Dr. Aruna Muralidhar MD, MRCOG (UK), FICM
Senior Consultant Obstetrician and Gynaecologist, Fortis La Femme Hospital, Bangalore
Introduction
Chronic pelvic pain (CPP) is a problem that vexes patients and clinicians equally in gynaecological practice and amounts for approximately 10-40 % of all OPD consultations.
CPP refers to intermittent or constant pain in the lower abdomen or pelvis of a woman of at least 6 months in duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy’.1
The pain may be constant or cyclical pain, which can be unprovoked or associated with specific activities including urination (dysuria), bowel opening (dyschaezia) or sexual intercourse (dyspareunia). Unfortunately, this condition affects quality of life and emotional health of the woman. Although there are many gynaecological causes for CPP, notably endometriosis- adenomyosis complex, adhesions, pelvic congestion, a significant number of women do not have a definite cause for the pain (Chronic Pelvic pain syndrome). Moreover, even where a cause is found, such as endometriosis, the painful symptoms experienced may be disproportionate to the extent of disease identified or persist after optimal treatment.5
CPP is considered the principal indication for approximately 20 percent of all hysterectomies performed for benign disease and at least 40 percent of all gynaecological laparoscopies performed annually in the United States.
Evaluation
At the outset, it is important to elicit a complete history of the patient’s symptoms in an empathetic, non-judgmental and compassionate manner. Adequate time should be allowed for the initial assessment of women with chronic pelvic pain. They need to feel that they have been able to tell their story and that they have been listened to and believed. Many women present because they want an explanation for their pain. Often they already have a theory or a concern about the origin of the pain. These ideas should ideally be discussed in the initial consultation.
The duration, location, intensity, nature, alleviating and precipitating factors of the pain, its association with urination and defaecation and radiation if any, would provide clues towards the cause of pain. The details of the menstrual cycle, relationship of the pain with the cycle, association with any heavy menstrual bleeding, intermenstrual or postcoital bleeding as well as presence of abnormal white discharge per vaginum are important in establishing a differential diagnosis of the pain. Sexual history is of significance and presence of dyspareunia, use of contraception and fertility status has to be elicited.
The thorough emotional and psychological assessment would include effect on quality of life, sex and work and other relationships as well as symptoms of underlying depression and anxiety. Some simple screening questions for depression and physical/sexual abuse include [15]:
●During the past month, have you felt down, depressed or hopeless?
●During the past month, have you felt little interest or pleasure in doing things?
●Have you ever been touched against your will?
The multifactorial nature of chronic pelvic pain should be discussed and explored from the start. The aim should be to develop a partnership between the clinician and the woman to plan a management programme. If the history suggests to the woman and doctor that there is a specific non-gynaecological component to the pain, referral to the relevant healthcare professional – such as gastroenterologist, urologist, genitourinary medicine physician, physiotherapist, psychologist or psychosexual counsellor – should be considered.
Examination
The examination is most usefully undertaken when there is time to explore the woman’s fears and anxieties. The examiner should be prepared for new information to be revealed at this point. The goal is to identify tender areas, correlate these areas with the patient’s pain map, and determine whether the pain produced on examination represents her CPP.
The assessment should include abdominal and pelvic examination, looking particularly for focal tenderness, enlargement, distortion or tethering, or prolapsed of the uterus. Highly localised trigger points may be identified in the abdominal wall and/or pelvic floor. The sacroiliac joints or the symphysis pubis may also be tender, suggestive of a musculoskeletal origin to the pain.
FINDINGS SUGGESTIVE OF SPECIFIC DISORDERS
Abnormalities of the uterosacral ligament, cervical displacement — Approximately 40 percent of women with CPP due to endometriosis have physical findings on pelvic examination that suggest the underlying disorder. Three physical findings characteristic of endometriosis are:
● Uterosacral ligament abnormalities (eg, nodularity or thickening, focal tenderness).
● Lateral displacement of the cervix caused by asymmetric endometriotic involvement of one uterosacral ligament causing it to shorten (figure 2).
● Cervical stenosis. A stenotic cervix increases retrograde menstruation, which increases the risk of developing endometriosis [17,18].
Adnexal enlargement may be palpable if an endometrioma is present. Non-gynaecologic physical findings that are observed more frequently among women with endometriosis are red hair colour, scoliosis, and dysplastic nevi [11,19,20].
