Chronic pelvic pain: an integrated approach to diagnosis and treatment

Chronic pelvic pain affects upward of 15% of women and is a frustrating condition for both patients and physicians. Chronic pelvic pain is not a disease, but a syndrome that results from a complex interaction between neurologic, musculoskeletal, and endocrine systems that is further influenced by behavioral and psychologic factors. Traditional approaches to this disorder have been surgical, although long-term success rates have been disappointing. Placebo response to surgery is common, and many conditions that contribute to the pain cannot be identified or treated with a surgical approach. Many patients will require a combination of both pharmacologic and nonpharmacologic treatments in addition to various types of invasive procedures. It is now recognized that many disorders contribute to the chronic pelvic pain symptom complex; thus, an integrated multidisciplinary approach to diagnosis and treatment is essential to achieve the greatest success. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader will be able to describe the pathophysiology of chronic pelvic pain, to outline the evaluation of a patient with chronic pelvic pain, and to explain the treatment options for patients with chronic pelvic pain.     

Laparoscopy in the diagnosis of gynecologic chronic pelvic pain

Laparoscopy was performed on 126 women with undiagnosed chronic pelvic pain. Abnormalities were demonstrated in 62.7% of the cases. Endometriosis was present in 32.5% of the women. Laparoscopy is useful in the differential diagnosis of chronic pelvic pain and is indicated when symptoms persist for over 6 months.     

Entzündliche Erkrankungen der Adnexe

Pelvic inflammatory disease (PID) and upper genital tract infection describe inflammatory changes in the uterus, tubes, ovaries and/or the peritoneum of the small pelvis. It is usually initiated by a sexually transmitted agent which distinguishes PID from pelvic infections caused by medical procedures, pregnancy and other primary abdominal processes. The most common initiating pathogens are Neisseria gonorrhoeae and Chlamydia trachomatis which account for many cases of tubal infertility, chronic pelvic pain and ectopic pregnancies. The clinical diagnosis is imprecise and includes symptoms, such as lower abdominal pain with cervical motion tenderness and the onset of pain during or shortly after menstruation. Clinicians should maintain a low threshold of suspicion for the diagnosis of PID and start antibiotic treatment early, preferably with a combination of broad spectrum antibiotics.     

The role of laparoscopy in the management of pelvic pain in women of reproductive age

Objective: To review the diagnostic and therapeutic roles of laparoscopy in women of reproductive age with acute and chronic pelvic pain.Data Identification: Studies relating to the use of laparoscopy in women with acute and chronic pelvic pain were identified through the literature and MEDLINE searches.Conclusion(s): Laparoscopy has an important place in the management of conditions that cause acute pelvic pain in women of reproductive age, including ectopic pregnancy, pelvic inflammatory disease, tubo-ovarian abscess, and adnexal torsion. The procedure frequently facilitates the diagnosis and provides the necessary access for surgical treatment. Prompt diagnosis and effective management prevent complications and help preserve fertility. The role of laparoscopy in women with chronic pelvic pain is more controversial and limited, but abnormal laparoscopic findings are detected in approximately 60% of those who have undergone a multidisciplinary investigation and received a tentative clinical diagnosis. The access provided by laparoscopy permits the effective surgical treatment of many of the conditions encountered, including endometriosis, pelvic adhesions, ovarian lesions, and symptomatic uterine retroversion.     

节育术后慢性盆腔痛

女性节育术后可发生慢性盆腔痛（CPP）。输卵管绝育术后CPP的主要原因有盆腔炎性疾病、大网膜粘连综合征、盆腔淤血综合征,神经官能症也是病因之一。妇科检查、影像学检查和腹腔镜检查可明确诊断;宫内节育器（IUD）放置后的CPP主要与IUD位置异常有关,X线与B超联合检查、腹腔镜检查是重要的检查方法。CPP治疗前首先要明确诊断,针对病因治疗是关键。     

Adnexitis – eine klinische Herausforderung

Inflammation of the female internal genital tract (pelvic inflammatory disease) is widespread among fertile women and a common cause of problems including infertility (about 20%), chronic pelvic pain (18%), and ectopic pregnancy (6%). Signs and symptoms of this syndrome vary widely, further complicating diagnosis and treatment. Diagnosis is on anamnestic data, clinical presentation, sonographic and invasive diagnostic procedures, elevated clinical and chemical findings, and suspicious microbiologic findings. Treatment should start promptly before any additional diagnostic measures, as delayed treatment onset carries increased risk of sterility and chronic lower abdominal disorders.     

