Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Chronic Pelvic Pain in Women Differential Diagnoses

  • Author: Manish K Singh, MD; Chief Editor: Michel E Rivlin, MD  more...
 
Updated: Jan 13, 2015
 
 

Diagnostic Considerations

Important considerations

Good rapport, tolerance, and an open-minded approach are important in the evaluation of any patient with chronic pain.

Patients with chronic pelvic pain (CPP) may exhibit exaggerated pain behavior or sensations that seem to be hysterical or appear nonanatomic or nonphysiologic; however, these patients always must be taken seriously and appropriate conservative steps should be taken.

Obtaining a thorough past history is important to avoid repeating invasive and expensive procedures.

Consultation with a psychologist, urologist, neurologist, and gastrointestinal specialist or other appropriate specialists is very important, especially before considering invasive or aggressive management.

Special concerns

Appropriate caution must be taken during treatment of patients with the following characteristics:

  • Poor response to prior appropriate treatment
  • Unusual unexpected response to prior specific treatment
  • Avoidance of school, work, or other social responsibilities
  • Severe depression
  • Severe anxiety disorder
  • Excessive pain behavior
  • Frequent health care provider changes
  • Noncompliance with past treatment
  • Drug abuse or dependence
  • Family, marital, or sexual problems
  • History of physical or sexual abuse

Pregnancy considerations include the following:

  • The use of medication during pregnancy is not contraindicated, but it should be limited and carefully justified. [16]
  • Initially, pain should be managed with nonpharmacologic measures such as reassurance, rest, hot or cold applications, positioning, stretching exercises, massage, ultrasound therapy, TENS, relaxation therapy, and biofeedback. If pain does not respond to a nonpharmacologic approach, symptomatic drugs may be used carefully.
  • Acetaminophen and codeine (alone or in combination) can be used during pregnancy.
  • Nonsteroidal anti-inflammatory drugs such as ibuprofen and aspirin may be considered during the first trimester of pregnancy, but they should be avoided especially during the last trimester. They may constrict or close the fetal ductus arteriosus and may cause maternal and fetal bleeding.
  • Limit benzodiazepine and barbiturate use. Do not use ergotamine, dihydroergotamine, and sumatriptan.

In men, chronic (nonbacterial) prostatitis, chronic orchalgia, and prostatodynia are common causes of CPP in men of any age.[17]

Other considerations to be considered

Other conditions to consider in women with chronic pelvic pain are discussed below.

Reproductive system considerations include the following:

  • Adenomyosis
  • Adhesions
  • Adnexal tumors
  • Cervical stenosis
  • Dyspareunia
  • Endocervical and endometrial polyps
  • Endometriosis and endosalpingiosis
  • Uterine leiomyomas
  • Ovarian retention syndrome
  • Ovarian remnant syndrome
  • Pelvic varicosities and pelvic congestion syndrome
  • Vulvodynia
  • Pelvic floor relaxation disorders
  • Accessory and supernumerary ovaries

Urinary system considerations include the following:

  • Chronic and recurrent urinary tract infections
  • Urolithiasis
  • Pelvic floor dysfunction
  • Urethral diverticula
  • Chronic urethral syndrome

GI system considerations include the following:

  • Chronic intermittent bowel obstruction
  • Colitis
  • Chronic constipation
  • Diverticular disease
  • Inflammatory bowel disease
  • Irritable bowel syndrome
  • Peritoneal abscess

Other disease considerations include the following:

  • Hernias (eg, obturator, sciatic, inguinal, femoral, perineal, spigelian, umbilical)
  • Neoplasia of the spinal cord or sacral nerves
  • Mononeuropathy and nerve entrapment
  • Abdominal epilepsy
  • Abdominal migraines
  • Pelvic floor pain syndrome
  • Rectus abdominis pain
  • Faulty posture
  • Bipolar affective disorder and depression
  • Chronic visceral pain syndrome
  • Chronic fatigue syndrome
  • Substance abuse
  • Spinal malformation
  • Spinal tumors

