Musculoskeletal causes of chronic pelvic pain: a systematic review of existing therapies: part II

Chronic pelvic pain is a common clinical problem with many causes. In addition to gynecologic causes, it is important to evaluate other potential etiologies, including the pelvic musculoskeletal system. There have been few published studies on musculoskeletal causes of pelvic pain and its treatment. The objective of this study was to evaluate treatment of pelvic musculoskeletal pain among women with chronic pelvic pain. We used a set of key words pertaining to pain and the pelvic musculoskeletal structures to initially review the PUBMED database. Additional articles were sought by discussion with a clinician specializing in this field and review of relevant textbook bibliographies. Study inclusion was restricted to English-language publications that reported a patient-related chronic pelvic pain outcome measure. Each report must have described at least four patients. For each selected article, two investigators separately summarized pertinent data on study characteristics, patient profiles, intervention characteristics, and treatment outcomes. Discrepancies were resolved by discussion. Twenty-nine treatment studies met entry criteria. The existing literature largely consists of retrospective, uncontrolled observational studies. The two studies that feature control groups lack sufficient size and scope to allow generalizability. Properly designed and executed randomized, controlled trials are urgently needed to determine the true effectiveness of treatments for pelvic musculoskeletal pain. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader should be able to summarize the current data on musculoskeletal causes of chronic pelvic pain, to outline the various techniques used to treat musculoskeletal causes of chronic pelvic pain, and to recall the lack of evidence based data on the subject and need for randomized controlled trials.     

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.     

Evaluating chronic pelvic pain. A consensus recommendation. Pelvic Pain Expert Working Group

OBJECTIVE: To identify a comprehensive approach to evaluating women with chronic pelvic pain based on findings in the literature. STUDY DESIGN: A working group of gynecologist pelvic pain specialists was convened to consider principles on which consensus could be reached and to identify areas in which consensus is not yet possible. RESULTS: Chronic pelvic pain affects 15% of American women. The diagnostic and therapeutic approach to the complaint may be influenced inordinately by the specialty of the practitioner to whom the woman presents. A comprehensive approach to the complaint requires recognition of the multiple organ systems that may be involved. Evaluation of the woman with chronic pelvic pain begins with a comprehensive history and physical examination, followed by selected laboratory and imaging studies. For those women in whom the evaluation does not yield a likely cause of the complaint, the empiric use of nonsteroidal antiinflammatory agents, oral contraceptives, and perhaps antibiotics or antispasmodics is indicated. Women who fail to respond to empiric therapy should be considered highly likely to have endometriosis or adenomyosis. Further diagnostic (laparoscopy) or therapeutic (gonadotropin-releasing hormone agonist) interventions should be directed toward the high likelihood of endometriosis or adenomyosis. CONCLUSION: A comprehensive approach to chronic pelvic pain includes consideration of multiple organ systems, with empiric therapy appropriate after a thorough history and physical examination, to further delineate the pain problem.     

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.     

Receiver operating characteristic curves of symptom scores in the diagnosis of interstitial cystitis/painful bladder syndrome

STUDY OBJECTIVE: Chronic pelvic pain is often a manifestation of interstitial cystitis (IC), for which several symptom scoring measures exist. However, the receiver operating characteristic (ROC) curves for these scores have not been described, even though such analysis could identify an optimal noninvasive test and suggest diagnostic test thresholds. The objective of this study was to develop ROC curves for IC symptom scores based on the standard of pain relief after cystoscopy with hydrodistention (HD). DESIGN: This is a retrospective analysis of IC symptom index (ICSI) and visual analog scale (VAS) bladder pain (VASb) scores recorded at initial patient visit. Patients underwent a diagnostic algorithm leading to selected HD. The ROC curves were calculated based on the presence of diagnostic criteria for IC found at HD (Canadian Task Force classification III). SETTING: A multidisciplinary chronic pelvic pain referral center. PATIENTS: A total of 277 women with chronic pelvic pain were evaluated. The mean duration of pain was 54 months; mean pelvic pain VAS score was 7.5. Those proved to have IC had a VASb score of 7 and an ICSI score of 11. INTERVENTIONS: Initial symptom score tabulation followed by a symptom-based diagnostic algorithm consisting of alkalinized lidocaine instillation with HD offered to responders. MEASUREMENTS AND MAIN RESULTS: The ROC curve for the VASb was shifted to the upper left compared with the ICSI, which was closer to the diagonal. Area under the curve was significantly greater for VASb (0.860) than ICSI (0.773) (p=.045). The maximum diagnostic accuracy for the ICSI was at a value of 14 or more (0.88) and for the VASb at a value of 7 or more (0.94). CONCLUSION: The most accurate symptom score for detecting IC based on this analysis was the VASb with a threshold of 7. Although the ICSI may have use, in this setting it is not as useful as the VAS for identifying patients who eventually prove to have IC.     

