Chronic pelvic pain: Difference between revisions

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==Overview==
==Overview==
Most women (and some men), at some time in their lives, experience pelvic pain. When the condition persists for longer than 3 months, it is called '''chronic pelvic pain''' (CPP). This is a poorly-understood condition that likely represents abnormal neurological function, either in the peripheral nervous system or central nervous system.  Many different etiologies have been proposed for CPP, but a major problem is that virtually none of them have been validated.  
[[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 syndrom'''e''' (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 ( [[Neuropathy|Peripheral sensitization]] may lead to [[Neuropathy|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 [[Neuropathy|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.
Women with symptoms of pain may want to see a gynecologist if problems don't go away after a few days, and workup should begin with a careful history and examination, followed by a pregnancy test. Some women may also need bloodwork or additional imaging studies, and a handful may also benefit from having surgical evaluation using small telescopes ([[laparoscopy]]). Many women will also benefit from a consultation with a physical therapist, a trial of anti-inflammatory medications, hormonal therapy, or even neurological agents.
 
This is a condition that although common, direly needs to be studied more closely.


==Historical Perspective==
==Historical Perspective==
[Disease name] was first discovered by [scientist name], a [nationality + occupation], in [year] during/following [event].
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.<ref name="pmid10694069">{{cite journal |vauthors=Carter JE |title=A systematic history for the patient with chronic pelvic pain |journal=JSLS |volume=3 |issue=4 |pages=245–52 |date=1999 |pmid=10694069 |pmc=3015355 |doi= |url=}}</ref>
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
[Disease name] may be classified according to [classification method] into [number] subtypes/groups:
[group1]
[group2]
[group3]
Other variants of [disease name] include [disease subtype 1], [disease subtype 2], and [disease subtype 3].
==Pathophysiology==
The pathogenesis of [disease name] is characterized by [feature1], [feature2], and [feature3].
The [gene name] gene/Mutation in [gene name] has been associated with the development of [disease name], involving the [molecular pathway] pathway.
On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].


==Chronic Pelvic Pain in Female Adolescents==
==Classification==
As girls enter gynecologic maturity, pelvic or abdominal pain becomes a frequent complaint.


Chronic pelvic pain (CPP) accounts for 10% of all visits to gynecologists. In addition, CPP is the reason for 20 - 30% of all laparoscopies in adults.
*Chronic pelvic pain may be classified into two subgroups based on existing pathology that explains the pelvic pain.<ref name="pmid23684447">{{cite journal |vauthors=Engeler DS, Baranowski AP, Dinis-Oliveira P, Elneil S, Hughes J, Messelink EJ, van Ophoven A, Williams AC |title=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 |journal=Eur Urol |volume=64 |issue=3 |pages=431–9 |date=September 2013 |pmid=23684447 |doi=10.1016/j.eururo.2013.04.035 |url=}}</ref>


==Causes==
:*'''1-specific disease-associated pelvic pain''' with pathology to explains the pain
Disease name] may be caused by [cause1], [cause2], or [cause3].
:**[[Pelvic inflammatory disease]]
:**[[Adenxal]] pathologies
:**[[Uterine]] pathologies
:**[[Pelvic organ prolapse]]
:**[[Iatrogenic]] causes
:*'''2-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:<ref name="pmid15548433">{{cite journal |vauthors=Fall M, Baranowski AP, Fowler CJ, Lepinard V, Malone-Lee JG, Messelink EJ, Oberpenning F, Osborne JL, Schumacher S |title=EAU guidelines on chronic pelvic pain |journal=Eur Urol |volume=46 |issue=6 |pages=681–9 |date=December 2004 |pmid=15548433 |doi=10.1016/j.eururo.2004.07.030 |url=}}</ref>
:**[[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 muscles|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]]
:**[[Epididymis|Epididymal]] pain syndrome
:**[[Penis|Penile]] pain syndrome
:**[[Urethra|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.
:**If the pain is localized to multiple organs, then the syndrome is a [[Complex regional pain syndrome]] which is considered as [[CRPS]].