Differential Diagnoses

 
 
Contributor Information and Disclosures
Author

Manish K Singh, MD Assistant Professor, Department of Neurology, Teaching Faculty for Pain Management and Neurology Residency Program, Hahnemann University Hospital, Drexel College of Medicine; Medical Director, Neurology and Pain Management, Jersey Institute of Neuroscience

Manish K Singh, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American Headache Society, American Association of Physicians of Indian Origin, American Medical Association, American Society of Regional Anesthesia and Pain Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Jashvant Patel, MBBS, MS, MD 

Jashvant Patel, MBBS, MS, MD is a member of the following medical societies: Alberta Medical Association, American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Society of Regional Anesthesia and Pain Medicine, Medical Society of the State of New York

Disclosure: Nothing to disclose.

Elizabeth E Puscheck, MD Professor, Department of Obstetrics and Gynecology, Wayne State University School of Medicine; In Vitro Fertilization Director, Gynecologic Ultrasound Director, Clinical Endocrine Laboratory Consultant, Department of Obstetrics and Gynecology, University Women's Care

Elizabeth E Puscheck, MD is a member of the following medical societies: American Institute of Ultrasound in Medicine, International Society for Clinical Densitometry, Society for Assisted Reproductive Technology, Society of Reproductive Surgeons, Society for Reproductive Endocrinology and Infertility, American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Endocrine Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

A David Barnes, MD, MPH, PhD, FACOG Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, CA), Pioneer Valley Hospital (Salt Lake City, UT), Warren General Hospital (Warren, PA), and Mountain West Hospital (Tooele, UT)

A David Barnes, MD, MPH, PhD, FACOG is a member of the following medical societies: American College of Forensic Examiners Institute, American College of Obstetricians and Gynecologists, Association of Military Surgeons of the US, American Medical Association, Utah Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD Former Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, Royal College of Surgeons of Edinburgh, Royal College of Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

Additional Contributors

Suzanne R Trupin, MD, FACOG Clinical Professor, Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Urbana-Champaign; CEO and Owner, Women's Health Practice; CEO and Owner, Hada Cosmetic Medicine and Midwest Surgical Center

Suzanne R Trupin, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, International Society for Clinical Densitometry, AAGL, North American Menopause Society, American Medical Association, Association of Reproductive Health Professionals

Disclosure: Nothing to disclose.

References
  1. Mathias SD, Kuppermann M, Liberman RF, et al. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol. 1996 Mar. 87(3):321-7. [Medline].

  2. Jamieson DJ, Steege JF. The prevalence of dysmenorrhea, dyspareunia, pelvic pain, and irritable bowel syndrome in primary care practices. Obstet Gynecol. 1996 Jan. 87(1):55-8. [Medline].

  3. Reiter RC. A profile of women with chronic pelvic pain. Clin Obstet Gynecol. 1990 Mar. 33(1):130-6. [Medline].

  4. Zondervan KT, Yudkin PL, Vessey MP, et al. Prevalence and incidence of chronic pelvic pain in primary care: evidence from a national general practice database. Br J Obstet Gynaecol. 1999 Nov. 106(11):1149-55. [Medline].

  5. Neis KJ, Neis F. Chronic pelvic pain: cause, diagnosis and therapy from a gynaecologist's and an endoscopist's point of view. Gynecol Endocrinol. 2009 Nov. 25(11):757-61. [Medline].

  6. Taran FA, Weaver AL, Coddington CC, Stewart EA. Understanding adenomyosis: a case control study. Fertil Steril. 2010 Sep. 94(4):1223-8. [Medline].

  7. Weijenborg PT, Ter Kuile MM, Stones W. A cognitive behavioural based assessment of women with chronic pelvic pain. J Psychosom Obstet Gynaecol. 2009 Dec. 30(4):262-8. [Medline].

