REAFFIRMED SOGC CLINICAL PRACTICE GUIDELINE

Disclaimer: This guideline has been reaffirmed for use and approved by Board of The Society of Obstetricians and Gynaecologists of
Canada. A revision is underway.

No 164, August 2005 (Reaffirmed November 2018)

No. 164-Consensus Guidelines for the

Management of Chronic Pelvic Pain
This guideline was developed by the Chronic Pelvic Pain Working Contributing author: Basim Abu-Rafea, MD, London, ON
Group and approved by the Executive and Council of the Society
of Obstetricians and Gynaecologists of Canada. Key Words: Pelvic pain, myofascial pain syndromes,
John F. Jarrell, MD, Calgary, AB endometriosis, endosalpingiosis, adenomyosis, pelvic peritoneal
defects, pelvic inflammatory disease, adhesions, ovarian cysts,
George A. Vilos, MD, London, ON
residual ovary syndrome, ovarian remnant syndrome, pelvic
Catherine Allaire, MD, Vancouver, BC congestion syndrome, hysterectomy, uterine fibroids, adnexal
Susan Burgess, MD, Vancouver, BC torsion, diagnostic imaging, laparoscopy, hormonal treatment,
complementary therapies
al, QC
Claude Fortin, MD, Montre
Robert Gerwin, MD, Baltimore, MD
al, QC
Louise Lapensee, MD, Montre
Robert H. Lea, MD, Halifax, NS
Nicholas A. Leyland, MD, Toronto, ON
Abstract

Paul Martyn, MB BS, Calgary, AB a Objective: To improve the understanding of chronic pelvic pain (CPP)
Hassan Shenassa, MD, Ottawa, ON and to provide evidence-based guidelines of value to primary care
health professionals, general obstetricians and gynaecologists, and
Paul Taenzer, PhD, CPsych, Calgary, AB
those who specialize in chronic pain.

Burden of Suffering: CPP is a common, debilitating condition affecting

J Obstet Gynaecol Can 2018;40(11):e747−e787
women. It accounts for substantial personal suffering and health
care expenditure for interventions, including multiple consultations
and medical and surgical therapies. Because the underlying
pathophysiology of this complex condition is poorly understood,
these treatments have met with variable success rates.

https://doi.org/10.1016/j.jogc.2018.08.015 Outcomes: Effectiveness of diagnostic and therapeutic options,

including assessment of myofascial dysfunction, multidisciplinary
© 2018 The Society of Obstetricians and Gynaecologists of Canada/La care, a rehabilitation model that emphasizes achieving higher
Société des obstétriciens et gynécologues du Canada. Published by function with some pain rather than a cure, and appropriate use of
Elsevier Inc. All rights reserved. opiates for the chronic pain state.

This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be
construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these
opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior
written permission of the publisher.
All people have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In order to
facilitate informed choice, patients should be provided with information and support that is evidence-based, culturally appropriate and tailored to
their needs.
This guideline was written using language that places women at the centre of care. That said, the SOGC is committed to respecting the rights of
all people - including transgender, gender non-binary, and intersex people - for whom the guideline may apply. We encourage healthcare
providers to engage in respectful conversation with patients regarding their gender identity as a critical part of providing safe and appropriate
care. The values, beliefs and individual needs of each patient and their family should be sought and the final decision about the care and
treatment options chosen by the patient should be respected.

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REAFFIRMED SOGC CLINICAL PRACTICE GUIDELINE
Evidence: Medline and the Cochrane Database from 1982 to 2004
were searched for articles in English on subjects related to CPP,
including acute care management, myofascial dysfunction, and
medical and surgical therapeutic options. The committee reviewed
the literature and available data from a needs assessment of
subjects with CPP, using a consensus approach to develop
recommendations.
Values: The quality of the evidence was rated using the criteria
described in the Report of the Canadian Task Force on the Periodic
Health Examination. Recommendations for practice were ranked
according to the method described in that report (Table 1).
Recommendations: The recommendations are directed to the
following areas: (a) an understanding of the needs of women with
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NOVEMBER JOGC NOVEMBRE 2018
CPP; (b) general clinical assessment; (c) practical assessment of
pain levels; (d) myofascial pain; (e) medications and surgical
procedures; (d) principles of opiate management; (f) increased use
of magnetic resonance imaging (MRI); (g) documentation of the
surgically observed extent of disease; (h) alternative therapies;
(i) access to multidisciplinary care models that have components
of physical therapy (such as exercise and posture) and
psychology (such as cognitive-behavioural therapy), along with
other medical disciplines, such as gynaecology and anesthesia;
G) increased attention to CPP in the training of health care
professionals; and (k) increased attention to CPP in formal, high-
calibre research. The committee recommends that provincial
ministries of health pursue the creation of multidisciplinary teams
to manage the condition.
 No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain
Disclaimer: This guideline has been reaffirmed for use
and approved by Board of The Society of Obstetri-
cians and Gynaecologists of Canada. A revision is
underway.
This guideline was developed by the Chronic Pelvic Pain
Working Group and approved by the Executive and
Council of the Society of Obstetricians and Gynaecolo-
gists of Canada.
Chapter 2: Scope, Definition, and Causes of Chronic Pelvic
Pain
1. Because of the complex nature and multifactorial devel-
opment of its common state, CPP should be increas-
ingly incorporated into the educational curricula of
health professionals (medical students, residents, nurses,
physiotherapists, specialists) (111-B).
Chapter 3: History-taking, Physical Examination, and Psy-
chological Assessment
1. Thorough history-taking that generates trust between
caregiver and patient and a pain-focused physical exami-
nation should be part of the complete evaluation of the
patient with CPP (Ill-B).
2. Clinical measurement of pain level could be done at
each visit for CPP (11-B).
3. The patient can be asked two questions that are
simple and effective: "On a scale of 0 to 10, 0
being no pain and 10 being the worst pain imagin-
able, How is your pain today and how was your
pain 2 weeks ago?" It is important to provide a ref-
erence for 10 such as "pain that is so bad that you
cannot care for your children, who are in imminent
danger" (11-8).
4. The physical examination can be conducted differently
in these patients, with special attention placed on indi-
vidual pelvic structures, to help differentiate sources of
pain. Identifying a focal area of tenderness can help tar-
get specific therapy (11-8).
5. Owing to the high prevalence of mental health
and other significant psychological coexisting
problems and sequelae of CPP, gynaecologists and
family physicians should routinely screen patients
for chronic pain syndrome and refer as appropri-
ate (II-2A).
6. Access to multidisciplinary chronic pain management
should be available for women with CPP within the
publicly funded health care system in each province and
territory of Canada (111-8).
Chapter 4: Investigations
1. Patient-assisted laparoscopy should be subjected to
clinical trial (Ill-C).
Chapter 5: Sources of Chronic Pelvic Pain
1. Hysterectomy for endometriosis or adenomyosis with
ovarian conservation can be an acceptable alternative.
The patient should be informed of the possible conse-
quences (residual ovary syndrome, persistent pain,
and reactivation of endometriosis) (II-2A).
2. Ovarian cystectomy, rather than oophorectomy,
should be an individual decision, based on the
patient's age and wishes, fertility issues, and surgical
feasibility (11-38).
3. The management of symptomatic uterine fibroids
should follow the clinical practice guidelines of the
Society of Obstetricians and Gynaecologists of
Canada (11-38).
4. The management of adnexal torsion should be deter-
mined according to the patient's age and wishes, fertil-
ity issues, and surgical judgment (11-38).
5. Since the rate of recurrence of endometriosis with
hormone replacement therapy (HRT) in women
undergoing hysterectomy plus bilateral salpingo-
oophorectomy (8SO) is very low, HRT should not be
contraindicated (1-8).
6. In women with an intact uterus, when total hysterec-
tomy has not been performed because of technical
difficulties, the recurrence of endometriosis contrain-
dicates the use of HRT (1-8).
7. Hysterectomy can be indicated in the presence of
severe symptoms with failure of other treatment
when fertility is no longer desired (1-8).
8. Pelvic peritoneal defects (pockets) are frequently asso-
ciated with endometriosis and should be treated surgi-
cally (11-8).
9. Endosalpingiosis is an incidental histologic finding and
does not appear to require specific treatment (11-28).
10. Current evidence does not support routine adhesioly-
sis for chronic pelvic pain. However, diagnostic lapa-
roscopy remains of value (1-8).
Chapter 6: Urologic and Gastrointestinal Causes of
Chronic Pelvic Pain
1. Cystoscopy by trained specialists, with or without diag-
nostic laparoscopy, should be considered when intersti-
tial cystitis (IC) is suspected (111-8).
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REAFFIRMED SOGC CLINICAL PRACTICE GUIDELINE
2. Women with chronic pelvic pain will require detailed
gynaecologic, urologic, gastroenterologic, and psycho-
logical assessment. Appropriate evaluation can lead to
optimal treatment and decrease the rate of inappropriate
interventions (111-8).
J Obstet Gynaecol Can 2005;27(8):781-801
Chapter 7: Myofascial Dysfunction
1. Health care providers should become more aware
of myofascial dysfunction as a cause of chronic pel-
vic pain (CPP) and the available treatment options
(IB).
2. Patients should participate in the management of CPP
due to myofascial dysfunction by actively using a home
stretching and exercise program (11-28).
Chapter 8: Medical Therapy-Evidence on Effectiveness
1. Opioid therapy can be considered for pain control
under adequate supervision (II-3B).
2. Hormonal treatment of chronic pelvic pain of gynaeco-
logic origin, including oral contraceptives, progestins,
danazol, and gonadotropin-releasing hormone agonists,
has been studied extensively and should be considered
as the first line for many women, especially those with
endometriosis (I and II-1A).
3. Adjuvant medications, such as antidepressants and anti-
biotics, can be of supporting help in specific situations
(11-38).
Table 1. Criteria for quality of evidence assessment and classification of recommendations
Level of evidence*
1: Evidence obtained from at least one properly designed randomized
controlled trial.
11-1: Evidence from well-designed controlled trials without
randomization.
11-2: Evidence from well-designed cohort (prospective or retrospective)
or case-control studies, preferably from more than one centre or
research group.
11-3: Evidence from comparisons between times or places with or with-
out the intervention. Dramatic results from uncontrolled experi-
ments (such as the results of treatment with penicillin in the 1940s)
could also be included in this category.
III: Opinions of respected authorities, based on clinical experience,
descriptive studies, or reports of expert committees.
Adapted from: Woolf SH, et al. Canadian Task Force on the Periodic Health Exam. Ottawa: Canadian Communication Group; 1994. p. xxxvii.
*
The quality of evidence reported in these guidelines has been adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on the Periodic
Health Exam.
y
Recommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in the Canadian Task Force on the
Periodic Health Exam.
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NOVEMBER JOGC NOVEMBRE 2018
Chapter 9: Surgery-Evidence on Effectiveness
1. The lack of robust clinical trials of the surgical manage-
ment of chronic pelvic pain should be addressed. The
use of alternative epidemiologic models, including case-
controlled and cohort-controlled trials, should be con-
sidered (III-A).
2. Further delineation of the role of appendectomy and of
presacral neurectomy appears warranted in the manage-
ment of endometriosis-related pain (III-A).
Chapter 11: Multidisciplinary Chronic Pain Management
1. Multidisciplinary chronic pain management should be
available for women with chronic pelvic pain within the
publicly funded health care system in each province and
territory of Canada (Ill-B).
Chapter 14: Future Directions
1. The curriculum for professional development should be
expanded to include theory and techniques in the man-
agement of myofascial dysfunction (A).
2. Research into CPP should be encouraged, particularly in
the areas of the impact of CPP on the use of health
services, the pathophysiology of myofascial dysfunction,
and gene therapy. Because randomized trials for qualita-
tive outcomes are exceedingly difficult, alternative
robust models, such as case-controlled or cohort-con-
trolled trials, should be pursued (A).
Classification of recommendationsy
A. There is good evidence to support the recommendation for use of
a diagnostic test, treatment, or intervention.
B. There is fair evidence to support the recommendation for use of a
diagnostic test, treatment, or intervention.
C. There is insufficient evidence to support the recommen dation for
use of a diagnostic test, treatment, or inter vention.
D. There is fair evidence not to support the recommendation for a
diagnostic test, treatment, or intervention.
E. There is good evidence not to support the recommendation for use
of a diagnostic test, treatment, or intervention.
 No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain
3. Methods of improving interaction with patients should
be explored. They might include formal contractual
approaches to managing pain with opiates and efforts to
better appreciate the patient's perceived needs (A).
J Obstet Gynaecol Can 2005;27(9): 869-887
CHAPTER 1: PHYSIOLOGICAL ASPECTS OF
CHRONIC PAIN
John F. Jarrell, MD, Calgary, AB
his consensus statement cannot provide a complete
T summary on the physiological aspects of pain, but
the members of ttie consensus panel felt that a brief sum-
mary, particularly in relation to chronic pain, was war-
ranted. Additional references are provided.1-4
PERIPHERAL NERVES
Pain sensation begins with the stimulation of a nocicep-
tor, or nerve ending, and resultant activation of a sensory
nerve. A signal passes through the lightly myelinated A
delta fibres, which are responsible for the appreciation of
cold and mechanical stimuli that produce stinging, sharp,
fast pain. Also stimulated are the C fibres, which are
associated with mechanical and thermal stimuli and
transmit warm pain. Specialized bodies are responsible
for the appreciation of texture (1vfeissner's corpuscles),
vibration, tickle, and deep pressure (pacinian corpuscles)
and for proprioception (Rufftni's corpuscles). The
peripheral nerves use L-glutamate, substance P, and calci-
tonin G-related peptide as neurotransmitters. Release of
chemicals (such as potassium, bradykinin, and arachi-
donic acid) from inflammatory processes is an endoge-
nous source of pain sensation.
Therapy directed to the peripheral nerves involves the use of
prostaglandin inhibitors, such as nonsteroidal anti-inflamma-
tory drugs and acetylsalicylic acid, as well as disruptors of
sodium channel activity, such as carbamazepine.z
CENTRAL NERVOUS SYSTEM
Stimuli travelling to the spinal cord pass through the cord's
dorsal roots, which contain the nuclei of the sensory nerves
from both the soma and the viscera. These nerves convey
stimuli to the spinothalamic tract of the spinal cord
through an important synapse governed by a complex
array of neurotransmitter messages that involve the N-
methyl- D-aspartate (NMDA) receptor.5,6
When stimuli through the sensory nerves become very
intense, a process called "winding up" can develop,
generating a great deal of electrical activity in this recep-
tor.7,8 One of the main roles of the brain in the response to
pain is the generation of inhibitory signals, which descend
through the cord to prevent some inappropriate actions.
The winding- up process may damage some of these inhib-
itory impulses. Another phenomenon that may occur is
more diffuse dispersal of the message within the cord,
such that the subject appreciates the pain over several der-
matomes and not simply the one at which the signal origi-
nated. Longer duration of the pain signal is responsible for
neuroplasticity, the permanent alteration of neuronal func-
tion in the spinal cord that results in allodynia (pain from
stimuli that are not normally painful), hyperalgesia (exces-
sive sensitivity to pain), and other types of inappropriate
pain.
THERAPY
Therapy at the level of the cord is directed to the NMDA
receptor. Novel neuroleptics, such as gabapentin, inhibit
excessive stimulation of the secondary neurons in the spi-
nal cord, as do carbamazepine, phenytoin, and clonaze-
pam. Modulation of gamma-aminobutyric acid-receptors
may be inhibited by electric stimulation.
Therapy directed at the central processes of central inhib-
ition include the use of opiates that act on the dorsal horns
of the spinal cord and agents that increase the inhibition of
serotonin uptake, thereby increasing its availability (paroxe-
tine and amitriptyline). This is an area of intense research
activity.
CHAPTER 2: SCOPE, DEFINITION, AND CAUSES OF
CHRONIC PELVIC PAIN
Catherine Allaire, MD, Vancouver, BC
SCOPE
Chronic pelvic pain (CPP) in women is one of the most
common and difficult problems encountered by health
care providers. CPP accounts for about 1 in 10 outpatient
gynaecology visits and is the indication for an estimated
15% to 40% of laparoscopies and 12% of hysterectomies
in the United States.9 The true incidence and prevalence,
as well as the socioeconomic impact, of the problem are
unknown. In a Gallup poll of 5325 US women, 16%
reported problems with pelvic pain: because of CPP, 11%
limited their home activity, 11.9% limited their sexual activ-
ity, 15.8% took medication, and 3.9% missed at least 1 day
of work per month.10
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REAFFIRMED SOGC CLINICAL PRACTICE GUIDELINE

DEFINITION problem, attribution of cause and effect can be difficult.

