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Pain, Chronic Pelvic

Paula J. Adams Hillard MD


Basics
Description
Chronic pelvic pain (CPP) is traditionally defined as pelvic pain that has been
present for 6 months.
CPP is further defined as leading to disability or requiring medical care.

The location of CPP includes the pelvis and the lower abdomen below the
umbilicus:
o

Vulvar pain is sometimes included in this category.

Lumbosacral pain and pain in the buttocks may also be included in this
category.

Gynecologic conditions, gastrointestinal, urologic, musculoskeletal, and


psychoneurologic disorders can contribute to CPP.

CPP includes a variety of symptoms that are described as:

Dysmenorrhea

Vulvar pain

Dyspareunia

As well as nonspecific pain of the lower abdomen, pelvic floor,


adnexae, and uterus

CPP is frequently accompanied by, associated with, and complicated by high


rates of psychological dysfunction including:
o

Depression

History of sexual or physical abuse

The following diagnostic subtypes of CPP have been suggested:


o

Diffuse abdominal/pelvic pain

Vulvovaginal pain

Cyclic pain

Neuropathic pain

Nonlocalized pain

Trigger point pain

Fibroid tumor pain

Some women with CPP have neuropathic painpain due to abnormal neural
activity which is persistent in the absence of active disease.

Age-Related Factors
Women of all ages develop chronic pelvic pain, although the prevalence of
disorders varies by age.
Evaluation and management of chronic pelvic pain in adolescents can have
long-term benefits of improving function and well-being, and avoiding chronic
disability.

Adolescents are more likely than adults to experience cycle-related pain and
frequently benefit from the contraceptive and noncontraceptive benefits of
COCs.

Endometriosis does occur in adolescents and can be a cause of chronic pain.

Epidemiology
Women with CPP do not differ from those without CPP by age, race or
ethnicity, education, socioeconomic or employment status.
Women with CPP may be slightly more likely to be separated or divorced.

It has been estimated that up to 1015% of outpatient gynecology visits


include a complaint of CPP.

CPP is the indication for ~40% of gynecologic laparoscopies in the US.

CPP is the indication for ~20% of hysterectomies for benign disease in the US.

Risk Factors
History of physical and sexual abuse
Pathophysiology
Multiple mechanisms of pain, depending on etiologies, although overall, the
pathogenesis of chronic pelvic pain is poorly understood.
Associated Conditions
Depression
History of physical or sexual abuse

Substance use or abuse

Fibromyalgia

Diagnosis
Signs and Symptoms
History
Pain description:
o Location
o

Intensity

Quality

Duration

Temporal or cyclic patterns

Precipitating or exacerbating factors:

Physical activity

Intercourse

Menses

Alleviating factors

Relationship to urination and defecation

Menstrual history

Screening for history of physical or sexual abuse

Past therapies

Past surgeries

Past history of PID/STDs

Family history of:


o

Endometriosis

Uterine leiomyomata

Review of Systems
GI symptoms and function
GU symptoms and function

Musculoskeletal symptoms and function

Physical Exam
Exam of abdomen:
o Localize tenderness
o

Note surgical scars

Presence of hernias

Abdominal masses

Carnett sign:

After localizing point(s) of maximal tenderness, the patient is


asked to do a crunch or bent knee sit-up during palpation of
this site; myofascial pain will be increased, whereas intrapelvic
or visceral pain is lessened due to splinting of the pelvis by the
abdominal wall musculature.

Careful exam of the vulva/external genitalia

Functional bimanual pelvic exam with gentle careful palpation using a


single vaginal finger for palpation, to assess for tenderness and reproduction of
the pain, isolating:

Pelvic floor muscles

Urethra/Bladder

Uterus

Adnexae

Cul-de-sac/Uterosacral ligaments

Speculum exam:
o

Cervicitis

Vaginitis

Tests
Labs

Pregnancy test
CBC

ESR

Urinalysis and culture

STD testing as indicated

Imaging
Pelvic US can be helpful in detecting:
Uterine fibroids
Ovarian cysts

Other pelvic masses

Differential Diagnosis
Infection
PID may lead to CPP in up to 30% of women diagnosed with PID.
GI/GU
IBS
Constipation

Inflammatory bowel disease

Diverticulitis

Interstitial cystitis

Urethral syndrome

Chronic or recurrent acute UTIs

Stone/Urolithiasis

Tumor/Malignancy

Uterine leiomyomata (fibroids)


Adenomyosis

Exclude malignancy if pelvic mass

Bladder or colon malignancies

Ovarian cancer

Ovarian remnant syndrome

Postoperative peritoneal cysts

Endometrial or cervical polyps

P.29
Trauma
History of sexual or physical abuse is associated with CPP.
Surgical history with resultant adhesions

Cervical stenosis

Other/Miscellaneous
Pelvic congestion syndrome
Genital prolapse

Pelvic floor myalgia

Endometriosis

Adnexal masses

Abdominal wall myofascial pain

Neuralgia of iliohypogastric, ilioinguinal, and/or genitofemoral nerves

Chronic back pain

Abdominal cutaneous nerve entrapment in surgical scar

Hernias: Ventral, inguinal, femoral, spigelian

Fibromyalgia

Abdominal migraine

Abdominal epilepsy

Management
General Measures
All women with CPP deserve a nonjudgmental listener, thorough evaluation,
careful history, explanations, and a commitment to work toward improving

pain. It can be helpful to state that the pain may not be cured, but can be
assessed in a stepwise fashion, managed, and improved.
One approach involves sequential drug therapy for the most likely causes of
pain as assessed by the history and exam.

