Chronic Pelvic Pain in Women Differential Diagnoses

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. ^[11]

• 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. ^[12]

Other considerations

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

• ALA Dehydratase Deficiency Porphyria

• Abdominal Hernias

• Acute Bacterial Prostatitis and Prostatic Abscess

• Acute Intermittent Porphyria

• Adjustment Disorders

• Adnexal Tumors

• Anorectal Abscess

• Benign Lesions of the Ovaries

• Benign Vulvar Lesions

• Bipolar Disorder

• Bladder Cancer

• Carcinoma In Situ of the Urinary Bladder

• Cervicitis

• Chronic Bacterial Prostatitis

• Chronic Fatigue Syndrome (Myalgic Encephalomyelitis)

• Chronic Pelvic Pain in Men

• Chronic Pyelonephritis

• Colon Cancer

• Colonic Obstruction

• Constipation

• Urinary Tract Infection (UTI) and Cystitis (Bladder Infection) in Females

• Cystitis, Nonbacterial

• Depression

• Diverticulitis

• Dysmenorrhea

• Endometrial Carcinoma

• Endometriosis

• Endometritis

• Familial Mediterranean Fever

• Gonorrhea

• Gynecologic Pain

• Hemorrhagic Cystitis: Noninfectious

• Herpes Zoster

• Inflammatory Bowel Disease

• Infrainguinal Occlusive Disease

• Interstitial Cystitis

• Intestinal Motility Disorders

• Irritable Bowel Syndrome (IBS)

• Lumbar Disc Disease

• Lumbar Spondylosis (Osteophytes, Bone Spurs)

• Malignant Neoplasms of the Small Intestine

• Mixed Connective-Tissue Disease (MCTD)

• Neurogenic Bladder

• Nonbacterial Prostatitis

• Ovarian Cancer

• Pelvic Inflammatory Disease

• Perianal Cysts

• Radiation Cystitis

• Rectal Cancer

• Complex Regional Pain Syndrome Type 1 (Reflex Sympathetic Dystrophy)

• Rehabilitation and Fibromyalgia

• Sleep-Wake Disorders

• Somatic Symptom Disorders

• Ulcerative Colitis

• Urethral Cancer

• Urethral Diverticula

• Urethral Diverticulum

• Urethral Strictures in Males

• Urethral Syndrome

• Urinary Tract Infection (UTI) in Males

• Uterine Cancer

• Uterine Prolapse

• Vaginitis

• Vesicovaginal and Ureterovaginal Fistula

• Vulvovaginitis