Chronic pelvic pain

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

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.

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

[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 [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].

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

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.

Causes

Disease name] may be caused by [cause1], [cause2], or [cause3].

OR

Common causes of [disease] include [cause1], [cause2], and [cause3].

OR

The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].

OR

The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click here.

Common Causes

Commonly proposed etiologies 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 [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

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 [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

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].

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 echocardiography/ultrasound findings associated with [disease name].

OR

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].

OR

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 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 [disease name].

OR

[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].

OR

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].

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

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

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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