Chronic pelvic pain resident survival guide

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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:


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 are 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. Ninety-nine percent of all cases of chronic pelvic pain is female. The Pathophysiology of chronic pelvic disease could be related to the somatic structure or viscera pathologies, central sensitization of pain, or both. 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.


Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

Gender-specific causes classification[1][2]

Women Infection, Endometriosis, Dysmenrrhea, Dysparenia, 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/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 syndrome,Sexual/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

Common Causes

Commonly proposed etiologies of chronic pelvic pain(CCP) include: [3] [4]


Shown below is an algorithm summarizing the diagnosis of chronic pelvic pain:[1][2]

Characterize the pelvic pain
Duration: More than 6 months
Frequency: Cyclical or non-cyclical
Type: like paresthesia, numbness, burning, or lancinating pain
location: In the pelvis, anus, and/or genitalia
Ask about associated symptoms
❑Painful periods
❑painful ovulation
❑painful intercourse
❑Heavy bleeding with periods
❑Irregular periods
Vaginal discharge
❑pain during ejaculation
❑Painful bowel movement with menses
Urgency with bowel movement
Diarrhea or constipation
Nausea, vomiting
Abdominal pain (episodic or constant)
Abdominal distension
Weight gain or loss
❑Low back pain
❑pain with certain movements
Urinary tract:
Dysuria, polyuria
sensory loss
❑Stress, depression, anxiety, anger
Erectile dysfunction, ejaculatory function, post-orgasmic pain
Inquire about

❑ Past medical history
Psychological disorder
❑Previous abdominal or pelvic surgery
Examine the patient

❑General Apperance:
❑ Check for weight loss

Abdominal and pelvic examination

❑ Check for:focal tenderness, enlargement, distortion on abdominal examination, pelvic floor muscles and gluteal muscles suprapubic tenderness
❑Examination of external and internal genitalia, Q tip test
Rectal examination
❑check for: for fecal incontinence, tender puborectal muscles, anal or rectal prolapse

❑Musculoskeletal examination:

❑check for:Tender sacroiliac joints are suggestive of a musculoskeletal origin to the pain
Full clinical examination of the spinal, muscular, nervous, and urogenital systems to detect any pathology
❑Neurolgical examination: Sacral reflexes, muscular function

❑ To rule out the pregnancy, chronic inflammation, or infection, mass or any pathologic cause, as the source of chronic pelvic pain, order:
Complete blood count with differential
❑Urine pregnancy test
Erythrocyte sedimentation rate
Semen culture
chlamydia, and gonorrhea test
Pap smear
❑Stool culture
❑Abdominal and pelvic Ultrasound
Urodynamic studies
Specific disease-associated pelvic pain
CPPS (without pathology to explains the pain)
Painful bladder syndrome
Vulvodynia: Vestibular pain syndrome, Clitoral pain syndrome
❑Generalised vulvar pain syndrome
❑Rectal pain syndrome
Irritable bowel syndrome
Proctalgia fugax
❑Pelvic floor muscle pain syndrome
Endometriosis- associated pain syndrome( pain remains even after endometriosis treatment)
Chronic prostatitis/chronic pelvic pain syndrome
Perineal pain syndrome
❑Epididymal pain syndrome
❑Penile pain syndrome
❑Urethral pain syndrome
Post-vasectomy pain syndrome
Dysmenorrhea: Pain with menstruation that is not associated with well-defined pathology. Dysmenorrhoea needs to be considered as a chronic pain syndrome if it is persistent and associated with negative cognitive, behavioral, sexual, or emotional consequences.
Low back pain
Muscle spasm
Pelvic girdle malrotation
❑Tension in the pelvic floor muscles
❑Degenerative joint disease
Disc herniation
❑Abdominal wall pain
❑Sexual/physical/psychological abuse


Shown below is an algorithm summarizing the treatment of chronic pelvic pain including: Specific disease-associated pelvic pain and CPPS[6][2][7][8][9][10][11][12][13][14]

Treatment of Chronic pelvic pain:
❑ Treatment is based on the origin of chronic pelvic pain. Treatments include pain relievers, oral contraceptive pills, pelvic floor therapy, cognitive behavioral therapy, nutrition counseling, neuromodulatory procedures, and surgery
Treatment of Specific disease-associated pelvic pain(with an underlying pathology)
❑Pain management: Usually, the first step in the treatment of CPP is analgesic drugs.
❑ Specific treatment for the identified cause, for example:
❑ in endometriosis, there are therapeutic options, including oral contraceptives, NSAIDS, GNRH agonists and laparoscopy are available
Treatment of CPPS( without underlying pathology
❑Pain management: Usually, the first step in the treatment of CPPS is analgesic drugs.
❑Pain education: education about the causes of pain
❑Physical therapy: if there is a pathology of the pelvic floor muscles, or treat myofascial pain if it is part of the pelvic pain syndrome.
Biofeedback treatment: for Anal pain syndrome
Microwave thermotherapy
Extracorporeal shockwave therapy
Posterior tibial nerve stimulation
Transcutaneous electrical nerve stimulation
Psychological therapy
❑Dietary treatment
❑Pharmacological management
NSAIDS,α-blockers, Antibiotic therapy, Pregabalin for prostate pain syndrome
Anti-histamines, Amitriptyline, Pentosane polysulphate, Intravesical Treatments, Local anesthetics for bladder pain syndrome
Botulinum toxin, injected in trigger points might be helpful in pelvic Floor, Abdominal and Chronic Anal Pain
Antidepressants, especially when there is a mood disorder


  • Managing chronic pelvic pain syndrome requires an interprofessional team of healthcare professionals that includes a physical therapist, psychologist, pharmacist, and several physicians in different specialties. The importance of multi-disciplinary treatment is emphasized by several reviews.
  • Depending on the severity of the patient's pain, prescription analgesics may be necessary for adequate analgesia. A pharmacist helps coordinate care and helps aid in patient understanding, including proper usage and side effects.
  • A cognitive-behavioral therapist helps in the coping and understanding of a patient's pain.



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