Chronic Pelvic Pain in Women

Various reproductive, GI, urologic, and neuromuscular disorders may cause or contribute to chronic pelvic pain. Sometimes, multiple contributing factors may exist in a single patient. About 50-90% of patients with chronic pelvic pain have musculoskeletal pain and dysfunction.[3]

Extrauterine reproductive disorders include the following:

• Endometriosis

• Adhesions

• Adnexal cysts

• Chronic ectopic pregnancy

• Chlamydial endometritis or salpingitis

• Endosalpingiosis

• Ovarian retention syndrome (residual ovary syndrome)

• Ovarian remnant syndrome

• Ovarian dystrophy or ovulatory pain

• Pelvic congestion syndrome

• Postoperative peritoneal cysts

• Residual accessory ovary

• Subacute salpingo-oophoritis

• Tuberculous salpingitis

Uterine reproductive disorders include the following:

• Adenomyosis

• Chronic endometritis

• Atypical dysmenorrhea or ovulatory pain

• Cervical stenosis

• Endometrial or cervical polyps

• Leiomyomata

• Symptomatic pelvic relaxation (genital prolapse)

• Intrauterine contraceptive device

Urologic disorders include the following:

• Bladder neoplasm

• Chronic urinary tract infection

• Interstitial cystitis

• Radiation cystitis

• Recurrent cystitis

• Recurrent urethritis

• Urolithiasis

• Uninhibited bladder contractions (detrusor-sphincter dyssynergia)

• Urethral diverticulum

• Chronic urethral syndrome

• Urethral caruncle

Musculoskeletal disorders include the following:

• Abdominal wall myofascial pain (trigger points)

• Compression fracture of lumbar vertebrae

• Faulty or poor posture

• Fibromyalgia

• Mechanical low back pain

• Chronic coccygeal pain

• Muscular strains and sprains

• Pelvic floor myalgia (levator ani spasm)

• Piriformis syndrome

• Rectus tendon strain

• Hernias (eg, obturator, sciatic, inguinal, femoral, spigelian, perineal, umbilical)

Gastrointestinal disorders include the following:

• Carcinoma of the colon

• Chronic intermittent bowel obstruction

• Colitis

• Chronic constipation

• Diverticular disease

• Inflammatory bowel disease

• Irritable bowel syndrome

Neurologic disorders include the following:

• Neuralgia/cutaneous nerve entrapment (surgical scar in the lower part of the abdomen; usually iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous nerves)

• Shingles (herpes zoster infection)

• Degenerative joint disease

• Disk herniation

• Spondylosis

• Abdominal epilepsy

• Abdominal migraine

• Neoplasia of spinal cord or sacral nerve

Psychologic and other disorders include the following:

• Personality disorders

• Depression

• Sleep disorders

• Sexual and/or physical abuse

Common causes of chronic pelvic pain in men include the following:

• Chronic (nonbacterial) prostatitis

• Chronic orchalgia

• Prostatodynia

United States statistics

Chronic pelvic pain is a common problem. It affects approximately 1 in 7 women.[2] In one study of reproductive-aged women in primary care practices, the reported prevalence rate of pelvic pain was 39%.[4] Of all referrals to gynecologists, 10% are for pelvic pain.[5]

International statistics

A similar prevalence of chronic pelvic pain has been described in other countries.[6]

Race-, sex-, and age-related demographics

Race

In one study, Blacks had a higher incidence of pelvic pain.[4]

Sex

Chronic pelvic pain is most common among reproductive-aged women. Common causes of chronic pelvic pain in men include chronic (nonbacterial) prostatitis, chronic orchalgia, and prostatodynia.

Age

Chronic pelvic pain is most common among reproductive-aged women, especially those aged 26-30 years.[4]

Morbidity/mortality

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

Complications

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

The patient and the patient's family should have a good understanding about the multifactorial nature of chronic pain. They need multidisciplinary and comprehensive management plans.

Instruct the patient to avoid uncomfortable stressful positions and bad posture. Also recommend regular exercise, good sleeping habits, and balanced meals.

Try biofeedback and relaxation techniques.

For patient education resources, see Osteoporosis Center and Women's Health Center, as well as Chronic Pain, Bladder Control Problems, Female Sexual Problems, Endometriosis, and Pain During Intercourse.

A proposed definition of chronic pelvic pain (CPP) is nonmenstrual pain of 3 months duration or longer that localizes to the anatomic pelvis and is severe enough to cause functional disability and require medical or surgical treatment. Most authorities agree that patients should be diagnosed with chronic pelvic pain if they have pain primarily located in the pelvis for more than 3-6 months duration.

