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:

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. Ninety-nine percent of all cases of chronic pelvic pain are 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.

Causes

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]

Diagnosis

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

 
 
 
 
 
 
 
 
Characterize the pelvic pain
❑Duration: more than 3-6 months
❑Frequency: cyclical or non-cyclical
❑ Type: like paresthesia, numbness, burning, or lancinating pain
❑location: in the pelvis, anus, and/or genitals
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask about associated symptoms

Gynecological:
Painful periods
painful ovulation
painful intercourse
heavy bleeding with periods
irregular periods
vaginal discharge
pain during ejaculation

Gastrointestinal:
Painful bowel movement with menses
the urgency with bowel movement
bloating
diarrhea or constipation
nausea, vomiting
Abdominal pain (episodic or constant)
Abdominal distension
Fever
Weight gain or loss
Anorexia
Dyspepsia
Musculoskeletal:
Low back pain
pain with certain movements
Urinary tract:
Dysuria, polyuria

Psychological:
Stress, depression, anxiety, anger
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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, 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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order

❑ 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
Urinalysis
chlamydia, and gonorrhea test
CA-125
Pap smear
❑Abdominal and pelvic Ultrasound
❑Cystoscopy
❑Urodynamic studies
❑Laprascopy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CPP( with pathology to explain the 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
Coccydynia
❑Pelvic floor muscle pain syndrome
Endometriosis- associated pain syndrome( pain remains even after endometriosis treatment)
Chronic prostatitis/chronic pelvic pain syndrome
Orchalgia
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.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-Gynecologic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Musculoskeletal
❑Low back pain
❑Muscle spasm
❑Pelvic girdle malrotation
❑Tension in the pelvic floor muscles
❑Degenerative joint disease
❑Disc herniation
 
Co-morbidities
Somatization
Depression/Anxiety
❑Abdominal wall pain
❑Sexual/physical/psychological abuse
 

Treatment

Shown below is an algorithm summarizing the treatment of chronic pelvic pain including: CPP and CPPS[6][2]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 CPP(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 laparscopy 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
 
 
 
 
 
 
 

Do's

  • The content in this section is in bullet points.

Don'ts

  • The content in this section is in bullet points.

References

  1. 1.0 1.1 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.
  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. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
  4. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
  5. 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.
  6. Dydyk AM, Gupta N. PMID 32119472 Check |pmid= value (help). Missing or empty |title= (help)


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