Some clinicians investigate intensively, including diagnostic laparoscopy, to


attempt to find a specific cause of CPP that can be treated.

Another approach includes a combination of interventions with


pharmacologic, physical, and psychological therapies. A pain management
clinic may be helpful, and such a multidisciplinary approach has been shown
in randomized trials to be of benefit in symptom relief.

Special Therapy
Complementary and Alternative Therapies
Chronic pain is one of the primary reasons given by women for the use of
adjunctive or alternative therapies.
With myofascial pain, physical therapy by a therapist trained in pelvic floor
and musculo-skeletal disorders can be helpful if available.

Although few of these therapies have been rigorously studied, treatment


modalities that may prove helpful for some symptoms of CPP include:
o

Acupuncture

Biofeedback

Relaxation therapies

Nerve stimulation devicesTENS

Medication (Drugs)
Scheduled NSAIDs rather than p.r.n. pain medications may be beneficial, but
attention must be given to GI, CV, and renal effects.
Menstrual or ovulation suppression with COCs may be helpful, particularly
for women with cycle-related pain:

As a traditional 21/7 regimen of hormonally active pills followed by 7


days of placebo or

As an extended regimen

A formulation packaged as 84/7

365 days of continuous pill use

Continuous progestin therapy, given as:


o

Norethindrone acetate 5 mg/d

Medroxyprogesterone acetate 50 mg/d was shown to be effective in


managing CPP believed due to pelvic congestion syndrome.

POP (norethindrone 0.35 mg/d)

Danazol 200400 mg/d up to 800 mg/d

Levonorgestrel intrauterine system may be helpful in managing


endometriosis.

Empiric therapy with GnRH-analog may be helpful.

Drugs that have been used in the management of neuropathic pain include:

Tricyclic antidepressants, such as amitriptyline, may be helpful in


chronic pain syndromes.

SSRIs have not been shown to be helpful.

Anticonvulsants such as carbamazepine, valproic acid, clonazepam,


gabapentin, pregabalin, lamotrigine may be beneficial.

The use of opioids for chronic pain not due to malignancy is controversial:
o

Studies suggest benefit for intermediate intervals, even for chronic


neuropathic pain.

Opioid therapy may be indicated after other therapies have failed:

Guidelines have been established for opioid therapy.

A single physician and pharmacy should prescribe and dispense


the drugs.

Surgery
Trigger-point injections for abdominal wall pain may be helpful.
Diagnostic laparoscopy is the definitive test for detecting pelvic
endometriosis:
o

A normal laparoscopy does not exclude a physical cause but can


exclude some specific causes.

Laparoscopic pain mapping: Laparoscopy performed under local anesthesia


with manipulation of specific sites to attempt to reproduce and localize pain

Surgical lysis of adhesions:


o

One controlled trial in which patients were assigned to lysis or no lysis


of adhesions at the time of laparoscopy showed no benefit.

One trial did suggest a benefit of adhesiolysis for pain relief in the
presence of dense vascularized adhesions involving bowel and
peritoneum.

Interventions that have been described include nerve blocks (ilioinguinal,


iliohypogastric, genitofemoral, hypogastric, presacral)

Nerve transection procedures:

A Cochrane systematic review of treatments for chronic pelvic pain


concluded that laparoscopic uterosacral nerve ablation (LUNA) has not
been shown to be effective.

Presacral neurectomy may benefit midline menstrual-associated pain.

Hysterectomy has a role in management; studies suggest 75% have relief at 1


year.

Followup
Regularly scheduled rather than pain-dictated follow-up visits can be helpful in
management.
Disposition
Issues for Referral
Referral to a comprehensive pain management team may be indicated.
Depression is common with CPP and warrants treatment.
Prognosis
The achievable goals of therapy include improved function, decreased pain by selfrating, and improved quality of life rather than cure of pain.
Bibliography
ACOG Practice Bulletin. Chronic Pelvic Pain, #51, March 2004.
Farquhar CM, et al. A randomized controlled trial of medroxyprogesterone acetate
and psychotherapy for the treatment of pelvic congestion. Br J Obstet Gynaecol.
1989;96(10):11531162.
Leserman J, et al. Identification of diagnostic subtypes of chronic pelvic pain and how
subtypes differ in health status and trauma history. Am J Obstet Gynecol
2006;195(2):554560; discussion 560.
Proctor M, et al. Surgical interruption of pelvic nerve pathways for primary and
secondary dysmenorrhoea Cochrane Database of Syst Rev 2005. CD001896.
Stones W, et al. Interventions for treating chronic pelvic pain in women. Review.
Cochrane Database Syst Rev 2007.
Miscellaneous
Clinical Pearls
The evaluation and management of women with CPP can be challenging, and does
not often result in a cure, but can be aimed at alleviating suffering and empowering
women to find management approaches that improve function and well-being.
Abbreviations
COCCombination oral contraceptives
CPPChronic pelvic pain
GnRHGonadotropin-releasing hormone
IBSIrritable bowel syndrome
LUNALaparoscopic uterosacral nerve ablation
PIDPelvic inflammatory disease
POPProgestin-only pills
SSRISelective serotonin reuptake inhibitors
TENSTranscutaneous electrical nerve stimulator
Codes
ICD9-CM
614.6 Adhesions, pelvic female

625 Pain and other symptoms associated with female genital organs
625.5 Pelvic congestion
Patient Teaching
ACOG Patient Education Pamphlet: Pelvic Pain