  8. Lampe A, Solder E, Ennemoser A, et al. Chronic pelvic pain and previous sexual abuse. Obstet Gynecol. 2000 Dec. 96(6):929-33. [Medline].

  9. Jacoby K, Rowbotham RK. Double balloon positive pressure urethrography is a more sensitive test than voiding cystourethrography for diagnosing urethral diverticulum in women. J Urol. 1999 Dec. 162(6):2066-9. [Medline].

  10. Howard FM, Perry PC, Carter JE, eds. Pelvic Pain: Diagnosis and Management. Baltimore, Md: Lippincott Williams & Wilkins; 2000.

  11. Kadan Y, Fiascone S, McCourt C, et al. Predictive factors for the presence of malignant transformation of pelvic endometriosis. Eur J Obstet Gynecol Reprod Biol. 2014 Dec 2. 185C:23-27. [Medline].

  12. [Guideline] American College of Obstetricians and Gynecologists (ACOG). Chronic pelvic pain. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2004 Mar. 17 p. (ACOG practice bulletin; no. 51). [Full Text].

  13. [Guideline] Chronic pelvic pain. In: Fall M, Baranowski AP, Elneil S, Engeler D, Hughes J, Messelink EJ, Oberpenning F, Williams AC. Guidelines on chronic pelvic pain. Arnhem, The Netherlands: European Association of Urology (EAU); 2008 Mar. p. 8-62. [Full Text].

  14. Ferreira Gurian MB, Poli Neto OB, Rosa E Silva JC, Nogueira AA, Candido Dos Reis FJ. Reduction of Pain Sensitivity is Associated with the Response to Treatment in Women with Chronic Pelvic Pain. Pain Med. 2014 Dec 19. [Medline].

  15. Everaert K, Devulder J, De Muynck M, et al. The pain cycle: implications for the diagnosis and treatment of pelvic pain syndromes. Int Urogynecol J Pelvic Floor Dysfunct. 2001. 12(1):9-14. [Medline].

  16. George JW, Skaggs CD, Thompson PA, Nelson DM, Gavard JA, Gross GA. A randomized controlled trial comparing a multimodal intervention and standard obstetrics care for low back and pelvic pain in pregnancy. Am J Obstet Gynecol. 2012 Oct 23. [Medline].

  17. Suskind AM, Berry SH, Ewing BA, Elliott MN, Suttorp MJ, Clemens JQ. The Prevalence and Overlap of Interstitial Cystitis/Bladder Pain Syndrome and Chronic Prostatitis/Chronic Pelvic Pain Syndrome in Men: Results of the RAND Interstitial Cystitis Epidemiology Male Study. J Urol. 2012 Nov 16. [Medline].

  18. Baker PK. Musculoskeletal origins of chronic pelvic pain. Diagnosis and treatment. Obstet Gynecol Clin North Am. 1993 Dec. 20(4):719-42. [Medline].

  19. Ben-David B, Friedman M. Gabapentin therapy for vulvodynia. Anesth Analg. 1999 Dec. 89(6):1459-60. [Medline].

  20. Benes J, Nadvornik P, Dolezel J. Abdominoinguinal pain syndrome treated by centrocentral anastomosis. Acta Neurochir (Wien). 2000. 142(8):887-91. [Medline].

  21. Bergqvist A. Current drug therapy recommendations for the treatment of endometriosis. Drugs. 1999 Jul. 58(1):39-50. [Medline].

  22. Bodden-Heidrich R, Küppers V, Beckmann MW, Rechenberger I, Bender HG. Chronic pelvic pain syndrome (CPPS) and chronic vulvar pain syndrome (CVPS): evaluation of psychosomatic aspects. J Psychosom Obstet Gynaecol. 1999 Sep. 20(3):145-51. [Medline].

  23. Bost BW. Deflecting sigmoid adhesions: an anatomic cause of chronic pelvic pain and irritable bowel syndrome. Obstet Gynecol. 2001 Apr. 97(4 Suppl 1):S27.

