eMedicine Specialties > Obstetrics and Gynecology > General Gynecology

Chronic Pelvic Pain: Follow-up

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
Coauthor(s): 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; Jashvant Patel, MD, Medical Director, Department of Pain Medicine and Comprehensive Rehabilitation, Medical College of Pennsylvania Hahnemann University
Contributor Information and Disclosures

Updated: Dec 22, 2008

Follow-up

Further Inpatient Care

Hospitalization usually is not required for patients with chronic pelvic pain (CPP); however, the need for hospitalization depends on the invasiveness of the treatment choice for pain control and on the severity of the case.

Further Outpatient Care

Patients with CPP generally are treated in an outpatient setting and require a variety of health care professionals to optimally manage their condition.

Complications

Like other chronic pain, CPP may lead to prolonged suffering, marital or family problems, loss of employment, disability, and various adverse medical reactions from lifelong therapy.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • 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
    • The use of medication during pregnancy is not contraindicated, but it should be limited and carefully justified.
    • 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.
  • CPP in men: Chronic (nonbacterial) prostatitis, chronic orchalgia, and prostatodynia are common causes of CPP in men of any age.
 


More on Chronic Pelvic Pain

Overview: Chronic Pelvic Pain
Differential Diagnoses & Workup: Chronic Pelvic Pain
Treatment & Medication: Chronic Pelvic Pain
Follow-up: Chronic Pelvic Pain
References
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References

  1. Mathias SD, Kuppermann M, Liberman RF, et al. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol. Mar 1996;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. Jan 1996;87(1):55-8. [Medline].

  3. Reiter RC. A profile of women with chronic pelvic pain. Clin Obstet Gynecol. Mar 1990;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. Nov 1999;106(11):1149-55. [Medline].

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

  6. 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. Dec 1999;162(6):2066-9. [Medline].

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

  8. 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].

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

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

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

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

  13. 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. Sep 1999;20(3):145-51. [Medline].

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

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

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

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

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

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

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

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

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

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

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

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

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

  27. 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].

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

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

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

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

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

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

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

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

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

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

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

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

  40. 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].

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

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

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

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

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

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

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

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

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

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

  51. 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].

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

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

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

  55. 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].

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

  57. 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].

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

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

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

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

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

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

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

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

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

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

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

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

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

  71. 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].

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

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

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

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Further Reading

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Keywords

chronic pelvic pain, CPP, bladder dysfunction, bowel dysfunction, sexual dysfunction, depression, anxiety disorder, drug addiction, drug abuse, prostatitis, chronic orchalgia, prostatodynia, pelvic congestion syndrome, endometriosis, uterine leiomyomas, adenomyosis, pelvic inflammatory disease, PID, cervical stenosis, deflecting sigmoid adhesion, pelvic floor relaxation disorder, pudendal neuralgia, somatization, physical abuse, sexual abuse, sexually transmitted disease, STD, nonmenstrual pain, vulvodynia, dyspareunia, Betty maneuver, piriformis syndrome, obturator sign, psoas sign, Patrick test, faber test

adnexal cysts, chronic urinary tract infection, abdominal wall myofascial pain, carcinoma of the colon, chronic intermittent bowel obstruction, cutaneous nerve entrapment, shingles, sleep disorders, chronic ectopic pregnancy, chlamydial endometritis, chlamydial salpingitis, endosalpingiosis, ovarian retention syndrome, residual ovary syndrome, ovarian remnant syndrome, ovarian dystrophy, ovulatory pain, postoperative peritoneal cysts, residual accessory ovary, subacute salpingo-oophoritis, tuberculous salpingitis, atypical dysmenorrhea, endometrial polyps, cervical polyps, leiomyomata, genital prolapse

intrauterine contraceptive device, bladder neoplasm, interstitial cystitis, radiation cystitis, recurrent cystitis, recurrent urethritis, urolithiasis, detrusor-sphincter dyssynergia, urethral diverticulum, chronic urethral syndrome, urethral caruncle, compression fracture of lumbar vertebrae, fibromyalgia, faulty posture, mechanical low back pain, chronic coccygeal pain, muscular strains and sprains, pelvic floor myalgia, levator ani spasm, rectus tendon strain, femoral hernia, perineal hernia, umbilical hernia, spigelian hernia, sciatic hernia, obturator hernia, colitis, chronic constipation, diverticular disease, inflammatory bowel disease, irritable bowel syndrome, herpes zoster infection, degenerative joint disease, disk herniation, spondylosis, abdominal epilepsy, abdominal migraine, neoplasia of spinal cord

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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 Association of Physicians of Indian Origin, American Headache Society, American Medical Association, and American Society of Regional Anesthesia and Pain Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

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 College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Endocrine Society, International Society for Clinical Densitometry, Society for Assisted Reproductive Technologies, Society for Reproductive Endocrinology and Infertility, and Society of Reproductive Surgeons
Disclosure: Ferring Grant/research funds Other

Jashvant Patel, MD, Medical Director, Department of Pain Medicine and Comprehensive Rehabilitation, Medical College of Pennsylvania Hahnemann University
Jashvant Patel, 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, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Medical Editor

Suzanne R Trupin, MD, Clinical Professor of Obstetrics and Gynecology, University of Illinois College of Medicine-Champaign; CEO and Owner, Women's Health Practice; CEO and Owner, Hada Cosmetic Medicine and Midwest Surgical Center
Suzanne R Trupin, MD is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, Association of Reproductive Health Professionals, International Society for Clinical Densitometry, and North American Menopause Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

A David Barnes, MD, PhD, MPH, FACOG, Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)
A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, 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, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

 
 
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