Patient history is important in cases of chronic pelvic pain. Because of the complex etiology and, often, the presence of associated disorders, a general approach with a thorough history that directs further evaluation and appropriate consultations is needed.[7] Perform a detailed review of systems, including reproductive, GI, musculoskeletal, urologic, and neuropsychiatric. As needed, ask specific questions, especially if the patient has an associated disorder. A thorough past history is also important to avoid repeating invasive and expensive procedures.

Focus history on characterizing the patient's pain, which can lead to appropriate diagnostic and therapeutic plans.

Location of pain

The location of pain is an important part of the history. Ask the patient to describe the pain location and type on a pain diagram (anteroposterior and lateral view of human picture).

Precipitating factors

Ask questions about factors that provoke or intensify pain. This may provide clues for possible etiologies or associated disorders. For example, in pelvic congestion syndrome, pain is related to posture and is worse at the end of day. In endometriosis, pain is commonly reported during or after intercourse.

Alleviating factors

Alleviating factors may be present. For example, rest may decrease pain of musculoskeletal or adnexal origin.

Quality of pain

Various terms can be used to describe the quality of pain. Such terms include throbbing, pounding, shooting, pricking, boring, stabbing, lancinating, sharp cutting, lacerating, pressing, cramping, crushing, pulling, pinching, stinging, burning, splitting, penetrating, piercing, squeezing, and dull aching.

Pain distribution

Spreading or radiation of pain is also important in the evaluation of neuropathic pain.

Severity or intensity of pain

Use some type of rating system to evaluate pain severity or intensity with a degree of objectivity and reproducibility. Different types of pain scales may be used. Numerical scales are more useful and reliable. The visual analog scale is one of the commonly used numerical scales.

Obtain a history specific to different systems and disorders, as discussed below.

Gynecologic and obstetric

For example, excessive bleeding with menses suggests uterine leiomyomas or adenomyosis. History of previous surgery may suggest intra-abdominal or pelvic adhesions. Patients with cervical stenosis usually have a history of chronic cervical infection or treatment with cryosurgery/laser surgery/loop excision or endometrial resection. Having multiple sexual partners is a risk factor for pelvic inflammatory disease.

Women with adenomyosis have higher levels of dysmenorrhea, pelvic pain, depression, and endometriosis than women with fibroids. Women undergoing hysterectomy with a histologic diagnosis of adenomyosis have a distinct symptomatology and medical history compared with women with leiomyomas.[8]

Urologic

A detailed history to evaluate the urological system is important. For example, as compared to patients with pelvic pain, patients with interstitial cystitis report urgency and increased frequency of urination as the most distressing features.

Gastrointestinal

For example, deflecting sigmoid adhesions are common in women with chronic pelvic pain and frequently are associated with GI symptoms.

Musculoskeletal

History of vaginal delivery with prolonged second-stage episiotomies or tears may suggest pelvic floor relaxation disorder.

Neurologic

Constant burning pain is a common complaint in patients with pudendal neuralgia. Patients may report dysesthesia and vulvodynia but usually not dyspareunia.

Psychologic

A good psychosocial or psychosexual history is needed when organic diseases are excluded, or coexisting psychiatric disorders are suggested. Obtain sufficient history to evaluate depression, anxiety disorder, somatization, physical or sexual abuse, drug abuse or dependence, and family problems, marital problems, or sexual problems.[9] Sexual abuse occurring before age 15 years is associated with later development of chronic pelvic pain.[10] Somatization is a common associated psychologic disorder in women with chronic pelvic pain. Somatization scales can be used for evaluation.

Good rapport, tolerance, and an open-minded approach are important in the evaluation of any patient with chronic pain. A thorough systematic examination usually suggests an appropriate diagnosis and therapy.

Obstetric-gynecologic and other system examinations could be long and stressful. Detailed examination of obstetric-gynecologic and other systems can be performed in different positions. Usually, this includes standing, sitting, supine, and lithotomy positions.

Lithotomy examination usually includes the following:

• Visual inspection of the external genitalia

• Basic sensory testing and evaluation for trigger points: A cotton-tipped swab can be used for precise sensory and tender-point evaluation of the vestibule, vaginal cuff, cervical os, paracervical region, and cervical region; single-digit examinations of the vulva, pubic arch, levator ani coccyx, introitus, urethral, trigonal, cervix, paracervical areas, vaginal fornices, uterus, and adnexa are indicated.

