1. Chronic Pelvic Pain Marvin L. Stancil, M.D. Associate Professor
Obstetrics and Gynecology
University of Nebraska Medical Center

2. Medical Student Objectives
Define chronic pelvic pain.
Cite the prevalence and common etiologies of chronic pelvic pain.
Describe the symptoms & physical exam findings associated with chronic pelvic pain.
Discuss the steps in the evaluation & management options for chronic pelvic pain.
Discuss the psychosocial issues associated with chronic pelvic pain.

3. past six months and is affecting the patient’s quality of life
Chronic Pelvic Pain
Definition
Chronic Pelvic Pain (CPP) is pain of apparent pelvic origin that has been present most of the time for the
past six months and is affecting the patient’s quality of life

4. Chronic Pelvic Pain Definition Difficult to diagnose Frustration for
patient and
physician
Difficult to treat
Difficult to cure

5. Chronic Pelvic Pain Incidence Accounts for 20% of all laparoscopies
Affects 15-20% of women of reproductive age
Accounts for 20% of all laparoscopies
Accounts for 12-16% of all hysterectomies
Associated medical costs of $3 billion annually

6. Etiology Psychological Gastrointestinal Urological Gynecological
Musculoskeletal

7. Chronic Pelvic Pain Demographics
Demographics of age, race, ethnicity, education, and socioeconomic status do not differ between those with and without chronic pelvic pain
Higher incidence in single, separated or divorced women
40-50% of women have a history of abuse

8. Chronic Pelvic Pain Etiology: United Kingdom Primary Care Database
25-50% of women had more than one diagnosis
Severity and consistency of pain increased with multisystem symptoms
Most common diagnoses:
endometriosis
adhesive disease
irritable bowel syndrome
interstitial cystitis
Gastrointestinal
Urinary
Gynecological
37.7%
30.8%
20.2%
Diagnosis Distribution
Found that diagnoses related to the urinary and GI tracts were more common than gynecological diagnoses.
For example, 43% of women with CPP without GI or urologic symptoms had moderate to severe pain; whereas 71% of women with both GI and urological symptoms had moderate to severe pain.

9. Chronic Pelvic Pain Diagnosis Obtaining a
COMPLETE and DETAILED HISTORY
is the most important key to
formulating a diagnosis

10. Diagnosis: Obtaining the History
Chronic Pelvic Pain
Diagnosis: Obtaining the History
Duration of Pain
Nature of the Pain
Sharp, stabbing, throbbing, aching, dull?
Specific Location of Pain
Associated with radiation to other areas?
Modifying Factors
Things that make worse or better?
Timing of the Pain
Intermittent or constant?
Temporal relationship with menses?
Temporal relationship with intercourse?
Predictable or spontaneous onset?
Detailed medical and surgical history
Specifically abdominal, pelvic, back surgery

11. Chronic Pelvic Pain Use the REVIEW OF SYSTEMS
Diagnosis: Obtaining the History
Use the REVIEW OF SYSTEMS
to obtain focused, detailed history of organ systems involved in the differential diagnosis

12. Gynecological Review of Systems
Chronic Pelvic Pain
Diagnosis: Obtaining the History
Gynecological Review of Systems
Associated with menses?
Association with sexual activity? (Be specific)
New sexual partner and/or practices?
Symptoms of vaginal dryness or atrophy?
Other changes with menses?
Use of contraception?
Detailed childbirth history?
History of pelvic infections?
History of gynecological surgeries or other problems?

13. Gastrointestinal Review of Systems
Chronic Pelvic Pain
Diagnosis: Obtaining the History
Gastrointestinal Review of Systems
Regularity of bowel movements?
Diarrhea/ constipation/ flatus?
Relief with defecation?
History of hemorrhoids/ fissures/ polyps?
Blood in stools, melena, mucous?
Nausea, emesis or change in appetite?
Abdominal bloating?
Weight loss?

14. Urological Review of Systems
Chronic Pelvic Pain
Diagnosis: Obtaining the History
Urological Review of Systems
Pain with urination?
History of frequent or recurrent urinary tract infection?
Hematuria?
Symptoms of urgency or urinary incontinence?
Difficulty voiding?
History of nephrolithiasis?

15. Musculoskeletal Review of Systems
Chronic Pelvic Pain
Diagnosis: Obtaining the History
Musculoskeletal Review of Systems
History of trauma?
Association with back pain?
Other chronic pain problems?
Association with position or activity?
Any abdominal wall complaints or surgery?

