CHRONIC PELVIC PAIN

Dr. Javardo McIntosh

Intern
Department of Obstetrics and Gynecology
Princess Margaret Hospital
14th March 2016

Overview
Introduction
Epidemiology
Etiology
Clinical Presentation
History
Examination

Investigations
Management

Introduction
Chronic pelvic pain
Intermittent or constant pain in the lower abdomen or pelvis of a woman of at
least 6 months in duration,
not occurring exclusively with menstruation or intercourse and not associated
with pregnancy
sufficient severity to cause functional disability or require medical care

It is a symptom not a diagnosis.

May significantly impact on a womans ability to function

Epidemiology
Frequency
Affects 1 in 7 women
Most common in women of reproductive age especially those aged 26-30
years.
Of all referrals to gynecologist 10% are for pelvic pain
Mortality/Morbidity
CPP may lead to prolonged suffering, marital and family problems, loss of
employment or disability, and various adverse medical reactions from
lifelong therapy.

Etiology
The pathophysiology of CPP is not well understood.
A definitive diagnosis is not made for 61 percent of women with CPP.
Many persons assume that all chronic pelvic pain results from a gynecologic
source.
One study in the United Kingdom found that diagnoses related to the
urinary and gastrointestinal systems were more common than gynecologic
diagnoses.*
The four most commonly diagnosed causes
endometriosis, adhesions, irritable bowel syndrome (IBS), and interstitial cystitis
*Zondervan KT, Yudkin PL, Vessey MP, Dawes MG, Barlow DH, Kennedy SH. Patterns of diagnosis and referral in women consulting for chronic pelvic pain in UK primary
care. Br J Obstet Gynaecol. 1999;106(11):11561161

Causes of CPP
SYSTEM

DIFFERENTIAL DIAGNOSES

Gynecologic

Adhesions, adenomyosis, adnexal cysts, chronic endometritis,

dysmenorrhea, endometriosis, gynecologic malignancies,
leiomyomata pelvic congestion syndrome, pelvic inflammatory
disease

Gastrointestinal

Celiac disease, colitis, colon cancer, inflammatory bowel

disease, irritable bowel syndrome

Musculoskeletal

Degenerative disk disease, fibromyalgia, levator ani syndrome,

myofascial pain, peripartum pelvic pain syndrome, stress
fractures

Causes of CPP
SYSTEM

DIFFERENTIAL DIAGNOSES

Psychiatric/neurologic

Abdominal epilepsy, abdominal migraines, depression, nerve

entrapment, neurologic dysfunction, sleep disturbances,
somatization

Urologic

Bladder malignancy, chronic urinary tract infection, interstitial

cystitis, radiation cystitis, urolithiasis

Other

Familial Mediterranean fever, herpes zoster, porphyria

History
Characteristics of pain

Nature

Throbbing, Aching, Intermittent, Sharp,

Colicky

Onset

Sudden vs gradual

Intensity

Mild, Moderate, Severe

Duration

Intermittent vs constant

Alleviating or aggravating factors

posture
meals
bowel movements
voiding
menstruation
intercourse
medications

Frequency

Radiation

When?

Menstrual cycle: before, during, or after

Intercourse: During and/or After

History
Associated Symptoms

Anorexia

Fatigue

Gastrointestinal symptoms

Diarrhea, Constipation, Hematochezia,

Gas

Urologic symptoms

Frequency, Hesitancy, Urgency,

Incontinence, Dysuria

GU

Non menstrual vaginal bleeding

PV discharge
Method of contraception
Vaginal Dryness

History
Past Medical/Surgical
history

Pelvic Infections

Infertility

Previous Surgeries

Use of IUD

Abuse

Psychological,
Physical
Sexual

History
RED FLAG
SYMPTOMS

Unexplained weight loss

Hematochezia

Perimenopausal irregular bleeding,

Postmenopausal vaginal bleeding

Postcoital bleeding

History
History of pelvic surgery, pelvic
infections, or use of intrauterine
device
Non-hormonal pain fluctuation

Adhesions

Adhesions, interstitial cystitis, irritable bowel

syndrome, musculoskeletal causes

Pain fluctuates with menstrual cycle Adenomyosis or endometriosis

Perimenopausal or postmenopausal Endometrial cancer
irregular vaginal bleeding
Postcoital bleeding

Cervical cancer or cervicitis (e.g., chlamydia or

gonorrhea)

Unexplained weight loss

Systemic illness or malignancy

Physical Examination
Can identify
Areas of Tenderness
Presence of masses
Other anatomical findings
Normal physical examination does not rule out intraabdominal pathology

Physical examination
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.