Various definitions of CPP have been used, but most inves-
tigators consider a minimum duration of 6 months to define
the pain as chronic. However, because of the delay in
seeking help and then getting appropriate referrals, there has
been a trend toward using 3 months instead. Either way,
these cut-off points are arbitrary and lack empiric validation.
Chronic pain syndrome usually encompasses the following
clinical characteristics11:

duration of 6 months or longer;

incomplete relief with most treatments;

significantly impaired function at home or work;

signs of depression, such as early awakening, weight loss,
or anorexia; and

altered family roles.
Individual response to chronic pain varies tremendously.
Whereas some women with CPP suffer for much longer
than 6 months without exhibiting the affective and behav-
ioural changes of a chronic pain syndrome, others exhibit a
full-blown chronic pain syndrome fairly quickly. This
speaks to the complexity of the problem and the multiple
contributing factors. If interacting physical and psychologi-
cal factors are present early in the clinical course of a pain
Also, pain intensity is often not proportional to tissue dam-
age. When multiple factors are present, treatment of only
some of them will lead to incomplete relief and frustration
for both patient and clinician.
CAUSES
There are many recognized causes of CPP; the Table 2.1
lists those that are common. Many gynaecologic pathologi-
cal conditions (adhesions, endometriosis, etc.) are more
frequent in women with CPP, but the development of a
chronic pain syndrome is often multifactorial. Clinical
evaluation must therefore be thorough from a medical,
surgical, and psychological standpoint. Organic and physi-
ological changes affecting the reproductive tract, surround-
ing viscera, and musculoskeletal system can coexist and
must be recognized. In addition, depression, sleep distur-
bance, and sexual dysfunction often become part of the
picture and complicate treatment. For example, a patient
may flrst experience pain and deep dyspareunia from endo-
metriosis, next have secondary vaginismus and vestibulitis,
then exhibit abdominal trigger points and irritable bowel
symptoms, and finally become depressed and disabled. All
these components of the patient’s pain must be treated
concurrently. If the initial pain symptoms had been treated

Table 2.1. Common causes of chronic pelvic pain and common coexisting conditions
Gynaecologic Urologic Gastrointestinal Musculoskeletal Psychological
Endometriosis Interstitial cystitis Irritable bowel Myofascial pain (trigger Depression
syndrome points)
Endosalpingiosis Urethral syndrome Chronic appendicitis Pelvic floor myalgia and Physical or sexual abuse
spasms (previous or current)
Adenomyosis Chronic urinary tract Constipation Nerve entrapment Sleep disturbance
infection syndromes
Pelvic adhesions Bladder stones Inflammatory bowel Mechanical low back Psychological stress
disease pain (marital, work)
Chronic pelvic infections Disc disease Substance abuse (alcohol,
narcotics, other drugs)

Ovarian cysts Hernias

Residual ovary syndrome
Ovarian remnant
syndrome
Post-hysterectomy pain
Pelvic congestion
syndrome
Fibroids
Vulvodynia*
*
Not dealt with in this consensus guideline.

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 No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain
adequately, the patient's problem might not have pro-
gressed to a chronic pain syndrome.
A useful model for understanding CPP is Steege's inte-
grated model,12 which includes the following elements:

biological events sufficient to initiate nociception

alterations of lifestyle and relationships over time

anxiety and affective disorders and

circular interaction (“vicious cycle”) among these elements.
There is evidence that a multidisciplinary approach to man-
agement (see Chapter 11 in Part two in the next issue) is
more effective.
Recommendation
Because of the complex nature and multifactorial devel-
opment of its common state, CPP should be increas-
ingly incorporated into the educational curricula of
health professionals (medical students, residents, nurses,
physiotherapists, specialists) (III-B).
CHAPTER 3: HISTORY-TAKING, PHYSICAL
EXAMINATION, AND PSYCHOLOGICAL
ASSESSMENT
Catherine Allaire, MD, Vancouver, BC
Paul Taenzer, PhD, CPsych, Calgary, AB
HISTORY-TAKING
Nowhere is the history more important than in assess-
ing patients with chronic pain. It is crucial to get a
detailed chronologie history of the problem, with care-
ful attention to aggravating and alleviating factors, as
well as results of previous attempts at treatment. It is
useful to get a sense of what the patient thinks is con-
tributing to her pain, as often she will have insight
into her condition and fears that need to be addressed.
The clinician should elicit symptoms denoting possible
involvement of the gastrointestinal system, urinary
tract, musculoskeletal system, and pelvic floor muscu-
lature and assess for psychological factors. Most
important, the clinician should establish the current
impact of the pain on the patient's quality of life and
the amount of medication used; these factors, followed
over time, can be used as indicators of response to
treatment.
A detailed questionnaire can be given to the patient before
her visit to facilitate history-taking and make it more
thorough and efficient. The pain questionnaire designed by
the International Pelvic Pain Society (www.pelvicpain.org/
pdf/FRM_Pain_Questionnaire.pdf) is a useful resource
and will allow data collection through a centralized data-
base in the future.
During the initial interview, it is important to convey inter-
est, to listen with attention, and to validate the patient's
experience. Unfortunately, patients who have had pain for
many years often feel dismissed by physicians frustrated at
their inability to cure. These physicians apply the Cartesian
model; that is, if no visible pathological condition is found,
the problem must be psychological. As detailed in Chapter
2, a biopsychosocial evaluation, which acknowledges the
possibility of multiple contributing factors, is more appro-
priate. When the patient feels that her experience of the
pain is believed and that the clinician will do his or her best
to help, a good therapeutic relationship can be established,
which will lead to better compliance with the proposed
treatment plan and perhaps to acceptance by the patient of
more realistic goals of treatment, such as improved func-
tion and quality of life, as opposed to complete resolution
of pain.
PHYSICAL EXAMINATION12
The physical examination of a patient with CPP is very dif-
ferent from a routine gynaecologic examination. It may be
necessary to defer the examination to the second visit
because of time or the patient's distress after recounting
her history. It is important to convey to the patient that she
will control the timing of the examination and may elect to
terminate it at any time.
If the pain is intermittent, it is best to examine the
patient when she is in pain. The goal of the examination
is to look for pathological conditions but also to repro-
duce the patient's usual pain to help identify physical
contributors. The examiner should elicit feedback from
the patient, preferably using a numeric scale to deter-
mine whether the pain is the same as or different from
her usual chronic pain, documenting the score for each
tender area. The examiner should also give feedback to
the patient about what is being looked for and what pel-
vic structures seem to be painful.
The following sequence of examination is important. The
bimanual exam should be done last, as it is the most threat-
ening, often the most painful, and the least discriminatory
part of the examination.
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REAFFIRMED SOGC CLINICAL PRACTICE GUIDELINE
General Demeanour, Mobility, and Posture
These can be observed the moment the patient walks
into the office and while she sits recounting her history.
Be aware of an abnormal gait, guarding, and careful
positioning.
Back
Look for scoliosis, sacroiliac tenderness, trigger points, and
pelvic asymmetry (gluteal fold out of alignment with the
line between the thighs). (See Chapter 7 in Part two in the
next issue for details on musculoskeletal examination.)
Abdomen
With the patient supine, look for skin lesions or hypersensi-
tivity, especially around scars. Examine all quadrants of the
abdomen for trigger points: vigorous pain responses to
light localized pressure, occasionally paired with a muscle
twitch). Do the head-raise test: if pain is lessened with
head-raising (and resultant tensing of the rectus muscles),
then it is likely intraperitoneal, as the rectus protects the
peritoneum from stretch; if, however, the pain is worsened
or unrelieved by head-raising, then an abdominal wall
source should be suspected.
Vulva
The patient is placed in the lithotomy position and may be
offered a mirror to participate in the examination and gain
more information about her body. A cotton swab is used
to perform a sensory examination and to identify areas of
tenderness. Particular attention should be given to identify-
ing vulvar vestibulitis, as it is common in CPP patients.
This condition causes introital discomfort with intercourse
and is often felt as a tearing and burning sensation.
Single-Digit Vaginal Examination
Insert one finger into the introitus and have the patient
contract and relax her perineal floor around the finger to
assess tone and muscle control and whether vaginismus is
present. Palpate the levator ani and coccygeus muscles and
their attachments. Palpate the vaginal side walls, looking
for reflex sympathetic hypersensitivity. Palpate the levator
muscles. Palpate the pyriformis and obturator muscles (see
Chapter 7 in Part two in the next issue for details on mus-
culoskeletal examination). Palpate the urethra and bladder
base. Gently touch the cervix and then the uterosacral liga-
ments, searching for nodularity and localized tenderness.
Gently move the cervix, looking for uterine mobility and
motion tenderness. Palpate the adnexal areas for ovarian
tenderness and the internal inguinal ring for inguinal ten-
derness.
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Bimanual Examination
This may not be possible and should not be attempted in
the presence of severe vaginismus. Perform the exam as
gently as possible to delineate the uterus and adnexae,
looking for mobility, tenderness, and masses. The pres-
ence of abdominal wall trigger points may render the
exam difficult and confusing; freezing the trigger points
with local anesthetic before performing the bimanual
exam can help isolate tender areas. If cul-de-sac disease
is palpated, a rectovaginal exam should be done to deter-
mine its extent.
Speculum Examination
This may not be possible if the patient has considerable
vaginismus. Use a small specUlum. Look at the cervix, vag-
inal fornices, and vaginal walls. Cervical lesions, mucosal
lesions, infections, and endometriosis implants can be iden-
tified. Use a long cotton swab to palpate the cervix and
vaginal fornices, looking for localized tenderness. Post-
hysterectomy dyspareunia may arise from localized lesions
or nerve entrapment at the vaginal vault: palpating the
vault with a long cotton swab may assist in identifying focal
sources of pain.
PSYCHOLOGICAL ASSESSMENT
Modern definitions of pain acknowledge both sensory and
affective aspects of the experience. Furthermore, particu-
larly when moderate or severe, CPP can have a negative
impact on the woman's capacity to function in family, sex-
ual, social, and occupational roles. This condition is called
chronic pain syndrome. Thorough evaluation of the
woman experiencing CPP must include an assessment of
her emotional experience and other aspects of the chronic
pain syndrome.
A psychosocial assessment conducted by a health psychol-
ogist or psychiatrist consists of an extensive interview and
an evaluation of the woman's response to standardized
pain and psychological tests that assess disability associated
with pain (Figure 3.1 illustrates one such test, the Func-
tional Pelvic Pain Scale),13-15 emotional distress,16-18 and
quality of life.19
The domains covered in a psychosocial assessment include:
(a) the woman's understanding of pain generators; (b) the
impact of the pain on functional roles (e.g., disability in
family, sexual, work, and recreational activities) and
emotional functioning (e.g., anxiety about pain and depres-
sion secondary to pain); (c) the woman's pain coping style
(e.g., ignoring the pain, becoming inactive, or going to the
emergency department for injections); (d) pain modulators
 No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain
Figure 3.1. Functional Pelvic Pain Scale Instructions: Please fill out this form by placing an X in the box that best
describes your pain when it is the WORST, even if it occurs at different times of your cycle. If any of these functions do not
apply to you, please write N/A (not applicable) in the box beside that function.
0 1
Function No pain; Some pain;
normal function with function
Bladder
Bowel
Intercourse
Walking
Running
Lifting
Working
Sleeping
Department of Obstetrics and Gynaecology, Foothills Provincial General Hospital, University of Calgary, Calgary AB, 1994
(e.g., stress, which exacerbates pain); (e) the woman's
perception of the meaning of her pain with regard to her
current and future life experience; (f) the quality of the
woman's relationships with health care providers; (g) the
woman's mental health history (past and current), espe-
cially clinical psychopathological disorders (e.g., major
depressive disorder), abuse and neglect (sexual, physical, or
emotional), and substance use or abuse; and (h) current
psychosocial stress and social support, including the wom-
an's strengths.
The data generated by the psychological assessment are
useful for determining appropriate psychosocial interven-
tions directed towards alleviating the psychological and
behavioural sequelae of chronic pain through lifestyle mod-
ification and alterations in pain coping style. If relevant,
interventions may be aimed at treating secondary or pri-
mary mental health disorders and reducing psychosocial
stress, which may moderate the pain experience. For
patients with moderate to severe pain, these interventions
are typically critical components of a comprehensive health
care plan.
Clearly, gynaecologists and family physicians cannot be
expected to conduct a thorough psychosocial assessment.
However, they have an important role in identifying
patients who will likely benefit from psychosocial assess-
ment and treatment. Women who are identified as
experiencing considerable psychosocial impact from their
CPP can be referred to a mental health practitioner with
2 3 4
Moderate pain; Severe pain; Cannot function
with function with function because of pain
training and experience in working with patients experienc-
ing the psychosocial sequelae of chronic health conditions.
The following screening questions can be used in the office
to identify women who would benefit from further psycho-
logical evaluation. Each question is followed by an explana-
tion and suggestions for how the information can be
evaluated.
Main Concern
What concerns you most about the pain?
Rationale: This open-ended question often elicits the wom-
an's perception about what is most distressing about the
pain, and interventions can be tailored accordingly.
Understanding of Pain and Treatment
Expectations
What do you believe to be the cause of your pain? Do you
feel that anything has been overlooked? What do you hope
to gain as a result of treatment?
Rationale: Women with CPP may have misconceptions and
fears concerning the cause of the pain (e.g., cancer), which in
turn increase distress. They benefit from an accurate, physi-
cal-based understanding of pain generators (e.g., disease and
myofascial trigger points). In contrast, psychological or psy-
chogenic explanations for the pain often cause more distress
and create fear that the pain will not be appropriately investi-
gated or treated. Patient expectations for treatment outcome
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REAFFIRMED SOGC CLINICAL PRACTICE GUIDELINE
(i.e., cure or elimination) may not be realistic and may con-
tribute to the viewing of treatment as unsuccessful.
Pain Impact
How has your pain affected your ability to function day to
day? Has pain affected your daily activities, work, relation-
ships, sleep, or sexual functioning?
Rationale: This question elicits the impacts of pain. As
appropriate, interventions can be focused on reducing the
impacts as well as the underlying condition. Moreover, the
acknowledgement that the pain has affected the woman's
quality of life can often contribute to increased rapport and
decreased distress.
Mood Disorders
How has the pain affected your mood? Are you feeling irri-
table or depressed? Are you feeling anxious or tense?
Rationale: Depression is the most common emotional conse-
quence of chronic pain. Office screening for clinical depres-
sion is often required. Clinical depression develops in 25%
to 50% of patients with chronic pain and if left untreated
may become an obstacle to alleviation of the pain.
Current Stress
How much stress do you have in your life? Very little, a
moderate amount, or a high or severe level? If the level is
high or severe, how do you feel that you are coping with
pain and stress?
Rationale: CPP can be considered a source of chronic stress,
adding to other sources of stress, from daily hassles to
major life events, and taxing a woman's coping resources.
Improved stress management can facilitate pain coping. If
the stress level is high or severe and coping is poor, con-
sider a mental health consultation.
Abuse History
Although abuse is rarely a cause of pelvic pain, a history of
abuse often makes it more difficult for a woman to deal
with pelvic pain. Have you ever been a victim of physical,
sexual, or emotional abuse? If you have, please explain.
Are you currently being abused? Are you concerned about
your safety or the safety of your children? (Explore safety
concerns and take action as appropriate.)
Rationale: Screening for past and current abuse is viewed as
routine in general practice. According to general popula-
tion studies, one would expect 25% to 50% of women
with CPP to have abuse histories. Untreated or unresolved
abuse may affect overall health and interfere with the
patient's coping with pain. Contrary to popular belief,
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NOVEMBER JOGC NOVEMBRE 2018
research has not substantiated a psychological causal link
between abuse and chronic pelvic pain.
Support System
Who is there to support you as you cope with your pain
(stress and abuse)?
Rationale: Women with social support cope more effectively
with chronic pain. Consider referring isolated women with
major problems to appropriate community resources.
Individual or Couple Counselling
Are you interested in counselling for pain coping skills,
depression, stress management, or unresolved abuse?
Rationale: Counselling by the appropriate health care pro-
vider (a pain specialist with mental health training) is an
adjunct to rather than a replacement for medical manage-
ment of CPP. As well, the promotion of a multidisciplinary
approach to management expands treatment options and
creates more realistic expectations for outcome (i.e., reduced
pain, improved coping, and improved quality of life).
SUMMARY STATEMENTS
1. Cognitive-behavioural therapies are the treatment of
choice for helping women develop effective pain
coping strategies (II-3).
2. Current evidence indicates that multidisciplinary
management of CPP is the most effective treatment
approach for women with chronic pain syndrome (I).
Recommendations
1. Thorough history-taking that generates trust between
caregiver and patient and a pain-focused physical
examination should be part of the complete evalua-
tion of the patient with CPP (III-B).
2. Clinical measurement of pain level could be done at
each visit for CPP (11-B).
3. The patient can be asked two questions that are sim-
ple and effective: "On a scale of 0 to 10, 0 being no
pain and 10 being the worst pain imaginable, how is
your pain today and how was you,r pain 2 weeks
ago?" It is important to provide a reference for 10
such as "pain that is so bad that you cannot care for
your children, who are in imminent danger" (II-B).
4. The physical examination can be conducted differ-
endy in these patients, with special attention placed
on individual pelvic Str!lctures, to help differentiate
sources of pain. Identifying a focal area of tenderness
can help target specific therapy (11-B).
 No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain
5. Owing to the high prevalence of mental health
and other significant psychological coexisting
problems and sequelae of CPP, gynaecologists
and. family physicians should routinely screen
patients for chronic pain syndrome and refer as
appropriate (II-2A).
6. Access to multidisciplinary chronic pain management
should be available for women with CPP within the
publicly funded health care system in each province
and territory of Canada (III-B).
CHAPTER 4: INVESTIGATIONS
Paul Martyn, MB, Calgary, AB
INTRODUCTION
After thorough history-taking and physical examination,
specific diagnostic tests may be appropriate in patients
with chronic pelvic pain (CPP). These may include com-
plete blood count, culture of cervical swabs, and urinalysis.
DIAGNOSTIC IMAGING
Diagnostic imaging should be performed only when indi-
cated by the history and physical findings.
Transvaginal ultrasonography is useful for evaluating pelvic
masses and adenomyosis and is more sensitive than trans-
abdominal scanning.20 When a mass is found in the pelvis,
ultrasonography is effective in distinguishing cystic from
solid lesions. Doppler studies evaluate the vascular charac-
teristics of the lesion.
Magnetic resonance imaging (MRI) is useful for character-
izing pelvic masses. It may be a useful, non-invasive tool in
the diagnosis of deep endometriosis, although it has limita-
tions in detecting small implants.21,22 Endometriomas are
readily visualized with MRI. Blood products are often seen
within masses. Adjacent bowel loops may be tethered to
the mass. Differential diagnoses include cystic teratomas
(dermoids) and hemorrhagic cysts.22 MRI remains the
imaging test of choice for adenomyosis.22
A study compared the diagnostic accuracy of laparoscopy, pre-
operative MRI, and histologic examination of specimens in 48
women with pelvic pain.23 MRI detected fewer endometriosis
lesions than laparoscopy or histologic examination, with sensi-
tivity of 69% and specificity of 75% in detecting biopsy-con-
firmed endometriosis. Only 67% of lesions detected
laparoscopically showed histologic evidence of endometriosis.
DIAGNOSTIC LAPAROSCOPY
Laparoscopy is indicated in patients with CPP in whom a
pelvic abnormality is suspected, the goal being to find and
treat contributing conditions. A thorough clinical assess-
ment may lead to avoidance of unnecessary surgical proce-
dures.
Forty percent of diagnostic laparoscopies are done for CPP,
and 40% of these reveal nothing abnormal. Of those reveal-
ing abnormalities, 85% show endometriosis or adhesions.24
Negative results of laparoscopy do not exclude disease or
mean there is no organic basis for the patient's pain.
In a retrospective controlleq study of 100 women with
CPP undergoing laparoscopy, Kresch and colleagues25
found adhesions and endometriosis to be the most com-
mon abnormalities, detected in 51% and 32% of the
women, respectively. In the control group of 100 women
undergoing tubal ligation and without a history of pelvic
pain, adhesions were noted in 14%, but these differed
from the adhesions in the CPP patients in that they were
generally fine and did not restrict organ mobility. Adhe-
sions in the CPP group were denser, tighter, and associated
with restricted mobility of the involved organs.
Findings on physical examination are not reliable predic-
tors of laparoscopic findings. Up to 50% of patients with
negative results of physical examination have abnormalla-
paroscopic findings.24 In a review of 11 studies of laparo-
scopic findings in women with CPP, Howard24 found that
28% of women without CPP had abnormal laparoscopic
findings adhesions and endometriosis being the most com-
mon, at 17% and 5%, respectively.
What is Adequate Laparoscopy?
After laparoscopic entry, a thorough, standardized exami-
nation is performed. A panoramic view of the pelvis, with
the patient in the Trendelenburg position and the uterus
anteverted, allows a general survey. A manipulating instru-
ment is inserted, and the bowel, appendix, liver, diaphragm,
and upper abdomen are inspected. The manipulating
instrument is then used to mobilize pelvic structures to
visualize all peritoneal surfaces, the ovaries and ovarian
fossae, and the cul-de-sac of Douglas, as well as the ante-
rior cul-de-sac. The instrument is used to probe areas of
tenderness reported by the patient on pelvic examination,
as well as adhesions and pelvic deformity.
Surgeons should be aware of the varied appearances of
endometriosis, atypical lesions being more common in
younger patients. Biopsy for histologic confirmation is rec-
ommended. Palpation of scar tissue with the probe may
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REAFFIRMED SOGC CLINICAL PRACTICE GUIDELINE
reveal endometrial nodules underneath. Peritoneal win-
dows may have endometrial implants at their base.
The diagnosis of pelvic venous congestion may be
obscured by Trendelenburg positioning. Dense adhesions
distorting the anatomy may be responsible for CPP, espe-
cially if they correlate with pelvic tenderness on preopera-
tive pelvic examination.
Videolaparoscopy or photography should be considered to
document abnormality or normality, which provides useful
feedback to the patient and a permanent record.
Laparoscopic Pain Mapping
Laparoscopic pain mapping, or patient-assisted laparos-
copy (PAL), is a technique involving conscious sedation
and local analgesia that is used to identify sources of CPP
by reproducing the patient's symptoms with probing or
traction of pelvic tissues. Howard26 found no difference in
outcome between 50 patients treated after laparoscopic
pain mapping and a historical cohort of 65 patients who
underwent traditional laparoscopy and treatment. Most
reports have been of small groups of patients and have not
reported outcomes 6 to 12 months after surgery. No ran-
domized trials have compared pain mapping with standard
laparoscopy. PAL remains an experimental procedure.
SUMMARY STATEMENTS
1. Permanent documentation of laparoscopic findings is
highly desirable (III).
2. Increased use of MRI in the evaluation of CPP
should be expected (III).
Recommendation
Patient-assisted laparoscopy should be subjected to clin-
ical trial (III-C).
CHAPTER 5: SOURCES OF CHRONIC PELVIC PAIN
George A. Vilos, MD;1 Hassan Shenassa, MD;2
Basim Abu-Rafea, MD1
1
London ON
2
0ttawa ON
Various abnormalities may lead to chronic pelvic pain
(CPP); however, not all women with these conditions will
exhibit CPP.
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NOVEMBER JOGC NOVEMBRE 2018
ENDOMETRIOSIS
A detailed consensus statement on endometriosis was pub-
lished by the Society of Obstetricians and Gynaecologists
of Canada (SOGC) in 1999.27
Endometriosis is a condition of unknown etiology and
pathogenesis. It is defined clinically as the presence of
endometrium outside of the endometrial cavity. Both
endometrial glands and stroma have to be present for a
histologic diagnosis of endometriosis.
Current etiologic theories suggest genetic and environmen-
tal interaction, as in many chronic conditions, including
adenomyosis. A search is under way for genetic pleomor-
phisms that might increase the risk of the disease. Possibly
the immune system is altered in some way, perhaps by
exposure to environmental toxins, to permit persistence of
endometriotic implants in the peritoneal lining.
The incidence of endometriosis in the general population is
thought to be 1% to 7%.28 In women undergoing laparos-
copy for CPP, the prevalence of endometriosis is more
than 30%.29 Accrual of such data is difficult, as they are
derived from selected populations of subjects with access
to laparoscopy for several unrelated reasons (e.g., pain,
infertility, and tubal ligation). In one of the largest studies
on the incidence of the disease, most of the risk factors
identified were not modifiable (e.g., age at menarche and
frequent menses).30 One protective modifiable risk factor
was prior use of oral contraceptives.
Although the data suggest an association between endome-
triosis and CPP, it is difficult to prove that endometriosis
causes the pain. There is evidence that the incidence of
endometriosis in asymptomatic women is much higher
than previously thought, perhaps as high as 45%.31 The
pain is thought to be due to inflammation, but the process
is not fully understood. The severity of endometriosis does
not necessarily correlate with the severity of the pain.32
Endometriosis-associated CPP may be managed with an
estrogen-progestin combination, a progestin alone, dana-
zol, or a gonadotropin-releasing hormone (GnRH) agonist,
with or without nonsteroidal anti-inflammatory drugs.33-36
In a randomized controlled trial of laparoscopic manage-
ment with laser treatment, adhesiolysis, and uterine nerve
transection compared with expectant management after
diagnostic laparoscopy, operative treatment was signifi-
cantly more effective than expectant management in reduc-
ing symptoms, as assessed subjectively and from pain
scores 6 months postoperatively.37
 No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain
There is no consensus on the merits of preoperative
versus postoperative medical treatment of CPP. Some
theoretical advantages of preoperative treatment include
decreased inflammation in the endometriotic implants
and decreased pelvic vascularity. Disadvantages may
include increased difficulty in diagnosis of the endome-
triosis and high costs of the medications and their side
effects.
There have been at least three randomized, placebo-con-
trolled clinical trials of surgical therapy followed by medical
management.36,38,39 Although it is not clear from these
studies whether postoperative medical therapy is effica-
cious, there is some evidence that 6 months of postopera-
tive treatment with GnRH analogues, danazol, or
medroxyprogesterone acetate lowers pain levels at 6
months but possibly not at 12 months.
Finally, if fertility is not desired, in the face of failed medical
and conservative surgical therapy, hysterectomy with or
without oophorectomy may be considered in accordance
with the SOGC practice guidelines.40 According to the
Canadian Hospital Morbidity File of Statistics Canada,
there were 120 854 hysterectomies performed during 1988
and 1989; the listed indications included fibroids (in 37.3%
of cases), menstrual disorder (in 17.7%), endometriosis (in
15.7%), prolapse (in 11.4%), other (in 9.1%), and cancer
(in 8.7%).41
Hysterectomy with bilateral oophorectomy is generally
regarded as the most effective procedure for the treatment
of CPP associated with endometriosis. However, after such
radical surgery, one study found a 3% rate of recurrence of
endometriosis.42 Possible mechanisms include residual
ovarian tissue or exogenous stimulation by hormones.
Another study found a recurrence rate of 3.5% (0.9%
per year) among 115 women randomly assigned to receive
hormone replacement therapy (HRT) after bilateral sal-
pingo-oophorectomy (BSO) with or without hysterectomy
but no recurrence among 57 women assigned to not
receive HRT after BSO.43 Among the women receiving
HRT, the recurrence rates were higher among those with
peritoneal involvement greater than 3 em (2.4% per year
vs. 0.3%) and incomplete excision (22% among the 9
women who underwent BSO with or without subtotal hys-
terectomy vs. 2% among the 106 who underwent BSO and
hysterectomy). The relative risk was 11.8 (confidence inter-
val [CI] 1.4-15.6, P = 0.03).
A retrospective study reported that 18 (62%) of 29 women
had recurrent pain and 9 (31%) required re-operation after
hysterectomy with retention of the ovaries,44
In addition to a woman's desire to maintain fertility, her age,
the severity of her symptoms, and the site of major endo-
metriotic involvement must be evaluated when considering
definitive surgery as an option for pain management.
ENDOSALPINGIOSIS
Endosalpingiosis first described by Sampson45 in 1927, is
the presence of ectopic fallopian tube-like ciliated epithe-
lium without stroma. As with endometriosis, the histogene-
sis is unknown. Possible mechanisms include coelomic
metaplasia or implantation of tubal epithelial tissue. The
distribution and gross appearance of the lesions of endo-
salpingiosis are the same as those of endometriosis. Several
case studies have reported that endosalpingiosis may be
associated with CPP.
A prospective study of 1107 consecutive women undergo-
ing laparoscopy over a year for a variety of indications
found histologically proven endosalpingiosis in 7.6%,
endometriosis in 27.5%, and both in 4.4%.46
Endosalpingiosis was found in 7.9% of the women with
pelvic pain, 7.3% of those without pelvic pain, 11.7% of
those with infertility, and 8.3% of those without symptoms
who were undergoing sterilization. The authors concluded
that, in contrast to endometriosis, endosalpingiosis plays
only a minor role in infertility and lower abdominal pain.
Another study of 16 women with endosalpingiosis who pre-
sented with a variety of symptoms, including pelvic pain (in
5) and no pelvic pain (in 5), determined that endosalpingiosis
seems to be an incidental fmding associated with other pelvic
problems rather than a frequent cause of pelvic pain.47
ADENOMYOSIS
Adenomyosis is a condition of unknown etiology and path-
ogenesis. It is defmed histologically as the presence of
endometrial glands and stroma deep within the myome-
trium. The uterus is usually enlarged and diffusely boggy
to palpation. The adenomyotic foci may be diffusely
distributed or be well-localized, forming adenomyomas
(nodules of hypertrophic myometrium and ectopic endo-
metrium). The reported incidence of adenomyosis ranges
from 5% to 70%.48 Most cases occur in parous women in
the fourth and fifth decades of life.49 Not all women with
adenomyosis are symptomatic. Symptoms may include pel-
vic pain, dysmenorrhea, and menorrhagia.
Transvaginal sonography may aid in the diagnosis of
adenomyosis.50 The senstttvtty and specificity of prehyster-
ectomy ultrasonography varied from 52% to 89% and
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REAFFIRMED SOGC CLINICAL PRACTICE GUIDELINE
from 50% to 99%, respectively, in 6 series (43 to 405
women).51
Several studies have shown magnetic resonance imaging
(MRI) to be an excellent, minimally invasive tool for diag-
nosing adenomyosis,52 with sensitivity and specificity rang-
ing from 86% to 100% in symptomatic women.53 One
recent, prospective, double-blind study of 119 consecutive
patients undergoing hysterectomy showed endovaginal
ultrasonography to be as accurate as MRI in the diagnosis
of uterine adenomyosis.54
Treatment options include danazol and GnRH agonists.
Adenomyotic foci have been shown to contain progester-
one and estrogen receptors and may undergo decidualiza-
tion when exposed to progesterone; symptoms may then
become more apparent.55 Progestogenic agents alone or in
combination with estrogen may therefore not be effective.
Adenomyosis in women with infertility can be treated with
a variety of medications.50
In one study of 15 women with MRI-diagnosed adeno-
myosis (and concurrent fibroids in 12), 12 of 13 patients
reported improvement in quality of life after uterine artery
embolization.56
Surgery is still the main method of diagnosing and manag-
ing adenomyosis. Hysterectomy is the gold standard for
relief of symptoms. However, there may be a role for hys-
teroscopic endometrial resection if the adenomyosis has
been confirmed to involve mostly the superficial 3 mm of
the myometrium.
For a recent review of adenomyosis, see the article by Mat-
alliotakis and colleagues.57
PELVIC PERITONEAL DEFECTS (POCKETS)
A defect, or a pocket, in the pelvic peritoneal floor was first
illustrated by Sampson45 in 1927 as he was describing
endometriotic implants in the peritoneal cavity. In 1981,
Chatman58 reported peritoneal defects in 25 (4%) of 635
consecutive patients undergoing diagnostic laparoscopy,
75% for CPP and 25% for infertility, among whom endo-
metriosis was found in 192 women (30%). The frequency
of peritoneal defects in women with CPP was 7%. In 7
(28%) of the 25 women, the defect was the only fmding,
but 17 (68%) had associated pelvic endometriosis.
In a follow-up study of an additional 309 patients undergo-
ing laparoscopy for CPP, infertility, or both, Chatman and
Zbella59 found that 53 patients had pelvic peritoneal
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NOVEMBER JOGC NOVEMBRE 2018
defects, 9 having more than one defect, and 42 (79%) also
having endometriosis. Of the 309 women, 148 had endo-
metriosis. The authors concluded that, when such defects
are found at laparoscopy, the presence of endometriosis
should be investigated thoroughly.
The defects have been postulated to result from peritoneal
irritation or invasion by endometriotic tissue, with resultant
scarring and retraction of the peritoneum,45,57 Batt and
Smith60 postulated that peritoneal pockets and associated
endometriosis localized to the posterior pelvis may repre-
sent a congenital form of endometriosis that is due to rudi-
mentary duplication of the milllerian system during
embryogenesis. Redwine61 reported that almost one-fifth
of 132 women with endometriosis had peritoneal pockets.
Two-thirds of the defects had endometriotic tissue around
the rim or inside, but since one-third lacked associated
endometriosis, and since fibrosis was not present as a pos-
sible cause, endometriosis did not seem to have been the
likely primary cause. Redwine postulated that such perito-
neal invaginations and endometriosis may be ontologically
related to a separate developmental factor.
Vilas and Vilos62 excised 140 pelvic peritoneal pockets
ranging from 0.5 to 6 em wide or deep from 106 women
15 to 50 years of age who had CPP. Of the pockets, 46%
were below the uterosacral ligaments (right, 40; left, 25),
41% above the uterosacral ligaments and medial to the ure-
ters (right, 20; left, 38), 6% lateral to the ureters (right, 6;
left, 2), 3% in the rectovaginal septum, and 3% anterior to
the broad ligament (right, 3; left, 1). Associated pelvic
endometriosis was seen in 85% of patients. Histologic
examination of the pockets revealed endometriosis in 39%,
chronic inflammation-in 20%, endosalpingiosis in 12%,
calcification in 4%, and no abnormalities in 25%. Excision
and suturing of the defects provided immediate relief of
CPP in some 75 women. The authors postulated that the
pockets were herniations of the pelvic peritoneum over
pelvic floor spaces and were related to the inflammatory
effects of the various conditions.
In a follow-up study of 2115 women with CPP, Vilos
and associates63 reported on 25 women who also com-
plained of cyclic pain radiating to the leg (right leg in
15 women, left leg in 9 women, and both legs in 1
woman), pain over the buttocks and paresthesia of the
thighs, knees, or both, exacerbated during menses.
Laparoscopic findings were endometriosis nodules in 5
patients, peritoneal pockets, endometriosis, or both in
19 patients, and inflammatory peritoneum in 1 patient.
Associated pelvic endometriosis was identified and
confirmed in 17 women (68%); no additional lesions
 No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain
were found in the other 8 (32%). After excision of the
15 pockets, histologic examination showed endometri-
osis in 9 (60%), endosalpingiosis in 2 (13%), chronic
inflammation in 1 (7%), and normal tissue in 3 (20%).
After laparoscopic excision, sciatic symptoms were
eliminated in 19, were lessened in 4, and remained the
same in 2; symptoms recurred in 3 patients after
2 years. The authors concluded that cyclic leg pain is
associated with pelvic peritoneal pockets, endometri-
osis nodules, or surface endometriosis of the postero-
lateral pelvic peritoneum. They hypothesized that the
pain was likely referred from the pelvic peritoneum
rather than due to direct irritation of the lumbar
plexus of the sciatic nerve.
ADHESIONS
Intraperitoneal adhesions are caused mainly by surgery and
to a lesser extent by endometriosis and abdominal and pel-
vic inflammation or infection.64 The fmancial impact of
adhesions is enormous.65 In the United States, adhesiolysis
was responsible for 303 836 hospitalizations during 1994,
primarily for procedures on the digestive and female repro-
ductive systems, which accounted for 846 415 days of inpa-
tient care and $1.3 billion in hospitalization and surgeon
expenditures.66
Adhesions are found in 25% to 50% of women with CPP,
but their role as a cause of CPP remains controversial.26,67
Diamond and Freeman65 reviewed four uncontrolled,
cohort studies involving 269 women and 4 men and found
rates of 69% to 82% for relief or reduction of chronic pain
after adhesiolysis.
One study randomly assigned 48 women with CPP and
laparoscopically diagnosed pelvic adhesions to adhesiolysis
by laparotomy (n = 24) or "wait-and-see" management
(n = 24).64 Adhesiolysis proved to be of no more benefit
than the wait-and-see approach. Only the 15 women with
severe multiple vascularized adhesions involving the serosa
of the small bowel or, to a lesser extent, the colon benefit-
ted from adhesiolysis (P < 0.01). The authors concluded
that adhesiolysis is not indicated for the treatment of pelvic
pain in women with mild or moderate pelvic adhesions but
that it may benefit women with severe adhesions involving
the intestinal tract.
A recent multicentre, blinded, randomized trial of laparo-
copic adhesiolysis versus diagnostic laparoscopy alone in
87 women and 13 men with chronic abdominal pain found
that at 12 months after randomization, 27% of patients in
the adhesiolysis group (n = 52) and 27% of the controls
(n = 48) reported resolution or substantial reduction of
pain.68 There were no complications in the diagnostic lapa-
roscopy group, but 5 of the 52 patients in the adhesiolysis
group had complications (some had more than one com-
plication): small bowel perforation in 2 patients and hemor-
rhage during surgery (necessitating blood transfusion),
abdominal abscess, rectovaginal fistula, and protracted par-
alytic ileus after surgery in 1 patient each. The authors con-
cluded that laparoscopic adhesiolysis cannot be
recommended as a treatment for adhesions in patients
with chronic abdominal pain.
A recent publication69 reviewed the relation between adhe-
sions and pelvic pain and the effectiveness of adhesiolysis
in pain control. The most common laparoscopic findings
in patients with or without pelvic pain were endometriosis
and adhesions. Multiple adhesiolysis techniques were used,
and outcomes of surgery ranged from no pain relief to
relief in 90% of patients. The authors concluded that a cor-
relation between pelvic pain and adhesions remains uncer-
tain. Adhesiolysis has not been shown to be effective in
achieving pain control in randomized clinical studies.
PELVIC INFLAMMATORY DISEASE (PID)
PID is a common condition that carries several long-term
sequelae, one of which is CPP. CPP has been reported to
occur in 18% to 33% of women after an episode of PID,
regardless of mode of antibiotic therapy.70,71 The corre-
sponding figure was 5% in a control series of women who
had never had PID.68 Although pelvic adhesions after PID
are thought to be the cause of CPP, the exact etiology
remains unknown. One study showed a reduction in physi-
cal and mental health among women with CPP after PID.72
Women with CPP were less likely to be black (P < 0.001)
and more likely to report a history of PID (P < 0.004), a
greater number of previous PID episodes (P < 0.001),
and continued pelvic pain at 30 days (P < 0.001). CPP
was associated with greater age (P = 0.079), being married
(P =0.084), lesser education (P = 0.074), and 3 or more
days between the onset of PID symptoms and treatment
(P =0.182). CPP was associated with lower physical (P <
0.001) and mental health composite scores (P < 0.001)
5 days after enrolment.70
Among 684 sexually active women with PID followed up
for a mean of 35 months,73 self-reported persistent and
consistent condom use was associated with lower rates of
PID sequelae. After adjustment for covariates, the relative
risk for condom users versus nonusers was 0.5 (95% CI
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REAFFIRMED SOGC CLINICAL PRACTICE GUIDELINE
0.3-0.9) for recurrent PID, 0.7 (95% CI 0.5-1.2) for CPP,
and 0.4 (95% CI 0.2-0.2) for infertility.
OVARIAN CYSTS
Unilateral CPP is often attributed to ovarian cysts, if pres-
ent. Chronic ovarian cysts, however, do not usually pro-
duce pain. Although small studies have shown successful
treatment of CPP in patients with ovarian cysts,74 no ran-
domized clinical trials have addressed this issue.
RESIDUAL OVARY SYNDROME (ROS)
ROS is characterized by either recurrent pelvic pain or a
persistent pelvic mass after hysterectomy.75
One study reported an incidence of ROS of 2.8%
(73 cases) after 2561 hysterectomies with preservation of
one or both ovaries over a 20-year period.76 There was no
correlation between unilateral or bilateral ovarian preserva-
tion and development of ROS. Indications for removal of
one or both of the residual ovaries included CPP in 52
patients (2.0%), persistent asymptomatic pelvic mass in 18
patients (0.7%), and acute pelvic pain in 3 patients (0.1%).
Re-exploration occurred within 5 years in 1.3% and within
10 years in 2.1% of patients. Ovarian malignancy was
found in 9 women (serous in 6 patients, mucinous in 1
patient, and borderline in 2 patients), for a rate of 3.5 per
1000 cases in which ovaries were preserved. Indications
for hysterectomy included combinations of fibroid uterus
(in 62 patients), abnormal uterine bleeding (in 34), uterine
prolapse (in 8), and grade 1 cervical intraepithelial neopla-
sia (in 1).
OVARIAN REMNANT SYNDROME (ORS)
ORS is the persistence of functional ovarian tissue after
the intended removal of the ovary. The true incidence
of ORS is not known. The condition is often not sus-
pected in women with CPP who have had oophorecto-
mies.77 The syndrome arises from unintentional,
incomplete dissection and removal of the ovary during
a difficult or emergency oophorectomy or implantation
and growth of displaced ovarian tissue in the abdomen
or pelvic cavity during oophorectomy. The condition is
often encountered in patients with severe endometriosis
and pelvic adhesions or similar conditions associated
with severe pelvic adhesions.
In a cohort study of 119 women presenting with CPP who
had previously undergone oophorectomy, ovarian rem-
nants were found in 18%.78 Five years after removal of the
ovarian remnants, 80% of women reported complete
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resolution of the CPP. Women with ovarian remnants may
present with CPP, sometimes cyclical, or a pelvic mass.
The absence of vasomotor symptoms should make one
suspicious of ORS in a woman with CPP who has previ-
ously undergone bilateral oophorectomy. On vaginal exam-
ination, a tender lateral pelvic cyst may be palpated.
Premenopausal levels of follicle-stimulating hormone and
estradiol, along with the ultrasonographic detection of a
pelvic cystic structure, are helpful in diagnosis.
Treatment of ORS may be attempted with agents such as
GnRH analogues with add-back therapy. There are no
reports of large series addressing this issue. The main man-
agement option at present is surgical excision of the ovar-
ian remnant with a retroperitoneal approach, wide local
excision, and lysis of adhesions.65,79 The risks of ureteric
and bowel injury should be discussed with the patient pre-
operatively.
PELVIC CONGESTION SYNDROME
For more than half a century, dilated pelvic veins have been
observed in some women with CPP. Symptoms may
include a dull aching pain as well as menstrual disorders.
Vulvar varicosities may be associated. Pelvic venography,
Doppler ultrasonography, and MRI have been used to
diagnose pelvic congestion syndrome.80-82 A recent study
of asymptomatic kidney donors showed a 38% incidence
of pelvic congestion syndrome, diagnosed by MRI detec-
tion of dilated pelvic veins. Hysterectomy as a management
option for pelvic congestion syndrome has fallen out of
favour. Although there have been case reports of ovarian
vein ligations and percutaneous embolizations, no con-
trolled clinical trials have evaluated the safety and long-
term effectiveness of these approaches.
POST-HYSTERECTOMY CPP
CPP has been listed as the principal preoperative indi-
cation for 10% to 12% of hysterectomies in the United
States83,84 and Canada.40 Stoval et al.85 evaluated 99
women with CPP of unknown etiology after excluding
endometriosis and adhesions. Histopathologic analysis
of surgical specimens revealed adenomyosis in 20% of
patients, fibroids in 12%, and both in 2%. At an aver-
age follow-up of 22 months, 22% of the women
reported persistent pelvic pain.
Hillis and colleagues84 reported on a prospective cohort
study of 279 women from the Collaborative Review of
Sterilization Study (CREST) who underwent non-emer-
gency hysterectomy for the relief of CPP. After 1 year,
 No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain
74% of the women reported complete resolution of
pain, 21% reported decreased but continued pain, and
5% reported unchanged or increased pain. The proba-
bility of persistent pain was higher among women less
than 30 years old, those with no identified pelvic dis-
ease, those who were economically disadvantaged, those
with more than two pregnancies, and those with a his-
tory of PID. For each of these subgroups, 30% to 40%
continued to have pelvic pain. Unilateral or bilateral sal-
pingo-oophorectomy was not found to play a role. A
separate set of 97 women with dysmenorrhea as their
primary complaint reported resolution (95%), reduction
(4%), or no change (1%) in their dysmenorrhea 1 year
after hysterectomy.84
POST-HYSTERECTOMY ENDOMETRIOSIS
Among women with a previous hysterectomy and BSO
(for different conditions), when laparoscopy was per-
formed because of CPP, endometriosis was found in
34%.86
PELVIC PAIN IN THE ABSENCE OF GENITAL
PELVIC ORGANS
Behera and associates87 evaluated laparoscopically 115
women, 22 to 68 years old, with chronic pain after hyster-
ectomy and BSO. Findings at laparoscopy were adhesions
in 107 patients, adnexal remnants in 32 (ovarian in 26 and
tubal in 6), abnormal appendix in 19, and abnormal perito-
neum in 14. Four peritoneal biopsies revealed endometri-
osis. Six appendices showed disease: endometriosis in two,
chronic inflammation in one, and obliterated lumen in
three. Of the 104 patients who were followed up for 1 to
12 years, 61 (59%) reported a reduction in pain and the
other 43 no change in pain. Reduced pain as reported by
70% of those with ovarian remnants, 62% of those with
endometriosis, 52% of those with adhesiolysis, and 50% of
those with appendectomy.
UTERINE FIBROIDS
Uterine fibroids (leiomyomas) are benign monoclonal
tumours derived from the smooth muscle of the uterus.
These tumours may be due to genetic pleiomorphisms,
with a genetic-environmental interaction. They may be sub-
mucosal, intramural, subserosa!, or pedunculated. A
detailed clinical practice guideline on uterine myomas was
published in the Journal if Obstetrics and GynaecoloJ!)I Canada
in 2003.88 Although dysmenorrhea and pelvic pressure
symptoms may be due to the fibroids, other conditions,
such as endometriosis, adenomyosis, irritable bowel
syndrome, and interstitial cystitis, should be suspected
when patients present with pain as the main symptom.
Pain associated with uterine fibroids may present as dysme-
norrhea, pressure symptoms, or both. Resection of submu-
cosal uterine fibroids associated with menorrhagia and
dysmenorrhea, as well as myomectomy or hysterectomy for
large, symptomatic uterine fibroids, may reduce the chronic
pain. However, no clinical trials have specifically assessed sur-
gical intervention for uterine fibroids as therapy for CPP.
The Maine Women's Health Study,89 a prospective cohort
study of 418 women undergoing hysterectomy, found that
35% of the procedures were performed for uterine fib-
roids. Hysterectomy was highly effective for the relief of
symptoms and was associated with a marked improvement
in quality of life.
ADNEXAL TORSION
Adnexal torsion may produce pain by mechanical, hypoxic,
or chemical tissue changes. Unilateral CPP is often attrib-
uted to ovarian cysts, if present. Chronic ovarian cysts,
however, do not usually produce pain. Although small
studies have shown successful treatment of CPP in patients
with ovarian cysts,74 no randomized clinical trials have
addressed this issue.
Recommendations
1. Hysterectomy for endometriosis or adenomyosis with
ovarian conservation can be an acceptable alternative.
The patient should be informed of the possible conse-
quences (residual ovary syndrome, persistent pain, and
reactivation of endometriosis) (II-2A).
2. Ovarian cystectomy, rather than oophorectomy,
should be an individual decision, based on the
patient's age and wishes, fertility issues, and surgical
feasibility (II-3B).
3. The management of symptomatic uterine fibroids
should follow the clinical practice guidelines of the
Society of Obstetricians and Gynaecologists of Can-
ada (II-3B).
4. The management of adnexal torsion should be deter-
mined according to the patient's age and wishes, fer-
tility issues, and surgical judgment (II-3B).
5. Since the rate of recurrence of endometriosis with
hormone replacement therapy (HR1) in women
undergoing hysterectomy plus bilateral salpingo-
oophorectomy (BSO) is very low, HRT should not
be contraindicated (I-B).
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6. In women with an intact uterus, when total hysterec-
tomy has not been performed because of technical
difficulties, the recurrence of endometriosis contrain-
dicates the use of HRT (I-B).
7. Hysterectomy can be indicated in the presence of
severe symptoms with failure of other treatment
when fertility is no longer desired (I-B).
8. Pelvic peritoneal defects (pockets) are frequently
associated with endometriosis and should be treated
surgically (II-B).
9. Endosalpingiosis is an incidental histologic finding
and does not appear to require specific treatment
(II-2B).
10. Current evidence does not support routine adhesiol-
ysis for chronic pelvic pain. However, diagnostic
laparoscopy remains of value (I-B).
CHAPTER 6: UROLOGIC AND GASTROINTESTINAL
CAUSES OF CHRONIC PELVIC PAIN
Louise Lapensee, MD, FRCSC
Montreal QC
Chronic pelvic pain (CPP) is a complex syndrome that
involves biologic and psychosocial phenomena. This chap-
ter will focus on urologic and gastrointestinal causes
(Table 6.1), particularly the two most frequently found in
women with CPP.
INTERSTITIAL CYSTITIS (IC)
IC is a poorly understood chronic inflammatory condition
of the bladder whose study is complex and frustrating. Its
causes are unknown, its pathophysiology remains uncer-
tain, and the efficacy of treatment regimens is questionable.
Table 6.1. Causes of chronic urologic and gastrointesti-
nal pelvic pain
Urologic Gastrointestinal
Interstitial cystitis (IC) Irritable bowel syndrome
Bladder dysfunction Chronic constipation
Urethral diseases Diverticular diseases
Bladder neoplasm Inflammatory bowel disease
Chronic urinary tract infection Appendiceal diseases
Radiation cystitis Meckel's diverticulum
Renal stone or urolithiasis Neoplastic lesions
Chronic intermittent bowel obstruction
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The prevalence ofiC in the United States is 10 to 67/100
000; women predominate 10 to 1.90-92 Possible causes
include infection, lymphatic or vascular obstruction,
immunologic deficiencies, glycosaminoglycan layer defi-
ciency, presence of a toxic urogenous substance, neural fac-
tors, and primary mast cell disorder.93
Characteristics and Clinical Significance
Most patients present with pelvic pain and irritative voiding
symptoms, such as frequency, urgency, and nocturia.
Patients void 8 to 15 times per day, with an average volume
of 70 to 90 mL. Voiding can occur once or twice per night.
Pain can radiate to any location in the pelvis, in the supra-
pubic area, to the perineum, vulva, vagina or low back, and
even to the medial thighs. Pain can increase during or after
sexual intercourse. Symptoms fluctuate during the men-
strual cycle, with a premenstrual flare, in 18% of women
with IC.94 Patients often have overlapping symptoms
related to the pelvic organs-urologic, gastrointestinal,
gynaecologic, and pelvic floor. Up to 75% of patients with
CPP who visit gynaecologists have urologic symptoms.95
In one retrospective study of 60 women with CPP,96 the
patients were noted to have presented with dyspareunia
and dysmenorrhea, along with CPP, with or without uri-
nary symptoms. Pelvic, uterine, and bladder tenderness
were noted on physical examination. Laparoscopy, cystos-
copy, and hydrodistention of the bladder were performed
in each patient. Of the 60 women, 58 (97%) had IC,
according to the guidelines of the US National Institutes of
Health (NIH). Of the 48 (80%) who had biopsy-confirmed
active endometriosis,47 98% had IC. Endometriosis is
commonly associated with CPP but is not always responsi-
ble for the pain. In this study, 78% of the patients had
both endometriosis and IC. The decision to perform cys-
toscopy should not be based on symptoms alone, because
25% of women with IC would have been missed.
In another study, 45 women scheduled to undergo laparos-
copy for CPP were recruited and screened for IC with the
Interstitial Cystitis Symptom Index and Problem
Index.97,98 Cystoscopy with hydrodistention of the bladder
was performed at the time of laparoscopy. The prevalence
of IC was 38%. Of the 21 women with endometriosis 7
(33%) hadiC; of the 10with adhesions, 4 (40%) had IC;
and of the 14 with normal results oflaparoscopy, 6 (43%)
had IC. The presence ofiC did not necessarily correlate
with the laparoscopic findings. It is therefore not possible
to suggest that cystoscopy is necessary only if the results
oflaparoscopy are negative or to suggest that cystoscopy is
unnecessary if endometriosis or other pelvic disorders are
found (III-C).
 No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain
Diagnosis
The diagnostic criteria and tests for IC are controversial;
Table 6.2 outlines some of those currently recommended.
Since the criteria of the NIH and the National Institute of
Diabetes and Digestive and Kidney Diseases are too
restrictive for clinical use, symptom-based clinical diagnosis
has become increasingly popular. Microscopic hematuria
and infections should be ruled out with urinalysis and urine
culture. If cystoscopy is performed, glomerulation, submu-
cosal hemorrhage, and terminal hematuria may be found.
Hydrodistention at the time of cystoscopy is therapeutic in
20% to 30% of patients, who experience relief for 3 to 6
months.99,100 Cystoscopic findings may help with progno-
sis, because patients with ulcers and significantly reduced
bladder capacity do not respond as favourably to treat-
ment.99,101 The intravesical potassium chloride (KCD sen-
sitivity test is a minimally invasive diagnostic test for IC
that can be done in the office. It may identify a subgroup
of IC patients with epithelial permeability dysfunction and
may predict the response to pentosan polysulfate sodium
(Elmiron).102,103 Only 66% to 75% ofiC patients will have
Table 6.2. Current diagnostic criteria and tests for IC99
Clinical
Pain and bladder irritability
Exclusion of infection and cancer
Diagnostic symptom scores (e.g., on indexes of O'Leary et al.98)
Clinical and cystoscopic (NIH-NIDDK criteria)
Ulcer, non-ulcer IC
Performed with general or spinal anesthesia
60% rate of underdiagnosis
Useful in prognosis
Bladder biopsy
Country- and region-specific
Low diagnostic rate Morbidity
Treatment predictor
Urodynamics
No need for complex UDS
Sensory or motor instability
Potassium chloride sensitivity test
25% rate of underdiagnosis
High false-positive and false-negative rates
Potentially painful
Urinary markers
Glycoprotein-51 and antiproliferative factor
Potentially useful
NIH: National Institutes of Health; NIDDK: National Institute of Diabetes and
Digestive and Kidney Diseases
a positive KCl test result. False-positive results can occur
with detrusor instability, radiation damage, and bacterial
cystitis.103
Treatment
Treatment options for IC include systemic agents, instilla-
tion therapy, and surgical management. Pentosan polysul-
fate sodium is widely used and probably works by
repairing the altered permeability of the bladder surface.104
Only 28% to 32% of patients will have improvement with
this therapy.102
One study evaluated retrospectively the use of gonado-
tropin-releasing hormone (GnRH) analogues or oral
contraceptives (OCs) in the treatment of IC with pre-
menstrual flare of symptoms.94 Of 23 women with
known IC who had irritable bladder symptoms that
fluctuated with the menstrual cycle, 15 chose to
undergo laparoscopy, repeat cystoscopy, and hydrodis-
tention. They were then offered a 6-month course of
treatment with either GnRH analogues or OCs. Symp-
toms were markedly reduced during therapy in eight of
the nine women treated with GnRH analogues but
relapsed in five after the treatment was stopped. Of the
six women treated with OCs, five improved during
treatment. The five women without endometriosis
improved with hormonal treatment.
Summary
IC should always be considered in the differential diagnos-
tic of CPP, especially in women presenting with bladder or
pelvic pain or dyspareunia, even if the symptoms increase
in the premenstrual period. Gynaecologists, urologists, and
family physicians should work together to increase their
diagnostic accuracy with this unusual condition. Gynaeco-
logic teaching traditionally does not focus on syndromes
originating from the bladder. Urologic and gastrointestinal
training has not focused on pelvic pain syndromes. IC
patients frequently end up in the gynaecologist's office,
which helps to explain the usual delay in diagnosis of IC of
more than 5 years.105,106
IRRITABLE BOWEL SYNDROME (IBS)
IBS affects up to 15% of adults, twice as many women as
men.107 Patients present with abdominal pain and discom-
fort, bloating, and disturbed bowel habits (diarrhea, consti-
pation, or both). The multifactorial pathophysiology
mcludes altered bowel motility, visceral hypersensitivity,
and psychosocial factors.
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Characteristics and Clinical Significance
Symptoms suggesting IBS exist in SO% to 80% of patients
presenting with CPP.67 Many women with IBS consult a
gynaecologist rather than a gastroenterologist.
Gynaecologic disease can also be misdiagnosed as IBS,
which indicates an overlap between gynaecologic and gas-
trointestinal symptoms. In fact, IBS can be associated with
dyspareunia, and bowel symptoms worsen during menstru-
ation in 50% of women. There is also an increased preva-
lence of IBS in women referred for menorrhagia and
intermenstrual bleeding.108 In a study of 728 women
referred to a gynaecology clinic, the prevalence of IBS was
37%, compared with 28% in a control group.109 Of 71
women with CPP presenting to a gynaecologic clinic, 52%
had symptoms suggesting IBS.110 A clear gynaecologic
diagnosis was reached in only 8% of those with IBS-type
symptoms, compared with 44% of those without such
symptoms. After 1 year, 65% of the women with IBS-type
symptoms were still symptomatic, compared with 32% of
those who had presented without such symptoms. In
another study, IS was diagnosed in 48% of women under-
going diagnostic laparoscopy for CPP, 40% of women
undergoing elective hysterectomy, and 32% of age-
matched controls.111 CPP was often the only pre-hysterec-
tomy diagnosis in the IBS patients, and women with IBS
were much less likely to have reduced symptoms 1 year
after laparoscopy or hysterectomy. Women with severe
constipation can also experience CPP, and many undergo
unnecessary gynaecologic surgery without pain relief
before seeing a gastroenterologist.112,13
Diagnosis
The Rome II criteria are currently the standard for clinical
diagnosis ofiBS.114 In the preceding year, the patient
should have had more than 12 weeks of abdominal dis-
comfort or pain and at least two of the following:

pain or discomfort that is relieved after defecation,

association of the onset of pain or discomfort with a
change in stool frequency, and

association of the onset of pain or discomfort with a
change in stool appearance.
The following symptoms can also be associated with IBS
but are not necessary for diagnosis:

abnormal stool frequency (fewer than three bowel move-
ments per week or more than three per day),

abnormal stool form,

abnormal stool passage (straining, urgency, or the feeling
of incomplete evacuation), and

passage of mucus.
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In the presence of bloating or a feeling of abdominal dis-
tension, organic disease must be excluded. For patients
over the age of 45 years or with rectal bleeding, weight
loss, anemia, or a family history of colorectal cancer, colo-
noscopy or sigmoidoscopy with a barium enema and a
flexible instrument should be performed. For patients
under the age of 40 and a negative history, evaluation
should include sigmoidoscopy with a flexible instrument.
Initial laboratory investigation should probably include a
complete blood count, measurement of thyroid-stimulating
hormone levels, and liver function tests.115
Treatment
Dietary manipulation may be of benefit in some patients.67
Elimination of dietary lactose, sorbitol, and fructose may
be of value. About 40% of patients with IBS have lactose
intolerance. Caffeinated products, carbonated products,
and gas-producing foods should be avoided, because they
may contribute to bloating. Smoking and gum chewing
lead to more swallowing of air and may increase gas or
bloating. Excessive alcohol consumption may lead to
increased rectal urgency.
The medical management of IBS is based on the patient's
symptoms. If pain is the predominant symptom, antispas-
modic agents or tricyclic compounds may be helpful. Con-
stipated patients benefit from increased dietary fibre along
with osmotic laxatives, if needed. Many patients have
increased gas when they increase their intake of dietary
fibre, and about 15% cannot tolerate fibre therapy. Long-
term use of stimulant laxatives should be discouraged.
Diarrhea can sometimes be managed with increased die-
tary fibre and with antidiarrheal agents as needed. Lopera-
mide (Imodium) is the most commonly used agent.116
Serotonin receptor agonists stimulate colonic motility and
may diminish visceral hypersensitivity. Peppermint oil, a
major constituent of several over-the-counter remedies for
IBS, appears, from several randomized clinical trials, to be
effective.117 It decreases abdominal distension reduces
stool frequency, decreases borborygmi, and reduces flatu-
lence. A double-blind, placebo-controlled, randomized
study reported a significant reduction in abdominal pain
and nausea in premenopausal women with functional
bowel disease treated with GnRH analogues.118 GnRH
analogues may help minimize long-term use of other pre-
scription medications, many of which provide only small
improvement over placebo.
Combining psychological treatment with medical therapy
improves the clinical response over that with medical ther-
apy only.119 One study determined that 21% of women
under 40 with IBS had undergone a hysterectomy, whereas
the national average rate was 6%.110 Whether this
 No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain
represents inaccurate diagnosis by gynaecologists, the pres-
ence of multiple disorders in women with IBS, or an etio-
logic link between gynaecologic disorders and IBS is not
clear.67
SUMMARY STATEMENTS
1. Urinary and gastrointestinal symptoms are often
present in women with CPP (II-2).
2. IC is a common cause of CPP and often coexists
with endometriosis (III).
3. IBS can coexist with other pelvic diseases or be the
sole cause of CPP in women (II-2).
4. Diagnosing IC or IBS in women with CPP will
improve management (III).
Recommendations
1. Cystoscopy by trained specialists, with or without
diagnostic laparoscopy, should be considered when
interstitial cystitis (IC) is suspected (III-B).
2. Women with chronic pelvic pain will require detailed
gynaecologic, urologic, gastroenterologic, and psy-
chological assessment. Appropriate evaluation can
lead to optimal treatment and decrease the rate of
inappropriate interventions (III-B).
SOGC CLINICALCHAPTER 7: MYOFASCJAL
DYSFUNCTION
Robert Gerwin, MD1; Paul Martyn, MB BS2;
John F. Jarrell, MD2
1
Baltimore MD
2
Calgary AB
INTRODUCTION
The diagnosis of myofascial abdominal and pelvic pain is
commonly overlooked by the general gynaecologist. Reiter
and Gambone120 reported on 122 patients with chronic
pelvic pain (CPP) who had been referred to a multidisci-
plinary clinic after negative results of laparoscopy and
underwent a thorough medical and psychological evalua-
tion and followup for a minimum of 6 months after com-
pletion of therapy. Myofascial pain was the most common
somatic diagnosis, accounting for 30% of such diagnoses.
In most of these cases, the pain was in lower abdominal
scars and responded well to trigger-point injection and, in
3 cases, scar revision. Gastrointestinal disorders were
found in 14% and genitourinary disorders in 11% of all
122 patients.
PATHOPHYSIOLOGICAL ASPECTS
In the neuromuscular stage, muscle hyperactivity and irrita-
bility are sustained by mechanical and postural stressors
and prolonged contraction of muscle. Injury or micro-
trauma releases free calcium within muscle. Conscious
awareness of pain provokes muscle guarding and splinting.
In the musculodystrophic stage, after sustained contractile
activity the muscle attempts to adapt by increasing meta-
bolic activity, which results in localized fibrosis.121
Travell and Simons122 defined a myofascial trigger point as
a focus of hyperirritability in a muscle or its fascia causing
pain symptoms. It refers pain in a pattern specific to that
muscle. An active trigger point is always tender, prevents
muscle lengthening, refers pain on direct compression,
mediates a local twitch response and often produces spe-
cific referred autonomic phenomena generally in its pain
reference zone.
Trigger points are thought to occur in a muscle in response
to acute or chronic stress caused by many factors, including
chronic microtrauma, sleep disorders, fatigue, macro-
trauma, systemic influences, and psychosocial stress. They
may also be due to nerve entrapment, particularly when a
Pfannenstiel incision was previously made in the distribu-
tion of the first to third lumbar nerves, where the ilioingui-
nal and iliohypogastric nerves are involved. They can occur
in the abdominal rectus and oblique muscles, hip flexors
(including the iliacus and psoas), adductor group, pirifor-
mis, gluteals, and pelvic floor musculature, referring pain
in and around the abdominal wall and pelvis.122 When a
trigger point on the abdominal wall is palpated, the patient
may respond with a jump or a local twitch. In Carnett's
test, the area of abdominal tenderness is palpated while the
patient voluntarily contracts her abdominal muscles by
raising her head or legs. An increase in the pain indicates a
myofascial origin, whereas a decrease indicates an intraperi-
toneal disorder.
MYOFASCIAL PELVIC PAIN
Hypertonus of the levator ani group of muscles (pelvic
floor tension myalgia) produces pain poorly localized to
the perivaginal and perirectal areas. Pain may also be felt in
the abdominal lower quadrants, suprapubic areas, coccyx,
and posterior thigh. Piriformis syndrome is a similar prob-
lem in the adjacent piriformis muscle. These disorders
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involve a high resting tone in the muscles and fascia that
attach to the bony pelvis.
Interstitial cystitis (IC), vulvodynia, and urethral syndrome
associated with pelvic floor tension myalgia may contribute
to the pain associated with these conditions.123 Dyspareu-
nia is common in patients with IC.
Weiss124 recently reported successful outcomes in 52
patients using manual physical therapy to treat IC and ure-
thral syndrome. The rationale was that pelvic floor myofas-
cial trigger points are not only a source of pain and voiding
symptoms but also a trigger for neurogenic bladder symp-
toms. Moderate to marked improvement occurred in 35
(83%) of the 42 patients with urethral syndrome and 7 of
the 10 patients with IC. Electromyography demonstrated a
decrease in pelvic floor resting tone. Symptoms had been
present for 6 to 14 years.
Scars in the abdominal wall may cause abdominal or pelvic
pain and in such cases usually demonstrate limited mobility.
Similarly, perineal scars can affect sexual function if not
sufficiently mobile. Reactive muscle contraction can pro-
duce vagtrusmus.
Myofascial pelvic pain may develop over time in response
to pain caused by gynaecologic disease or as a direct result
of faulty body mechanics or other problems. Differentiat-
ing the cause of the pelvic pain is often difficult for the
gynaecologist and is best approached in conjunction with a
physical therapist.
TREATMENT OVERVIEW
Patient education on pelvic floor function is vital to suc-
cessful physical therapy. Physiological quieting and general
relaxation with the use of biofeedback are taught to
patients.
Manual soft tissue release is essential to reduce pelvic floor
resting tone and tension. Acupuncture may also be
helpful.121
It is important to inactivate trigger points to restore muscle
to its normal resting length before strengthening. Trigger
points can be injected with local anesthetic, dry-needled,
massaged, or sprayed with a coolant such as ethylchloride
and then actively stretched, a technique that has been
reported to be effective.122 Physical therapists may use
other modalities, such as high-voltage galvanic stimulation,
ultrasound, heat, and ice. Therapeutic exercises are used to
correct muscle weakness, tightness, and spasms.
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OFFICE APPROACH TO MYOFASCIAL SOURCES
OF GYNAECOLOGIC PAIN
Gynaecologic pain, or pain of pelvic origin, can arise from
visceral organs in the pelvis, the muscular body wall
(including the abdomen and low back muscles), the
muscles of the hip region and upper thigh, and the lumbo-
sacral nerves (nerve roots and peripheral nerves). Visceral
pain has a wide variety of causes, both pathological (e.g.,
those associated with tissue damage or inflammation) and
nonpathological (e.g., distention or increased capsular pres-
sure). Pain in muscles, whether those of the body wall (e.g.,
abdominal or low back muscles) or of the hips and extrem-
ities (e.g., gluteal and adductor muscles) is associated with
discrete bands of muscle hardness and tenderness (myofas-
cial trigger points).
Visceral and myofascial sources of pain can refer pain else-
where. In particular, visceral pain can cause pain to be felt in
the body wall and hip region, and myofascial trigger points
can cause pain to be felt as deep pain, as if coming from the
viscera. Myofascial trigger points are also associated with vis-
ceral organ dysfunction, such as irritable bladder syndrome
and irritable bowel syndrome. Conditions such as IC associ-
ated with urinary frequency and pain can be worsened by
myofascial trigger points in the abdomen, hip region, and pel-
vic floor. These trigger points can also cause pain that is felt
to be coming from pelvic organs and can be indistinguishable
from the pain of endometriosis.
Myofascial trigger points are caused by muscle stress or
overuse and are most likely associated with local ischemia,
which promotes both the contracted, hard band of the trig-
ger point and the release ofvasoactive substances that cause
vasodilation and neurogenic edema and activate peripheral
nerve nociceptive receptors, causing pain. Trigger points are
identified by physical examination. Treatment of the muscu-
lar or myofascial component of pelvic pain syndromes is
accomplished by inactivating the trigger point through man-
ual means, as in physical therapy, or by needling or injection
of local anesthetic into the trigger point. Identification and
correction of predisposing, initiating, and perpetuating fac-
tors associated with the pain syndrome, whether muscular
or visceral, is necessary to complete treatment and reduce or
eliminate the likelihood of recurrence.
The gynaecologist can evaluate the abdomen for tender-
ness and myofascial trigger points, particularly looking for
those that reproduce the patient's pain. The same can be
done with the pelvic floor muscles, including the obturator,
piriformis, and levator ani muscles. The muscle examina-
tion can be done at the time of the pelvic examination or
in conjunction with it. A careful examination to exclude
 No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain
abdominal wall hernias must be performed, and the clini-
cian must bear in mind that myofascial pain may coexist
with other pelvic disorders. The interested and knowledge-
able gynaecologist can extend the examination, as needed,
using the following multiple-level examination protocol, a
screening examination for mechanical causes of pelvicre-
gion pain. The protocol guides the examiner through the
examination process and instructs him or her in the treat-
ment or correction of the low back and pelvic structural
dysfunctions that often accompany visceral pelvic pain
problems. The protocol assumes that a neurologic exami-
nation for disorders of the ilioinguinal, iliohypogastric, gen-
itofemoral, and pudendal nerves has been conducted.
Examination for Hip and Pelvic-Region Function
and Symmetry
1. Evaluate the patient while she is walking for scoliosis
and for foot and knee abnormalities, such as excessive
foot pronation, leg and foot rotation, and knee defor-
mities.
2. Evaluate the patient while she is standing for shoulder
height and iliac crest asymmetry. If the ipsilateral
shoulder and iliac crest are both high, there is S-
shaped scoliosis. If the contralateral iliac crest and
shoulder are high, there is C-shaped scoliosis. In
either case, the clinician must determine whether the
scoliosis is caused by a fixed structural abnormality or
a correctable functional abnormality.
3. Assess posterior superior iliac spine (PSIS) symmetry.
If one PSIS is higher than the other, there is either a
tilt of the pelvis due to real or pseudo-inequality in leg
length or pelvic torsion, similar to asymmetry in iliac-
crest height.
4. Assess anterior superior iliac spine (ASIS) symmetry.
If one ASIS is higher than the other, there is either
pelvic tilt or torsion. If the PSIS and the ASIS are
both high on one side, there is real or pseudo-inequal-
ity in leg length. If the contralateral PSIS and ASIS are
high, there is pelvic torsion.
5. Perform a standing forward-flexion test, palpating the
PSISs, to determine if they move symmetrically or if
one moves more rostrally than the other. The one
that moves is "hypermobile" and the one that does
not move as well is "fixed" or "hypomobile". If the
PSISs do not move symmetrically, there is torsion of
the pelvis during flexion. Torsion can be seen with
any restriction or imbalance of the pelvis, including
leg-length inequality, iliac bone rotation, and sacroiliac
joint hypomobility. The examination sequence is
intended to distinguish between these possibilities.
6. Perform a sitting forward-flexion test. If there is scoli-
osis when the patient is sitting, then there is pelvic
height asymmetry, or shortening of one of the
muscles that bends the spine (quadratus lumborum
or iliopsoas). Palpate the PSISs as the patient bends
forward. The PSISs should move symmetrically. If
they do but there was an abnormal result in the stand-
ing forward-flexion test, then the abnormality is
caused by iliac bone rotation (pelvic torsion). Sitting
stabilizes the iliac bone so that it will not rotate when
the body flexes while sitting. If the PSISs move asym-
metrically, then there is sacroiliac joint hypomobility.
7. If there is evidence of iliac bone rotation, correct it.
The side that is ipsilateral to the rising or rostrally
moving PSIS is anteriorly rotated and needs to be
posteriorly rotated. This can be done with muscle
energy techniques, using the gluteus maximus to pos-
teriorly rotate the iliac bone and the rectus femoris to
anteriorly rotate the iliac bone.
8. To check the abnormality in a second examination
position, have the patient lie supine and stand at the
foot of the examination table. With the patient
straight, check the anterior and posterior heights of
the ASISs to determine if one side is high, which
would indicate anterior or posterior rotation of the
pelvis (which accompanies anterior or posterior rota-
tion of the sacrum). Assess the positions of the medial
malleoli relative to each other. They should be level. If
not, note which one is higher (and thus which leg is
functionally shorter). The patient then sits, the legs
sliding downward with the anterior rotation of the
pelvis. Note if one side moves further down than the
other. They should move equally. If not, there is pelvic
rotation. The side that moves further is anteriorly
rotating. In general, there is agreement between the
results of the forward-flexion tests and the supine-to-
sitting test. Correct rotation as described for the iliac
bone.
9. Assess levels of the inferior lateral angle of the sacrum
for tilt. Assess the angle for anterior or posterior dis-
placement. A sacral tilt will increase pressure on the
ipsilateral sacroiliac joint.
10. Assess function of the gluteus medius muscle with the
Trendelenburg test. A drop of the hip on the side
opposite to the standing leg means that the gluteus
medius is weak, either actually or functionally. Exam-
ine the gluteus medius for trigger points. If present,
they should be treated and the Trendelenburg test
repeated to see if the result becomes normal.
11. Evaluate the pubic symphysis for tenderness and
symmetry. If abnormal, the symphysis should be
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mobilized by activating the adductor muscles. The
patient is supine, feet together, and hips and knees
flexed. The knees are abducted 45° to 60°. Standing
at the patient's side, place a forearm between the
patient's knees, your hand on the far knee and your
elbow against the near knee. Ask the patient to adduct
the knees against your forearm, which causes the
adductor muscles to pull on the pubic ramus, widen-
ing the pubic symphysis. Do this at the same time as
the sacroiliac flare described in step 13.
12. The patient is now prone. Standing at the patient's
side, examine the sacrum for movement of the sacro-
iliac joint. The sacrum rotates about a diagonal line
that runs from one superior aspect of the joint to the
opposite inferior lateral angle. Depress one inferior
lateral angle while palpating the contralateral superior
aspect of the joint. The sacrum should rock across
the diagonal axis. If not, it must be mobilized.
13. Before mobilizing the sacrum, flare the sacroiliac
joints by having the patient lie supine, knees and hips
flexed and feet together. The thighs are abducted 45°
to 60°. Place your hands on the outside (lateral aspect)
of each knee. Ask the patient to abduct the thighs
against your hands. This places a laterally directed
force on the iliac bones.
14. To mobilize the sacrum, place the hypermobile side
superiorly while the patient lies in the lateral decubitus
position. The legs are flexed at the hip and at the knee.
If the hypermobile side is posteriorly rotated (the sacral
sulcus on the hypermobile side being more shallow
than on the freely moving side), it must be rotated ante-
riorly. To accomplish this, bring the upper shoulder for-
ward during mobilization of the sacroiliac joint. If the
hypermobile side is anteriorly rotated (the sacral sulcus
on the hypermobile side being deeper than the freely
moving joint), place the upper shoulder posteriorly dur-
ing mobilization. Correction of anterior or posterior
rotation is accomplished by creating the opposite condi-
tion (posterior rotation when the side is anterior, ante-
rior rotation when the side is posterior). Now, have the
patient bring her knees to the edge of the table, ankles
and feet together, and bring the ankles and feet off the
side of the table. Stand in front of the patient at the side
of the table so that the patient's knees are stabilized by
your left hand under the thigh, just above the knee.
Place your right hand on top of both of the patient's
ankles and rotate the legs downward together slowly
(over 5 to 10 seconds) until a barrier is reached. Have
the patient use the Lewit technique125 of post-isometric
contraction and relaxation to facilitate stretch and mobi-
lization. Repeat this sequence until full motion is
achieved. This action lifts the superior iliac bone away
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from the sacrum, to increase the joint space and achieve
mobility.
Muscle Examination for Myofascial Trigger Points
Record the areas of tenderness and the referred-pain pat-
tern of myofascial trigger points on a body diagram.
Levell
The patient lies supine, with the knees bent and supported
on a pillow to relax the abdomen. Palpate the abdominal
wall, including the insertions of the abdominal muscles at
the costal margins, at the iliac crest, and at the pubic bones,
to assess tenderness and tightness of the abdominal wall.
Palpate in both diagonal directions to detect tight linear
bands of contracted muscle in the external and internal
oblique abdominal muscles, as well as vertically to detect
tight bands of contracted muscle in the horizontal fibres of
the transverse abdominal muscle. Palpate the rectus
abdominus muscle across the fibres (i.e., with a transverse
motion of the fingers) to detect tight, contracted bands of
muscle. Assess tenderness of the abdominal wall through-
out the examination. The patient then distends the abdom-
inal wall, lifting it away from the contents of the abdominal
cavity. The patient should be able to maintain the disten-
tion while breathing and talking. Palpate the abdominal
wall again for tenderness (which will be from the abdomi-
nal wall and not from the internal organs) and discrete
areas of hardness.
Palpate the adductor muscles of the medial thigh for bands
of tight muscle and tenderness. Compress any tender spot
firmly for 5 to 10 seconds to elicit referred pain, which
might be felt in the groin, inner aspect of the thigh, or (in
the case of the adductor magnus muscle) deeply, but poorly
localized, in the pelvis.
The patient now turns to the lateral decubitus position, the
head and arm supported by pillows. Position the superior
leg behind the lower leg to drop the pelvis and increase the
space between the rib cage and the iliac crest to facilitate
palpation of the quadratus lumborum muscle. The lateral
border of this muscle is between the 12th rib and the iliac
crest, directly above the transverse processes of the lumbar
spine, into which the muscle inserts medially. Note any
tight bands and tenderness in this muscle.