Enlarged or irregular uterus — Women with adenomyosis can have a slightly enlarged, globular, tender uterus on physical examination. The diagnosis of uterine myomas is usually based upon the finding of an enlarged, mobile uterus with an irregular contour.
Uterine, adnexal, or cervical motion tenderness — Uterine tenderness and/or cervical motion tenderness are the most common findings on physical examination in women with chronic endometritis related to PID, although many affected women have a completely normal examination. Other symptoms of infection include abnormal uterine bleeding: intermenstrual bleeding; spotting; postcoital bleeding; menorrhagia; or amenorrhea in addition to vague, crampy lower abdominal pain.
Adhesions resulting from a surgical procedure can cause pain with movement of viscera. The presence of adhesions should be considered in women with a history of PID, endometriosis, prior pelvic surgery, postoperative history of small bowel obstruction, or impaired fertility.
Pelvic congestion syndrome is a controversial entity. Although nonspecific, the major finding on physical examination is marked ovarian tenderness upon gentle compression. There may also be tenderness of the uterus, with cervical motion, and upon deep palpation of the ovary abdominally. The diagnosis is strengthened if the history confirms the shifting location of pain, deep dyspareunia, post-coital pain, and exacerbation of pain after prolonged standing [21].
Adnexal mass — An adnexal mass suggests an ovarian neoplasm. Tenderness on palpation of the adnexa implies as inflammatory process, while ascites suggests malignancy. An adnexal mass in the setting of abnormalities of the uterosacral ligament or cervical displacement suggests an endometrioma. A mass at the sidewall after oophorectomy or hysterectomy suggests ovarian remnant or residual ovary syndrome, respectively.
Diffuse tenderness — Variable tenderness of the abdominal wall, hip girdle, soft tissues of the buttocks, pelvic floor, bladder base, and urethra is almost universally present in women with interstitial cystitis/painful bladder syndrome.
Suburethral or suprapubic pain — The possibility of a urethral diverticulum should be considered if there is a suburethral mass, fullness, or tenderness. Suprapubic pain could be related to chronic urinary tract infection, interstitial cystitis/painful bladder syndrome, or osteitis pubis.
Tenderness and contraction of pelvic muscles — Piriformis/levator ani muscle syndrome is suggested by pain upon single digit, one-handed intravaginal examination of these muscles. The muscles tend to be tightly contracted on vaginal examination and may fasciculate. The anal wink reflex (gently stroking the skin immediately surrounding the anus results in a reflexive contraction of the external anal sphincter) may be absent because the pelvic floor muscles are already contracted. The absence of this reflex could also be due to nerve damage and interruption of the spinal arc.
Abdominal pain — Abdominal pain can be caused by myriad illnesses including, acute intermittent porphyria, diverticular disease, abdominal malignancies, irritable bowel syndrome, lactose intolerance, and helminthic, and other tropical infectious diseases. Specific considerations pertaining to examination of patients with abdominal pain are reviewed elsewhere.
Vulvar and vestibular pain — In vulvodynia, vulvar pain is usually described as burning pain, which may be generalized or localized, and provoked, unprovoked (spontaneous), or mixed (provoked and unprovoked). Vestibulodynia is characterized by severe pain upon vestibular touch or attempted vaginal entry or tenderness to pressure localized within the vulvar vestibule. These disorders may be mistaken for CPP if examination of the vulva is not performed.
Pelvic pain which varies markedly over the menstrual cycle is likely to be attributable to a hormonally driven condition such as endometriosis. The cardinal symptoms of dysmenorrhoea, dyspareunia and chronic pelvic pain are said to be characteristic of endometriosis or adenomyosis.11
Adhesions may be a cause of pain, particularly on organ distension or stretching. Dense vascular adhesions may cause chronic pelvic pain. However, adhesions may be asymptomatic. Evidence to demonstrate that adhesions cause pain or that laparoscopic division of adhesions relieves pain is lacking. However, in a randomised controlled trial, 48 women with chronic pelvic pain underwent laparotomy with or without division of adhesions. Although overall there was no difference between the two groups, a subset analysis showed that division of dense, vascular adhesions produced significant pain relief.19
In a 2003 study of 100 women, no difference in pain scores was found between a group undergoing laparoscopic adhesiolysis and those having laparoscopy alone.20 Adhesions may be caused by endometriosis, previous surgery or previous infection. Two distinct forms of adhesive disease are recognised: residual ovary syndrome (a small amount of ovarian tissue inadvertently left behind following oophorectomy which may become buried in adhesions) and trapped ovary syndrome (in which a retained ovary becomes buried in dense adhesions post-hysterectomy). Removal of all ovarian tissue or suppression using a GnRH analogue may relieve pain.
