Kai-Wen Chuang, MD
Robert M. Moldwin, MD, FACS
BASICS
DESCRIPTION
• Chronic pelvic pain (CPP) is defined as discomfort below the umbilicus lasting ≥6 mo
• Etiology often unclear and symptom severity often out of proportion to objective findings
• Bears impact on physical, mental, emotional, and sexual well-being
EPIDEMIOLOGY
Incidence
N/A
Prevalence
• Difficult to ascertain due to varied definition
– Affects ∼1 in 7 women
– 39% prevalence rate in primary care setting
– Accounts for 10% of all gynecologic referrals
RISK FACTORS
• Depression, anxiety
• Personal history of abuse
• Prior sexually transmitted infections (STIs)
• Prior pelvic inflammatory disease (PID) increases risk 4-fold, prior STI/STD
• Substance dependence
• 1st-degree family with CPP
Genetics
• Twin studies and familial clustering do suggest genetic basis for increased nociception
• No established inheritance pattern
PATHOPHYSIOLOGY
• Exact mechanism unknown
• Complex and multifactorial, combining, biologic, psychological, and social factors
ASSOCIATED CONDITIONS
• Endometriosis, ectopic pregnancy, ovarian cysts, adhesions
• Urinary tract infections (UTIs), STIs, and PID
• Irritable bowel syndrome (IBS)
• Interstitial cystitis (IC)
GENERAL PREVENTION
• Prompt recognition
• Safe sex practices
DIAGNOSIS
HISTORY
• History of present illness
– Onset/pallaition or provocation quality/radiation/severity/timing (OPQRST) of pain
– Alleviating or aggravating factors
– Ask if symptomatic during sexual intercourse
– Menstrual history
• Past medical and surgical history
– Check history of PID, STIs, ectopic pregnancy
– Obtain history of trauma
– Abdominal and pelvic surgeries contribute to adhesions
– Check trigger points from incisional scars
• Family and social history
– 1st-degree family with CPP
– Inquire about physical and/or sexual abuse
– Number of sex partners, method of contraception
– Substance dependence, exposure to analgesics
PHYSICAL EXAM
• Vital signs
– Fever, hypotension, and tachycardia suggest infectious etiology
• Abdominal exam
– Search for trigger points
– Assess peritoneal signs
– Sensory evaluation of dermatomes
• Back and musculoskelet al exam
– Evaluate posture and gait
– Rule out scoliosis or lordosis
• Pelvic exam
– Inspect vulva for skin lesions, signs of trauma, and irritation
– Speculum exam to assess vaginal mucopurulent discharge and erythema
– One-hand pelvic exam to identify muscular trigger points, cervical motion tenderness, urethral tenderness, and to delineate bladder base and vaginal fornix
– Bimanual exam to assess uterine shape, direction, tenderness and mobility; assess adnexal masses and tenderness
• Rectal exam
– Check rectal tone, rectovaginal septum, cul-de-sac, and uterosacral ligaments
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Serum
– Complete blood count: Leukocytosis and left shift suggest infection
– Erythrocyte sedimentation rate: Nonspecific markers of subacute or chronic inflammation
– Cancer antigen-125: Marker for endometriosis, PID, and certain cancers
– β-Human chorionic gonadotropin: Becomes positive 7 days after conception, a negative test excludes ectopic pregnancy
• Urine
– Urine pregnancy test
– Urine analysis
– Urine culture
– Nucleic acid amplification test for gonorrhea and Chlamydia
– Cytology, if hematuria to evaluate for bladder cancer
• Others
– Cervical culture
– Vaginal wet mount
– PAP smear
– Fecal occult blood test
Imaging
• Ultrasound
– Transvaginal and/or pelvic ultrasound: Modality of choice in the initial evaluation of pelvic pain
– Renal and bladder ultrasound: Assess hydronephrosis, renal stone disease, and bladder distension
• Plain films
– Kidney, ureter, bladder x-ray (KUB): Assess urinary stone burden or dermoid cyst
– Spinal and bony x-ray: Indicated when osseous and skelet al etiologies of pelvic pain are suspected
• Hysterosalpingography: Allow anatomic evaluation of the uterus and fallopian tubes
• Pelvic venogram: Assess pelvic vascular anatomy and venous congestion
• Axial imaging (CT, MRI)
– Indicated when ultrasound negative or inconclusive
– With intravenous and/or oral contrast
– More sensitive evaluation of the gastrointestinal and genitourinary systems
Diagnostic Procedures/Surgery
• Diagnostic laparoscopy
– Endometriosis most common (33%)
– Adhesions (24%)
– Negative 35–66% of the time
– Negative findings do not exclude somatic cause and positive findings do not necessarily represent true etiology of CPP
• Barium enema or colonoscopy
• Urodynamics
• Cystoscopy, bladder biopsy, hydrodistension
Pathologic Findings
Based on diagnosis
DIFFERENTIAL DIAGNOSIS
• Gynecologic: Accounts for 20% of CPP
– Cervical stenosis
– Chronic PID (occurs after 30% of acute PID)
– Endometriosis/chronic endometriosis
– Gynecologic cancers
– Pelvic congestion syndrome
– Uterine fibroids
• Gastrointestinal
– Colorectal cancers
– Diverticulitis
– IBS
– Inflammatory bowel disease (IBD)
• Genitourinary
– Bladder cancer
– Cystitis, urinary retention
– IC/painful bladder syndrome (PBS)
– Kidney stones
– Urethral diverticulum, urethritis
– Urethral syndrome
• Others
– Abdominal myofascial pain
– Fibromyalgia
– Pelvic floor muscular pain
– Physical and/or sexual abuse
– Psychiatric disorders
– Radiculopathy
– Surgical adhesions
TREATMENT
GENERAL MEASURES
• Goals of care for managing CPP
– Symptomatic control
– Patient education
– Patient empowerment
• Multidisciplinary and individualized approach
– Psychosocial counseling
– Chronic pain management
– Biofeedback
– Physical therapy
– Medications and surgery when needed
• Validated questionnaires and fluid diaries can help monitor progress
MEDICATION
First Line
• Target underlying condition, nerve block
• Nonsteroidal antiinflammatory drug (1)[B]
– Superior to placebo
– Can be given with acetaminophen
• Opioids (2)[A]
– Oral, intramuscular, or transdermal
• Tricyclic antidepressants
– More effective in neuropathic pain
ALERT
Common contraindications to antidepressants include recent infarction, arrhythmias, and severe hepatic/renal disease.
