Key points

Introduction

The evaluation and successful treatment of pelvic pain is a complex problem. Chronic pelvic pain (CPP) may encompass gastroenterologic, urologic, gynecologic, oncologic, musculoskeletal, and psychosocial systems. Subspecialists often lack interdisciplinary training and understanding of the diverse causes needed to evaluate and treat patients. This deficit makes comprehensive evaluation, diagnosis, and treatment difficult, and may frustrate patients who are sent from one specialist to another for further evaluation and diagnosis.

This article attempts to create a multidisciplinary overview for evaluation, testing and treatment options. It reviews the most common causes of CPP and discusses management options. Finally, some obstacles to treatment are reviewed and ways to improve efficiency of evaluation and treatment are suggested.

Introduction

The evaluation and successful treatment of pelvic pain is a complex problem. Chronic pelvic pain (CPP) may encompass gastroenterologic, urologic, gynecologic, oncologic, musculoskeletal, and psychosocial systems. Subspecialists often lack interdisciplinary training and understanding of the diverse causes needed to evaluate and treat patients. This deficit makes comprehensive evaluation, diagnosis, and treatment difficult, and may frustrate patients who are sent from one specialist to another for further evaluation and diagnosis.

This article attempts to create a multidisciplinary overview for evaluation, testing and treatment options. It reviews the most common causes of CPP and discusses management options. Finally, some obstacles to treatment are reviewed and ways to improve efficiency of evaluation and treatment are suggested.

Definition of CPP

Pelvic pain is divided into acute and chronic pain. Acute pain is typically caused by a precise cause, such as anal fissure or thrombosed external hemorrhoid. Acute pain tends to diminish and it resolves with treatment and healing; it is not discussed in this article. In contrast, CPP is described as pain lasting a minimum of 6 months in duration, which may be sudden or gradual in onset and affects “the visceral or somatic system and structures supplied by the nervous system from the 10th thoracic spinal level and below.” Because of the broad definition of pelvic pain, the evaluation of pelvic pain extends across many subspecialties and organ systems.

Epidemiology of CPP

CPP is a ubiquitous disease; in the United States it is estimated that 9 million women between ages 18 and 50 or 15% of the female population suffer from CPP. A study from the United Kingdom demonstrated a CPP rate of 24%, with 33% of women reporting 5 years or greater duration. A study in New Zealand found a prevalence of 25.4%. A 1994 Gallup poll estimated the direct cost of CPP at $881.5 million dollars annually, with 15% of women with CPP noting lost work revenue and 45% reporting decreased work productivity.

Ideally, a specific cause can be elucidated; however, in many cases, a distinct diagnosis is never discovered. Population studies demonstrate between 50% and 61% of all women with pelvic pain lack a clear diagnosis. Even patients who undergo diagnostic laparoscopy still lack a diagnosis in 30% to 40% of cases.

An epidemiologic study found that women with CPP are more likely to have a history of spontaneous abortion, military service, nongynecologic surgery, and nonpelvic somatic complaints than controls. Additional studies have demonstrated a correlation with history of multiple sexual partners and psychosexual trauma or abuse. CPP subjects are four times as likely to have a history of pelvic inflammatory disease. Subjects with CPP also have a higher incidence of constipation, irritable bowel syndrome (IBS), depression, and anxiety than control groups.

Although CPP is better described and is more prevalent in women, it is not exclusive to the female gender. Chronic prostatitis/chronic pelvic pain (CP/CPP) is a well-described cause of pelvic pain in men. Musculoskeletal disorders may also be present with pelvic pain. As the diagnosis of CPP is better understood and known, it is likely that more men will present with similar complaints.

Relevant history for patients with CPP

History is a vital element in evaluation of CPP. Given the complexity of elements involved, a thorough history must include history of gastroenterologic, gynecologic, urologic, musculoskeletal, and pain symptoms. A full review of systems, including infectious diseases, endocrine disorders, and psychiatric disorders, is necessary. The International Pelvic Pain Society provides an extensive history intake form.

A discussion of the character, intensity, radiation, and chronicity of pain should be obtained. Duration of pain, and exacerbating and alleviating factors, should be determined. Daily variation may give clues to the cause. Pelvic congestion syndrome typically increases in intensity as the day progresses, whereas proctalgia fugax tends to awaken the patient at night.

Determining the relationship of pain to each organ system is important. From a gynecologic perspective, correlation with sexual activity is also important. Pain associated with superficial stimulation is more consistent with vaginitis or vulvodynia; whereas deep dyspareunia is consistent with endometriosis or pelvic inflammatory disease. Abnormal vaginal bleeding may be symptomatic of uterine leiomyomas, adenomyosis, or malignancy, and should be evaluated with pelvic ultrasound. A history of high-risk sexual behavior, multiple partners, and/or genital discharge can suggest pelvic inflammatory disease.

A history of pain or pressure with urination, difficulty emptying, or frequency suggests urologic causes. History of gastrointestinal disorders, including constipation and IBS, can be helpful. Manual evacuation and vaginal digitation are consistent with obstructed defecation. A history of recent trauma or pregnancy may help illuminate a musculoskeletal cause and surgical interventions 3 to 6 months ago may suggest adhesive disease. Copies of colonoscopies, operative reports, or pathologic specimens are crucial. Previous perineal operations, mesh placement, and radiation may suggest iatrogenic causes.