Role of hysterectomy in the treatment of chronic pelvic pain

Chronic pelvic pain affects nearly 15% of women annually in the United States. It is associated with significant comorbidity, and annual costs to the health care system are estimated at approximately 2 billion dollars per year. The multifactorial nature of chronic pelvic pain makes it difficult to evaluate and treat. Therapies vary and may include surgical interventions such as hysterectomy. Although hysterectomy is an accepted treatment for chronic pelvic pain, it has important limitations that need to be discussed with the patient before surgery. Women can expect improvement in pain levels and function from their preoperative baseline. However, studies show that in the absence of any obvious pathology, 21-40% of women having a hysterectomy for chronic pelvic pain may continue to experience pain after the surgery and 5% may have new onset of pain. Women may experience improvements in mental health, physical function, social function, and dyspareunia; however, sexual frequency is not likely to change. Comorbidities such as preoperative depression may lower the chances of pain resolution after hysterectomy. Approximately 14% of women report having results worse than expected and almost 26% may have a slower recovery than expected. To maximize the chances of pain resolution, all women with chronic pelvic pain should undergo a full evaluation of the urologic, gastroenterologic, neurologic, and musculoskeletal organ systems before surgery to exclude nonreproductive causes of pain.     

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.     

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.     

A comparative study of women with chronic pelvic pain, chronic nonpelvic pain and those with no history of pain attending general practitioners

Objective To investigate and compare the demographic and psychosocial profiles of women with chronic pelvic pain, chronic pain in a different site, and those with no history of pain with specific reference to a history of sexual abuse.
Design A prospective comparative study.
Setting Pelvic Pain Clinic at Leicester General Hospital NHS Trust, Pain Management Clinic at Leicester Royal Infirmary NHS Trust and two General Practices.
Participants Thirty women with chronic pelvic pain, 30 women with chronic pain in a different site and 30 women attending their general practitioner with no history of pain.
Interventions A specifically designed patient profile questionnaire to identify and explore incidents of sexual and physical abuse was administered to each woman by a research psychologist for confidential self-completion. Data were also collected on other demographic, medical and psychosocial characteristics.
Results Women with chronic pelvic pain were found to have a higher lifetime prevalence of sexual abuse, involving penetration or other genital contact compared with the two comparison groups. The prevalence of physical abuse was the same in all groups. Women in the pelvic pain group were more likely to have approached their GP for symptoms not related to pelvic pain than women in the other two groups and the incidence of clinical anxiety was significantly higher in this group compared with the pain-free group. The prevalence of sexual problems was much higher in the group with pelvic pain compared with the other two groups.
Conclusion These findings indicate that women with chronic pelvic pain have a higher incidence of past sexual abuse compared with women in a comparison pain group and with women with no pain.     

Citalopram in the treatment of women with chronic pelvic pain: an open-label trial

OBJECTIVE: To determine the efficacy of citalopram in the treatment of chronic pelvic pain by measuring changes in pain severity, depressive symptoms and functional disability. STUDY DESIGN: Fourteen women between 18 and 50 years of age with chronic pelvic pain were enrolled in a 12-week, open-label, flexible-dose study. Following a single-blind washout, placebo nonresponders were treated with citalopram (20-60 mg/d). RESULTS: Twelve patients completed the study. Depression scores decreased significantly on the Hamilton Psychiatric Rating Scale for Depression (p = 0.006), pain severity showed a trend toward improvement on the McGill Pain Intensity Scale (p = 0.096), but there was no significant differences on the Pain Disability Index (p = 0.158). Eleven of 12 (91.7%) patients elected to continue taking citalopram after study completion. CONCLUSION: Citalopram is effective in reducing depressive symptoms, shows a statistical trend toward improvement in pain intensity in women with chronic pelvic pain and is well tolerated. It appears minimally effective in reducing disability. Larger, controlled studies are needed to evaluate the role of citalopram in treating chronic pelvic pain.     

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.     

The value of laparoscopy in women with chronic pelvic pain and a "normal pelvis"

During the period January 1976--December 1982 laparoscopy was performed on 186 women complaining of pelvic pain of at least 6 months' duration. In all these cases, the routine pelvic examination and other medical and laboratory tests were negative. Laparoscopy revealed pelvic pathology in only 8.2%: in the vast majority (91.8%) entirely normal pelvic organs were seen. Evidence from the literature is compiling as to the psychogenic origin of most cases of chronic pelvic pain. Recently, it has been shown that laparoscopically negative pelvic pain can be relieved or abolished by psychological intervention. Since pathological findings on laparoscopy are of very low percentage and since the pain is psychogenic in most cases, the value of routine laparoscopy in chronic pelvic pain is very low. We propose that all women with chronic pelvic pain and normal pelvic examination should undergo psychological assessment and treatment if necessary. Laparoscopy should then be reserved for only those cases who show no amelioration on psychological intervention. Our estimation is that this approach would reduce the rate of laparoscopies performed for chronic pelvic pain by about 90%.     