OR
==Pathophysiology==


Common causes of [disease] include [cause1], [cause2], and [cause3].
*[[Pathophysiology]] could be related to  [[somatic]] structure or [[viscera]] pathologies, [[Neuropathy|central sensitization]] of pain, or both.<ref name="pmid26355825">{{cite journal |vauthors=Fenton BW, Grey SF, Tossone K, McCarroll M, Von Gruenigen VE |title=Classifying Patients with Chronic Pelvic Pain into Levels of Biopsychosocial Dysfunction Using Latent Class Modeling of Patient Reported Outcome Measures |journal=Pain Res Treat |volume=2015 |issue= |pages=940675 |date=2015 |pmid=26355825 |doi=10.1155/2015/940675 |url=}}</ref> <ref name="pmid32089831">{{cite journal |vauthors=Ball E, Khan KS |title=Recent advances in understanding and managing chronic pelvic pain in women with special consideration to endometriosis |journal=F1000Res |volume=9 |issue= |pages= |date=2020 |pmid=32089831 |doi=10.12688/f1000research.20750.1 |url=}}</ref><ref name="pmid32357440">{{cite journal |vauthors=Grinberg K, Sela Y, Nissanholtz-Gannot R |title=New Insights about Chronic Pelvic Pain Syndrome (CPPS) |journal=Int J Environ Res Public Health |volume=17 |issue=9 |pages= |date=April 2020 |pmid=32357440 |doi=10.3390/ijerph17093005 |url=}}</ref>
 
*'''[[Neuropathy|Central sensitization]]''' mechanisms:
OR
**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.<ref name="SmithFors2019">{{cite journal|last1=Smith|first1=Blair H.|last2=Fors|first2=Egil A.|last3=Korwisi|first3=Beatrice|last4=Barke|first4=Antonia|last5=Cameron|first5=Paul|last6=Colvin|first6=Lesley|last7=Richardson|first7=Cara|last8=Rief|first8=Winfried|last9=Treede|first9=Rolf-Detlef|title=The IASP classification of chronic pain for ICD-11|journal=PAIN|volume=160|issue=1|year=2019|pages=83–87|issn=0304-3959|doi=10.1097/j.pain.0000000000001360}}</ref>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.<ref name="pmid32119472">{{cite journal |vauthors=Dydyk AM, Gupta N |title= |journal= |volume= |issue= |pages= |date= |pmid=32119472 |doi= |url=}}</ref>
 
*'''Recurrent [[trauma]], [[infection]] or ongoing [[inflammation]] or [[muscle]] [[tenderness]]'''
The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].
*'''Psychological mechanisms'''
 
** More common with history of prior abuse (childhood: 64% vs 23%)<ref name="pmid3337296">{{cite journal| author=Walker E, Katon W, Harrop-Griffiths J, Holm L, Russo J, Hickok LR| title=Relationship of chronic pelvic pain to psychiatric diagnoses and childhood sexual abuse. | journal=Am J Psychiatry | year= 1988 | volume= 145 | issue= 1 | pages= 75-80 | pmid=3337296 | doi=10.1176/ajp.145.1.75 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3337296  }} </ref>. Laparoscopic findings may not correlated with pains<ref name="pmid1824741">{{cite journal| author=Stout AL, Steege JF, Dodson WC, Hughes CL| title=Relationship of laparoscopic findings to self-report of pelvic pain. | journal=Am J Obstet Gynecol | year= 1991 | volume= 164 | issue= 1 Pt 1 | pages= 73-9 | pmid=1824741 | doi=10.1016/0002-9378(91)90630-a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1824741  }} </ref>.
OR
**[[Emotional]], [[cognitive]], [[behavioral]], and [[sexual]] responses also could involve in chronic pelvic pain.
 
