Chronic pelvic pain

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor(s)-in-Chief: Roghayeh Marandi, M.D.

Synonyms and Keywords:

Overview

Chronic pelvic pain is a symptom, not a diagnosis, and is defined as persistent or recurrent pelvic pain of either men or women for longer than three to six months. It can be classified into two subgroups: specific disease-associated pelvic pain that there is a pathology to explain the pain such as pelvic inflammatory disease, infections, adnexal pathologies, endometriosis, etc., and chronic pelvic pain syndrome (CPPS), which its diagnosis often based on the history and physical examinations and imaging and laboratory findings are often inconclusive in diagnosing it, and usually, no specific etiology can be found. It is likely represents an abnormal neurological function and is a form of centralized pain, where the body develops a low threshold for pain, often a result of chronic pain. For example, the acute pain associated with endometriosis could become centralized ( Peripheral sensitization may lead to central sensitization) during a three to six months duration, as the pain becomes chronic Sensoryry neurons' chemistry in the central nervous system is altered with central sensitization, changing how pain signals are processed. As a result, neurons in the central nervous system's pain pathways remain in a persistent state of high reactivity, resulting in heightened pain perceptions. In centralized pain, the previous mild to moderate pain is experienced as severe pain (hyperalgesia), or tactile sensations can be interpreted as painful (allodynia). Also, chronic pelvic pain has a strong association with previous physical or emotional trauma, so the etiology of chronic pelvic pain could be related to functional somatic pain syndrome. Treatment of chronic pelvic pain is often complicated and is usually focused on the suspected etiology of the chronic pelvic pain, such as treating a comorbid mood disorder, neuropathy, or uterine dysfunction, which can exacerbate chronic pain.

Historical Perspective

Systemic approach to chronic pelvic pain was first described by Kresch, who developed a series of forms to obtain information from the pelvic pain patient.[1]

Classification

  • Chronic pelvic pain may be classified into two subgroups based on existing pathology that explains the pelvic pain.[2]

Pthophysiology

Causes

Gender-specific causes classification[9][2]

Women Infection, Endometriosis, Dysmenorrhea, Dysparunia, Myofascial Pain Syndrome, Vulvodynia, Vulvitis, Cystitis, bladder pain syndrome, Ovarian Remnant Congestion, Sympathetically Mediated Pain, Pelvic Congestion, Pelvic Fibrosis, Pelvis Neurodystonica, Irritable Bowel Syndrome, Sexual abuse/Physical abuse, Cancer, Psychiatric Disorders, Surgical Procedures(adhesions), Pelvic floor muscle pain syndrome, Vulvodynia,Vestibular pain syndrome,Endometriosis- associated pain syndrome
Men Prostatitis, Chronic Orchalgia, Prostadynia, Interstitial Cystitis, Ureteral Obstruction, Irritable Bowel Syndrome, bladder pain syndromeSexual/Physical Abuse, Cancer,Psychiatric Disorders, Proctalgia fugax, Radiation proctitis, Surgical Procedures (adhesions), Rectal pain syndrome,Pelvic floor muscle pain syndrome,Prostatic pain syndrome, Scrotal pain syndrome, Testicular pain syndrome, Epididymal pain syndrome, Penile pain syndrome, Urethral pain syndrome, Post-vasectomy scrotal pain syndrome

