Chronic pelvic pain

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List of terms related to Chronic pelvic pain

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Chronic pelvic pain 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: Chronic pelvic pain( CPP) 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 is 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 chronicSensoryry 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

• [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. If the pain can be localized to an organ, then a more specific term may be used such as:
  • Bladder pain syndrome
  • Rectal pain syndrome
  • Vulvodynia
  • Prostatic pain syndrome
  • Scrotal pain syndrome
  • Perineal pain syndrome
  • Testicular pain syndrome
  • Epididymal pain syndrome
  • Penile pain syndrome
  • Urethral pain syndrome
  • Post-vasectomy scrotal pain syndrome
  • Vulvar pain syndrome
  • Vestibular pain syndrome
  • Pelvic floor muscle pain syndrome
• If the pain is localized to multiple organs, then the syndrome is a regional pain syndrome.

Pathophysiology

• Chronic pelvic pain is a defined condition with well-defined classical pathology (such as infection or cancer) and pathophysiology depends on the cause of it. Chronic pelvic pain syndrome (CPPS) is a syndrome that can encompass one or more underlying pathophysiological processes including the pelvic viscera, muscles, and peripheral or central nervous system and many CPPSs are associated with a range of concurrent negative psychological, behavioral and sexual consequences
• Although a peripheral stimulus such as infection may initiate the start of a CPP condition, the condition may become self-perpetuating as a result of CNS centralization. As well as pain, these central mechanisms are associated with several other sensory, functional, behavioral, and psychological phenomena.
• Central sensitization mechanisms:
  • 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. 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.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.
• Recurrent trauma, infection or ongoing inflammation or muscle tenderness
• Psychological mechanisms
  • Emotional, cognitive, behavioral, and sexual responses also could involve in chronic pelvic pain.
• Nerve damage

Causes

• Gynecological causes: PID, pelvic congestion syndrome, endometriosis, pelvic adhesions,...
• Urological causes: Urethral syndrome, interstitial cystitis
• Gasteroentrological causes IBS, diverticulitis,...
• Neurological and musculoskeletal causes: Nerve entrapment, myofascial pain,
• Non-organic (psychological) causes Depression, Somatotisation disorders, Physical and sexual abuse.

Common Causes

Commonly proposed etiologies of chronic pelvic pain(CCP) include

• Endometriosis (very controversial) 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

Cardiovascular	Pelvic vein thrombosis
Chemical / poisoning	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	No underlying causes
Ear Nose Throat	No underlying causes
Endocrine	No underlying causes
Environmental	No underlying causes
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
Genetic	No underlying causes
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
Neurologic	Nerve entrapment in pelvis, Peripheral neuropathy in pelvis, Post herpetic neuralgia, Post infectious neurological hypersensitivity, Pudendal nerve neuralgia
Nutritional / Metabolic	No underlying causes
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
Oncologic	Colon cancer, Neuromas, Pelvic tumor, Testicular tumors
Opthalmologic	No underlying causes
Overdose / Toxicity	No underlying causes
Psychiatric	Chronic stress, Depression
Pulmonary	No underlying causes
Renal / Electrolyte	Loin pain hematuria syndrome
Rheum / Immune / Allergy	Fibromyalgia
Sexual	Clitorodynia, Epididymo-orchitis, Sexual abuse
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
Dental	No underlying causes
Miscellaneous	No underlying causes

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

• 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.

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

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 chronic pelvic syndrome are genetic, psychological state, recurrent somatic trauma, and endocrine factors.

Natural History, Complications and Prognosis

• The patient's pain is located within the pelvis and has lasted greater than six months duration.
• Common complications are having pain even after hysterectomy, dependency on opioids, infection, and bleeding after laparoscopy.
• Prognosis is generally poor in patients with chronic pelvic pain, similar to other chronic pain syndromes.

Diagnosis

Diagnostic Criteria

• It is a symptom, not a diagnosis, pain is an intermittent or constant pain in the lower abdomen or pelvis, lumbosacral back, buttocks being for at least 6 months and not occurring exclusively with menstruation or intercourse or associated with pregnancy.

Symptoms

• Symptoms of chronic pelvic pain may include the following:

• persistent non-cyclical or cyclical pelvic pain
• paresthesias, numbness, burning, or lancinating pain, in the pelvis, anus, and/or genitals
• Pain often occurs with sitting, urinating, defecating, intercourse, and ejaculation.

Physical Examination

• Physical examination may be remarkable for:

• focal tenderness, enlargement, distortion on abdominal examination, suprapubic tenderness
• Tender sacroiliac joints are suggestive of a musculoskeletal origin to the pain
• Traditional bimanual examination to examine the uterus, adnexa, anorectal
• Q-tip test

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

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 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.

Other Diagnostic Studies

• Laparoscopy is used for diagnosis and treatment of endometriosis, adhesions
• Colonscopy
• 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:

• Pain management: Usually, the first step in the treatment of CPP is analgesic drugs.
• Behavioral therapy
• Pelvic floor physical therapy
  • If the cause of chronic pelvic pain is pelvic floor muscle dysfunction
• Medications
• Surgery

Medical Therapy

• Treatment of a patient with chronic pelvic pain without any pathologies responsible for pain is over-the-counter analgesic (acetaminophen, NSAIDs).
• If OTC is inadequate for pain relief and the pain is cyclical, oral contraceptive pills, depot medroxyprogesterone, or an intrauterine device is recommended if the pain is cyclical.
• If hormonal treatment is ineffective, or the pain not cyclical, or pelvic pain is suspected to be neuropathic, it is essential to evaluate the patient for an underlying mood disorder.
• If there is a mood disorder, antidepressant therapy (SSRI) is recommended.
• If a patient with suspected chronic pelvic pain secondary to neuropathic pain does not have an underlying mood disorder, various treatment options exist, such as antidepressants (TCAs), pregabalin, gabapentin, or SNRIs such as venlafaxine or duloxetine.
• If pain is uncontrolled with those various treatment options, it is recommended to refer to a Pain Medicine specialist and possibly start a trial of opioid analgesics.
• Local steroid injection can be considered in sacral nerve injury.
• Adjunct, non-pharmacological treatments such as pelvic floor therapy for chronic pain with the musculoskeletal origin, cognitive behavioral therapy, nutrition counseling, neuromodulatory procedures are also be offered.

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

There are no primary preventive measures available for [disease name]. Effective measures for the primary prevention of [disease name] include [

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

• Abdominal adhesions
• Coccydynia (coccyx pain, tailbone pain)

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

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