*'''[[Nerve damage]]'''
The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click [[Pericarditis causes#Overview|here]].
*'''Vascular hypothesis'''
 
**Pain arises from dilated [[pelvic veins]] in which [[blood flow]] is markedly reduced (citation needed)
===Common Causes===
Commonly proposed etiologies include: <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref> <ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X</ref>
 
* [[Endometriosis]] (very controversial)<ref name="pmid1824741">{{cite journal| author=Stout AL, Steege JF, Dodson WC, Hughes CL| title=Relationship of laparoscopic findings to self-report of pelvic pain. | journal=Am J Obstet Gynecol | year= 1991 | volume= 164 | issue= 1 Pt 1 | pages= 73-9 | pmid=1824741 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1824741  }} </ref> 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==
'''Gender-specific causes classification'''<ref name="pmid29565946">{{cite journal |vauthors=Hunter CW, Stovall B, Chen G, Carlson J, Levy R |title=Anatomy, Pathophysiology and Interventional Therapies for Chronic Pelvic Pain: A Review |journal=Pain Physician |volume=21 |issue=2 |pages=147–167 |date=March 2018 |pmid=29565946 |doi= |url=}}</ref><ref name="pmid23684447">{{cite journal |vauthors=Engeler DS, Baranowski AP, Dinis-Oliveira P, Elneil S, Hughes J, Messelink EJ, van Ophoven A, Williams AC |title=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 |journal=Eur Urol |volume=64 |issue=3 |pages=431–9 |date=September 2013 |pmid=23684447 |doi=10.1016/j.eururo.2013.04.035 |url=}}</ref>
{| style="width:80%; height:100px" border="1"
| style="width:25%" bgcolor="LightSteelBlue" ; border="1" |'''Women'''
| style="width:75%" bgcolor="Beige" ; border="1" |[[Infection]], [[Endometriosis]], [[Dysmenorrhea]], [[Dyspareunia|Dysparunia]], [[Myofascial pain syndrome|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 assault|Sexual abuse]]/[[Physical abuse]], [[Cancer]], [[Psychiatric Disorders]], [[Surgical Procedures]]([[adhesions]]), [[Pelvic floor muscle pain syndrome]], [[Vulvodynia]],[[Vestibular pain syndrome]],[[Endometriosis- associated pain syndrome]]
|- bgcolor="LightSteelBlue"
|'''Men'''
| bgcolor="Beige" |[[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]]
|-
|}
===Causes by Organ System===
===Causes by Organ System===
{|style="width:80%; height:100px" border="1"
{| style="width:80%; height:100px" border="1"
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
| style="width:25%" bgcolor="LightSteelBlue" ; border="1" |'''Cardiovascular'''
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[Pelvic vein thrombosis]]
| style="width:75%" bgcolor="Beige" ; border="1" |[[Pelvic vein thrombosis]]
|-
|- bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
|'''Gastroenterologic'''
| '''Chemical / poisoning'''
| bgcolor="Beige" |[[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)]]
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dermatologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Drug Side Effect'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Ear Nose Throat'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Endocrine'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Environmental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
|bgcolor="Beige"| [[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]]
|-
|-bgcolor="LightSteelBlue"
| '''Genetic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Hematologic'''
|bgcolor="Beige"| [[Porphyria]]
|-
|-bgcolor="LightSteelBlue"
| '''Iatrogenic'''
|bgcolor="Beige"| [[Ovarian remnant]]
|-
|-bgcolor="LightSteelBlue"
| '''Infectious Disease'''
|bgcolor="Beige"| [[UTI]]
|-
|-bgcolor="LightSteelBlue"
| '''Musculoskeletal / Ortho'''
|bgcolor="Beige"| [[Coccydynia]], [[Low back pain]], [[Muscle spasm]], [[Pelvic girdle malrotation]], [[Tension in the pelvic floor muscles]]
|-
|-bgcolor="LightSteelBlue"
| '''Neurologic'''
|bgcolor="Beige"| [[Nerve entrapment in pelvis]], [[Peripheral neuropathy in pelvis]], [[Post herpetic neuralgia]], [[Post infectious neurological hypersensitivity]], [[Pudendal nerve neuralgia]]
|-
|-bgcolor="LightSteelBlue"
| '''Nutritional / Metabolic'''
|bgcolor="Beige"| No underlying causes
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Obstetric/Gynecologic'''
|'''Hematologic'''
|bgcolor="Beige"| [[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]]
| bgcolor="Beige" |[[Porphyria]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Oncologic'''
|'''Iatrogenic'''
|bgcolor="Beige"| [[Colon cancer]], [[Neuromas]], [[Pelvic tumor]], [[Testicular tumors]]
| bgcolor="Beige" |[[Ovarian]] remnant
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Opthalmologic'''
|'''Infectious Disease'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" |[[UTI]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Overdose / Toxicity'''
|'''Musculoskeletal / Ortho'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" |[[Coccydynia]], [[Low back pain]], [[Muscle spasm]], [[Pelvic girdle malrotation]], [[Tension in the pelvic floor muscles]], [[Degenerative joint disease]]. [[Disc herniation]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Psychiatric'''
|'''Neurologic'''
|bgcolor="Beige"| [[Chronic stress]], [[Depression]]
| bgcolor="Beige" |[[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
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Pulmonary'''
|'''Obstetric/Gynecologic'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" |[[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]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Renal / Electrolyte'''
|'''Oncologic'''
|bgcolor="Beige"| [[Loin pain hematuria syndrome]]
| bgcolor="Beige" |[[Colon cancer]], [[Neuromas]], [[Pelvic tumor]], [[Testicular tumors]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Rheum / Immune / Allergy'''
|'''Psychiatric'''
|bgcolor="Beige"| [[Fibromyalgia]]
| bgcolor="Beige" |[[Chronic stress]], [[Depression]], [[drug addiction]], [[dependence]],family problems, [[Somatotisation disorders]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Sexual'''
|'''Renal / Electrolyte'''
|bgcolor="Beige"| [[Clitorodynia]], [[Epididymo-orchitis]], [[Sexual abuse]]
| bgcolor="Beige" |[[Loin pain hematuria syndrome]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Trauma'''
|'''Rheum / Immune / Allergy'''
|bgcolor="Beige"| [[Physical abuse]]
| bgcolor="Beige" |[[Fibromyalgia]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Urologic'''
|'''Sexual'''
|bgcolor="Beige"| [[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]]
| bgcolor="Beige" |[[Clitorodynia]], [[Epididymo-orchitis]], [[Sexual abuse]], [[sexual dysfunction]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Dental'''
|'''Trauma'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" |[[Physical abuse]]
|-
|-
|-bgcolor="LightSteelBlue"
|- bgcolor="LightSteelBlue"
| '''Miscellaneous'''
|'''Urologic'''
|bgcolor="Beige"| No underlying causes
| bgcolor="Beige" |[[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]]
|-
|-
|}
|}
===Causes in Alphabetical Order===
 