Palpate the lumbar paraspinal muscles for linear bands of
hardness or tautness, and note the patterns of any referred
pain.
Palpate the three gluteal muscles (maximus, medius, and
minimus), the piriformis, and the tensor fascia lata muscles
 No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain
for discrete bands of hardness or tautness and tenderness,
and note the patterns of any referred pain.
Level 2
The patient lies supine, with the knee ipsilateral to the side
being examined bent to relax the abdomen. Stand at the
patient's side, the fmgertips of the palpating hand lateral to
the border of the rectus abdominus muscle, from the level of
the umbilicus caudally. Place the other hand over the examin-
ing hand and guide the examining fmgers so that the fmger-
tips are pointing to the psoas muscle. Move the hand slowly
into the abdomen, over six breaths from the patient, to
move aside the bowel. The fmgers will come to rest on the
psoas muscle. Confirm location by moving the ipsilateral
knee a few inches toward the chest to contract the psoas.
Assess the muscle for tenderness. The examining technique
can also be used for manual treatment of the muscle.
Examine the obturator internus with the patient supine and
the legs flexed at the hips and knees, feet together, the legs
falling away to the side. Palpate the muscle posterior (dor-
sal) to the adductor brevis, where it inserts onto the femur.
Palpate the pectineus muscle for groin pain, as it lies under-
neath the femoral neurovascular bundle. Palpate the mus-
cle medially and superiorly to the femoral artery.
Level 3
Examine the levator ani muscle per rectum, sweeping the
examining fmger from anterior to posterior on each side,
noting any tenderness and horizontal bands of tightness or
hardness.
Examine the piriformis and obturator internus muscles for
tenderness and discrete bands of tightness rectally or vaginally.
Reproduction of all or part of the patient's pain is sought
when examining the pelvic and abdominal regions for ten-
derness and muscle hardness.
TREATMENT OF MYOFASCIAL TRIGGER POINTS
Injections
Inactivation of a trigger point by injection appears to result
from the mechanical action of the needle at the trigger
point, since it can be accomplished by dry needling without
local anesthesia or the use of other materials. Local anes-
thesia is more comfortable for many patients and results in
a longer-lasting reduction in trigger-point pain.126,127
A local twitch response or a report of referred pain indi-
cates that the trigger zone has been entered. A small
amount of anesthetic, usually 0.1 or 0.2 mL, is injected into
the trigger zone. The needle is withdrawn to just below the
skin and its angle changed; the needle is then passed
through the muscle to another trigger zone. A conical vol-
ume of muscle can thus be examined for active trigger
points without withdrawal of the needle through the skin.
The trigger zone is explored in this manner until no further
local twitch responses are obtained. At this point, the taut
band is usually gone, and the spontaneous pain of the trig-
ger point has subsided.
Historically, procaine has been used for this purpose,
although lidocaine is also commonly used today. Procaine, in
a dilute solution of 0.5%, has a short half-life, which is an
advantage if the anesthetic solution spreads between tissue
planes and produces a nerve block. When diluted to 0.25%
in water, lidocaine has been shown to produce the least pain
after injection, although when diluted in normal saline it
works well enough, with minimal pain after injection.
Glucocorticosteroids and ketorolac have also been used,
but they have not been the subject of controlled studies
comparing their effectiveness against that of either local
anesthesia or dry needling. Steroids have the disadvantage
of being locally myotoxic, and repeated administration can
produce all of the associated unwanted side effects. Saline
or dry needling can be performed on persons allergic to
local anesthetics. A systematic review of the literature
found no advantage to the addition of any substance,
whether steroids, ketorolac, or vitamin B12, which is some-
times added to the mix.128
Botulinum toxin has been successful in trigger-point inactiva-
tion.129-131 It is of particular interest in the treatment of myo-
fascial pain syndromes, including myogenic headaches or
headaches of muscular origin, because it has a direct effect
on pain mechanisms as well as on muscle contraction.132
There is no limit to the number of trigger-point injec-
tions that can be given. Common sense and patient
comfort dictate restraint. Nevertheless, a sufficient
number of muscles in the region must be treated to
resolve a regional myofascial pain syndrome and allow
effective stretching. Five to ten trigger-point sites can
readily be treated per session, and some skilled physi-
cians will treat considerably more in one session.
Repeat injections into the same area are best done after
an interval of a week to allow the muscle to recover.
Complications are infrequent and include bleeding,
pain, and, rarely, anaphylaxis if local anesthetics are
used. Inadequate attention to postinjection aspects of
treatment leads to failure to relieve pain.
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Gunn and colleagues133,134 reported on a method of trigger-
point inactivation called intramuscular stimulation (IMS).
IMS involves insertion of the needle directly into the trigger
point and is a form of dry needling. It may be combined
with electrical stimulation through the needle (percutaneous
electroneural stimulation). None of these techniques has
been subjected to clinical trials for effectiveness.
The abdominal contents can be avoided by depressing the
abdominal wall with a tongue blade or the finger, so that the
needle can be inserted laterally into the wall trigger point
without risking injection through the wall into the bowel.
Trigger points in the lateral abdominal wall can be needled or
injected by grasping the wall musculature between the index
and long fingers and the thumb to move the bowel out of
the way and then injecting the grasped muscle with the nee-
dle, perpendicular to the plane of the muscle.
The piriformis muscle can be injected from the outside
(percutaneously), after identifying the muscle by palpation,
between the superior trochanteric insertion of the muscle
and the sacral origin of the muscle below the PSIS.
The obturator internus can be injected from outside the
pelvis or through the vagina. Rhonda Kotarinos, a Chicago
physical therapist, uses a metal flute to guide the needle to
the muscle trigger point when her gynaecologic colleagues
inject trigger points through the vagina.
The levator ani muscle can be injected by inserting the needle
lateral and a little ventral to the coccyx, one finger of the other
hand in the rectum at the trigger point guiding the needle.
Physical Therapy
The goal of physical therapy for myofascial pain syndrome
is to restore function to the affected person. Dysfunction
is the result of pain that interferes with use of a body part
or with sleep. Dysfunction therefore results from the mani-
festations of the trigger point; namely, tenderness, shorten-
ing of the muscle, with resultant limited or painful range of
motion, and weakness. Referred pain falls into the category
of pain-associated limitations, except that trigger points
can be found in the zone of referred pain.
Physical therapy, or, more properly, manual therapy, is
directed toward decrease of pain and restoration of a nor-
mal, pain-free range of motion. Referred pain will decrease
with this treatment, but trigger points in the referred-pain
zone must also be treated directly.
A treatment protocol that we have found to be effective
has been adapted from the work of Dejong122 of Switzer-
land and Travell and Simons122 of the United States. The
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techniques have been influenced by the work of Gunn133
of Canada and Lewit125 of Czechoslovakia.
The protocol involves the decrease or elimination of pain
by direct finger pressure on the trigger zone; that is, the ten-
der part of the hard or taut band of muscle. Decrease in
pain usually occurs within 15 to 20 seconds, and relaxation
of the taut band usually occurs within 1 minute of compres-
sion. Compression is followed by a firm stretch of the local
segment of muscle: a fmger is run along the taut band for
about 1 to 2 inches for about 3 to 5 repeats. Mobilization
of the fascia is done next, with strong, firm pressure on the
muscle directed through the referred-pain pattern. These
therapeutic stretches of each muscle treated are performed
to lengthen the shortened bands of contracted or hard mus-
cle. The stretches are muscle-specific and must be done
with knowledge of the functional anatomy of the muscle.
Stretching must be limited in hypermobile women.
Concurrently, the patient is taught a home-treatment
program.
Most muscles can be treated outside of the internal pelvis.
However, stretching the levator ani can be very helpful to
some patients and requires a stretch per rectum. The piri-
formis muscle can be stretched via the pelvic approach but
also can be treated outside the pelvis.
This program is continued until pain is reduced and range
of motion is improved, at which time strengthening and
core or lumbar stabilization can be introduced.
Other physical therapy modalities can supplement this pro-
tocol. Few studies have been published on the effectiveness
of specific treatment techniques in myofascial pain syn-
dromes, and fewer have been controlled or randomized.
The reported outcome, however, is that ultrasound, mas-
sage, stretching, and heat can all be helpful in reducing
pain and restoring function. Relaxation techniques and
then manual stretching of the rectal sphincter and levator
ani can be very helpful in persons with pelvic pain. Disten-
sion of the bladder can be very effective in reducing urinary
frequency in persons with irritable bladder syndrome.
Rolfing and other techniques have their advocates and can
also be effective. Rolfing is defined as creating a holistic
system of soft tissue manipulation and movement educa-
tion that organizes the whole body in gravity. It is named
after Ida Rolf, who first described the technique.135
Part of a physical therapy program is the identification and
treatment of structural abnormalities, such as pelvic asym-
metry and scoliosis.
 No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain
In a word, physical therapy can be effective when carried
out about twice weekly, until the myofascial syndrome has
begun to resolve. A home program is essential. Treatment
can be brief for acute syndromes but can continue for
months for CPP.
Sacroiliac Joint
The sacroiliac joint and its relation to pelvic pain are of his-
torical importance as well as interest. Pain emanating from
the region of this joint was recognized in the late 19th cen-
tury and has remained in the fields of osteopathy and chi-
ropractic ever since. The sacroiliac joint lost its popularity
in favour of disc surgery and is only now being evaluated
in relation to CPP. This joint is included in the discussions
of CPP because of the clinical presentation, which may
mimic visceral problems, especially in the lower quadrants
of the abdomen, and the recent availability of treatments
that hold promise.
The sacroiliac joint is a large joint made of articular carti-
lage. In men, there are ridges that interlock and prevent
movement of the joint. This interlocking is generally absent
in women, who have a smooth articular surface that has
been assumed to assist with mechanical changes associated
with childbirth. The sacroiliac joint braces the weight of
the torso and conveys force outward toward the ilium.
Movement in the joint spaces has been appreciated by
experienced therapists, and recently, more thorough testing
of this movement has begun. The joint is held in place by
dense ligaments. Current observations indicate that for-
ward movement of the pelvis in relation to the spine (nuta-
tion) is limited by the long dorsalligament of the spine and
the thoracolumbar fascia. The opposite movement, coun-
ternutation, in which the sacrum flexes on the vertebral
column, is held in check by the sacrotuberous ligament.
The role of these ligaments, regulating nutation (forward
movement of the sacrum) and counternutation (backward
movement of the sacrum), is considered important in
sacroiliac stability.136,137 The actual mechanisms of pain in
this joint remain poorly understood.
Clinically, pain emanating from the sacroiliac joint is appre-
ciated in the posterior pelvis, with some radiation into the
lateral aspect of the thigh. Some women experience
abdominal pain in the right and left lower quadrants that is
perhaps due to irritation of the psoas muscle, which
courses along the anterior aspect of the joint.
Diagnosis of the sacroiliac problem is based on the appre-
ciation of pain associated with strain induced in the region
of the joint. A number of procedures are used in evaluating
the joint, but their description is beyond the scope of this
chapter. Although many of these functional tests have not
been validated among therapists, it is generally recognized
that individual therapists have particular skills in this area
of investigation and are capable of evaluating pain from
this site and establishing its relation to sacroiliac joint laxity.
At present, there are no commonly used tests of sacroiliac
stability other than clinical examination, although research-
ers are beginning to use ultrasound to detect movement in
the joint.138,139
This pattern of pain is very common in women. There still
is no clear understanding of the mechanics of the joint in
relation to pain and joint mobility, although there have
been investigations into the biomechanics of the joint.140
New approaches to the management of pain that are under
increasing evaluation include prolotherapy,141 in which a
sucrose solution is injected into the sacroiliac joint space or
into multiple joint spaces in the vertebral column. The
inflammation produced in the joint space results in restric-
teq motion and reduced mobility. Although this therapy is
becoming popular for pain in the lower back due to joint
laxity, additional clinical trials into its use in the manage-
ment of sacroiliac pain would be ideal.142
SUMMARY STATEMENT
Physical therapists are an important part of the health
team in relation to CPP due to myofascial dysfunction (I).
Recommendations
1. Health care providers should become more aware of
myofascial dysfunction as a cause of chronic pelvic
pain (CPP) and the available treatment options (IB).
2. Patients should participate in the management of
CPP due to myofascial dysfunction by actively using
a home stretching and exercise program (II-2B).
CHAPTER 8: MEDICAL THERAPY-EVIDENCE ON
EFFECTIVENESS
Claude Fortin, MD; 1 Robert H. Lea, MD2
1
Montreal QC
2
Halifax NS
INTRODUCTION
In clinical practice, there are two approaches to the treat-
ment of chronic pelvic pain (CPP). One is to treat the pain
as a diagnosis and the other is to treat the disorders that
cause or contribute to the pain.26 In many patients,
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effective medical therapy could be achieved by using both
approaches.
Detailed treatment of CPP associated with endometriosis
was outlined in the SOGC consensus guideline in 1999.27
A meta-analysis of interventions for CPP not associated
with endometriosis, primary dysmenorrhea, chronic pelvic
inflammatory disease (PID), or irritable bowel syndrome
determined that medroxyprogesterone acetate (MPA) was
associated with a reduction of pain during treatment.
Counselling supported by ultrasound scanning was associ-
ated with reduced pain and improvement in mood. A mul-
tidisciplinary approach was beneficial for some outcome
measures. Adhesiolysis was not associated with an
improved outcome except where adhesions were severe.143
Treatment of chronic pain, which is different from acute
pain, requires acceptance of the concept of managing
rather than curing pain.
Pharmacologic treatment of pain is based on the knowledge
that different proftles and mechanisms for transmission of
pain information are involved.9 After proper evaluation for
possible causes of CPP, collection of adequate objective and
subjective data, and determining that the pain could be
related to or associated with endometriosis, most gynaecol-
ogists will choose a course of medical management, either
empiric or specific, before further testing. This course could
very well be both diagnostic and therapeutic.
ANALGESICS
These include acetylsalicylic acid, nonsteroidal antiinflam-
matory drugs (NSAIDs), acetaminophen, narcotics, and
medicinal marijuana. NSAIDs have been studied exten-
sively in randomized controlled trials (RCTs) for dysme-
norrhea and have proven efficacious.144,145 However,
individual response varies widely, and it seems reasonable
to try different compounds before abandoning or adding
another therapy. Even if not specifically studied for noncy-
clic CPP, empiric use of NSAIDs is among the first-line
treatments recommended in ost publications.146 Opioids
are the main category of analgesics with central activity.
Despite the paucity of data on their efficacy in chronic
noncancer pain, chronic pain syndrome is frequently
treated with opioids, alone or in combination with other
drugs, in nonpalliative circumstances.147 Clinical experience
in pain centres suggests that opiate therapy may allow the
return of normal function without significant adverse
effects in those in whom other treatments have failed.148 If
there is no increase in function, opiate use should be
reviewed. Hence, opioid maintenance therapy for CPP
should be considered only after all reasonable attempts at
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pain control have failed and when persistent pain is the
major impediment to improved function.
Successful pain management with opioids requires that
adequate analgesia be achieved without excessive adverse
effects (constipation, nausea, and vomiting). Although
there may be individual variability in sensitivity to opioid
side effects, there is little information in the literature sug-
gesting that one opioid has a better or worse adverse effect
proftle than any other.149 Withdrawal symptoms can occur
when therapy is stopped or after conversion from another
opioid.
The advocated approach to the relief of moderate to severe
chronic pain involves around-the-dock use of sustained-
release opioids, the dose individually tailored according to
response, with assessment of safety, compliance, and mis-
use. There should be detailed documentation in the
patient's chart that non-narcotic treatment has failed and
that the patient has been counselled on potential risks.
There should also be a written contract with the patient
stating that the treating doctor is the sole provider of
opioids and that the patient will actively participate in strat-
egies to develop alternative pain therapies.26 Close and reg-
ular follow-up are essential, and most patients should be
seen monthly. If inappropriate use, drug diversion, or
hoarding occurs and control cannot be maintained, the
opioid treatment should be stopped.
HORMONAL AGENTS
Oral Contraceptives (OCs)
Various low-dose OCs have proven successful in studies of
the initial management of dysmenorrhea.150,151 These
studies included patients not screened by laparoscopy,
which suggests that patients with or without endometriosis
were included. Only one report of an RCT of low-dose
OCs for CPP and endometriosis has been published so
far.151 In this 6-month trial comparing cyclic OCs with a
gonadotropin-releasing hormone (GnRH) agonist in
women with laparoscopically diagnosed endometriosis,
OCs were found to be of similar efficacy in relieving dys-
pareunia and nonmenstrual pain but less effective than a
GnRH agonist in relieving dysmenorrhea. Six months after
discontinuation of treatment, original symptoms had
recurred in all patients.
It is recommended that OCs be used in the early medical
management of CPP. Continuous use may be beneficial in
suppressing the possible pain associated with estrogen and
progesterone withdrawal.152 Whether continuous OC use
is more effective than cyclic use in CPP has not been
 No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain
evaluated in RCTs, but, with its low side-effect proflle and
risks, as well as high level of comfort, continuous mono-
phasic treatment should be in the first line in most
regimens.9,36
Progestins
Progestins induce decidualization and acyclicity _of endo-
metrium and endometriotic tissue. Therefore, in patients
with CPP suspected to be endometriosis-related, MPA has
shown beneficial effects. In one 12-month trial, MPA
depot (150 mg every 3 months) had effects equivalent to
GnRH agonists.143 Oral MPA in a 50-mg daily dosage was
effective in reducing pain scores at the end of therapy, but
the benefit was not sustained.33,144
Since the introduction of the levonorgestrel-medicated
intrauterine contraceptive device (IUD) (Mirena) in North
America, we are awaiting studies on its possible beneficial
effect on CPP in patients with suspected endometriosis. In
one study, the use of this IUD alleviated pain and reduced
the size of lesions in patients with endometriosis of the rec-
tovaginal septum,153 and in a pilot study insertion of the
IUD after laparoscopic surgery for symptomatic endome-
triosis significantly reduced the medium-term risk of recur-
rence of moderate or severe dysmenorrhea.154
Danazol
Danazol, a synthetic androgen that inhibits ovarian ste-
roidogenesis and the pulsatile release of pituitary gona-
dotropins, has been the gold standard for the
evaluation of most other medical treatments.34 Danazol
has been found to be more effective for pain relief
than placebo in patients with a laparoscopic diagnosis
of endometriosis34 and in patients who had not under-
gone surgery.155 At a dose of 400 to 800 mg/ day,
danazol is effective for CPP; it should be given for a
minimum of 3 months before other medical options
are considered.9 The use of a danazol-medicated IUD
to treat endometriosis-related CPP is being evaluated.
GnRH Agonists
GnRH agonists induce a hypoestrogenic state by inhibiting
ovarian steroidogenesis. Five generic compounds have
been evaluated: goserelin, leuprolide, buserelin, nafarelin
and tryptorelin. Each suppresses estradiol levels to the
postmenopausal range.156 The suppression is more pro-
found and constant with a monthly depot preparation.157
Most studies of GnRH agonists for endometriosis-related
pain and CPP are comparing these agents with danazol,
progestins, or OCs.145,146 Double-blind placebo-controlled
studies have demonstrated that after 2 to 3 months of use
of a GnRH agonist, pain was 80% to 100% relieved,
whereas the results were inferior with the other medica-
tions or placebo.147,151 Empiric use of a GnRH agonist