Continuous or recurrent abdominal pain or discomfort on at least 3 days a month in the last 3 months, with the onset at least 6 months previously, associated with at least two of the following:
● improvement with defecation
● onset associated with a change in frequency of stool
● onset associated with a change in the form of stool.
Symptoms alone may be used to diagnose IBS positively in this group
‘Red flag’ symptoms and signs
● Bleeding per rectum
● New bowel symptoms over 50 years of age
● New pain after the menopause
● Pelvic mass
● Suicidal ideation
● Excessive weight loss
● Irregular vaginal bleeding over 40 years of age
● Postcoital bleeding
Investigations
The history, physical examination, and psychological assessment are the most important components of the diagnostic evaluation. They are complemented by findings from laboratory tests, imaging, and surgical evaluation, when indicated.
Laboratory — Laboratory testing is of limited value in evaluating women with CPP. Based upon the clinical findings, baseline tests may be obtained to screen for a chronic infectious or inflammatory process, and to exclude pregnancy [25]:
●Complete blood count with differential and erythrocyte sedimentation rate
●Urinalysis
●Testing for chlamydia and gonorrhoea infection
●Pregnancy test
Further laboratory testing is based on the clinical impression that emerges after a complete history and physical examination, as well as laboratory and imaging studies.
Imaging — Pelvic ultrasound is highly sensitive for identifying pelvic masses/cysts and determining the origin of the mass (ovary, uterus, fallopian tube). It is less reliable for distinguishing between benign and malignant neoplasms and diagnosing adenomyosis.
Sonography is particularly useful for detecting small pelvic masses (less than 4 cm in diameter), which often cannot be palpated on bimanual examination. It is also very useful for detecting hydrosalpinges, which point to pelvic inflammatory disease as the cause of CPP.
Magnetic resonance imaging is obtained in some cases to better define an abnormality suspected by sonography [26] and for diagnosis of adenomyosis.
Laparoscopic surgery — Approximately one-third of outpatient laparoscopic surgical procedures in women are performed because of abdominal/pelvic pain [27]. In large series, the type and frequency of laparoscopic findings in women with CPP were: no visible pathology (35 percent), endometriosis (33 percent), adhesions (24 percent), chronic PID (5 percent), ovarian cysts (3 percent), with occasional other diagnoses [28].
The role of laparoscopy in the evaluation of women with CPP is uncertain. The absence of visible pathology does not exclude a physical basis for the patient’s pain, but does exclude several common disorders which can be visualized at surgery (endometriosis, adnexal mass, adhesions, some uterine abnormalities, PID) [29]. Nevertheless, the use of laparoscopy in women with CPP should be individualized since histological diagnosis of endometriosis is not mandatory before medical therapy, adhesiolysis is not necessarily effective for relief of CPP, and adnexal masses and uterine abnormalities can be diagnosed noninvasively by ultrasound [30].
If we think CPP is related to endometriosis, we initiate treatment with nonsteroidal antiinflammatory drugs and/or combined estrogen-progestin contraceptives (cyclic or continuous). After a two- to three-month course of empiric medical treatment, we offer laparoscopy to women who have not achieved relief of symptoms and have no strong contraindications to laparoscopic surgery. At the same time, we offer the woman a course of empiric therapy with a GnRH-analogue. CPP will resolve in approximately 50 percent of women who undertake this therapy, so laparoscopy can be avoided [28].
