Chronic pelvic pain
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Chronic pelvic pain is defined as persistent pelvic pain for longer than three to six months, and the diagnosis is often based on the history and physical 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. With central sensitization, the chemistry of sensory neurons in the central nervous system is altered, changing how pain signals are processed. As a result, neurons in the pain pathway in the central nervous system remain in a persistent state of high reactivity, resulting in heightened perceptions of pain. 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
- [Disease name] was first discovered by [scientist name], a [nationality + occupation], in [year] during/following [event].
- In [year], [gene] mutations were first identified in the pathogenesis of [disease name].
- In [year], the first [discovery] was developed by [scientist] to treat/diagnose [disease name].
Classification
- Chronic pelvic pain may be classified into two subgroups based on existing pathology that explains the pelvic pain.
- Chronic pelvic pain(CPP) with pathology to explains the pain
- Pelvic inflammatory disease
- Adenxal pathologies
- Uterine pathologies
- Pelvic organ prolapse
- Iatrogenic causes
- Chronic pelvic pain syndrome( CPPS) without pathology to explain the pain
- Chronic Urogenital pain:
- Bladder pain syndrome
- Vulvodynia
- Chronic Urogenital pain:
- Chronic pelvic pain(CPP) with pathology to explains the pain
Pathophysiology
- The pathogenesis of chronic pelvic pain depends on the cause of pain. For example, the cyclical pain in endometriosis is due to recurrent bleeding in the endometriotic implants, or pain in pelvic congestion syndrome is due to engorged and dilated pelvic veins causing the decreased venous washout.[1]As one organ system becomes dysfunctional, such as in interstitial cystitis, another organ can also develop pathology, such as irritable bowel syndrome. As comorbidities develop, the chronic nature of symptoms leads to centralized pain, only enhancing pain. Collectively, persistent and increased sensitivity to pain becomes chronic pelvic pain.[2]
Causes
Chronic pelvic pain may be caused by comorbid conditions such as irritable bowel syndrome, interstitial cystitis, bladder pain syndrome, mental health disorders such as posttraumatic stress disorder and major depressive disorder, pelvic adhesions, endometriosis.
Common Causes
The five most common etiologies of chronic pelvic pain include irritable bowel syndrome, musculoskeletal pelvic floor pain, painful bladder syndrome, peripheral neuropathy, and chronic uterine pain disorders. Commonly proposed etiologies include [3] [4]
- Endometriosis (very controversial)[5] Deeply Infiltrative Endometriosis may be more important
- Infection or post-infectious neurological hypersensitivity
- Exaggerated bladder, bowel, or uterine pain sensitivity (also known as visceral pain)
- Ovarian cysts, uterine leiomyoma - often found in asymptomatic patients as well, however
- Less common emergencies: ovarian torsion - sudden loss of circulation to the ovary, appendicitis - infection of one part of the intestine, with right lower abdominal pain, ectopic pregnancy - where an early pregnancy grows outside of the uterus and can cause sudden, heavy intra-abdominal bleeding
- Pelvic girdle pain (SPD or DSP)
Causes by Organ System
Causes in Alphabetical Order
- Adenomyosis
- Adhesions in the pelvic area
- Anal fissure
- Appendicitis
- Cervical polyps
- Chronic bacterial prostatitis
- Chronic bladder irritation
- Chronic non bacterial prostatitis
- Chronic pelvic pain syndrome
- Chronic stress
- Chronic urethritis
- Chronic vulvovaginitis
- Clitorodynia
- Coccydynia
- Colitis
- Colon cancer
- Colonic polyps
- Constipation
- Depression
- Diarrhea
- Diverticulitis
- Dysmenorrhea
- Ectopic pregnancy
- Endometrial polyps
- Endometriosis
- Epididymal cysts
- Epididymo-orchitis
- Fibroids
- Fibromyalgia
- Gastrointestinal cancers
- Hemorrhoids
- Hydrocele
- Internal hernia
- Interstitial cystitis
- Irritable bowel syndrome
- Loin pain hematuria syndrome
- Low back pain
- Miscarriage
- Mittelschmerz pain
- Mullerian abnormalities
- Muscle spasm
- Nerve entrapment in pelvis
- Neuromas
- Ovarian cysts
- Ovarian remnant
- Ovarian torsion
- Pelvic congestion syndrome
- Pelvic girdle malrotation
- Pelvic inflammatory disease
- Pelvic relaxation
- Pelvic tumor
- Pelvic vein thrombosis
- Peripheral neuropathy in pelvis
- Physical abuse
- Placental abruption
- Porphyria
- Post herpetic neuralgia
- Post infectious neurological hypersensitivity
- Proctitis
- Pudendal nerve neuralgia
- Reproductive tract cancers
- Retroverted uterus
- Sexual abuse
- Strangulated hernia
- Tension in the pelvic floor muscles
- Testicular tumors
- Ulcerative colitis
- Urinary tract calculi
- Uterine leiomyoma
- UTI
- Varicocele
- Vulvodynia
Differentiating chronic pelvic pain from other Diseases
Differential diagnosis by organ system:
- Gynecological - Endometriosis, pelvic inflammatory disease, pelvic adhesion disease, recurrent ovarian cysts, leiomyoma, adenomyosis, hydrosalpinx, and post-tubal ligation pain syndrome
- Gastroenterological - Irritable bowel syndrome, celiac disease, inflammatory bowel disease, colorectal carcinoma, and hernias
- Urological - Interstitial cystitis (painful bladder syndrome), recurrent cystitis
- Radiation cystitis, chronic urolithiasis, bladder cancer, and urethral syndrome
- Musculoskeletal - Abdominal wall myofascial pain, fibromyalgia, coccygodynia, pelvic floor tension myalgia, piriformis syndrome
- Neurological/vascular - ilioinguinal nerve entrapment, iliohypogastric nerve entrapment, pudendal neuralgia, spinal cord injury, pelvic congestion syndrome, peripheral neuropathy, and vulvar varicosities
Epidemiology and Demographics
The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide. In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].
