being.



Chronic pelvic pain is a common clinical problem in women, as prevalent in primary care as asthma or back pain.1,2 It is often associated with lost work days and decreased productivity, increased healthcare spending, mood disorders, and negative effects on personal relationships.1–3

While specialty care referral may eventually be indicated, primary care doctors can take steps to diagnose and effectively manage the condition.


Chronic pelvic pain is defined as pain in the lower abdomen persisting for 3 to 6 months and of sufficient severity to require medical care or cause a functional disability.3 It is often detrimental to a woman’s personal life and overall health, making a comprehensive assessment and multidisciplinary approach to management especially important.

The ideal care-delivery model is the patient-centered medical home, whereby a primary care physician coordinates comprehensive care with the help of an interdisciplinary team.4,5 For complex cases, referral may be needed to other specialties (eg, obstetrics and gynecology, pain medicine) to help manage care.

Common causes of chronic pelvic pain and associated findings


Chronic pelvic pain often coexists with other systemic pain syndromes or psychiatric conditions common in primary care. Table 1 lists common causes and associated findings.

Detailed history is critical

The history is of utmost importance. Clinicians should query patients about the characteristics of the pain as well as their medical and surgical history. Particular attention should be given to obtaining a complete gynecologic history, including pregnancy, delivery complications, dyspareunia, sexual assault, and trauma. A detailed review of systems should focus on the reproductive, gastroenterologic, musculoskeletal, urologic, and neuropsychiatric systems.

As with many pain syndromes, allowing the patient to “tell her story” helps to establish rapport and obtain a more complete assessment. Chronic pelvic pain has been associated with physical or sexual abuse as a child or adult, so is essential to foster the doctor-patient relationship and create a safe and open space for disclosure.3,6 It is important to screen women for safety at home as well as for satisfaction or dissatisfaction with their relationships with their spouse or partner and family.

Physical examination

The physical examination should be directed by the history but should always include abdominal and pelvic examinations. These should be conducted slowly and gently, assessing for areas of tenderness, masses, and other abnormalities. Clinicians should aim to pinpoint the exact anatomic locations of tenderness if possible. Ongoing dialogue facilitates this process by inquiring about pain at each point of the examination.

Pelvic floor anatomy
Figure 1. Pelvic floor anatomy. During the pelvic examination, the levator ani muscles should be directly palpated for tone and tenderness, and the pelvic floor should be evaluated with attention to any tenderness of the bladder and musculoskeletal structures.

The pelvic examination should begin with visual inspection for redness, discharge, lesions, fissures, excoriations, and other abnormalities. A moistened cotton swab may be used to evaluate the vulva and vestibule for localized tenderness. The manual portion of the pelvic examination should begin with a single digit, noting any introital tenderness or spasm. Next, the levator ani muscles should be directly palpated for tone and tenderness. The pelvic floor should be evaluated with attention to tenderness of the bladder or musculoskeletal structures (Figure 1). A bimanual examination assessing uterine size and tenderness, nodularity, or a fixed, immobile uterus should be conducted.

Diagnostic workup

Because the differential diagnosis of chronic pelvic pain is broad, the diagnostic workup and testing should be based on findings of the history and physical examination. In general, extensive laboratory testing is of limited use for evaluating women with chronic pelvic pain.3,7

Urinalysis should be obtained for symptoms suggesting bladder involvement such as interstitial cystitis.

Pelvic ultrasonography can help identify pelvic masses palpated during the physical examination, but routine use of imaging is not recommended.3,7 If pelvic congestion syndrome is suspected, starting with pelvic ultrasonography is reasonable before incurring the risk or cost of computed tomography or magnetic resonance imaging.8

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