Lack of Data-driven Treatment Guidelines and Wide Variation in Management of Chronic Pelvic Pain in Adolescents and Young Adults

Study ObjectiveCurrent literature lacks data-driven guidelines for surgical treatment of adolescent and young adult (AYA) patients with chronic pelvic pain. We hypothesized that there is a significant variation in treatment of these patients, which might be an indicator of over- or undertreatment by some providers.Design and SettingWe completed a retrospective population-based analysis of the Nationwide Inpatient Sample from 1998 to 2016.ParticipantsWe included AYA patients aged 9-25 years whose primary diagnosis was adenomyosis, endometriosis, or chronic pelvic pain. Patients who might have undergone pelvic or abdominal procedures for other primary diagnoses were excluded.Interventions and Main Outcome MeasuresTrends of inpatient surgical intervention were calculated. Logistic regression was performed to determine the likelihood of undergoing an intervention, adjusted for patient demographic characteristics.ResultsA total of 13,111 AYA patients were analyzed. Median age at diagnosis was 22 (interquartile range, 20-24) years. The overall inpatient intervention rate was 5879/13111 (45.0%) (2445/5897 (18.6%) for excision/ablation, 2057/5897 (15.7%) for hysterectomy, 1239/5897 (9.5%) for diagnostic laparoscopy, and 156/5897 (1.2%) for biopsy). Rate of hysterectomy increased in the late 2000s while rates of all other interventions decreased. Patients in the northeast were less likely to undergo an intervention than patients in the rest of the country. Rates of intervention also differed according to race, insurance status, and type of hospital.ConclusionThere is wide variation in the use of surgical treatment for chronic pelvic pain in AYA patients across the country and between types of institutions. Of concern, the rate of hysterectomy has increased over time. There is a need for data-directed treatment guidelines for the management of AYA patients with chronic pelvic pain to ensure appropriate application of surgical treatments and expand high-value surgical care.     

Diagnosis, treatment and follow up of women undergoing conscious pain mapping for chronic pelvic pain: a prospective cohort study

OBJECTIVE: To assess the efficacy of conscious pain mapping in diagnosing and treating chronic pelvic pain (CPP). DESIGN: Prospective cohort study. Setting Gynaecology Department, UK District General Hospital. POPULATION: Forty-three women diagnosed with CPP. METHODS: The cohort was followed up for 18-24 months after diagnosis and treatment based on conscious pain mapping. MAIN OUTCOME MEASURES: Improvement of pain assessed by using visual analogue scale (VAS) pain scores at 6-month follow up. RESULTS: Thirty-nine women had successful conscious pain mapping. Pelvic pathology was identified in 18, pelvic congestion in 13 and 8 women had normal pelvic organs. In 35 women (90%), conscious pain mapping identified the cause of pain. Five out of eight women (63%) who were judged to have a normal pelvis had positive findings at pain mapping. VAS scores fell significantly from pre-treatment to post-treatment values at 6-month follow up (P < 0.01). Overall, 26 women (74%) felt that their symptoms had improved after treatment based on findings at pain mapping. However, we concluded that pain mapping only contributed to the diagnosis and treatment in seven women (27%), who may not have received appropriate diagnosis and treatment if they had a laparoscopy under general anaesthetic. Conclusions CONSCIOUS: pain mapping is a useful additional investigation in the management of women with CPP. It can be employed in women with a negative laparoscopy or with visible pathology where the conventional treatment has failed.     