• Colposcopic evaluation of the vulva and vestibule

• Sims retractor or single-blade speculum examination of the vagina and pelvic muscles

• Bimanual pelvic examination

• Rectovaginal examination

Perform detailed examinations for other systems (eg, GI, urologic, neurologic, musculoskeletal) as required. For example, gait and posture evaluation, spine examination, and sensory and motor examination are often useful.

• Betty maneuver (for piriformis syndrome): When abduction of the thigh against resistance is requested, the patient will report pain.

• Obturator sign (dysfunction of the obturator muscles or fascia)

• Straight-leg raising test (possible herniated disc, radiculopathy)

• Psoas sign: If pain is elicited during flexion of hip against resistance, this may suggest dysfunction of the psoas muscles or fascia.

• Patrick or faber (flexion in abduction and external rotation) test for hip evaluation

The decision to perform laboratory or imaging evaluations in patients with chronic pelvic pain (CPP) is based on the need for confirmation of the diagnosis and to help rule out other potentially life-threatening illnesses. Certain investigations sometimes are needed to provide appropriate and safe medical or surgical treatment.

CBC count and sedimentation rate

These tests provide nonspecific findings, but the results can be sensitive indicators of inflammation or infection and, occasionally, malignancy.

Serum drug screen

Perform this if any suggestion of prescription or street drug abuse is present.

Urine test

Urinalysis and urine culture are relatively inexpensive and noninvasive and should be performed when necessary.

If hematuria is present, carefully evaluate the condition with a history, physical examination, urine culture, urine cytology, cystourethroscopy, and intravenous pyelography or CT scan.

If malignancy is suggested, perform urine cytology in addition to urinalysis and culture, especially if the patient smokes.

Sexually transmitted disease testing

Testing for sexually transmitted diseases in women with chronic pelvic pain includes cervical cultures or smears, syphilis serology (rapid plasma reagent, microhemagglutination-Treponema pallidum), hepatitis B screening, chlamydial polymerase chain reaction, and HIV testing.

Other tests used to help rule out specific infections may include vaginal cultures, vaginal wet preparations, vaginal pH, and urine analysis and culture.

Hormone assays

Follicle-stimulating hormone level, estradiol level, and gonadotropin-releasing hormone agonist stimulation testing can be helpful in cases of ovarian remnant syndrome.

Thyroid-stimulating hormone testing

This is used for evaluation of hypothyroidism, especially in a patient with depression.

Perform stool guaiac testing in patients with gastrointestinal symptoms and in patients older than 50 years. Testing stool specimens for ova and parasites also may be helpful in selected cases.

MRI

MRI is a noninvasive tool that can provide excellent structural information without any radiation harm. Intravenous contrast can be used when inflammation, infection, or malignancy is suggested.

CT scanning

This is useful in patients with pelvic masses and sometimes is helpful in differentiating an ovarian mass from a uterine mass, but it is more expensive than sonography.

Ultrasonography

This is a noninvasive diagnostic tool and could be helpful in many patients with chronic pelvic pain. It is commonly used to help identify pelvic masses or cysts and their origin, pelvic varicosities, and hernias (spigelian hernias).

Transabdominal longitudinal and transverse views of the female pelvis using ultrasonography are shown in the images below.

Plain film radiography

Obtaining chest and spine radiographs may be useful in fractures, infections, tumors, and other structural abnormalities.

Flat and upright abdominal radiographs may be obtained to help rule out intestinal obstruction and pelvic infection (eg, tuberculosis).

Hysterosalpingography

Hysterosalpingography (HSG) is not a first-choice diagnostic tool for endometriosis; however, it may be useful in patients with infiltrative endometriosis of the uterosacral ligaments. Adolescents with endometriosis also can be evaluated for obstructive anomalies.

HSG may be useful in cases suggestive of endometrial polyps, Asherman syndrome, and adenomyosis.

Barium enema radiography,colonoscopy, sigmoidoscopy, upper gastrointestinal series, and anorectal manometry

These can be used to evaluate a GI etiology of chronic pain. Anorectal balloon manometry can be used to assess colonic transit time.

Vaginal sonography

This is useful in patients with possible pelvic congestion syndrome. Transuterine venography commonly is recommended.

Voiding cystourethrography

When interstitial cystitis is suggested, consider cystoscopy with hydrodistention.

Double-balloon cystourethrography

This is a more sensitive diagnostic test than voiding cystourethrography for diagnosing urethral diverticula in women.[13]

Herniography (perineal hernia herniography) and bone scanning are other imaging modalities that can be used to investigate causes of chronic pelvic pain.

Endoscopic procedures used commonly in the evaluation and treatment of patients with chronic pelvic pain include laparoscopy, cystourethroscopy, hysteroscopy, sigmoidoscopy, and colonoscopy.