16. Psychological Review of Systems
Chronic Pelvic Pain
Diagnosis: Obtaining the History
Psychological Review of Systems
History of verbal, physical or sexual abuse?
Diagnosis of psychiatric disease?
Onset associated with life stressors?
Exacerbation associated with life stressors?
Familial or spousal support?

17. A bimanual exam alone is NOT sufficient for evaluation
Chronic Pelvic Pain
Diagnosis: The Physical Exam
Evaluate each area individually
Abdomen
Anterior abdominal wall
Pelvic Floor Muscles
Vulva
Vagina
Urethra
Cervix
Viscera – uterus, adnexa, bladder
Rectum
Rectovaginal septum
Coccyx
Lower Back/Spine
Posture and gait
A bimanual exam alone is
NOT sufficient for evaluation

18. Diagnosis: Objective Evaluative Tools
Chronic Pelvic Pain
Diagnosis: Objective Evaluative Tools
Basic Testing
Pap Smear
Gonorrhea and Chlamydia
Wet Mount
Urinalysis
Urine Culture
Pregnancy Test
CBC with Differential
ESR or CRP
Specialized Testing
MRI or CT Scan
Endometrial Biopsy
Laparoscopy
Cystoscopy
Urodynamic Testing
Urine Cytology
Colonoscopy
Electrophysiologic studies
PELVIC ULTRASOUND
Referral to Specialist

19. Differential Diagnosis
Chronic Pelvic Pain
Differential Diagnosis
The differential diagnosis for Chronic Pelvic Pain is extensive
Challenges the gynecologist to “think outside the uterus”
Diagnosis, evaluation and treatment plans:
Should align with pertinent positives and negatives from the History and Physical
Often requires an interdisciplinary approach

20. Differential Diagnosis:
Chronic Pelvic Pain
Differential Diagnosis:
Gynecological Conditions that may Cause or Exacerbate Chronic Pelvic Pain
Level A
Endometriosis
Gynecologic malignancies
Ovarian Retention Syndrome
Ovarian Remnant Syndrome
Pelvic Congestion Syndrome
Pelvic Inflammatory Syndrome
Tuberculosis Salpingitis
Level B
Adhesions
Benign Cystic Mesothelioma
Liomyomata
Postoperative Peritoneal Cysts
Level C
Adenomyosis
Dysmenorrhea/ Ovulatory Pain
Nonendometriotic Adnexal Cysts
Cervical Stenosis
Chronic Ectopic Pregnancy
Chronic Endometritis
Endometrial or Cervical Polyps
Endosalpingiosis
Intrauterine Contraceptive Device
Ovarian Ovulatory Pain
Residual accessory ovary
Symptomatic Pelvic Prolapse
Source: ACOG Practice Bulletin #51, March 2004

21. Differential Diagnosis: Gynecological Conditions
Chronic Pelvic Pain
Differential Diagnosis: Gynecological Conditions
Cyclical
Non-cyclical
Endometriosis
Adenomyosis
Primary Dysmenorrhea
Ovulation Pain/ Mittleschmertz
Cervical Stenosis
Ovarian Remnant Syndrome
Pelvic Masses
Adhesive Disease
Pelvic Inflammatory Disease
Tuberculosis Salpingitis
Pelvic Congestion Syndrome
Symptomatic Pelvic Organ Prolapse
Vaginismus
Pelvic Floor Pain Syndrome

22. Chronic Pelvic Pain Endometriosis
Presence of endometrial tissue outside of uterine cavity
Usually found in dependent areas of the pelvis
Most commonly in ovaries, posterior cul-de-sac, uterosacral ligaments
Endometrial glands and stroma on biopsy
May be at distant sites such as bowel, bladder, lung, skin, plurae
Etiology not well understood
Retrograde menstruation
Lymphatic and hematologic spread of menstrual tissue
Metaplasia of coelomic epithelium
Immunologic dysfunction

23. Endometriosis: Prevalence
Chronic Pelvic Pain
Endometriosis: Prevalence
Typically diagnosed in women years of age
Diagnosed in approximately 45% of women undergoing laparoscopy for any indication
Diagnosed in approximately 30% of women undergoing laparoscopy with primary complaint of chronic pelvic pain
Found in 38% of women with infertility
Family history increases risk ten-fold
Significant cause of morbidity