  24. Braverman PK. Sexually transmitted diseases in adolescents. Med Clin North Am. 2000 Jul. 84(4):869-89, vi-vii. [Medline].

  25. Carter JE. A systematic history for the patient with chronic pelvic pain. JSLS. 1999 Oct-Dec. 3(4):245-52. [Medline].

  26. Carter JE. Surgical treatment for chronic pelvic pain. J Soc Laparoendosc Surg. 1998 Apr-Jun. 2(2):129-39. [Medline].

  27. Clemons JL, Arya LA, Myers DL. Diagnosing interstitial cystitis in women with chronic pelvic pain. Obstet Gynecol. 2002 Aug. 100(2):337-41. [Medline].

  28. Cody RF Jr, Ascher SM. Diagnostic value of radiological tests in chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. 2000 Jun. 14(3):433-66. [Medline].

  29. Demco LA. Pain referral patterns in the pelvis. J Am Assoc Gynecol Laparosc. 2000 May. 7(2):181-3. [Medline].

  30. Dwarakanath LS, Persad PS, Khan KS. Role of laparoscopy in the management of chronic pelvic pain. Hosp Med. 1998 Aug. 59(8):627-31. [Medline].

  31. Economy KE, Laufer MR. Pelvic pain. Adolesc Med. 1999 Jun. 10(2):291-304. [Medline].

  32. Ehlert U, Heim C, Hellhammer DH. Chronic pelvic pain as a somatoform disorder. Psychother Psychosom. 1999 Mar-Apr. 68(2):87-94. [Medline].

  33. Finnerup NB, Otto M, McQuay HJ, et al. Algorithm for neuropathic pain treatment: an evidence based proposal. Pain. 2005 Dec 5. 118(3):289-305. [Medline].

  34. Ghaly AF, Chien PF. Chronic pelvic pain: clinical dilemma or clinician's nightmare. Sex Transm Infect. 2000 Dec. 76(6):419-25. [Medline].

  35. Grace VM. Pitfalls of the medical paradigm in chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. 2000 Jun. 14(3):525-39. [Medline].

  36. Gurel H, Atar Gurel S. Dyspareunia, back pain and chronic pelvic pain: the importance of this pain complex in gynecological practice and its relation with grand multiparity and pelvic relaxation. Gynecol Obstet Invest. 1999. 48(2):119-22. [Medline].

  37. Hewitt GD, Brown RT. Acute and chronic pelvic pain in female adolescents. Med Clin North Am. 2000 Jul. 84(4):1009-25. [Medline].

  38. Holley RL, Richter HE, Wang L. Neurologic disease presenting as chronic pelvic pain. South Med J. 1999 Nov. 92(11):1105-7. [Medline].

  39. Howard FM. Abuse history and chronic pain in women: I. Prevalences of sexual abuse and physical abuse. Obstet Gynecol. 1995 Jan. 85(1):158-9. [Medline].

  40. Howard FM. An evidence-based medicine approach to the treatment of endometriosis- associated chronic pelvic pain: placebo-controlled studies. J Am Assoc Gynecol Laparosc. 2000 Nov. 7(4):477-88. [Medline].

  41. Howard FM. Laparoscopic evaluation and treatment of women with chronic pelvic pain. J Am Assoc Gynecol Laparosc. 1994 Aug. 1(4 Pt 1):325-31. [Medline].

  42. Howard FM. The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. 2000 Jun. 14(3):467-94. [Medline].

  43. Howard FM. The role of laparoscopy in chronic pelvic pain: promise and pitfalls. Obstet Gynecol Surv. 1993 Jun. 48(6):357-87. [Medline].

  44. Howard FM. The role of laparoscopy in the evaluation of chronic pelvic pain: pitfalls with a negative laparoscopy. J Am Assoc Gynecol Laparosc. 1996 Nov. 4(1):85-94. [Medline].