Second Line
• Selective serotonin reuptake inhibitors
• Anticonvulsants
– Gabapentin (3)[A]
More effective in neuropathic pain
No place in acute pain
SURGERY/OTHER PROCEDURES
• Local injection of anesthetics
• Sacral neuromodulation (4)
• Surgical removal of endometriosis
• Hysterectomy
– May be beneficial in women who have completed reproduction and whose CPP is believed to be due to uterine disorders such as adenomyosis or fibroids
• Presacral neurectomy
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Pelvic floor physical therapy
• Biofeedback and relaxation therapies
• Transcutaneous electrical nerve stimulation (TENS)
• Intravesical instillations or injections
Complementary & Alternative Therapies
• Acupuncture
• Massage and manipulations
ONGOING CARE
PROGNOSIS
Variable and dependent on underlying etiology and treatment modalities
COMPLICATIONS
• Risk of pharmacologic dependence, tolerance, and abuse associated with long-term analgesia
• Surgical complications such as bleeding and infections are procedure specific
FOLLOW-UP
Patient Monitoring
• CPP is typically managed in outpatient setting
• Monitor serum hepatic/renal function and electrocardiogram when using antidepressants
Patient Resources
• The International Pelvic Pain Society
– www.pelvicpain.org
REFERENCES
1. Marjoribanks J, Proctor ML, Farquhar C. Nonsteroidal anti-inflammatory drugs for primary dysmenorrhea. Cochrane Database Syst Rev. 2003:CD001751.
2. Eisenberg E, McNicol E, Carr DB. Opioids for neuropathic pain. Cochrane Database Syst Rev. 2006:CD006146.
3. Wiffen P, Collins S, McQuay H, et al. Anticonvulsant drugs for acute and chronic pain. Cochrane Database Syst Rev. 2005:CD001133.
4. Kemler MA, Barendse GA, van Kleef M, et al. Spinal cord stimulation in patients with chronic reflex sympathetic dystrophy. N Engl J Med. 2000;343:618–624.
ADDITIONAL READING
• Engeler DS, Baranowski AP, Dinis-Oliveira P, et al. The 2013 EAU guidelines on chronic pelvic pain: Is management of chronic pelvic pain a habit, a philosophy, or a science? 10 years of development. Eur Urol. 2013;64(3):431–439.
• Fall M, Baranowski AP, Elneil S, et al. EAU guidelines on chronic pelvic pain. Eur Urol. 2010;57(1):35–48.
See Also (Topic, Algorithm, Media)
• Chronic Pelvic Pain Syndrome (CPP) In Females Section II Table.
• Inflammatory Bowel Disease (Ulcerative Colitis and Crohn Disease), Urologic Considerations
• Interstitial Cystitis (IC)/Painful Bladder Syndrome
• Prostatitis, Chronic, Nonbacterial, Inflammatory and Noninflammatory (NIH CP/CPPS III A and B)
CODES
ICD9
• 338.29 Other chronic pain
• 617.9 Endometriosis, site unspecified
• 625.9 Unspecified symptom associated with female genital organs
ICD10
• G89.29 Other chronic pain
• N80.9 Endometriosis, unspecified
• R10.2 Pelvic and perineal pain
CLINICAL/SURGICAL PEARLS
• The pathophysiology of CPP is multifactorial, and the treatment for it is multidisciplinary.
• Initial evaluation for CPP aims to identify life- or organ-threatening conditions and rule out anatomic or structural abnormalities.
• Subsequent management of CPP focuses on symptomatic control and patient education.
• Treatment takes time, and cure may not be possible. Therefore, it is important to set patient-centered yet realistic goals of care.