Basics
Description
- Chronic pelvic pain (CPP) is any nonmenstrual pain lasting >6 months.
- CPP is often vague and difficult to assess.
- The degree of pain is often out of proportion to the clinical findings.
- CPP is extremely distressing to women.
- CPP is extremely frustrating for physicians.
- Over 60% of patients never receive a diagnosis.
Epidemiology
Incidence
- As high as 20% of women of reproductive age
- Accounts for 20% of laparoscopies
- Accounts for 12-16% of hysterectomies
- Associated medical costs total nearly $3 billion annually
Etiology
- CPP is a syndrome whose etiology remains unknown.
- In patients without a clear source of pain, one theory is that an acute event triggers the pain, but the pain continues even after the trigger is gone.
Associated Conditions
- Interstitial cystitis (IC)
- Irritable bowel syndrome
- Depression/anxiety
- Dyspareunia
- Vulvar dystrophy
Diagnosis
History
- Obtaining a complete history is the key to the diagnosis.
- Assess the nature of the pain, intensity, distribution, associated symptoms, and temporal relations.
- Identify prior surgeries, infections, infertility, and birth complications.
- Evaluate the patient's bleeding patterns.
- Evaluate the patient for associated psychiatric symptoms such as depression or anxiety.
- Evaluate the patient for current or prior sexual abuse.
- Determine the role pain plays in the patient's life.
- A 3-month pain diary may be helpful.
- Signs and symptoms to help assess possible etiology:
- Vague pain is associated with a visceral/intra-abdominal process.
- Localized pain is associated with a musculoskeletal origin.
- Constipation/flatulence/bloating are associated with a GI origin.
- Urinary frequency or burning is associated with a urinary origin.
Physical Exam
- Evaluate each anatomic area individually:
- Anterior abdominal wall/hernias
- Pelvic bones/symphysis
- Pelvic floor musculature/levator ani
- Vulva/vestibule
- Vagina
- Urethra
- Cervix
- Viscera-uterus, adnexa, bladder
- Rectum
- Rectovaginal septum
- Coccyx
- Posture and gait
- Perform the exam standing, sitting, supine, and lithotomy.
- A bimanual exam alone is insufficient as it cannot differentiate between anterior abdominal wall, cervix, and intra-abdominal organs.
Tests
Surgery
- Basic testing:
- Pap smear
- Gonorrhea and chlamydia cultures
- Wet mount if associated discharge or odor
- Urinalysis
- Urine culture
- Pregnancy test
- CBC with differential
- ESR (nonspecific for inflammatory process)
- Pelvic ultrasound, which could possibly lead to MRI or CT
- Specialized testing (as directed by findings of history and physical examination):
- Potassium sensitivity testing - IC requires evaluation by urology or urogynecology
- Cystoscopy/ureteroscopy - IC, urethral diverticulum, neoplasia
- Urodynamics - detrusor instability
- Electrophysiologic studies - nerve compression, muscular spasm
- X-ray - fracture
- Laparoscopy - endometriosis, adhesions, hernia
- Specialists may consider "awake laparoscopy"� for pain mapping.
Differential Diagnosis
- CPP often remains undiagnosed.
- The identification of the source of CPP is elusive.
- Patient complaints can too often be ignored by the provider.
- The differential diagnosis for CPP is extensive.
- If the pain seems gynecologic in origin, the differential includes:
- Adenomyosis
- Adhesions
- Chronic ectopic pregnancy
- Chronic infection
- Endometriosis
- Ovarian carcinoma
- Ovarian cysts
- Ovulation pain (Mittelschmerz)
- Pelvic congestion syndrome
- Pelvic organ prolapse
- Postpartum lordosis
- Tuberculous salpingitis
- Uterine fibroids
Treatment
Medication
- Oral contraceptive
- Gonadotropin-releasing hormone (GnRH) agonist
- Progesterone
- NSAIDs
- Antidepressants for depression, but not pain
- Narcotic analgesics should be used under a "drug contract"� for refractory pain.
Additional Treatment
General Measures
- A multidisciplinary approach to CPP has been shown to be most effective (1)[B].
- Identify the most likely organ system causing CPP and treat or refer appropriately.
- Recommend therapy for pain management techniques and emotional support.
- If the pain is gynecologic in origin:
- Trial of NSAIDs
- Suppress the menstrual cycle with oral contraceptive or GnRH agonist for a 3-month trial.
- If suppression fails, perform diagnostic laparoscopy.
- A negative pelvic sonogram and diagnostic laparoscopy can be very reassuring to the patient.
- A positive laparoscopy can be curative.
- If muscular "trigger"� points are identified, lidocaine injections may be considered.
Additional Therapies
- Physical therapy
- For patients where the pain originates from muscular spasms, physical therapy can be helpful (2)[B].
- Transcutaneous electrical nerve stimulation (TENS) units may be of benefit.
Complementary and Alternative Medicine
- Results of clinical trials are limited.
- Acupressure and acupuncture have demonstrated efficacy equal to ibuprofen (2)[B].
- Chiropractic and osteopathic spinal manipulations may be of benefit.
- Meditation and breathing improve symptoms and relieve anxiety.
- Journaling may be of benefit.
- Saw palmetto has insufficient information to support its use.
Surgery
- Laparoscopic fulguration of endometriosis
- Lysis of adhesions has shown some benefit for thin adhesions where movement could cause tension on the band (3)[A].
- Lysis of adhesions for dense adhesions has shown little benefit (3)[A].
- Hysterectomy should be reserved for refractory cases where the etiology of the pain is thought to be gynecologic in origin.
- Laparoscopic uterine nerve ablation has not been shown to be helpful.
- Hernia repair if hernia present
Ongoing Care
Follow-Up Recommendations
- Establishing a supportive relationship is essential to care of the patient with CPP.
- It is very important to schedule regular visits to establish trust.
- Scheduled visits also eliminate the patient's need to have pain in order to have an office visit (eliminate secondary gain).
- A team approach with specialists improves patient care and outcome.
Diet
- Identify triggers associated with food, such as lactose intolerance, celiac sprue, and acid reflux.
- Recommend a diet high in complex carbohydrates and fiber for general health and regular bowel movements.
- Avoid constipating food or foods that cause gaseous distension.
Patient Education
- Activity:
- Regular exercise has been shown to increase endorphins and, thus, pain tolerance is increased.
- Exercise has also been shown to improve symptomatic depression.
- Unless there is a specific indication (i.e., fracture), bed rest should be avoided.
References
1Stones �RW. Chronic pelvic pain in women: New perspectives on pathophysiology and management. Reprod Med Rev. 2000;8:229-240.2ACOG. Pelvic Pain Practice Bulletin. No. 51 (March) 2004:364-374.3Peters �AA, Trimbos-Kemper �GC. A randomized clinical trial on the benefit of adhesiolysis in patients with intraperitoneal adhesions and chronic pelvic pain. Br J Obstet Gynaecol. 1992;99:59-62. �[View Abstract]
Additional reading
1Carter �JE. Chronic pelvic pain: Diagnosis and management. International Pelvic Pain Society. Available at www.pelvicpain.org [Accessed 2005].2Daniels �JP, Kahn �KS. Chronic pelvic pain in women. BJM. 2010;341:c4834. �[View Abstract]3Stones �W, Cheong �YC, Howard �FM. Interventions for treating chronic pelvic pain in women. The Cochrane Collaboration. 2005, Vol. 4.4Wenof �M, Perry �CP. Chronic pelvic pain: A patient education booklet. International Pelvic Pain Society. Available at www.pelvicpain.org. [Accessed 1998].
Codes
ICD9
- 614.6 Pelvic peritoneal adhesions, female (postoperative) (postinfection)
- 617.0 Endometriosis of uterus
- 625.9 Unspecified symptom associated with female genital organs
- 625.2 Mittelschmerz
- 218.9 Leiomyoma of uterus, unspecified
ICD10
- N73.6 Female pelvic peritoneal adhesions (postinfective)
- N80.0 Endometriosis of uterus
- R10.2 Pelvic and perineal pain
- N83.20 Unspecified ovarian cysts
- N94.0 Mittelschmerz
- N94.89 Oth cond assoc w female genital organs and menstrual cycle
- D25.9 Leiomyoma of uterus, unspecified
SNOMED
- 237067000 chronic pain in female pelvis (finding)
- 76376003 endometriosis of uterus (disorder)
- 62394006 female pelvic peritoneal adhesions (disorder)
- 79883001 cyst of ovary (disorder)
- 43548008 Mittelschmerz (finding)
- 39402007 pelvic congestion syndrome (disorder)
- 95315005 uterine leiomyoma (disorder)
Clinical Pearls
- Chronic pelvic pain (CPP) is a syndrome whose etiology remains unknown; however, uncovering a definitive diagnosis improves prognosis and treatment.
- Evaluate all pelvis-gynecologic, urologic, gastrointestinal, neurologic, and musculoskeletal organ systems.
- Screen for concomitant psychological disorders.
- A team approach between the specialists and the primary provider improves patient care and outcome.
- Establishing a supportive relationship is essential to care of the patient with CPP.
- Even in the patient with depression, chronic pelvic pain is not "all in her head."� A combined approach of mind and body will provide optimal results.