Causes by Organ System

Cardiovascular Pelvic vein thrombosis
Gastroenterologic Anal fissure, Appendicitis, Colitis, Colonic polyps, Constipation, Diarrhea, Diverticulitis, Gastrointestinal cancers, Hemorrhoids, Internal hernia, Irritable bowel syndrome, Proctitis, Reproductive tract cancers, Strangulated hernia, Ulcerative colitis,Abdominal epilepsy, Proctalgia fugax, Radiation proctitis, Surgical Procedures (adhesions)
Hematologic Porphyria
Iatrogenic Ovarian remnant
Infectious Disease UTI
Musculoskeletal / Ortho Coccydynia, Low back pain, Muscle spasm, Pelvic girdle malrotation, Tension in the pelvic floor muscles, Degenerative joint disease. Disc herniation
Neurologic Nerve entrapment in pelvis(surgical scar in the lower part of theabdomen), Peripheral neuropathy in pelvis, Post herpetic neuralgia, Post infectious neurological hypersensitivity, Pudendal nerve neuralgia, iliohypogastric, ilioingiunal, genitofemoral, lateral femoral cutaneous nerve, shingles (herpes zoster infection), spine-related nerve compressions
Obstetric/Gynecologic Adenomyosis, Adhesions in the pelvic area, Cervical polyps, Chronic vulvovaginitis, Dysmenorrhea, Ectopic pregnancy, Endometrial polyps, Endometriosis, Fibroids, Miscarriage, Mittelschmerz pain, Mullerian abnormalities, Ovarian cysts, Ovarian torsion, Pelvic congestion syndrome, Pelvic inflammatory disease, Pelvic relaxation, Placental abruption, Retroverted uterus, Uterine leiomyoma, Vulvodynia,Dyspareunia
Oncologic Colon cancer, Neuromas, Pelvic tumor, Testicular tumors
Psychiatric Chronic stress, Depression, drug addiction, dependence,family problems, Somatotisation disorders
Renal / Electrolyte Loin pain hematuria syndrome
Rheum / Immune / Allergy Fibromyalgia
Sexual Clitorodynia, Epididymo-orchitis, Sexual abuse, sexual dysfunction
Trauma Physical abuse
Urologic Chronic bacterial prostatitis, Chronic bladder irritation, Chronic non bacterial prostatitis, Chronic pelvic pain syndrome, Chronic urethritis, Epididymal cysts, Hydrocele, Interstitial cystitis, Urinary tract calculi, Varicocele

Common Causes

Commonly proposed etiologies of chronic pelvic pain(CCP) include: [10] [11]

Differentiating chronic pelvic pain from other Diseases

Differential diagnosis by organ system:

Epidemiology and Demographics

  • Chronic pelvic pain affects one in seven women in the United States.
  • No adequate data on incidence were found.

Age

Chronic pelvic pain is more commonly observed among women aged 18-50 years old.[13]

Gender

  • Chronic pelvic pain affects one in seven women in the United States.
  • Ninety-nine percent of all cases of chronic pelvic pain are female.

Race

Risk Factors

Common risk factors in the development of chronic pelvic syndrome are genetic, psychological state, recurrent somatic trauma, and endocrine factors.[2]

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Criteria

Symptoms

  • Symptoms of chronic pelvic pain may include the following:[9]
  • The systemic approach should be used to identify the source of pain. [1]

Physical Examination

Laboratory Findings

There are no specific laboratory findings associated with making the diagnosis of the chronic pelvic syndrome. They might be useful in the diagnosis of comorbid conditions responsible for the development of chronic pelvic pain. To rule out the pregnancy, chronic inflammation, or infection as the source of chronic pelvic pain, a complete blood count with differential, urine pregnancy test, erythrocyte sedimentation rate, urinalysis, chlamydia, and gonorrhea, CA-125, ESR, pap smear are often ordered.

Electrocardiogram

There are no ECG findings associated with chronic pelvic pain.

X-ray

An x-ray may be helpful in the diagnosis of co-morbidities associated with chronic pelvic pain.

Echocardiography or Ultrasound

There are no ultrasound findings associated with chronic pelvic pain. However, an ultrasound may be helpful in the diagnosis of comorbid conditions responsible for the development of chronic pelvic pain such as cysts, masses, and adenomyosis, hydrosalpinx which is an indicator of pelvic inflammatory disease; comorbidity is often seen in chronic pelvic pain, and rule out anatomic abnormalities.

CT scan

CT scan may be helpful in the diagnosis of pelvic congestion syndrome, uterine or adnexal or other pathologies as the cause of pelvic pain.

MRI

MRI may be helpful in the diagnosis of comorbidities responsible for chronic pelvic pain such as adhesions, adenomyosis, endometriosis, fibroids, and it is usually ordered following an ultrasound if abnormalities are seen.

Other Imaging Findings

  • Hysteroscopy may be helpful in the diagnosis and resection of uterine fibroids.
  • Pelvic venography for diagnosis of pelvic congestion syndrome

Other Diagnostic Studies

  • Laparoscopy is used for diagnosis and treatment of endometriosis, adhesions
  • Colonoscopy
  • Diagnostic nerve blocks may help the patient with chronic pelvic pain complains of symptoms of neuropathic pain. The sacral nerve root is numbed from a nerve block. If the patient's pain is eliminated, this helps confirm the chronic pelvic pain secondary to peripheral nerve dysfunction.