Laparoscopy can be used as a diagnostic tool in patients with chronic pelvic pain, as follows:

• More than 40% of laparoscopies are performed for the diagnosis of chronic pelvic pain.

• More then 60% of women with chronic pelvic pain have at least one condition detectable by laparoscopy.

• Most commonly, diagnoses made via laparoscopy include endometriosis, pelvic adhesions, and chronic pelvic inflammatory disease. Other diagnoses include ovarian cysts, hernias, pelvic congestion syndrome, ovarian remnant syndrome, ovarian retention syndrome, postoperative peritoneal cysts, and endosalpingiosis.

Urodynamic testing can be performed if chronic urethral syndrome or interstitial cystitis is suggested in a patient with chronic pelvic pain.

Nerve-conducting velocities and needle-electromyographic studies are used to help evaluate compression or entrapment neuropathy and pelvic floor function.

Cancer antigen 125 (CA-125), used as a diagnostic test, has low sensitivity and specificity. It may be elevated with diseases associated with pelvic pain, such as endometriosis or leiomyomata. CA-125 levels also are elevated with malignancy (eg, ovarian, endometrial, colon, or breast cancer), pelvic inflammatory disease, pregnancy, and menses.[14]

However, although elevated, levels of serum CA-125 do not appear to be a significant predictor of malignant transformation of endometriosis. Significant predictive factors for the presence of malignant transformation of endometriosis appear to include age older than 49 years and cysts that are multilocular and have solid components.[15]

Perform electroencephalography if the rare disorder of abdominal epilepsy is suggested.

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

Hospitalization is not usually 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.

Treatment of chronic pelvic pain (CPP) is complex in patients with multiple problems.[16, 17] It usually requires specific treatment and simultaneous psychological and physical therapy. A good relationship should be established between the clinician and the patient. Treatment of chronic pelvic pain must be tailored for the individual patient.

The goals of treatment must be realistic. They should be focused toward restoration of normal function (minimal disability), better quality of life, and prevention of relapse of chronic symptoms.

Pharmacotherapy

Pharmacotherapy consists of symptomatic abortive therapy to stop or reduce the severity of the acute exacerbations and long-term therapy for chronic pain. Initially, pain may respond to simple over-the-counter (OTC) analgesics such as paracetamol, ibuprofen, aspirin, or naproxen. If treatment results are unsatisfactory, the addition of other modalities or the use of prescription drugs is recommended.

If possible, avoid use of barbiturate or opiate agonists. Also discourage long-term use and overuse of all symptomatic analgesics because of the risk of dependence and abuse.

Tizanidine may improve the inhibitory function in the central nervous system and can provide pain relief. Therapy with tizanidine is not considered the standard of care

Amitriptyline (Elavil) and nortriptyline (Pamelor) are the tricyclic antidepressants (TCAs) used most frequently for chronic pain.

The selective serotonin reuptake inhibitors (SSRIs) fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) also are commonly prescribed. Other antidepressants such as doxepin, desipramine protriptyline, and buspirone also can be used.

A randomized, controlled trial found that treatment with gabapentin did not result in significantly lower pain scores in women with chronic pelvic pain. Moreover, 7% of women in the gabapentin group had serious adverse events, compared with 2% in the placebo group, a statistically significant difference. Gabapentin was also associated with a higher rate of side effects, including dizziness, drowsiness, and visual disturbances.[18]

Physical therapy

Physical therapy techniques include hot or cold applications, positioning, stretching exercises, traction, massage, ultrasound therapy, transcutaneous electrical nerve stimulation (TENS), and manipulations. Heat, massage, and stretching can be used to alleviate excess muscle contraction and pain. Pelvic floor training also may be recommended.

In a Brazilian study of 58 women with pelvic pain of at least 6 months' duration and who received 6 months of multidisciplinary management, reduction of skin pain sensitivity with TENS was associated with an increase in pelvic pain threshold (P< 0.0001).[19] The investigators applied TENS to the anterior surface of the nondominant arm; in the group that experienced chronic pelvic pain reduction following 6 months of multidisciplinary treatment, the effect size of the electrical pain threshold was 0.86, whereas in the group that did not experience a reduction in pelvic pain, the size increase was 0.53.[19]

Psychophysiological therapy

Psychophysiological therapy includes reassurance, counseling, relaxation therapy, a stress management program, and biofeedback techniques. With these modalities of treatment, both frequency and severity of chronic pain may be reduced.

Biofeedback may be helpful in some patients when combined with medications.

Other treatment

A study by Teixeira et al that included 50 women with deeply infiltrating endometriosis evaluated the efficacy and safety of potentized estrogen compared to placebo in homeopathic treatment of endometriosis-associated pelvic pain. The study reported that potentized estrogen (12cH, 18cH and 24cH) at a dose of 3 drops twice daily for 24 weeks decreased the endometriosis-associated pelvic pain global score by 12.82 (P< 0.001) and that the group that used potentized estrogen also showed partial score (VAS: range 0 to 10) reduction in dysmenorrhea (3.28; P< 0.001), non-cyclic pelvic pain (2.71; P=0.009), and cyclic bowel pain (3.40; P< 0.001).[20]

Various minimally invasive techniques may provide pain relief. These techniques include the following:

• Trigger point injections: These injections are used mostly for localized trigger points (myofascial pain or neuroma).

• Peripheral nerve blocks: Specific peripheral nerve block with local anesthetic and steroids may be helpful in selected cases.

Neuroablation of selected nerves can be performed by using different techniques, including thermocoagulation (radiofrequency ablation), cryoablation, or injection of chemical agents (alcohol, hypertonic saline, phenol). An intrathecal morphine pump may be used, but careful selection for appropriate patients is very important. Sacral nerve stimulation may be effective in the treatment of therapy-resistant pelvic pain syndromes linked to pelvic floor dysfunction.[21]

Various surgical procedures may be considered to treat chronic pelvic pain. Surgical procedures include presacral neurectomy (superior hypogastric plexus excision), paracervical denervation (laparoscopic uterine nerve ablation), and uterovaginal ganglion excision (inferior hypogastric plexus excision).

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

Pharmacotherapy in chronic pelvic pain (CPP) consists of symptomatic abortive therapy to stop or reduce the severity of acute exacerbation of pain and long-term therapy for chronic pain.

Class Summary

These agents are generally used in mild-to-moderate pain; however, they may also be effective for severe pain.

Acetaminophen (Tylenol)

First choice for pain, especially during pregnancy and breastfeeding.

Ibuprofen (Advil, Motrin)

Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis.

Naproxen (Aleve, Naprosyn, Naprelan)

For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.

Class Summary

These agents are commonly used for many pain syndromes.

Fentanyl (Duragesic patch)

Potent narcotic analgesic with much shorter half-life than morphine sulfate. DOC for conscious sedation analgesia. Ideal for analgesic action of short duration during anesthesia and immediate postoperative period. Excellent choice for pain management and sedation; short duration (30-60 min) and easy to titrate.

Easily and quickly reversed by naloxone. When using transdermal dosage form, most patients are controlled with 72-h dosing intervals.

However, some patients require dosing intervals of 48 h.

Available in 12, 25, 50, 75, and 100 mcg doses.

Class Summary

Certain antiepileptic drugs (eg, the GABA analogue gabapentin and pregabulin [Lyrica]) have proven helpful in some cases of neuropathic pain. Other anticonvulsant agents (eg, clonazepam, topiramate, lamotrigine, zonisamide, tiagabine) have also been tried in chronic pelvic pain (CPP).

Gabapentin (Neurontin)

Has anticonvulsant properties and antineuralgic effects; however, exact mechanism of action is unknown.

Structurally related to GABA but does not interact with GABA receptors.

Pregabalin (Lyrica)

Structural derivative of GABA. Mechanism of action unknown. Binds with high affinity to alpha2 -delta site (a calcium channel subunit). In vitro, reduces calcium-dependent release of several neurotransmitters, possibly by modulating calcium channel function. FDA approved for neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia and as adjunctive therapy in partial-onset seizures.

Class Summary

These agents increase synaptic concentration of serotonin and/or norepinephrine in the CNS by inhibiting reuptake by the presynaptic neuronal membrane (eg, duloxetine [Cymbalta], venlafaxine [Effexor]).

Nortriptyline (Pamelor)

Demonstrated effectiveness in the treatment of chronic pain.

Amitriptyline (Elavil)

Analgesic for certain chronic and neuropathic pain.

Class Summary

These agents selectively inhibit presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine. SSRIs can be used in second-line or third-line treatment of painful diabetic neuropathy. They are used in patients who are already depressed.

Fluoxetine (Prozac)

Considered an alternative to TCAs, with fewer adverse anticholinergic and cardiovascular effects.

Sertraline (Zoloft)

Considered an alternative to TCAs, with fewer adverse anticholinergic and cardiovascular effects.

Paroxetine (Paxil)

Considered an alternative to TCAs, with fewer adverse anticholinergic and cardiovascular effects.