Prevalence of pelvic musculoskeletal disorders in a female chronic pelvic pain clinic

OBJECTIVE: To determine the prevalence of 2 musculoskeletal pain disorders among women presenting to a referral chronic pelvic pain clinic. STUDY DESIGN: This was a retrospective, cross-sectional study of 987 women (aged 14-79) presenting for evaluation from 1993 to 2000 at a university-based gynecologic chronic pelvic pain clinic. RESULTS: At the initial visit, all women completed standardized interviews and underwent a pelvic examination. Single-digit palpation of the levator ani and piriformis muscles was performed intravaginally. Among these women, 212 of 955 (22%) had tenderness of the levator ani muscles, while 128 of 943 (14%) had tenderness of the piriformis muscle (pain score > 3 of 10 on a visual analogue scale). Both levator ani tenderness and piriformis tenderness were associated with a higher total number of pain sites, previous surgery for pelvic pain, Beck Depression Inventory score, McGill Pain Inventory score and pain worsened with bowel movements (p < 0.05). CONCLUSION: Piriformis and levator ani pain are present in a significant proportion of female chronic pelvic pain patients. Further research into the natural course, diagnosis and treatment of pelvic musculoskeletal pain is needed to determine its true contribution to chronic pain.     

Focus on primary care: chronic pelvic pain in women.

Chronic pelvic pain (CPP) is a major health problem. It is the reason for 10% of all outpatient visits to gynecologist as well as being responsible for approximately 40% of laparoscopies and 10% to 15% of hysterectomies. A significant number of patients have no obvious etiology for their pain at the time of laparoscopy. The condition may not be cured in a large number of patients. This is ultimately unsatisfying for both the patient and physician. Although CPP may not be curable, it can be managed so those patients attain normal or near-normal levels of functions. To identify and review the methods used for diagnosis and treatment of chronic pelvic pain in women, a MEDLINE and Cochrane systematic review search from 1980 to 2000 was performed to collect information and evidence on diagnosis and treatment of women suffering from chronic pelvic pain.     

Chronic pelvic pain

Chronic pelvic pain is a common and significant disorder of women. It is estimated to have a prevalence of 3.8% in women. Often the etiology of chronic pelvic pain is not clear, as there are many disorders of the reproductive tract, gastrointestinal system, urological organs, musculoskeletal system, and psychoneurological system that may be associated with chronic pelvic pain. The history and physical examination are crucial in evaluating a woman with chronic pelvic pain and must address all of the possible systems potentially involved in chronic pelvic pain, not just the reproductive system. Laboratory and imaging studies should be selectively utilized, as should laparoscopy. Conscious laparoscopic pain mapping has been proposed as a way to improve information derived from laparoscopic evaluations. Treatment of chronic pelvic pain may consist of two approaches. One is to treat chronic pain itself as a diagnosis, and the other is to treat diseases or disorders that might be a cause of or a contributor to chronic pelvic pain. These two approaches are not mutually exclusive, and in many patients effective therapy is best achieved by using both approaches. Treatment of chronic pain as well as treatment of four of the more common disorders associated with chronic pelvic pain (endometriosis, adhesions, irritable bowel syndrome, and interstitial cystitis) are discussed in this review.     

Contributions of physical and sexual abuse to women's experiences with chronic pelvic pain

OBJECTIVE: To examine the roles of physical and sexual abuse in women with chronic pelvic pain using multi-dimensional pain assessment and to compare the chronic pelvic pain experiences of women with physical abuse to those of women with sexual abuse. STUDY DESIGN: Structured questionnaires were used to measure self-reported abuse, pain severity, psychological distress, physical functioning, interpersonalfunctioning, and coping in 63 women attending a tertiary care gynecologic clinic for diagnosis and treatment of chronic pelvic pain. RESULTS: Women with chronic pelvic pain who reported abuse demonstrated significantly more psychological distress than did women who reported no abuse, but there were no differences in pain severity, physical functioning, interpersonal functioning or coping. Women with physical abuse reported more overall psychological distress, depression, anxiety and somatization than women who reported no physical abuse. Women who reported sexual abuse showed more overall psychological distress and anxiety than women who reported no sexual abuse. While physical abuse was more consistently associated with psychological distress than was sexual abuse, both types of abuse were risk factors for distress. CONCLUSION: These results suggest that both physical and sexual abuse are associated with psychological distress in women with chronic pelvic pain but not with other domains of pain experience. Additional research to improve identification and treatment of women with both chronic pelvic pain and abuse is indicated.     