*[[Adenomyosis]]
===Common Causes===
*[[Adhesions in the pelvic area]]
Commonly proposed etiologies of chronic pelvic pain(CCP) include: <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref> <ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X</ref>
*[[Anal fissure]]
 
*[[Appendicitis]]
*[[Endometriosis]] (very controversial)<ref name="pmid1824741">{{cite journal| author=Stout AL, Steege JF, Dodson WC, Hughes CL| title=Relationship of laparoscopic findings to self-report of pelvic pain. | journal=Am J Obstet Gynecol | year= 1991 | volume= 164 | issue= 1 Pt 1 | pages= 73-9 | pmid=1824741 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1824741  }} </ref> Deeply Infiltrative Endometriosis may be more important
*[[Cervical polyps]]
*[[Infection]] or post-infectious neurological [[hypersensitivity]]
*[[Chronic bacterial prostatitis]]
*Exaggerated bladder, bowel, or uterine pain sensitivity (also known as visceral pain)
*[[Chronic bladder irritation]]
*[[Ovarian cysts]], uterine [[leiomyoma]] - often found in asymptomatic patients as well
*[[Chronic non bacterial prostatitis]]
*Less common emergencies: [[ovarian torsion]], [[appendicitis]], [[ectopic pregnancy]]
*[[Chronic pelvic pain syndrome]]
*[[Pelvic girdle pain]] ([[Pubic Symphysis Dysfunction]], SPD or DSP)
*[[Chronic stress]]
 