24. Endometriosis: Signs and Symptoms
Chronic Pelvic Pain
Endometriosis: Signs and Symptoms
Symptoms
Physical Exam
Visible lesions on cervix or vagina
Tender nodules in the cul-de-sac, uterosacral ligaments or rectovaginal septum
Pain with uterine movement
Tender adnexal masses (endometriomas)
Fixation (retroversion) of uterus
Rectal mass
Normal findings
Dysmenorrhea
Dyspareunia
Infertility
Intermenstrual Spotting
Painful Defecation
Pelvic Heaviness
Asymptomatic
Symptoms are not well correlated with extent of disease – pain is out of proportion to the physical exam findings or radiologic findings or laparoscopic findings.
Dyspareunia is usally with deep (rather than superficial) penetration.
Symptoms usually regress with pregnancy and menopause

25. Endometriosis: Diagnosis
Chronic Pelvic Pain
Endometriosis: Diagnosis
Diagnosis can be made on clinical history and exam
Serum CA125 may be elevated but lacks sufficient specificity and sensitivity to be useful
Imaging studies lack sufficient resolution to detect small endometrial implants
Laparoscopy is gold standard for diagnosis
Multiple appearances: red, brown, scar, white, powder burn, vesicular lesions, adhesions, defects in peritoneum, endometriomas
Allows diagnosis and treatment

26. Laparoscopic Appearance of Endometriosis
Chronic Pelvic Pain
Laparoscopic Appearance of Endometriosis

27. Endometriosis: Diagnosis
Chronic Pelvic Pain
Endometriosis: Diagnosis
Revised classification system by the ASRM (1996)
Poor correlation between symptoms and extent of disease
Classification system has been revised three times – last time in 1986.
Useful for comparing patients to themselves and for comparing research.
However, there is no correlation between stage of endometriosis and extent of disease. Some people can be found to have minimal disease but have excruiating pain whereas others can have extensive disease but have no pain at all.

28. Chronic Pelvic Pain
Staging of
Endometriosis

29. Endometriosis: Medical Treatment
Chronic Pelvic Pain
Endometriosis: Medical Treatment
NSAIDS for mild disease
First Line: Oral contraceptives
Suppress ovulation and menstruation
Cyclic or continuous therapy
Improves symptoms in up to 70-80%
Second Line: Progestins, GnRH agonists, Danazol
Lupron Depot (x 6-12 months)
Improves symptoms in up to 80-85%
Side effects: hot flashes, vaginal dryness, insomnia, bone loss irritability
“Add back” estrogen +/- progestin

30. Endometriosis: Surgical Treatment
Chronic Pelvic Pain
Endometriosis: Surgical Treatment
Laparoscopic Removal or Destruction
Treatment at time of diagnosis
Used in conjunction with medical therapy
Improves pain in up to 80-90% of patients
Laparotomy (TAH/BSO)
Inadequate response to medical treatment or conservative surgical treatment with no desire for future fertility
May preserve ovaries in young women, but 30% with recurrent symptoms
LUNA
Laparoscopic Uterosacral Nerve Ablation (LUNA), Presacral neurectomy
Involves transecting the nerve plexus at the base of the cervical-uterosacral ligament junction or retroperitoneum

31. Chronic Pelvic Pain Adenomyosis
Description: Presence of endometrial glands and stroma within the myometrium
Symptoms: Dysmenorrhea; Menorrhagia; Enlarged boggy uterus; typically affects women age 30-40’s
Diagnosis: Pathology, MRI (ultrasound limited usefulness)
Treatment: Hysterectomy; usually when diagnosis is made

32. Chronic Pelvic Pain Primary Dysmenorrhea
Description: Pain associated with menses that usually begins 1-3 days prior to the onset of menses; last 1-3 days
Risk Factors: Nulliparity, Young Age, Heavy menses, Cigarette Smoking
Symptoms: Crampy lower abdominal pain; +/- nausea, emesis, diarrhea or headache, normal physical exam
Treatment: NSAIDS, Multivits with B-complex, Hormonal Therapy (OCPs, OrthoEvra, Nuvaring, Mirena IUD, Depo-Provera. Usual improvement after childbirth.