Relations entre endométriose et algie pelvienne chronique : quel est le niveau de preuve ?

The relationship between chronic pelvic pain symptoms and endometriosis is unclear because painful symptoms are frequent in women without this pathology, and because asymptomatic forms of endometriosis exist. Our comprehensive review attempts to clarify the links between the characteristics of lesions and the semiology of chronic pelvic pain symptoms. Based on randomized trials against placebo, endometriosis appears to be responsible for chronic pelvic pain symptoms in more than half of confirmed cases. A causal association between severe dysmenorrhoea and endometriosis is very probable. This association is independent of the macroscopic type of the lesions or their anatomical locations and may be related to recurrent cyclic microbleeding in the implants. Endometriosis-related adhesions may also cause severe dysmenorrhoea. There are histological and physiopathological arguments for the responsibility of deeply infiltrating endometriosis (DIE) in severe chronic pelvic pain symptoms. DIE-related pain may be in relation with compression or infiltration of nerves in the subperitoneal pelvic space by the implants. The painful symptoms caused by DIE present particular characteristics, being specific to involvement of precise anatomical locations (severe deep dyspareunia, painful defecation) or organs (functional urinary tract signs, bowel signs). They can thus be described as “location indicating pain”. A precise semiological analysis of the chronic pelvic pain symptoms characteristics is useful for the diagnosis and therapeutic.     

Medical and surgical management of chronic pelvic pain

Chronic pelvic pain is common and is estimated to affect over one million women in the UK. It may be a symptom of a number of different conditions and is often multifactorial in nature, caused by a combination of physical, psychological and social factors. For many women, a primary cause cannot be identified. This can make both diagnosis and management difficult. Gynaecological causes of chronic pelvic pain include endometriosis, chronic pelvic inflammatory disease and adhesions. The gynaecologist must also consider non-gynaecological causes of pain related to the gastrointestinal, urinary, neurological, musculoskeletal and psychological systems if satisfactory management of the woman's pain is to be achieved.This review addresses the approach to diagnosis and management of women presenting with chronic pelvic pain. It details specific disease management but also seeks to encourage a holistic approach to all women with chronic pelvic pain, whether or not a primary diagnosis is established.     

Endometriosis in adolescents. Incidence, diagnosis and treatment.

OBJECTIVE: To review the incidence and diagnosis of endometriosis in adolescents and to evaluate the surgical and medical treatment options for this special population. STUDY DESIGN: Literature research. RESULTS: Endometriosis is the most common cause of chronic pelvic pain in adolescents, affecting up to 70% of girls with chronic pelvic pain unresponsive to medical management. There may be a natural progression of endometriosis from atypical lesions in adolescents to classic lesions in adults. CONCLUSION: Endometriosis should be strongly suspected in adolescent girls with chronic pelvic pain unresponsive to oral contraceptives and nonsteroidal antiinflammatory drugs. Initial management of endometriosis involves surgical resection or destruction at the time of diagnosis followed by medical management with continuous oral contraceptives. Gonadotropin-releasing hormone agonists should be considered for adolescents over 16 years of age who have completed pubertal maturation.     

Medical and surgical management of chronic pelvic pain

Chronic pelvic pain is common and is estimated to affect over one million women in the UK. It may be a symptom of a number of different conditions and is often multifactorial in nature, caused by a combination of physical, psychological and social factors. For many women, a primary cause cannot be identified. This can make both diagnosis and management difficult. Gynaecological causes of chronic pelvic pain include endometriosis, chronic pelvic inflammatory disease and adhesions. The gynaecologist must also consider non-gynaecological causes of pain related to the gastrointestinal, urinary, neurological, musculoskeletal and psychological systems if satisfactory management of the woman's pain is to be achieved.This review addresses the approach to diagnosis and management of women presenting with chronic pelvic pain. It details specific disease management but also seeks to encourage a holistic approach to all women with chronic pelvic pain, whether or not a primary diagnosis is established.     

Efficacy of laparoscopic excision of visually diagnosed peritoneal endometriosis in the treatment of chronic pelvic pain

OBJECTIVE: To determine the efficacy of laparoscopic excision of visually diagnosed endometriosis in the treatment of chronic pelvic pain. STUDY DESIGN: Sixty-two women with chronic pelvic pain and who underwent laparoscopic excision of visually diagnosed peritoneal lesions suggestive of endometriosis returned postal questionnaires. The main outcomes measures were change in pelvic pain symptoms measured on a continuous and ordinal scale and patient satisfaction following treatment. Secondary outcomes were quality of life, time off work and use of health service resources. RESULTS: 42/62 (68%) women with an average follow up time of 13 months (range 6-38 months) returned completed outcome questionnaires. The mean amount of pelvic pain was reduced following surgery compared to immediately prior to treatment, regardless of the nature of the pain (P<0.05). Overall, 67% (95% CI 50-80%) of women reported improvement in pain symptoms and 71% (95% CI 55-84%) were satisfied with the results of treatment. Satisfaction with treatment was comparable whether the visual diagnosis of peritoneal endometriosis was confirmed histologically or not (62% versus 64%, P=1.0). CONCLUSION: Laparoscopic excision of visually diagnosed endometriosis appears to be efficacious in the treatment of women with chronic pelvic pain. The launch of a long-term randomised controlled trial to confirm these provisional results is now required.     

Internal Herniation of Adnexa Through a Defect of the Broad Ligament: Case Report and Literature Review

Internal herniation through a defect of the broad ligament occurs rarely. Herniation of the ovary rather than the small intestine or colon is extremely rare. We present only the third known case of herniation of the adnexa into a broad ligament defect. A 42-year-old woman, gravida 3, para 2, aborta 1, had severe continuing right lower quadrant pain that was resistant to medical and surgical treatments. The clinical history was significant for long-standing endometriosis, 2 previous laparoscopic procedures to treat endometriosis, and chronic pelvic pain despite medical and surgical treatments. At the second laparoscopic procedure, pelvic endometriosis was excised, and a large defect of the right broad ligament was noted but not treated. At the third operation, right salpingo-oophorectomy was performed to eliminate the large broad ligament defect and the possibility of internal herniation on the right side as a possible explanation for the patient's chronic right lower quadrant pain. Postoperatively, the pain resolved, and the patient has been pain-free for 9 months. This type of internal herniation should be considered in the differential diagnosis in female patients with pelvic pain.     

The Use of Botulinum Toxin in the Pelvic Floor for Women with Chronic Pelvic Pain–A New Answer to Old Problems?

Chronic pelvic pain occurs in about 15% of women and has a variety of causes requiring accurate diagnosis and appropriate treatment if pain reduction is to be effected. Superficial conditions such as provoked vestibulodynia and deeper pelvic issues such as pelvic floor myalgia were traditionally difficult to diagnose and adequately treat. For provoked vestibulodynia, there are limited data, in the form of case reports and small series, to indicate that botulinum toxin (BoNT) injections may provide short-term (3–6 months) benefit. Retreatment is reported to be successful and side effects are few. Class-I studies are essential to adequately assess this form of treatment. For pelvic floor myalgia, 1 class-I study and 3 class-II to -III studies indicate efficacy of BoNT. In the only double-blind, randomized, controlled study, significant reduction in pelvic floor pressures with significant pain reduction for some types of pelvic pain are reported compared with baseline. No differences in pain occurred compared with the control group who had physical therapy as an intervention. Physical therapy should be used as a noninvasive first-line treatment, with BoNT injections reserved for those who are refractory to treatment. Pelvic floor disorders should be considered as a cause for chronic pelvic pain in women and an attempt made to diagnose and treat such problems as a routine practice. The use of BoNT as a therapeutic option for pelvic floor muscle spasm and pain is still in its infancy. Initial reports suggest that there may be a significant role for women with chronic pain that is refractory to currently available medical and surgical treatments, however, there are very few high-quality studies and research is essential before this novel treatment can be accepted into widespread use for pelvic pain attributable to the pelvic floor.