Treatment

where the origin of the pain is known, the underlying disease should be treated. However, if the source of the pain is unknown, it is recommended for the patient to undergo further evaluation to find the underlying disease. Treatment may include:[8]

Treatment of specific disease-associated pelvic pain:

Treatment of chronic pelvic pain syndrome

  • There are different types of therapeutic options, psychological treatment such as CBT and surgery available to treat chronic pelvic pain syndromes.

Surgery

  • The surgical procedure can only be performed for patients experiencing severe, uncontrolled pain, or there is a concern for acute abdomen, and the patient should be referred for laparoscopic surgery or sent to the emergency department. If laparoscopic surgery is inconclusive, the patient's pain is likely secondary to chronic regional pain syndrome.
  • Peripheral nerve blocks and neuromodulation of sacral nerves may also be necessary in severe cases.
  • Hysterectomy sometimes can be considered in chronic pelvic pain secondary to the uterine origin.

Prevention

The measures that are thought to reduce the risk of some diseases responsible for chronic pelvic pain could be considered primary prevention of chronic pelvic pain.

References

  1. 1.0 1.1 Carter JE (1999). "A systematic history for the patient with chronic pelvic pain". JSLS. 3 (4): 245–52. PMC 3015355. PMID 10694069.
  2. 2.0 2.1 2.2 Engeler DS, Baranowski AP, Dinis-Oliveira P, Elneil S, Hughes J, Messelink EJ, van Ophoven A, Williams AC (September 2013). "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. 64 (3): 431–9. doi:10.1016/j.eururo.2013.04.035. PMID 23684447.
  3. Fall M, Baranowski AP, Fowler CJ, Lepinard V, Malone-Lee JG, Messelink EJ, Oberpenning F, Osborne JL, Schumacher S (December 2004). "EAU guidelines on chronic pelvic pain". Eur Urol. 46 (6): 681–9. doi:10.1016/j.eururo.2004.07.030. PMID 15548433.
  4. Fenton BW, Grey SF, Tossone K, McCarroll M, Von Gruenigen VE (2015). "Classifying Patients with Chronic Pelvic Pain into Levels of Biopsychosocial Dysfunction Using Latent Class Modeling of Patient Reported Outcome Measures". Pain Res Treat. 2015: 940675. doi:10.1155/2015/940675. PMID 26355825.
  5. Ball E, Khan KS (2020). "Recent advances in understanding and managing chronic pelvic pain in women with special consideration to endometriosis". F1000Res. 9. doi:10.12688/f1000research.20750.1. PMID 32089831 Check |pmid= value (help).
  6. Grinberg K, Sela Y, Nissanholtz-Gannot R (April 2020). "New Insights about Chronic Pelvic Pain Syndrome (CPPS)". Int J Environ Res Public Health. 17 (9). doi:10.3390/ijerph17093005. PMID 32357440 Check |pmid= value (help).
  7. Smith, Blair H.; Fors, Egil A.; Korwisi, Beatrice; Barke, Antonia; Cameron, Paul; Colvin, Lesley; Richardson, Cara; Rief, Winfried; Treede, Rolf-Detlef (2019). "The IASP classification of chronic pain for ICD-11". PAIN. 160 (1): 83–87. doi:10.1097/j.pain.0000000000001360. ISSN 0304-3959.
  8. 8.0 8.1 Dydyk AM, Gupta N. PMID 32119472 Check |pmid= value (help). Missing or empty |title= (help)
  9. 9.0 9.1 Hunter CW, Stovall B, Chen G, Carlson J, Levy R (March 2018). "Anatomy, Pathophysiology and Interventional Therapies for Chronic Pelvic Pain: A Review". Pain Physician. 21 (2): 147–167. PMID 29565946.
  10. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
  11. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
  12. Stout AL, Steege JF, Dodson WC, Hughes CL (1991). "Relationship of laparoscopic findings to self-report of pelvic pain". Am J Obstet Gynecol. 164 (1 Pt 1): 73–9. PMID 1824741.
  13. Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF (March 1996). "Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates". Obstet Gynecol. 87 (3): 321–7. doi:10.1016/0029-7844(95)00458-0. PMID 8598948.
  14. Kyama CM, Mwenda JM, Machoki J, Mihalyi A, Simsa P, Chai DC, D'Hooghe TM (September 2007). "Endometriosis in African women". Womens Health (Lond). 3 (5): 629–35. doi:10.2217/17455057.3.5.629. PMID 19804040.

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