Visceral and somatic pain may be sensed differently. Because visceral innervation of the pelvic structures share common neural pathways, distinguishing the cause of visceral pain may be difficult. Visceral pain is associated with dull, crampy, or poorly localized pain, and may be associated with autonomic phenomena such as nausea, vomiting, and sweating. Somatic pain, in contrast, originates from muscles, bones, and joints, and typically presents according to specific dermatomes. Somatic pain is associated with sharp or dull pain. Neuropathic pain may produce burning, paresthesia, or lancing pain. A history of pain syndromes, or drug or alcohol, abuse may also factor into evaluation and treatment. Janicki has described a centralized sensitization of the pain receptors in patients with CPP and has suggested that understanding this may also be necessary for success.

An evaluation should also determine level of functional disability. The patient’s ability to work, engage in daily activities, and emotional and sexual relationships is relevant. A full psychological evaluation should be considered for patients with history of sexual, physical abuse, depression, or anxiety. This does not alleviate the need for physical diagnosis; however, recognition and treatment may be important elements in symptom improvement.

Physical examination

The physical examination encompasses multiple specialty examinations and may be time consuming for the practitioner and difficult for the patient with CPP. The entire examination and evaluation may require several visits to complete. All practitioners should have a chaperone during invasive examinations and at least one member of the medical team should be female.

Before commencing a formal examination, the practitioners should evaluate patient gait, movement, and sitting pose. Patients with pelvic girdle pain or spinal pain may have difficulty ambulating and sit off to one side; the practitioner should question the patient on this.

Specific areas of concern include the abdomen and abdominal wall. Patients should be examined for scars and previous surgeries or complications from surgeries should be reviewed. The abdomen should be palpated for tenderness, masses, or lesions. Distension and bloating may suggest history of constipation or bowel obstruction. The area of greatest abdominal pain should be localized. Performing a Valsalva maneuver or asking the patient to raise her head and legs separates the visceral organs from abdominal wall and may identify pressure points. Flexion of the head reduces abdominal pain and points to a visceral origin; conversely, increasing pain suggests abdominal wall or musculoskeletal origin.

The pelvic examination should commence with visual inspection noting areas of discoloration, dermatologic disorders, or sequelae of infection. A Q-tip examination using light touch is used to evaluate the sensory and neurologic systems of the perineum. Signs of incontinence at baseline or with straining should be noted. Pelvic organ prolapse quantification (Pop-Q) examination should be performed. Rectal prolapse can be noted during propulsive activity as well. Preferably, patients should be examined in both a reclining and standing position for greater sensitivity.

Anteriorly, the urethra and bladder trigone should be evaluated. A mass by the urethra suggests ureteral diverticulum, whereas tenderness and dysuria suggests urethritis, urethral syndrome, or interstitial cystitis (IC). A urinalysis can evaluate for infectious causes of urologic origin. Hematuria is associated with endometriosis. If urinary tract cause is suggested, a cystoscopy with evaluation for Hunner ulcers and a potassium chloride (KCl) sensitivity test to evaluate for IC are warranted. Urodynamics are indicated if urinary dysfunction exists.

In the vaginal compartment, an evaluation for vaginal discharge, Pap smear, and bimanual examination should be performed. Vaginal discharge and cervical motion tenderness are concerning for sexually transmitted diseases and can be further evaluated with cultures or histology. Tenderness may suggest vulvodynia or vaginitis.

A rectal examination should include digital examination and anoscopy to evaluate for lesions. For patients with bleeding, inflammation, or lesions noted on anoscopy, a colonoscopy may be warranted. Fissures, hemorrhoids, fistulas, or abscesses can cause chronic anal pain. Pain on rectal examination without fluctuance can be a sign of an intersphincteric abscess, which may have no external signs.

The musculoskeletal examination should evaluate the abdominal wall and pelvic floor muscles. During vaginal examination, the levator plate should be palpated on both sides of the vagina. A finger is curved over the levators during relaxation and contraction to evaluate for tenderness. The piriformis muscle is palpated through the vagina, cephalad to the ischial spine in a posterior lateral direction. The piriformis is lateral to the bulbospongiosus and transverse perineum that run parallel to the vagina. The internal and external sphincter muscles are evaluated transanally at rest and with contraction. Note should be made of weakness or deficiency. During normal contraction, a slight upward pull should be felt from the coccygeus, puborectalis, and pubovaginalis muscles. During propulsion, descent of the pelvic wall and motility of the rectum should be noted.

The coccyx should be evaluated for coccygodynia. Pain with palpation or mobility is a sign of coccygodynia; a normal coccyx should rotate 25° to 30° without discomfort. External rotation of the leg against resistance may exacerbate the pain. Flexion of the hip and knee against resistance may demonstrate psoas pain. Additional musculoskeletal evaluation includes evaluation of pelvic ring instability, which is particularly common after delivery. Straight leg raise, resisted hip abduction, adduction tests, and posterior provocative pain test may be helpful in evaluating the stability of the pelvic ring.

If the examination fails to elicit a clear cause for their pain, an MRI may be helpful. In a study of subjects with CPP and no specific clinical findings, MRI was able to elucidate a cause in 39% of cases. For the remainder, 36% of subjects were ultimately diagnosed with levator ani syndrome and 25% with unspecified anorectal pain. Other testing includes pelvic ultrasound, cystoscopy, and colonoscopy. In the past, laparoscopy was performed for diagnostic purposes but is no longer indicated.

Common causes for CPP

The three most common documented findings on laparoscopy for CPP are endometriosis (33%), adhesions (24%), and absence of pathologic condition on laparoscopy (35%). However, hundreds of different causes may cause pelvic pain ( Fig. 1 ). Because normal pelvic function requires coordinated activity of the muscular, connective, visceral, and neural tissues of the pelvis, dysfunction in any area can create a complex situation that may ultimately manifest itself as pelvic pain.

Some of the causes of CPP.