  45. Howard FM, El-Minawi AM, Sanchez RA. Conscious pain mapping by laparoscopy in women with chronic pelvic pain. Obstet Gynecol. 2000 Dec. 96(6):934-9. [Medline].

  46. Jarrell JF. The weight of chronic pelvic pain. J Obstet Gynaecol Can. 2004 May. 26(5):453-4. [Medline].

  47. Justins DM. Management strategies for chronic pain. Ann Rheum Dis. 1996 Sep. 55(9):588-96. [Medline].

  48. Kanazi GE, Perkins FM, Thakur R, Dotson E. New technique for superior hypogastric plexus block. Reg Anesth Pain Med. 1999 Sep-Oct. 24(5):473-6. [Medline].

  49. Kontoravdis A, Hassan E, Hassiakos D, et al. Laparoscopic evaluation and management of chronic pelvic pain during adolescence. Clin Exp Obstet Gynecol. 1999. 26(2):76-7. [Medline].

  50. Large RG. Psychological aspects of pain. Ann Rheum Dis. 1996 Jun. 55(6):340-5. [Medline].

  51. Luzzi G, O'Leary M. Chronic pelvic pain syndrome. BMJ. 1999 May 8. 318(7193):1227-8. [Medline].

  52. Malik E, Berg C, Meyhofer-Malik A, et al. Subjective evaluation of the therapeutic value of laparoscopic adhesiolysis: a retrospective analysis. Surg Endosc. 2000 Jan. 14(1):79-81. [Medline].

  53. McCrory P, Bell S. Nerve entrapment syndromes as a cause of pain in the hip, groin and buttock. Sports Med. 1999 Apr. 27(4):261-74. [Medline].

  54. McDonald JS. Management of chronic pelvic pain. Obstet Gynecol Clin North Am. 1993 Dec. 20(4):817-38. [Medline].

  55. Moore J, Kennedy S. Causes of chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. 2000 Jun. 14(3):389-402. [Medline].

  56. Morikawa JH. Laparoscopy for chronic pelvic pain. Hawaii Med J. 1999 Jan. 58(1):22-3. [Medline].

  57. Negre E, Chaptal PA, Grolleau-Raoux D, Caporiccio A. [Systemic embolism after closure of an ostium secundum (author's transl)]. Ann Chir Thorac Cardiovasc. 1975 Jan. 14(1):21-4. [Medline].

  58. Nezhat FR, Crystal RA, Nezhat CH, Nezhat CR. Laparoscopic adhesiolysis and relief of chronic pelvic pain. JSLS. 2000 Oct-Dec. 4(4):281-5. [Medline].

  59. Nickel JC, Tripp DA. Clinical and psychological parameters associated with pain pattern phenotypes in women with interstitial cystitis/bladder pain syndrome. J Urol. 2015 Jan. 193(1):138-44. [Medline].

  60. Olive DL, Schwartz LB. Endometriosis. N Engl J Med. 1993 Jun 17. 328(24):1759-69. [Medline].

  61. Papathanasiou K, Papageorgiou C, Panidis D, Mantalenakis S. Our experience in laparoscopic diagnosis and management in women with chronic pelvic pain. Clin Exp Obstet Gynecol. 1999. 26(3-4):190-2. [Medline].

  62. Pashley DH. Dentin permeability and dentin sensitivity. Proc Finn Dent Soc. 1992. 88 Suppl 1:31-7. [Medline].

  63. Prentice A. Medical management of chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. 2000 Jun. 14(3):495-9. [Medline].

  64. Reiter RC. Evidence-based management of chronic pelvic pain. Clin Obstet Gynecol. 1998 Jun. 41(2):422-35. [Medline].

  65. Richter HE, Holley RL, Chandraiah S, Varner RE. Laparoscopic and psychologic evaluation of women with chronic pelvic pain. Int J Psychiatry Med. 1998. 28(2):243-53. [Medline].