Some women prefer to have the diagnosis of endometriosis confirmed surgically and then discuss all of their treatment options, rather than undergo empiric medical therapy, even if the therapy adequately controls their symptoms [31]. Disadvantages of surgery include cost, operative complications, and possible under diagnosis since some women with endometriosis have subtle or poorly visualized endometriotic lesions. Positive findings at laparoscopy are treated as appropriate for the diagnosis
The management of women with no abnormal findings on physical examination or at laparoscopy is challenging. The accuracy of laparoscopic diagnosis of endometriosis depends upon the location and type of the lesion, the experience of the operator, and whether disease is mild or extensive. A negative laparoscopy by a highly experienced clinician is very reliable for excluding endometriosis, although occult microscopic implants may be present submesothelially in normal appearing peritoneum. For these reasons, a trial of GnRH-analogue therapy is reasonable if the clinical suspicion of endometriosis remains high after a negative laparoscopy.
Pelvic congestion is a gynaecologic cause of CPP that cannot be visualized on imaging or laparoscopy (varicosities alone are not diagnostic). If pelvic congestion is suspected based on characteristic symptoms (shifting location of pain, deep dyspareunia, post-coital pain, and exacerbation of pain after prolonged standing) and physical findings (ovarian tenderness), pelvic venography should be done to establish the diagnosis.
Patients with normal laparoscopic findings should be thoroughly evaluated for nongynecologic causes of CPP (table 1). In particular, it is important that evaluation for irritable bowel syndrome, interstitial cystitis, and myofascial pain syndrome be thorough and complete. In many cases, referral to a multidisciplinary pain practice is helpful since the diagnostic and therapeutic approach to CPP varies by the specialty of the treating physician. Psychiatrists often focus on somatisation, a history of sexual or physical abuse, and depression. Gastroenterologists evaluate for irritable bowel syndrome. Urologists look for painful bladder syndrome and urethral disorders. Gynaecologists concentrate on endometriosis, adenomyosis, and chronic PID as likely causes of the CPP.
SUMMARY AND RECOMMENDATIONS
●Gastrointestinal, urological, gynaecological, psychological, and musculoskeletal sources should be considered in evaluating women with chronic pelvic pain (CPP) (table 1). (See ‘History’ above.)
●Use of the International Pelvic Pain Society’s form facilitates obtaining the history and performing the physical examination. Asking the patient to complete a pain map can also be helpful for localizing pain (figure 1). (See ‘History’ above.)
●The goal of the evaluation is to identify tender areas, correlate these areas with the patient’s pain map, and determine whether the pain produced on examination represents her CPP. (See ‘Physical examination’ above.)
●Laboratory testing is of limited value in evaluating women with CPP. A complete blood count with differential and erythrocyte sedimentation rate, urinalysis, testing for chlamydia and gonorrhoea infection, and a pregnancy test may be useful to screen for a chronic infectious or inflammatory process, and to exclude pregnancy. (See ‘Laboratory’ above.)
●Pelvic ultrasound is highly sensitive for identifying pelvic masses and determining the origin of the mass (ovary, uterus, fallopian tube).
●The use of laparoscopy in women with CPP should be individualized. If we think CPP is related to endometriosis, we suggest empiric treatment with nonsteroidal antiinflammatory drugs and/or combined estrogen-progestin contraceptives (cyclic or continuous) (Grade 2C). After a two- to three-month course of empiric medical treatment, we offer laparoscopy to women who have not achieved relief of symptoms and have no strong contraindications to laparoscopic surgery. At the same time, we offer the woman a course of empiric therapy with a GnRH-analogue. CPP will resolve in approximately 50 percent of women who undertake this therapy, so laparoscopy can be avoided.
References:
- Royal College of Obstetricians and Gynaecologists. The Initial Management of Chronic Pelvic Pain. Green-top Guideline No. 41. London: RCOG; 2012
| Characteristics of the pain: |
| Location and radiation |
| Intensity, including intensity with menstrual cycle, urination, defecation, and physical activity, if relevant |
| Timing, especially if only at menses or with intercourse |
| Quality |
| Thorough review of systems and past medical/surgical history with particular attention to symptoms or diagnosis of: |
| Endometriosis |
| Pelvic inflammatory disease |
| Gastrointestinal disease, especially irritable bowel syndrome |
| Urinary disease, especially interstitial cystitis/painful bladder syndrome |
| Musculoskeletal disease |
| Psychiatric disease |
| Any previous diagnostic tests or treatments for pain? |
| Menstrual, contraceptive, sexual, gynecologic, and obstetric history |
| