Chronic pelvic pain
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: [1] [2]
- Endometriosis (very controversial)[3] Deeply Infiltrative Endometriosis may be more important
- Infection or post-infectious neurological hypersensitivity
- Exaggerated bladder, bowel, or uterine pain sensitivity (also known as visceral pain)
- Ovarian cysts, uterine leiomyoma - often found in asymptomatic patients as well, however
- Less common emergencies: ovarian torsion - sudden loss of circulation to the ovary, appendicitis - infection of one part of the intestine, with right lower abdominal pain, ectopic pregnancy - where an early pregnancy grows outside of the uterus, and can cause sudden, heavy intra-abdominal bleeding
- Pelvic girdle pain (SPD or DSP)
Causes by Organ System
Causes in Alphabetical Order
- Adenomyosis
- Adhesions in the pelvic area
- Anal fissure
- Appendicitis
- Cervical polyps
- Chronic bacterial prostatitis
- Chronic bladder irritation
- Chronic non bacterial prostatitis
- Chronic pelvic pain syndrome
- Chronic stress
- Chronic urethritis
- Chronic vulvovaginitis
- Clitorodynia
- Coccydynia
- Colitis
- Colon cancer
- Colonic polyps
- Constipation
- Depression
- Diarrhea
- Diverticulitis
- Dysmenorrhea
- Ectopic pregnancy
- Endometrial polyps
- Endometriosis
- Epididymal cysts
- Epididymo-orchitis
- Fibroids
- Fibromyalgia
- Gastrointestinal cancers
- Hemorrhoids
- Hydrocele
- Internal hernia
- Interstitial cystitis
- Irritable bowel syndrome
- Loin pain hematuria syndrome
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- 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
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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 [
References
- ↑ Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
- ↑ Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
- ↑ Stout AL, Steege JF, Dodson WC, Hughes CL (1991). "Relationship of laparoscopic findings to self-report of pelvic pain". Am J Obstet Gynecol. 164 (1 Pt 1): 73–9. PMID 1824741.
Additional Resources
- Milburn A, Reiter R, Rhomberg A: Multi-disciplinary approach to chronic pain. Obstet Gynecol Clin 1993;20:643 - 661.
- Stovall DW: Endometriosis associated pelvic pain: Evidence for an association between the stage of disease and a history of chronic pelvic pain. Fertil Steril 1997;68:13 - 17.
- Schroeder B, Sanfillippo JS: Chronic Pelvic Pain and Recurrent Abdominal Pain in Female Adolescents. Pediatr Clin North Am 1999;46:566 - 567.
- Elisabeth Thibaud, Hyams JS: Clinical aspects of recurrent abdominal pain. Pediatric and Adolescent GynecologyPediatr Ann 2001;30:17–21.
- Jantos M.: Understanding Chronic Pelvic Pain. Pelviperineology Vol. 26 N.2 June 2007 66-68
Related Chapters
External Links
- International Pelvic Pain Society
- Pelvic Floor Digest: Free Selected medical abstracts on pelvic pain. Updated
- American Pain Society
- Endometriosis Research Center
- endometriosis.org
- Endometriosis Association
- Pelviperineology The multidisciplinary open access pelvic floor journal