33. Pelvic Inflammatory Disease
Chronic Pelvic Pain
Pelvic Inflammatory Disease
Description: Spectrum of inflammation and infection in the upper female genital tract
Endometritis/ endomyometritis
Salpingitis/ salpingo-oophritis
Tubo-ovarian Abscess
Pelvic Peritonitis
Pathophysiology: Ascending infection of vaginal and cervical microorganisms
Chlamydia ,Gonorrhea (developed countries)
Tuberculosis (developing countries)
Acute PID usually polymicrobial infection

34. Pelvic Inflammatory Disease
Chronic Pelvic Pain
Pelvic Inflammatory Disease
Risk Factors
Adolescent
Multiple sexual partners
Greater than 2 sexual partners in past 4 weeks
New partner in the past 4 weeks
Prior history of PID
Prior history of gonorrhea or chlamydia
Smoking
None or inconsistent condom use
Instrumentation of the cervix and lower reproductive tract

35. Pelvic Inflammatory Disease: CDC Diagnostic Guidelines (2006)
Chronic Pelvic Pain
Pelvic Inflammatory Disease: CDC Diagnostic Guidelines (2006)
Minimum Criteria (one required):
Uterine Tenderness
Adnexal Tenderness
Cervical Motion Tenderness
No other identifiable causes
Specific criteria for dx:
Pathologic evidence of endometritis
US or MRI showing hydrosalpinx, TOA
Laparosopic findings consistent with PID
Additional criteria for dx:
Oral temperature greater than 101F
Abnormal cervical or vaginal discharge
Presence of increased WBC in vaginal secretions
Elevated ESR or C-reactive protein
Documented of GC or CT

36. Pelvic Inflammatory Disease
Chronic Pelvic Pain
Pelvic Inflammatory Disease
Treatment: Outpatient and Inpatient Abx dosing regimens; Total therapy for 14 days, maybe longer if TOA
Sequelae
Infertility
Ectopic Pregnancy
Chronic Pelvic Pain
Occurs in 18-35% of women who develop PID
May be due to inflammatory process with development of pelvic adhesions
Refer to revised 2010,
updated Aug for outpt. GC treatment

37. Pelvic Congestion Syndrome
Chronic Pelvic Pain
Pelvic Congestion Syndrome
Description: Retrograde flow through incompetent valves venous valves can cause tortuous and congested pelvic and ovarian varicosities; Etiology unknown.
Symptoms: Pelvic ache or heaviness that may worsen premenstrually, after prolonged sitting or standing, or following intercourse
Diagnosis: Pelvic venogrpahy, CT, MRI, ultrasound, laparoscopy
Treatment: Progestins, GnRH agonists, ovarian vein embolization or ligation, and hysterectomy with bilateral salpingo-oophorectomy (BSO)

38. Pelvic Floor Pain Syndrome
Chronic Pelvic Pain
Pelvic Floor Pain Syndrome
Description: Spasm and strain of pelvic floor muscles
Levator Ani Muscles
Coccygeus Muscle
Piriformis Muscle
Symptoms: Chronic pelvic pain symptoms; pain in buttocks and down back of leg, dyspareunia
Levator Ani Muscle: supports pelvic viscera, constricts lower end of rectum and vagina
Coccygeus muscle: aids in raising and supporting pelvic floor
Piriformis: rotates thigh laterally
Treatment: Biofeedback, Pelvic Floor Physical Therapy, TENS (Transcutaneous Electrical Nerve Stimulation) units, antianxiolytic therapy, cooperation from sexual partner

39. Chronic Pelvic Pain Differential Diagnosis:
Urological Conditions that may Cause or Exacerbate Chronic Pelvic Pain
Level A
Bladder Carcinoma
Interstitial Cystitis
Radiation Cystitis
Urethral Syndrome
Level B
Detrusor Dyssynergia
Urethral Diverticulum
Level C
Chronic Urinary Tract Infection
Recurrent Acute Cystitis
Recurrent Acute Urethritis
Stone/urolithiasis
Urethral Caruncle
Source: ACOG Practice Bulletin #51, March 2004

40. Interstitial Cystitis
Chronic Pelvic Pain
Interstitial Cystitis
Description: Chronic inflammatory condition of the bladder
Etiology: Loss of mucosal surface protection of the bladder and thereby increased bladder permeability
Also called Painful Bladder Syndrome
Symptoms:
Urinary urgency and frequency
Pain is worse with bladder filling; improved with urination
Pain is worse with certain foods
Pressure in the bladder and/or pelvis
Pelvic Pain in up to 70% of women
Present in 38-85% presenting with chronic pelvic pain

41. Interstitial Cystitis
Chronic Pelvic Pain
Interstitial Cystitis
Diagnosis:
Cystoscopy with bladder distension
Intravesicular Potassium Sensitivity Test
Presence of glomerulations (Hunner Ulcers)
Treatment:
Avoidance of acidic foods and beverages
Antihistamines
Tricyclic antidepressants
Elmiron (pentosan polysulfate sodium)
Intravesical therapy: DMSO (dimethyl sulfoxide)
Elmiron: helps to prevent the formation of Hunner Ulcers by coating the bladder wall, thus making it harder for the acid in the urine to irritate the bladder wall lining which can lead to ulceration.

42. Differential Diagnosis:
Chronic Pelvic Pain
Differential Diagnosis:
Gastrointestinal Conditions that may Cause or Exacerbate Chronic Pelvic Pain
Level A
Colon Cancer
Constipation
Inflammatory Bowel Disease
Irritable Bowel Syndrome
Level B
None
Level C
Colitis
Chronic Intermittent Bowel Obstruction
Diverticular Disease
Source: ACOG Practice Bulletin #51, March 2004

43. Irritable Bowel Syndrome (IBS)
Chronic Pelvic Pain
Irritable Bowel Syndrome (IBS)
Description: Chronic relapsing pattern of abdomino-pelvic pain and bowel dysfunction with diarrhea and/or constipation
Prevalence
Affects 12% of the U.S. population
2:1 prevalence in women: men
Peak age of 30-40’s
Rare on women over 50
Associated with elevated stress level
Symptoms
Diarrhea, constipation, bloating, mucousy stools
Symptoms of IBS found in 50-80% women with CPP

44. Irritable Bowel Syndrome (IBS)
Chronic Pelvic Pain
Irritable Bowel Syndrome (IBS)
Diagnosis based on Rome II criteria
Treatment
Dietary changes
Decrease stress
Cognitive Psychotherapy
Medications
Antidiarrheals
Antispasmodics
Tricyclic Antidepressants
Serotonin receptor (3, 4) antagonists

45. Differential Diagnosis:
Chronic Pelvic Pain
Differential Diagnosis:
Musculoskeletal Conditions that may Cause or Exacerbate Chronic Pelvic Pain
Level A
Abdominal Wall Myofascial Pain (Trigger Points)
Chronic Back Pain
Poor Posture
Fibromyalgia
Neuralgia of pelvic nerves
Pelvic Floor Myalgia
Peripartum Pelvic Pain Syndrome
Level B
Herniated Disk
Low Back Pain
Neoplasia of spinal cord or sacral nerve
Level C
Lumbar Spine Compression
Degenerative Joint Disease
Hernia
Muscular Strains and Sprains
Rectus Tendon Strains
Spondylosis
Source: ACOG Practice Bulletin #51, March 2004

46. Differential Diagnosis:
Chronic Pelvic Pain
Differential Diagnosis:
Psychological/Other Conditions that may Cause or Exacerbate Chronic Pelvic Pain
Level A
Abdominal cutaneous nerve entrapment in surgical scar
Depression
Somatization Disorder
Level B
Celiac Disease
Neurologic Dysfunction
Porphyria
Shingles
Sleep Disturbances
Level C
Abdominal Epilepsy
Abdominal Migraines
Bipolar Personality Disorder
Familial Mediterranean Fever
Source: ACOG Practice Bulletin #51, March 2004

47. Psychological Associations
Chronic Pelvic Pain
Psychological Associations
40 – 50% of women with CPP have a history of abuse (physical, verbal , sexual)
Psychosomatic factors play a prominent role in CPP
Psychotropic medications and various modes of psychotherapy appear to be helpful as both primary and adjunct therapy for treatment of CPP– Multidisciplinary pain clinic
Approach patient in a gentle, non-judgmental manner
Do not want to imply that “pain is all in her head”

48. Chronic Pelvic Pain Conclusions
Chronic Pelvic Pain requires patience, understanding and collaboration from both patient and physician
Obtaining a thorough history is key to accurate diagnosis and effective treatment
Diagnosis is often multifactorial – may affect more than one pelvic organ
Treatment options often multifactorial – medical, surgical, physical therapy, cognitive therapy