Possible role of the long dorsal sacroiliac ligament in women with peripartum pelvic pain

BACKGROUND: To enhance the understanding of the pathophysiology of women with peripartum pelvic pain, it is necessary to couple anatomical insights with relevant clinical research. In this context, the long dorsal sacroiliac ligament is especially of interest because it was noticed that women diagnosed with peripartum pelvic pain frequently experience pain within the boundaries of this ligament. Njoo (1) found a high intertester reliability and a high specificity for long dorsal sacroiliac ligament pain. The present article focuses on the possible role of the long dorsal sacroiliac ligament in the pain pattern of women with peripartum pelvic pain. The diagnostic and therapeutic consequences are considered. STUDY DESIGN: A cross-sectional analysis was performed in a homogenous group of women meeting strict criteria for posterior pelvic pain since pregnancy, diagnosed as having peripartum pelvic pain and excluded for any history of fracture, neoplasm or previous surgery of the lumbar spine, the pelvic girdle, the hip joint or the femur. The patients were also excluded for signs indicating radiculopathy: asymmetric Achilles tendon reflex and/or (passive) straight leg raising restricted by pain in the lower leg. METHODS: The study group comprised 178 women diagnosed with peripartum pelvic pain, selected from the outpatient clinic of a specialized rehabilitation center. Selection was based on criteria enabling a strict division between lumbar and pelvic complaints. Pain in the long dorsal sacroiliac ligament was detected by standardized palpation of the long dorsal sacroiliac ligament by specifically trained physicians and scored on a modified scale. Comparisons with the posterior pelvic pain provocation test and the active straight leg raise test was carried out. RESULTS: The present study confirms that the long dorsal sacroiliac ligament frequently shows tenderness on palpation in patients with peripartum pelvic pain. Sensitivity was 76%. Sensitivity in a group of 133 women of the study group that scored positive on both active straight leg raise and posterior pelvic pain provocation tests was 86%. When only severe pelvic patients were included, sensitivity increased to 98%. In comparisons between the posterior pelvic pain provocation and the long dorsal sacroiliac ligament tests on the left and right side, Pearson's correlation coefficient was 0.33 and 0.41, respectively. In comparisons between the active straight leg raise and the long dorsal sacroiliac ligament tests on the left and right side, Pearson's correlation coefficient was 0.35 and 0.41, respectively. CONCLUSIONS: The present study, carried out on a group of peripartum pelvic pain patients with strict in- and exclusion criteria, attempts to further elucidate the pathophysiology of patients with peripartum pelvic pain by adding a simple pain provocation test. It is concluded that the combination of the active straight leg raise, the posterior pelvic pain provocation and the long dorsal sacroiliac ligament pain tests combined with the proposed in- and exclusion criteria seems promising in differentiating between mainly lumbar and pelvic complaints. Although the sensitivity of the long dorsal sacroiliac ligament pain test seems promising, further clinical study is necessary in targeting specifically the long dorsal sacroiliac ligament. It is suggested that studies initiated to show the prevalence of sacroiliac joint pain in patients presenting nonspecific lumbopelvic pain, by using intra-articularly double block injection techniques, should include a peripheral injection of at least the long dorsal sacroiliac ligament.     

Health-related quality of life measurement in women with common benign gynecologic conditions: a systematic review

Endometriosis, menorrhagia, chronic pelvic pain, and polycystic ovary syndrome are major sources of psychologic morbidity and can negatively affect quality of life. Although comparative studies have been published on the measurement of health-related quality of life for gynecologic malignancies, a similar review for these benign gynecologic conditions has not been conducted. Consequently, we searched the literature systematically to identify the impact of symptoms and treatments for these conditions on health status and to report on the types and psychometric properties of the instruments used. Papers were retrieved by systematically searching 6 electronic databases and hand-searching relevant reference lists and bibliographies. Forty-six studies used a questionnaire to measure health status: 34 studies (74%) used standardized instruments; of these, 23 studies (68%) used generic tools. Although a meta analysis was not possible, it appears that women with chronic pelvic pain and conditions that are associated with pelvic pain (such as endometriosis) report worse health-related quality of life. Despite the development of disease-specific questionnaires, only 2 questionnaires were generated from interviews of patients with the condition of interest, and few questionnaires are being used to evaluate the outcomes of treatment on subjective health status.     