Physical Examination
Colposcopic evaluation of the vulva,
vestibule and cervix

Sims retractor or single-blade

speculum examination of the vagina
and pelvic muscles

Physical Examination
Pelvic examination
Bimanual Pelvic examination
Palpate for nodules, masses, or
point tenderness along the bladder
or other musculoskeletal structures.

Rectovaginal examination

Physical Examination
Carnett's sign for patients with pelvic pain.

The examiner places his or her finger on the

tender area of the patient's abdomen and asks
the patient to raise both legs off the table.

An increase in the patient's pain during this

maneuver is considered a positive test.
Indicates a myofascial cause of the pain.
This may also indicate that the cause of the pain is
within the abdominal wall (e.g., fibromyalgia or trigger
point).
Visceral pain should not worsen during the maneuver

Physical examination
Physical Examination Finding
Lack of uterus mobility on
bimanual examination

Condition
Endometriosis, pelvic adhesions

Nodularity or masses on
Adenomyosis, endometriosis, hernias,
abdominal, bimanual pelvic and/or malignancy, tumors
rectal examination
Pain on palpation of outer back
and outer pelvis

Abdominal/pelvic wall source of pain, trigger

points

Point tenderness of vagina, vulva,

or bladder

Adhesions, endometriosis, nerve entrapment,

trigger points, vulvar vestibulitis

Positive Carnett's sign

Myofascial or abdominal wall cause of pain

Investigations
Initial test
Cervical cytology
Endocervical cultures
Neisseria gonorrhoeae
Chlamydia

Stool hemoccult
Urine studies
Urinalysis
Urine culture
Cytology

Investigations
Other Investigations
Complete blood count
Infection, systemic illness, or malignancy
(elevated/decreased white blood cell
count or anemia)

ESR
Infection, malignancy, systemic illness

Investigations
Transvaginal ultrasound
Adenomyosis,
Endometriosis/endometrioma,
Malignancy

Hysterosalpingography
not a first-choice diagnostic tool
may be useful in patients with
infiltrative endometriosis of the uterosacral
ligaments.
endometrial polyps
Asherman syndrome
adenomyosis

Investigations
MRI and CT
Not routinely used
can help assess any abnormalities
found on ultrasound.
Laparoscopy
used when the diagnosis remains
elusive after the initial workup
can confirm, and possibly treat,
suspected endometriosis
adhesions

Management
Myofascial pain
Physical therapy
Trigger points can often be treated
with
Injections of a local anesthetic (eg,
bupivacaine [Marcaine]),
a corticosteroid

Muscle relaxants
may prove useful in patients with
guarding, splinting, or reactive
muscle spasms.

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

Management
Pain related to the menstrual cycle
treatment aimed at suppressing the
cycle may help.
Common methods to accomplish this
include
depot medroxyprogesterone (Depo-Provera)
Oral contraceptives
Birth control implant

Management
Psychophysiological therapy
Reassurance
Counselling
Cognitive-behavioral therapy
Relaxation therapy
Stress management

Management
Pharmacotherapy
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.
Amitriptyline and nortriptyline are the tricyclic antidepressants used most
frequently for chronic pain.
The selective serotonin reuptake inhibitors (SSRIs) fluoxetine, paroxetine,
and sertraline also are commonly prescribed.

Management
Laparoscopy
When endometriosis or pelvic adhesions are discovered on diagnostic
laparoscopy, they are usually treated during the procedure.

Hysterectomy may be warranted if

the pain has persisted for more than six months
does not respond to analgesics (including anti-inflammatory agents)
and impairs the woman's normal function.

References