Chronic Pelvic Pain

Chronic Pelvic Pain
By:Jennifer Griffin, MD
M3 Student Clerkship Lecture
University of Nebraska Medical Center

Chronic Pelvic Pain
* Definition = Pain of apparent pelvic origin that has been present most of the time for 6 months
* Difficult to diagnose.
* Difficult to treat.
* Difficult to cure.
* =Physician and patient frustration.

Just because you’re a hammer doesn’t necessarily make every problem a nail.

Chronic Pelvic Pain
* Gynecologic
* Gastrointestinal
* Urologic
* Musculoskeletal/ Pelvic Floor
* Psychological
* United Kingdom data:
o Urinary dx 30.8%
o GI dx 37.7%
o Gynecologic 20.2%
o 25-50% have >1 dx
o MC Dx = endometriosis, adhesions, IBS, IC
Getting the History
* Nature of the Pain:
o Sharp, stabbing, colicky, burning?
o Where specifically is it located?
* Timing of the Pain:
o Does it come and go or is it constant?
o Does it occur with certain activities?
o Is it related to menses?
o Is it consistent and predictable?
* Modifying factors:
o Can you do anything to make it better/ worse?

Review of Systems
* Gynecologic:
o Association with menses?
o Association with sexual activity? (be specific)
o New sexual partners/ practices?
o Symptoms of vaginal dryness / atrophy?
o Other changes in menses?
o Use of contraceptives?
o Childbirth history and any associations?
o History of pelvic infections?
o History of other gyn problems/ surgeries?
* Gastrointestinal:
o Regularity of bowel movements?
o Diarrhea/ constipation/ flatus?
o Relief with defecation?
o History of hemorrhoids/ fissures/ polyps?
o Blood in stools, melena, or mucous?
o Nausea, vomiting, or appetite change?
o Weight loss?
* Urologic:
o Pain with urination?
o History of frequent / recurrent UTIs?
o Blood in urine?
o Symptoms of urgency or incontinence?
o Difficulty voiding?
* Musculoskeletal:
o History of trauma?
o Association with back pain?
o Other chronic pain problems?
o Association with position or activity?
* Psychological:
o History of abuse (verbal/ physical/ sexual)?
o Diagnosis of psychiatric disease?
o Association with life stressors?
o Exacerbated by life stressors?
o Family/ spousal support?
Chronic Pelvic Pain
* Diagnosis
o History and Physical
o Targeted imaging studies (U/S best for gyn evaluation)
o EMB/D&C
o Laparoscopy
o Cystoscopy/ Colonoscopy
o Physical therapy evaluation
* Gynecologic Origin
o Endometriosis
o Primary Dysmenorrhea
o Leiomyomas
o Dyspareunia
o Vaginismus
o Adenomyosis
o Infectious causes
o Pelvic congestion syndrome
o Pelvic organ immobility
o Cancer
* ACOG Practice

Gyn Causes
* Cyclic:
o Primary dysmenorrhea
o Endometriosis
o Adenomyosis
o Mittleschmertz
* Non-cyclic:
o Pelvic masses
o Adhesions
o Infections
o Non-gyn causes
* Related to intercourse:
o Endometriosis
o Vaginismus
o Vaginal atrophy
o Musculoskeletal
o Any non-cyclic cause could be exacerbated.

Chronic Pelvic Pain: Cyclic
* Endometriosis
Chronic Pelvic Pain: Cyclic
* Endometriosis: Etiology
* Endometriosis: Classic Triad
* But may present with:
o Chronic pelvic pain
o Adnexal mass
* Endometriosis: Diagnosis
* Endometriosis:
* Endometriosis: Treatment
* Dysmenorrhea
* Leiomyomas
* Adenomyosis
* Dyspareunia
* Vaginismus

Chronic Pelvic Pain: Dyspareunia
* Pelvic Floor Muscle Spasm and Strain
Chronic Pelvic Pain: Non-cyclic
* Pelvic congestion syndrome
* Pelvic organ immobility
* PID
* Infectious causes
* Gynecologic malignancies
* Other Gynecologic origin:
* Treatment of Gynecologic Problems
* Urologic Origin, Level A:
o Bladder malignancy
o Interstitial Cystitis
o Radiation Cystitis
o Urethral Syndrome
* Bladder origin, Level B:
* Urologic origin, Level C:
* Urologic origin
* Urologic origin: Interstitial Cystitis
* Gastrointestinal Origin, Level A:
* IBS
* Irritable Bowel Syndrome
* IBS Treatment
* Colon carcinoma
* Constipation
* Inflammatory Bowel Disease
* Gastrointestinal origin, Level C (no Level B):
* Musculoskeletal, Level A:
* Musculoskeletal origin, Level B:
* Musculoskeletal origin, Level C:
* Other Non-Gynecologic Origin, Level A:
* Psychological
* Other Non-Gynecologic origins, level B:
* Other Non-Gynecologic origin, Level C:
Clinical Pearl of Wisdom
Pelvic Pain Treatment Triad
* Medical treatment of most likely diagnosis.
* Psychiatric evaluation and treatment.
* Pelvic physical therapy.

Case Studies
Chronic Pelvic Pain
* Conclusions:
o Thorough history and physical
o Imaging and lab studies
o Many treatment options available

Chronic Pelvic Pain.ppt