The prevalence of chronic pelvic pain in women in the United Kingdom: a systematic review

Objective Toobtain a prevalence estimate for chronic pelvic pain in women in the United Kingdom by analysing published data.
Design Systematic review of published papers.
Setting The general population or hospitals in the United Kingdom.
Population Women participating in relevant community surveys or control women participating in hospital-based studies.
Methods Papers were retrieved by systematically searching the databases MEDLINE, EMBASE and PsycLit, and by hand searching. Studies were included if they 1. were community-based and reported prevalence rates of chronic pelvic pain, dyspareunia, dysmenorrhoea, or abdominal pain, or 2. referred to a clinical population but reported prevalence rates in a disease-free control group.
Main outcome measures Prevalence rates for chronic pelvic pain including any overlap with dyspareunia, dysmenorrhoea and abdominal pain.
Results No community-based study has been performed that provides an estimate of the prevalence of chronic pelvic pain in the general UK population. A rate of 39% was reported in women undergoing laparoscopy for sterilisation or investigation of infertility in the single study from the United Kingdom investigating chronic pelvic pain unrelated to menstruation or intercourse. Prevalence rates for dyspareunia, dysmenorrhoea, and abdominal pain found in UK community-based studies were 8%, 45%, to 97%, and 23% to 29%, respectively, but definitions used varied greatly.
Conclusions Because chronic pelvic pain can reduce the quality of life and general wellbeing, there is a need for a community-based study into the prevalence of chronic pelvic pain and its effect upon the lives of women in the UK.     

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.     

Psychosocial and sexual functioning in women with vulvodynia and chronic pelvic pain. A comparative evaluation

OBJECTIVE: To determine whether women with vulvodynia differ from women with chronic pelvic pain and normal controls in their psychological functioning, somatic preoccupation, pain experience and sexual functioning. STUDY DESIGN: Cross-sectional, self-report study of women presenting to University of Michigan specialty and general clinics for the treatment of vulvodynia or chronic pelvic pain or seeking a routine gynecologic examination. All subjects completed questionnaires assessing demographic characteristics, pain, depressive symptoms, general affective state, marital adjustment, functional activity, somatic complaints, exposures, and medical and sexual history. Univariate analyses, chi 2 tests, analyses of variance and logistic regression were used to assess associations between these variables and the diagnostic category. RESULTS: Women with vulvodynia (n = 31) were similar to asymptomatic control women (n = 23) in demographic characteristics, sexual relationship variables, sexual behaviors, current and past depression, somatic sensitivity, and history of sexual or physical abuse. Women with chronic pelvic pain (n = 18) were younger and less educated than the other two groups and were more likely to have a history of physical and sexual abuse, to report recent depression and to screen positive for current depression, to have more work absences and to have more somatic complaints. CONCLUSION: Women with vulvodynia are psychologically similar to control women but differ significantly from women with chronic pelvic pain. A primary psychological cause of vulvodynia is not supported.     

Laparoscopy in the Management of Women with Chronic Pelvic Pain

A review of 232 women who had diagnostic laparoscopy for chronic pelvic pain was undertaken. Diagnostic error in the preoperative pelvic examination in the series varied from 21% to 61%; of 135 patients who had normal pelvic examination findings preoperatively, 82 (61%) were found to have pelvic pathology on diagnostic laparoscopy, whereas 21 of 97 women (21.6%) who had abnormal pelvic examination, had normal findings on laparoscopy. The overall incidence of pelvic pathology in the series was found to be 69%. Our results suggest that there is poor correlation between findings of pelvic examination and the existence of pelvic disease. Laparoscopy has a definite place in the evaluation of patients with chronic pelvic pain and certainly justifies its increasing use in their management.     

Pain in endometriosis: effectiveness of medical and surgical management

PURPOSE OF REVIEW: Endometriosis is a common cause of chronic pelvic pain and has a detrimental effect on the quality of life for women affected with the condition. It is also clear that early diagnosis with prompt effective management does not always occur. This review will discuss the medical and surgical treatment options and support conclusions with randomized double blind placebo-controlled studies where possible. RECENT FINDINGS: Assessment of the pelvic pain associated with endometriosis can be categorized according to its relation to the menstrual cycle. Dysmenorrhoea and ovulatory pain occur with cyclical changes, as compared with chronic non-cyclic pain and deep dyspareunia. Dyskesia and urinary pain may have a relation to the menstrual cycle. The severity of pain symptoms, as well as the effect on the woman's quality of life, should be quantified. The preoperative symptoms can be compared with the operative findings and the stage of endometriosis according to the revised American Fertility Score. SUMMARY: Review of the current literature demonstrates that a combined medical and conservative surgical approach is beneficial for most women with endometriosis associated pelvic pain.