  66. Rickert VI, Kozlowski KJ. Pelvic pain. A SAFE approach. Obstet Gynecol Clin North Am. 2000 Mar. 27(1):181-93. [Medline].

  67. Robert R, Prat-Pradal D, Labat JJ. Anatomic basis of chronic perineal pain: role of the pudendal nerve. Surg Radiol Anat. 1998. 20(2):93-8. [Medline].

  68. Sand PK. Chronic pain syndromes of gynecologic origin. J Reprod Med. 2004 Mar. 49(3 Suppl):230-4. [Medline].

  69. Scialli AR. Evaluating chronic pelvic pain. A consensus recommendation. Pelvic Pain Expert Working Group. J Reprod Med. 1999 Nov. 44(11):945-52. [Medline].

  70. Selfe SA, Matthews Z, Stones RW. Factors influencing outcome in consultations for chronic pelvic pain. J Womens Health. 1998 Oct. 7(8):1041-8. [Medline].

  71. Selfe SA, Van Vugt M, Stones RW. Chronic gynaecological pain: an exploration of medical attitudes. Pain. 1998 Aug. 77(2):215-25. [Medline].

  72. Steege JF. Office assessment of chronic pelvic pain. Clin Obstet Gynecol. 1997 Sep. 40(3):554-63. [Medline].

  73. Stewart P, Slade P. Comparative study of pelvic and non-pelvic pain/the prevalence of chronic pelvic pain. Br J Obstet Gynaecol. 1998 Dec. 105(12):1338-9. [Medline].

  74. Stone AR, Kim JH. Pelvic, perineal, and genital pain. Gershwin ME, Hamilton ME eds. The Pain Management Handbook: A Concise Guide to Diagnosis and Treatment. Totowa, NJ: Humana Press; 1998. 147-63.

  75. Stones RW, Mountfield J. Interventions for treating chronic pelvic pain in women. Cochrane Database Syst Rev. 2000. CD000387. [Medline].

  76. Stones RW, Selfe SA, Fransman S, Horn SA. Psychosocial and economic impact of chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. 2000 Jun. 14(3):415-31. [Medline].

  77. Stovall DW. Transvaginal ultrasound findings in women with chronic pelvic pain. Obstet Gynecol. 2000 Apr 1. 95(4 Suppl 1):S57.

  78. Summitt RL Jr. Urogynecologic causes of chronic pelvic pain. Obstet Gynecol Clin North Am. 1993 Dec. 20(4):685-98. [Medline].

  79. Toozs-Hobson P, Bidmead J, Cardozo L. Chronic pelvic pain. Br J Obstet Gynaecol. 1998 Nov. 105(11):1238. [Medline].

  80. Vercellini P, De Giorgi O, Pisacreta A, et al. Surgical management of endometriosis. Baillieres Best Pract Res Clin Obstet Gynaecol. 2000 Jun. 14(3):501-23. [Medline].

  81. Walker JJ, Irvine G. How should we approach the management of pelvic pain?. Gynecol Obstet Invest. 1998. 45 Suppl 1:6-10; discussion 10-1, 35. [Medline].

  82. Winkel CA, Scialli AR. Safety of medical and surgical management of chronic pelvic pain and endometriosis. Obstet Gynecol. 2001 Apr. 97(4 Suppl 1):S28.

  83. Wise TN, Arnold LM, Maletic V. Management of painful physical symptoms associated with depression and mood disorders. CNS Spectr. 2005 Dec. 10(12 Suppl 19):1-13. [Medline].

  84. Zondervan K, Barlow DH. Epidemiology of chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. 2000 Jun. 14(3):403-14. [Medline].

 
Previous
Next
 
Transabdominal longitudinal view of the female pelvis.
Transabdominal transverse view of the female pelvis: The bladder is rectangular. The ovaries are seen bilaterally in the adnexa.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.