was evaluated in an RCT involving 100 women with non-
cyclic pain and clinically suspected endometriosis.159 After
12 weeks of therapy with depot leuprolide acetate (3.75
mg/month) the treatment group showed a significant
reduction in pain scores, dysmenorrhea, and tenderness.
Laparoscopy performed after completion of therapy
showed less endometriosis in the group treated with the
GnRH agonist than in the placebo group. Even patients
with no visualized endometriosis responded favourably to
treatment with a GnRH agonist.
Empiric use in selected patients could be considered, but
even if a diagnostic/therapeutic modality has been found to
be cost effective in the United States160 the evidence is lack-
ing, and the long-term outcomes are unknown. Although
the efficacy of GnRH agonist regimens has been proven,
the short- and long-term side effects remain to be eluci-
dated. Vasomotor symptoms and osteopenia can now be
controlled with add-back therapy. Many steroidal and non-
steroidal agents have been used that suppress vasomotor
symptoms completely and protect against decreases in bone
density without affecting pain relief. Therefore, when ther-
apy with GnRH agonists is prolonged beyond 6 months,
add-back therapy should be considered.108
ANTIBIOTICS
The value of antibiotics in the management of CPP is con-
troversial. Most US management algorithms include antibi-
otics, but these agents are of value only if criteria for PID
are present. The US Centers for Disease Control recom-
mends treating suspected PID, even if cervical cultures are
negative, to prevent complications such as infertility.161
ANTIDEPRESSANTS
Antidepressants have been used to treat numerous chronic
pain syndromes. However, some studies on tricyclic anti-
depressants in women with CPP and normal results of lap-
aroscopy have reported a decreased intensity and duration
of pain.162 Since depression is more frequent in patients
with CPP, antidepressant therapy and psychological sup-
port, in conjunction with other medical therapy, might
improve clinical outcomes.162
NEUROLYTIC THERAPY
Neurolytic therapy may be done by injecting neurotoxic
chemicals (phenol or alcohol) or using energy (heat, cold,
or laser) in doses sufficient to destroy neural tissue.
Although these therapies are most often used to treat a
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particular nerve dysfunction, they may also be used more
centrally to try to decrease pain even if there is no specific
diagnosis or specific nerve dysfunction.146
TREATMENT OF SPECIFIC DISORDERS
CPP often originates from a specific disorder. Intersti-
tial cystltls, irritable bowel syndrome, adhesions, muscu-
loskeletal diseases, endometriosis, and psychosocial
problems are the most frequent. Most of these com-
mon diagnoses have been studied in reasonably good
trials, and their treatment has been addressed elsewhere
in this consensus guideline.
SUMMARY
Selection of a first-line medical therapeutic agent should be
based on the nature of the pain, contraindications to medica-
tions, and desire for contraception. NSAIDs, OCs, or both
should be tried early on, especially if the origin of the pain is
suspected to be endometriotic. If therapy fails, second-line
options, such as danazol, a progestin, or a GnRH agonist
(with add-back therapy), have to be considered for a prede-
termined period. Empiric medical therapy could be cost-
effective. If adequate pain relief is obtained, an appropriate
maintenance regimen should be selected. Treatment failure
should prompt review of diagnosis and treatment, in view of
the multiple causes of CPP. Re-evaluation and treatment revi-
sion, including a surgical approach, should be considered.
CPP is a serious problem. Diagnosis and treatment can be
complex. Medical therapy alone could be insufficient.
Even if there is no cure, a combination of medical and sur-
gical approaches might meet expectations in light of the
multiple causes and contributing factors.
In summary, health care providers should be aiming towards
the least complicated treatment that improves functional
capacity despite the fact that chronic pain may continue.
SUMMARY STATEMENTS
1. Most commonly, treatment of CPP will require
manag ing rather than curing pain (III).
2. Medical therapy alone may not be sufficient to allevi-
ate pain in light of the complexity and the multiple
causes of CPP (III).
Recommendations
1. Opioid therapy can be considered for pain control
under adequate supervision (II-3B).
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NOVEMBER JOGC NOVEMBRE 2018
2. Hormonal treatment of chronic pelvic pain of .gynae-
cologic origin,including oral contraceptives, proges-
tins, danazol, and gonadotropin-releasing hormone
agonists, has been studied extensively and should be
considered as the first line for many women, espe-
cially those with endometriosis (I and II-1A).
3. Adjuvant medications, such as antidepressants and
antibiotics, can be ofsupporting help in specific situa-
tions (II-3B).
CHAPTER 9: SURGERY-EVIDENCE ON
EFFECTIVENESS
Nicholas A. Leyland, BSc, MD, FRCSC, FSOGC;1
Hassan Shenassa, MD, FRCSC2
1
Toronto ON
2
Ottawa ON
SURGICAL MANAGEMENT OF PELVIC ADHESIONS
There is evidence from one Cochrane study163 that the sur-
gical management of pelvic adhesions associated with
endometriosis is effective in the management of pain for 6
months. The combined surgical approach of laparoscopic
laser ablation, adhesiolysis, and uterine nerve ablation is
likely to benefit patients with pelvic pain associated with
minimal, mild, or moderate endometriosis. However, since
only one trial was included in the analysis, this conclusion
should be interpreted with caution.
Laparoscopic Adhesio/ysis
Intra-abdominal and pelvic adhesions are causes of intesti-
nal obstruction64,67 and infertility.164 As a cause of pelvic
pain, their role is less clear. At the time of laparoscopy,
intra-abdominal and pelvic adhesions can be found in
approximately 25% of women with chronic pelvic pain
(CPP).165 If adhesions cause CPP, then adhesiolysis should
resolve the pain. A randomized trial of adhesiolysis by lapa-
rotomy versus no adhesiolysis, however, failed to show any
significant reduction in pain in the group treated with adhe-
siolysis compared with the control group.166 The subgroup
of women with severe adhesions showed a significant
reduction in pain that was attributed to the adhesiolysis. A
number of observational studies have also shown a signifi-
cant reduction in pain among women with CPP after lysis
of adhesions. These findings suggest that some adhesive
disease may contribute to CPP.167
Although some imaging techniques may facilitate the diag-
nosis of adhesive disease, the gold standard is laparoscopy.
 No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain
Laparoscopy is also the gold standard for the treatment of
adhesive disease; its advantage is well-documented.
Patients undergoing laparoscopy for the surgical treatment
of adhesive disease have often had prior abdominal and
pelvic surgery, however, so the risk of bowel and omental
injuries is significant.
Techniques to minimize the risk of such injuries include
open laparoscopy and placement of a trocar-cannula in the
left upper quadrant to allow insertion of the umbilical trocar
under direct vision or to carry out periumbilical adhesiolysis
before the trocar insertion. Adhesiolysis may be facilitated
by laser, electrosurgical, or sharp scissors dissection. Hemo-
stasis should be obtained, and any injuries to the bowel
should be immediately repaired. Adhesion barriers to pre-
vent reformation of adhesions should be considered.
Uncontrolled studies have shown that laparoscopic adhesiol-
ysis reduces pain perception in 60% to 90% of patients.168
However, many patients have laparoscopically confirmed
adhesive disease without any perception of pain. Better-
designed trials are needed to clarify the issue of adhesiolysis.
Appendectomy
In gynaecologic practice, the appendix has been an under-
appreciated source of CPP. Many women with CPP are
found to have appendicopathy. Conversely, many women
with chronic appendicopathy are found to have gynaeco-
logic disorders when undergoing laparoscopic appendec-
tomy.169 Appendiceal disease as a source of CPP may
coexist with endometriosis. Approximately 20% of women
with endometriosis have appendiceal disease.170 In patients
with endometriosis who present with pelvic or abdominal
pain (especially right lower quadrant pain), one should
therefore consider nongynaecologic sources of CPP,
including chronic or recurrent appendicitis.171,172
One study suggested that the amount of histopathologic
abnormality exceeds visible disease of the appendix by
11%.169 Moreover, the investigators demonstrated that
34% of patients with reduced pain after appendectomy
alone had no visible or histopathologic abnormalities. Two
studies further suggested that prophylactic appendectomy
may be beneficial in women with CPP as both a therapeutic
and a preventive measure.173,174
We reviewed six uncontrolled retrospective and prospec-
tive studies that all described laparoscopic appendectomy
as advantageous in the treatment of CPP.168,173,175-178 Five
of these studies reported relief of chronic pelvic or lower
abdominal pain after appendectomy in 85% to 97% of
women undergoing appendectomy alone or in conjunction
with other surgical procedures. Adjunctive surgical treat-
ments for CPP may include lysis of adhesions, resection of
endometriosis, presacral neurectomy (PSN), laparoscopic
uterine ne:rve ablation (LUNA), salpingo-oophorectomy,
and hysterectomy. Since gynaecologic disease often accom-
panies appendiceal disease, it is difficult to demonstrate
that disease of the appendix is responsible for the pain.
One recent retrospective study found that 12% of women
undergoing diagnostic laparoscopy with appendectomy
experienced relief of CPP in the absence of any other dis-
order.169 Appendectomy was the main procedure in 102
patients, of whom 92 (90%) reported relief of their pelvic
pain. These results suggest that disease of the appendix
may be a significant cause of CPP.
PSNAND LUNA
Adjunctive laparoscopic surgical procedures, including
PSN and LUNA, can be technically demanding but con-
tinue to have a role in the management of CPP.179
Any surgical management of pelvic pain requires an under-
standing of the autonomic innervation of the pelvis. The
disruption of afferent neural signals from the pelvic organs
can reduce the perception of pain caused by endometriosis
and other disorders.180
A prospective comparison of PSN and LUNA indicated
that they were equally efficacious in the treatment of dys-
menorrhea but that PSN had a more prolonged effect.181
A recent randomized, double-blind trial of conservative
laparoscopic surgery with adjunctive PSN or LUNA in
women with severe dysmenorrhea caused by endometriosis
demonstrated more pronounced and prolonged pain relief
with PSN than with LUNA.182
SUMMARY STATEMENTS
1. The qualitative evaluation of surgery in the manage-
ment of CPP is limited in terms of randomized clini-
cal trials (III).
2. Laparoscopy is the mainstay of diagnosis and surgical
treatment of CPP. Careful judgffient is important
when repeat surgery is being considered (I and II).
Recommendations
1. The lack of robust clinical trials of the surgical man-
agement of chronic pelvic pain should be addressed.
The use of alternative epidemiologic models, includ-
ing case-controlled and cohort-controlled trials,
should be considered (III-A).
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2. Further delineation of the role of appendectomy and
of presacral neurectomy appears warranted in the
management of endometriosis-related pain (III-A).
CHAPTER 10: PSYCHOLOGICAL TREATMENT FOR
CHRONIC PELVIC PAIN
Paul Taenzer, PhD, CPsych
Calgary AS
INTRODUCTION
Among the psychological treatments for chronic pain, cog-
nitive-behavioural therapies (CBTs) are the most widely
used and have the strongest empiric support.183 CBTs for
chronic pain management address the multiple determi-
nants of the chronic pain experience. This spectrum of
treatment methods engages chronic pain sufferers in an
exploration of their personal pain modulators. The treat-
ment approach provides instruction in strategies and skills
for controlling the modulators through the patient's own
efforts.
STRATEGIES
Treatment strategies included within the rubric of CBT
include training in muscular relaxation, meditation,
stress management techniques, recognizing and modi-
fying negative or catastrophic cognitions or thoughts
that amplify arousal and feelings of helplessness, life-
style modification (including pacing of activities to
avoid overexertion followed by exhaustion and physical
de-conditioning), re-engagement in physically appropri-
ate and personally fulftlling activities, and effective
communication with family, friends, and health care
providers.
To be successful, this treatment approach requires that
patients come to understand their pain problem as
being determined by psychological, social, and physical
causes. Patients must also come to understand that
reduction of pain and suffering is possible through their
own efforts in addition to treatments such as medica-
tion and surgery.
Over the past 20 years, CBTs for chronic pain manage-
ment have been extensively investigated for a variety of
pain syndromes and have shown to be effective.184-187
There is a limited literature applying these strategies to
chronic pelvic pain (CPP).146,188
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CBT is typically provided in a group setting, with 8 to
12 patients and 1 or 2 therapists, typically psychologists
or other care providers with a mental health back-
ground. Health care providers with a background in
caring for people with psychological consequences of
chronic pelvic disorders may also offer these treatments
in community settings. CBTs are a typical component
of services offered in multidisciplinary pain manage-
ment programs.
In summary, CBTs have broad empiric support for their
effectiveness in reducing perceived pain intensity and distress
in populations with chronic pain. Preliminary data suggest
that this approach is effective for women with CPP.
SUMMARY STATEMENT
CBTs are considered the treatment of choice for helping
women develop effective pain coping strategies (I).
CHAPTER 11: MULTIDISCIPLINARY CHRONIC PAIN
MANAGEMENT
Paul Taenzer, PhD, CPsych
Calgary AB
DEFINITION
Multidisciplinary chronic pain management refers to
assessment, treatment planning, and ongoing coordination
of intervention provided by a team of health care providers
from relevant medical specialties and allied health provider
disciplines.
MANAGEMENT CENTRES
Multidisciplinary pain management is typically provided in
a chronic pain clinic or centre wherein the providers are all
located and routinely provide joint assessment and treat-
ment services. A standardized classification of pain centres
has been developed by the International Association for
the Study of Pain. The four types of centres include modal-
ity- oriented clinics, pain clinics, multidisciplinary pain clin-
ics, and multidisciplinary pain centres. Modality-oriented
clinics provide one or several specific interventions, with
no emphasis on comprehensive or integrated care. Pain
clinics specialize in a particular diagnosis or pain in a spe-
cific area of the body; care is typically delivered by a single
physician. Multidisciplinary pain clinics are staffed by a
spectrum of health care providers and provide comprehen-
sive assessment and integrated, coordinated intervention
 No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain
through inpatient or outpatient facilities; the clinics are not
engaged in professional training or research and are typi-
cally not associated with major educational or research
institutions. Multidisciplinary pain centres provide clinical
services similar to those of multidisciplinary pain clinics as
well as clinical training and research.
SCOPE OF CARE
Multidisciplinary care is commonly tailored to the par-
ticular needs of the patient and may include a combi-
nation of medical and rehabilitative intervention
focused on eliminating or modifying the biological
pain generators, as well as psychological and psychoso-
cial intervention focused on helping the client, and her
important social and family contacts, adapt successfully
to the changes in function and capacity engendered by
the chronic pain state. Multidisciplinary pain centres
extend their reach into the community through culti-
vating relationships with other specialist providers, the
family physician, and relevant community agencies.
Multidisciplinary pain management for chronic pelvic
pain (CPP) may involve treatment by physicians special-
izing in gynaecology, gastroenterology, physical medicine
and rehabilitation, urology, anesthesiology, psychiatry,
sleep medicine, and addictions. Other team members
represent nursing, physiotherapy, occupational therapy,
kinesiology, clinical nutrition, psychology, pharmacy,
and social work. Treatment strategies include medical,
surgical, and rehabilitative interventions directed to
resolving the biological pain generators, as well as a
variety of psychosocial and rehabilitation strategies
directed towards improved coping, appropriate lifestyle
changes, physical fitness, and fitness for work.146
OUTCOMES RESEARCH
Multidisciplinary chronic pain management has been the
subject of extensive outcomes research for the past
25 years. Systematic reviews of this literature189-191 have
confirmed the value of this treatment approach with regard
to clinical outcomes for low back pain. A Cochrane system-
atic review of interventions for the treatment of CPP in
women143 provided support for multidisciplinary manage-
ment that was based on one randomized controlled trial.192
Systematic reviews of the economic outcomes of multidis-
ciplinary chronic pain management have stressed the need
for higher quality research.193 In summary, these data sug-
gest that multidisciplinary chronic pain management pro-
vided by qualified teams of medical and rehabilitation
specialists with tertiary- level knowledge of CPP is the ideal
treatment approach for women with CPP.
SUMMARY STATEMENT
Current evidence indicates that tertiary-level multi- dis-
ciplinary chronic pain management is the most effective
treatment approach for women with CPP (I).
Recommendation
1. Multidisciplinary chronic pain management should
be available for women with chronic pelvic pain
within the publicly funded health care system in each
province and territory of Canada (III-B).
CHAPTER 12: COMPLEMENTARY AND
ALTERNATIVE MEDICINE
Susan Burgess, MD, Vancouver BC
INTRODUCTION
The pathogenesis of chronic pelvic pain (CPP) remains
poorly understood, and, therefore, treatment is often
unsatisfactory.194 Consequently, complementary and alter-
native medicine (CAM) is increasingly of interest to both
patients and health care providers. The Cochrane Collabo-
ration now has more than 1750 completed Cochrane
reviews, of which more than 100 relate to CAM.195
However, the literature specifically relating to CPP and
CAM is limited. As with the literature from allopathic sour-
ces, the studies have been small, they might have been pilot
studies that compared treatment modalities but could not
always be double-blinded,196 and they might not have been
fully randomized. Most studies to date have been con-
cerned with dysmenorrhea (primary or secondary) or pel-
vic pain associated with pregnancy.197 There are no current
references on the use of homeopathy for CPP.
TRANSCUTANEOUS ELECTRICAL NERVE
STIMULATION AND ACUPUNCTURE
The Cochrane Collaboration has reviewed the use of
TENS and acupuncture, when compared with one
another, with placebo, with pharmacotherapy, and with no
treatment.196 Nine RCTs were identified, and the review
concluded that high-frequency TENS was effective in the
treatment of dysmenorrhea. One methodologically sound
trial of acupuncture also suggested benefit.199
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A case report on a 23-year-old primigravida with CPP at 27
weeks gestation documented that acupuncture significantly
reduced the patient's use of narcotics and allowed her to
maintain normal activity.197 Several recent studies have
also found benefit from acupuncture in back pain200 and
in lumbar and pelvic pain in pregnancy.201 Further, acu-
puncture appears to be a durable therapy for symptom
relief in men with chronic prostatitis and CPP syn-
drome.202 Acupuncture/acupressure has received approval
from the Food and Drug Administration in the United
States for use in the relief of chronic pain in oncology
patients.197
As a therapeutic modality, acupuncture has a long tradition
in Chinese medicine for the treatment of gynaecologic and
obstetric problems. There is, as yet, no comprehensive allo-
pathic explanation for its clinical benefits, but proposed
mechanisms include gate control of pain pathways, increased
endogenous opioid release, and altered sympathetic tone.202
PLANTS AND' HERBAL AND DIETARY THERAPIES
Traditional healing provides for a large percentage of pri-
mary health care needs in many populations. One study
screened plants used by South African Zulu traditional
healers in the treatment of dysmenorrhea.203 Several plant
extracts exhibited high inhibitory activity against cyclooxy-
genase and therefore the prostaglandin biosynthetic path-
way responsible for painful uterine contractions.
The Cochrane Review of herbal and dietary therapies for pri-
mary and secondary dysmenorrhea204 suggested that magne-
sium supplementation might help reduce symptoms.
SUMMARY
CPP is a frustrating and disabling condition, with as yet
unclear neuroendocrine etiology. A multidisciplinary
approach to diagnosis and care is currently recom-
mended.191 For visceral-peritoneal pain, acupuncture is
beneficial. Musculoskeletal sources of pain respond to
physiotherapy and biofeedback training. Somatic-myofas-
cial pain has been reduced with massage, ultrasound stimu-
lation, TENS, and, especially, trigger-point injection and
dry-needling modalities. Grounding all treatment is the sin-
cere acknowledgement of the complexity and authenticity
of this chronic condition.
SUMMARY STATEMENT
Alternative therapies for chronic pelvic pain that have
been found helpful include acupuncture, physiotherapy,
and biofeedback training. Use of pelvic ultrasonography
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with explanation has been found to help. Massage, sur-
face ultrasound stimulation, and TENS may also help
relieve pain.
CHAPTER 13: PATIENT PERSPECTIVES
John F. Jarrell, MD, Calgary AB
PATIENTS' NEEDS
A 2002 needs assessment survey by the Society of Obste-
tricians and Gynaecologists of Canada (SOGC) of subjects
with chronic pelvic pain (CPP), undertaken using the prin-
ciples of qualitative research, determined that the following
were the most important needs of these patients:

the need for the health care professional to legitimize the
pain,

the need for the patient to be heard during the patient
contact visit,

the need for the patient to receive support in numerous
forms, and

the need for the patient to take responsibility for a path
towards health (III-B).
A LOOK INTO THE FUTURE
In the future, a woman with CPP will be recognized as hav-
ing a condition that requires rehabilitation and not solely
acute care management. She will be managed by a team of
individuals who are aware of the principles of multidisci-
plinary care, including a physiotherapist, a psychologist, a
primary care physician, and a gynaecologist. Such an
approach will be funded by the local hospital or regional
health authority on the basis of its effectiveness and cost
efficiency.
Emphasis will be placed on achieving higher function in
life with some pain rather than cure. The management of
directed therapy will be based on treatments that have
been subjected to clinical trial. There will be a permanent
record of the findings at any previous laparoscopy that can
be shared and compared over time. Health personnel
involved in the patient's management will have been
trained in the specific areas of myofascial dysfunction and
the appropriate clinical use of opiates in the chronic pain
state.
In addition to participating in clinical trials of various thera-
pies, the patient will become aware of newer approaches
that may be of assistance through Internet access to the
results of clinical trials. One of the main areas of
 No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain
development will be the use of gene therapy to overcome
problems in spinal cord pathophysiology.
SUMMARY STATEMENT
Qualitative analysis of data on the needs of patients
with CPP has revealed the following as the most
important:

the need for the health care professional to legiti-
mize the pain,

the need for the patient to be heard during the
patient contact visit,

the need for the patient to receive support in numer-
ous forms, and

the need for the patient to take responsibility for a
path towards health. (III-B)
CHAPTER 14: FUTURE DIRECTIONS
John F. Jarrell, MD, Calgary, AB
EDUCATION
A 2002 needs assessment survey by the Society of Obste-
tricians and Gynaecologists of Canada (SOGC) on the
management of chronic pelvic pain (CPP) revealed a desire
for more training in the recognition and management of
CPP. SOGC members expressed the need to modify the
approach to CPP and for help in diagnosing its causes.
The lack of knowledge in assessing CPP etiology is most
evident in the identification of trigger points. The broad
scope of CPP requires further education of medical stu-
dents, residents, and health care providers. This means a
complete reversal of attitude, from considering these
patients hopeless and time-consuming to being genuinely
concerned and seeing an opportunity to provide encour-
agement and hope.
Adult education has evolved from large-group lectures to
small-group interactive sessions with hands-on participa-
tion. This approach to learning about CPP should be
incorporated into our medical school and residency train-
ing programs. The issues raised in this consensus docu-
ment could be addressed through postgraduate courses
that teach identification of trigger points in the abdomen,
back, and pelvis. CPP should be discussed at all continuing
health education events, by means of case presentations
and audience participation. Also, to help our members and
the public understand and appreciate CPP, a patient infor-
mation pamphlet should be produced and distributed.
RESEARCH
Research is needed to identify psychoneurologic dysfunc-
tions that are responsible for CPP so that we can ade-
quately treat and possibly cure the condition.
Recommendations
1. The curriculum for professional development should
be expanded to include theory and techniques in the
management of myofascial dysfunction (A).
2. Research into CPP should be encouraged, particu-
larly in the areas of the impact of CPP on the use of
health services, the pathophysiology of myofascial
dysfunction, and gene therapy. Because randomized
trials for qualitative outcomes are exceedingly diffi-
cult, alternative robust models, such as case-con-
trolled or cohort- controlled trials, should be pursud
(A).
3. Methods of improving interaction with patients
should be explored. They might include formal con-
tractual approaches to managing pain with opiates
and efforts to better appreciate the patient's per-
ceived needs (A).
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an integrative model. Obstet Gynecol Surv 1993;48:95–110.
2. Benson TJ. Neuropathic pain. In: Steege JF, Metzger DA, Levy BS, editors.
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