*[[Chronic urethritis]]
==Differentiating chronic pelvic pain from other Diseases==
*[[Chronic vulvovaginitis]]
Differential diagnosis by organ system:
*[[Clitorodynia]]
 
*[[Coccydynia]]
*[[Gynecological]] - Endometriosis, pelvic inflammatory disease, pelvic adhesion disease, recurrent ovarian cysts, leiomyoma, adenomyosis, hydrosalpinx, and post-tubal ligation pain syndrome
*[[Colitis]]
*[[Gastroenterological]] - [[Irritable bowel syndrome]], [[celiac disease]], [[inflammatory bowel disease]], [[colorectal carcinoma]], and [[hernias]]
*[[Colon cancer]]
*[[Urological]] [[Interstitial cystitis]] (painful bladder syndrome), recurrent cystitis, [[Radiation cystitis]], chronic [[urolithiasis]], bladder cancer, and urethral syndrome
*[[Colonic polyps]]
*[[Musculoskeletal]] - Abdominal wall myofascial pain, [[fibromyalgia]], [[coccygodynia]], pelvic floor tension myalgia, piriformis syndrome
*[[Constipation]]
*[[Neurological]]/[[vascular]] - [[ilioinguinal]] [[nerve entrapment]], iliohypogastric nerve entrapment, pudendal neuralgia, spinal cord injury, [[pelvic congestion syndrome]], [[peripheral neuropathy]], and vulvar varicosities
*[[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]]
{{ColBreak}}
*[[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]]
{{EndMultiCol}}
Differentiating [disease name] from other Diseases
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as:
[Differential dx1]
[Differential dx2]
[Differential dx3]


==Epidemiology and Demographics==
==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].
*Chronic pelvic pain affects one in seven women in the United States.
*No adequate data on incidence were found.
 
===Age===
===Age===
Patients of all age groups may develop [disease name].
Chronic pelvic pain is more commonly observed among women aged 18-50 years old.<ref name="pmid8598948">{{cite journal |vauthors=Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF |title=Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates |journal=Obstet Gynecol |volume=87 |issue=3 |pages=321–7 |date=March 1996 |pmid=8598948 |doi=10.1016/0029-7844(95)00458-0 |url=}}</ref>
[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===
===Gender===
[Disease name] affects men and women equally.
 
[Gender 1] are more commonly affected with [disease name] than [gender 2].
*Chronic pelvic pain affects one in seven women in the United States.
The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.
*Ninety-nine percent of all cases of chronic pelvic pain are female.
 
===Race===
===Race===
There is no racial predilection for [disease name].
 
[Disease name] usually affects individuals of the [race 1] race.
*African-American women are more likely to develop [[endometriosis]].<ref name="pmid19804040">{{cite journal |vauthors=Kyama CM, Mwenda JM, Machoki J, Mihalyi A, Simsa P, Chai DC, D'Hooghe TM |title=Endometriosis in African women |journal=Womens Health (Lond) |volume=3 |issue=5 |pages=629–35 |date=September 2007 |pmid=19804040 |doi=10.2217/17455057.3.5.629 |url=}}</ref>
[Race 2] individuals are less likely to develop [disease name].
 
==Risk Factors==
==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].
Common risk factors in the development of chronic pelvic syndrome are genetic, psychological state, recurrent somatic trauma, and endocrine factors.<ref name="pmid23684447">{{cite journal |vauthors=Engeler DS, Baranowski AP, Dinis-Oliveira P, Elneil S, Hughes J, Messelink EJ, van Ophoven A, Williams AC |title=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 |journal=Eur Urol |volume=64 |issue=3 |pages=431–9 |date=September 2013 |pmid=23684447 |doi=10.1016/j.eururo.2013.04.035 |url=}}</ref>
 
==Natural History, Complications and Prognosis==
==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].
*The patient's pain is located within the pelvis and has lasted greater than six months duration.
If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*Common [[complications]] are having pain even after [[hysterectomy]], dependency on [[opioids]], [[infection]], and [[bleeding]] after [[laparoscopy]].
Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
*[[Prognosis]] is generally poor in patients with chronic pelvic pain, similar to other chronic pain syndromes.
Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].


