Clinical Review

The enigma of chronic pelvic pain: Systematically tracing the cause

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Is the pain due to endometriosis? Pelvic inflammatory disease? Psychosomatic factors? The search for an answer is aided by consensus guidelines, key data, and an expert’s clinical experience.


 

References

KEY POINTS
  • If thorough investigation yields no diagnosis or indications for immediate surgery, empiric medical therapy for endometriosis is appropriate without laparoscopic confirmation. If empiric medical therapy fails, proceed to diagnostic laparoscopy.
  • Referral to a multidisciplinary pain clinic has been shown to be more effective than episodic gynecologic management of patients, especially those with significant psychological issues.
  • Schedule regular follow-ups. Do not instruct patients to call only during a pain crisis—this practice may create pain behaviors directed at obtaining sympathy and dramatic medical attention.

One woman complains of daily pain that worsens premenstrually. Another reports frequent aches radiating through her lower back and abdomen. A third says intercourse exacerbates her pain. And the list goes on.

Chronic pelvic pain (CPP) can manifest in dozens of ways, and the words patients use to describe it vary just as widely. Its multifaceted nature poses one of the biggest challenges to accurate diagnosis and appropriate management. Success is most likely when a compassionate attitude is combined with a systematic assessment to identify and understand the underlying cause—a blend of artful practice and scientific reasoning.

This article draws from consensus guidelines, other data, and personal experience to describe the components of careful diagnosis of this common but elusive condition.

10% of gynecology visits

CPP, which refers to pelvic pain of more than 6 months’ duration, accounts for roughly 10% of a gynecologist’s outpatient encounters, as well as many invasive procedures. For example, 1 in 5 gynecologic laparoscopies and 15% to 20% of hysterectomies are performed solely or in part for CPP.1,2

Noncyclic pelvic pain is not necessarily gynecologic

CPP is not always of gynecologic origin, even though the patient may perceive the pain as emanating from the reproductive organs. Because of this, careful evaluation is needed to distinguish gynecologic pain from CPP caused by orthopedic, gastrointestinal (GI), urologic, or neurologic conditions, or CPP that has a psychosomatic basis.

Purely cyclic uterine pain, which is referred to as dysmenorrhea, is usually characterized as primary or secondary. Although dysmenorrhea is frequently chronic and is an important clinical problem, this review focuses on noncyclic pelvic pain.

The relationship between CPP and underlying gynecologic pathology is often enigmatic. Many clinicians attribute the pain to psychological causes before completing a thorough assessment. An example of the hazards inherent in such an attitude is primary dysmenorrhea: Before the primary role of prostaglandins was elucidated, this form of dysmenorrhea was thought to be largely psychosomatic. As a result, it went untreated.

The TABLE lists major gynecologic and nongynecologic causes of noncyclic CPP. Endometriosis is the most common gynecologic condition associated with CPP.

TABLE

Causes of noncyclic chronic pelvic pain

GYNECOLOGIC CAUSES
Endometriosis
Chronic pelvic inflammatory disease
Ovarian
  Rapid ovarian capsule distension
  Ovarian remnant syndrome
  Recurrent hemorrhagic ovarian cysts
Uterine (uncommon)
  Adenomyosis
  Uterine myomas (under certain circumstances)
  Uterine retroversion (if associated with other intraperitoneal pathology or dyspareunia)
Pelvic congestion syndrome
NONGYNECOLOGIC CAUSES
Genitourinary
  Interstitial cystitis
  Trigonitis
  Urinary retention
  Urethral syndrome
Gastrointestinal
  Crohn disease
  Diverticulitis
  Hernia formation
  Irritable bowel syndrome
  Inflammatory bowel disease
  Neoplasm
  Partial bowel obstruction
  Ulcerative colitis
Musculoskeletal (eg, low back pain)
Psychological factors

Questions to elicit useful clues

The patient’s description of the location and pattern of pain, as well as history, are invaluable clues.

10 key questions. To elicit the most useful information from the patient, it may be necessary to ask numerous specifically phrased questions, such as:

  1. What is the the exact location of yourpain?
  2. What is the quality of the pain (sharp? dull?)
  3. Does it radiate, or spread, to other areas of the body? If so, where?
  4. How many times have you experienced this pain?
  5. How long does each episode last?
  6. How intense is each episode?
  7. What makes the pain worse? What makes it feel better?
  8. Does the pain change with your menstrual cycle (or with bowel movements, urination, sexual intercourse, or physical activity)?
  9. How much, and how, does the pain interfere with your daily activities?
  10. How would you rate the severity of the pain on a scale of 0 to 10, where 0 = no pain and 10 = the worst pain imaginable?

A complete medication history, especially of pain medication, is important.

Medical history should include information about nongynecologic conditions that may account for CPP, such as irritable bowel syndrome, ulcerative colitis, Crohn disease, and interstitial cystitis.

Pending compensation or litigation issues should be recognized and addressed.

Patient’s depiction of pain may lead to source

Understanding the anatomy of the nerves that transmit pain can facilitate interpretation of patient reports. It may explain, for example, why GI pathology can cause the perception of gynecologic pain. See “The anatomy of pelvic pain perception”.

  • Pain relieved by defecation as well as irregular defecation patterns lasting at least 3 months suggest irritable bowel syndrome.
  • Urinary urgency, frequency, nocturia, and pelvic pain may point to early interstitial cystitis.
  • In multiparous women, pelvic pain that worsens premenstrually and with fatigue, standing, and sexual intercourse indicates possible pelvic congestion syndrome. Venographic studies may document pelvic vein varicosities in such cases.

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