Age
Patients of all age groups may develop [disease name]. [Disease name] is more commonly observed among patients aged [age range] years old. [Disease name] is more commonly observed among [elderly patients/young patients/children].
Gender
[Disease name] affects men and women equally. [Gender 1] are more commonly affected with [disease name] than [gender 2]. The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.
Race
There is no racial predilection for [disease name]. [Disease name] usually affects individuals of the [race 1] race. [Race 2] individuals are less likely to develop [disease name].
Risk Factors
Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
Natural History, Complications and Prognosis
- The majority of patients with [disease name] remain asymptomatic for [duration/years].
- Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
- If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
- Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
- Prognosis is generally [excellent/good/poor], and the [1/5/10year mortality/survival rate] of patients with [disease name] is approximately [#%].
Diagnosis
Diagnostic Criteria
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1] [criterion 2] [criterion 3] [criterion 4] History and Symptoms [Disease name] is usually asymptomatic. Symptoms of [disease name] may include the following: [symptom 1] [symptom 2] [symptom 3] [symptom 4] [symptom 5] [symptom 6] Physical Examination Patients with [disease name] usually appear [general appearance]. Physical examination may be remarkable for: [finding 1] [finding 2] [finding 3] [finding 4] [finding 5] [finding 6]
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.
Electrocardiogram
There are no ECG findings associated with chronic pelvic pain.
X-ray
There are no x-ray findings associated with [disease name].
OR
An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
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
There are no CT scan findings associated with [disease name].
OR
[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
MRI
There are no MRI findings associated with chronic pelvic pain. However, an MRI may be helpful in the diagnosis of comorbidities responsible for chronic pelvic pain and it is usually ordered following an ultrasound if abnormalities are seen.
Other Imaging Findings
There are no other imaging findings associated with [disease name].
OR
[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
Other Diagnostic Studies
There are no other diagnostic studies associated with [disease name].
OR
[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].
Treatment
Medical Therapy
There is no treatment for [disease name]; the mainstay of therapy is supportive care. The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2]. [Medical therapy 1] acts by [mechanism of action 1]. Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].
Surgery
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.
Prevention
There are no primary preventive measures available for [disease name]. Effective measures for the primary prevention of [disease name] include [
References
- ↑ 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.
- ↑ Dydyk AM, Gupta N. PMID 32119472 Check
|pmid=value (help). Missing or empty|title=(help) - ↑ Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
- ↑ Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
- ↑ 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.
Additional Resources
- Milburn A, Reiter R, Rhomberg A: Multi-disciplinary approach to chronic pain. Obstet Gynecol Clin 1993;20:643 - 661.
- Stovall DW: Endometriosis associated pelvic pain: Evidence for an association between the stage of disease and a history of chronic pelvic pain. Fertil Steril 1997;68:13 - 17.
- Schroeder B, Sanfillippo JS: Chronic Pelvic Pain and Recurrent Abdominal Pain in Female Adolescents. Pediatr Clin North Am 1999;46:566 - 567.
- Elisabeth Thibaud, Hyams JS: Clinical aspects of recurrent abdominal pain. Pediatric and Adolescent GynecologyPediatr Ann 2001;30:17–21.
- Jantos M.: Understanding Chronic Pelvic Pain. Pelviperineology Vol. 26 N.2 June 2007 66-68
Related Chapters
External Links
- International Pelvic Pain Society
- Pelvic Floor Digest: Free Selected medical abstracts on pelvic pain. Updated
- American Pain Society
- Endometriosis Research Center
- endometriosis.org
- Endometriosis Association
- Pelviperineology The multidisciplinary open access pelvic floor journal