==Diagnosis==
==Diagnosis==
===Diagnostic Criteria===
===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 [disease name].
A [positive/negative] [test name] is diagnostic of [disease name].
An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].
Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
===Electrocardiogram===
There are no ECG findings associated with [disease name].


OR
*It is a symptom, not a diagnosis, pain is an intermittent or constant pain in the lower [[abdomen]] or [[pelvis]][[Lumbosacral trunk|, lumbosacral back]], [[buttocks]] being for at least 6 months.
 
===Symptoms===
 
*Symptoms of chronic pelvic pain may include the following:<ref name="pmid29565946">{{cite journal |vauthors=Hunter CW, Stovall B, Chen G, Carlson J, Levy R |title=Anatomy, Pathophysiology and Interventional Therapies for Chronic Pelvic Pain: A Review |journal=Pain Physician |volume=21 |issue=2 |pages=147–167 |date=March 2018 |pmid=29565946 |doi= |url=}}</ref>


An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
:*persistent non-cyclical or cyclical pelvic pain which is like [[paresthesia]], [[numbness]], burning, or lancinating pain, in the [[pelvis]], [[anus]], and/or [[genitals]]


===X-ray===
*The systemic approach should be used to identify the source of pain. <ref name="pmid10694069">{{cite journal |vauthors=Carter JE |title=A systematic history for the patient with chronic pelvic pain |journal=JSLS |volume=3 |issue=4 |pages=245–52 |date=1999 |pmid=10694069 |pmc=3015355 |doi= |url=}}</ref>
There are no x-ray findings associated with [disease name].


OR
:*[[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]], [[nausea]], [[vomiting]]
:*[[Musculoskeletal]]:
:**[[Low back pain]], pain with certain movements
:*[[Urinary tract]]:
:**[[Dysuria]], [[polyuria]]
:*[[Psychological]]:
:**[[Stress]], [[depression]], [[anxiety]], [[anger]]


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].
*Be careful about the symptoms that suggest life-threatening conditions such as :
**unexplained [[weight loss]], new bowel symptoms over 50, new pain after the [[menopause]], [[pelvic mass]], [[Rectal bleeding|bleeding per rectum,]] irregular [[vaginal bleeding]] over 40, [[post-coital bleeding]]
**Rule out [[malignancy]] or serious systemic disease.


OR
===Physical Examination===


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].
*As well as a local examination, a full clinical examination should be done.
**[[Abdominal]] and [[pelvic]] examination to exclude gross pelvic pathology ([[focal tenderness]], enlargement, [[distortion]] on abdominal examination, [[suprapubic tenderness]])
**Examination of external and internal [[genitalia]], Q tip test: cotton-tipped applicator can trigger pain in vulvar pain syndrome, [[vulvodynia]]
**Clinical [[pelvic]] examination ( Traditional bimanual examination to examine the [[uterus]], [[adnexa]], [[anorectal]])
**[[Rectal]] examination, looking for [[fecal incontinence]], tender [[puborectal muscles]], [[anal]] or [[rectal prolapse]],...
**Musculoskeletal examination: 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]]


===Echocardiography or Ultrasound===
===Laboratory Findings===
There are no echocardiography/ultrasound findings associated with [disease name].
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.


OR
===Electrocardiogram===
There are no [[ECG]] findings associated with chronic pelvic pain.


Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
===X-ray===
An x-ray may be helpful in the diagnosis of co-morbidities associated with chronic pelvic pain.


OR
===Echocardiography or Ultrasound===


There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===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 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|pelvic inflammatory diseas]]<nowiki/>e; comorbidity is often seen in chronic pelvic pain, and rule out anatomic abnormalities.


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].
===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===
There are no MRI findings associated with [disease name].
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.


OR
===Other Imaging Findings===


[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
*[[Hysteroscopy]] may be helpful in the diagnosis and resection of uterine [[fibroids]].
*Pelvic venography for diagnosis of pelvic congestion syndrome


OR
===Other Diagnostic Studies===


There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
*[[Laparoscopy]] is used for diagnosis and treatment of [[endometriosis]], [[adhesions]]
*[[Colonoscopy]]
*Diagnostic [[Nerve block|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.


===Other Imaging Findings===
==Treatment==
There are no other imaging findings associated with [disease name].
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:<ref name="pmid32119472">{{cite journal |vauthors=Dydyk AM, Gupta N |title= |journal= |volume= |issue= |pages= |date= |pmid=32119472 |doi= |url=}}</ref>


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


[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].
===Treatment of specific disease-associated pelvic pain:===


===Other Diagnostic Studies===
*Treat the underlying pathology; for example, in [[endometriosis]], there are therapeutic options, including pharmacotherapy and surgery are available
There are no other diagnostic studies associated with [disease name].
*All other gynecological conditions (including [[dysmenorrhea]], obstetric injury, [[pelvic organ prolapse]], and gynecological [[malignancy]]) can be treated effectively using [[pharmacotherapy]] or [[surgery]].


OR
===Treatment of chronic pelvic pain syndrome===


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


OR
:*In general
:**Treatment of a patient with chronic pelvic pain syndromes( 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|cognitive behavioral therapy,]] nutrition [[counseling]], [[Neuromodulator|neuromodulatory]] procedures are also be offered.


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].
===Surgery===


==Treatment==
*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.
===Medical Therapy===
*[[Peripheral nerve blocks]] and [[neuromodulation]] of [[sacral nerves]] may also be necessary in severe cases.
There is no treatment for [disease name]; the mainstay of therapy is supportive care.
*[[Hysterectomy]] sometimes can be considered in chronic pelvic pain secondary to the uterine origin.
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===
Surgery is the mainstay of therapy for [disease name].
[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
[Surgical procedure] can only be performed for patients with [disease stage] [disease name].


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


==References==
==References==
Line 405: Line 295:
==Related Chapters==
==Related Chapters==


* Abdominal [[Adhesion (medicine)|adhesions]]
*Abdominal [[Adhesion (medicine)|adhesions]]
* [[Coccydynia| Coccydynia (coccyx pain, tailbone pain)]]
*[[Coccydynia| Coccydynia (coccyx pain, tailbone pain)]]
 
==External Links==


== External Links ==
*[http://www.pelvicpain.org International Pelvic Pain Society]
* [http://www.pelvicpain.org International Pelvic Pain Society]
*[http://www.pelvicfloordigest.org/2006/pelvic_pain.html Pelvic Floor Digest: Free Selected medical abstracts on pelvic pain. Updated]
* [http://www.pelvicfloordigest.org/2006/pelvic_pain.html Pelvic Floor Digest: Free Selected medical abstracts on pelvic pain. Updated]
*[http://www.ampainsoc.org American Pain Society]
* [http://www.ampainsoc.org American Pain Society]
*[http://www.endocenter.org Endometriosis Research Center]
* [http://www.endocenter.org Endometriosis Research Center]
*[http://www.endometriosis.org endometriosis.org]
* [http://www.endometriosis.org endometriosis.org]
*[http://www.endometriosisassn.org/endo.html Endometriosis Association]
* [http://www.endometriosisassn.org/endo.html Endometriosis Association]
*[http://www.pelviperineology.org/ Pelviperineology] The multidisciplinary open access pelvic floor journal
*[http://www.pelviperineology.org/ Pelviperineology] The multidisciplinary open access pelvic floor journal


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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]

Pathophysiology

Causes

Gender-specific causes classification[11][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: [12] [13]

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.[14]

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:[11]
  • 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. Walker E, Katon W, Harrop-Griffiths J, Holm L, Russo J, Hickok LR (1988). "Relationship of chronic pelvic pain to psychiatric diagnoses and childhood sexual abuse". Am J Psychiatry. 145 (1): 75–80. doi:10.1176/ajp.145.1.75. PMID 3337296.
  10. 10.0 10.1 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. doi:10.1016/0002-9378(91)90630-a. PMID 1824741.
  11. 11.0 11.1 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.
  12. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
  13. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
  14. 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.
  15. 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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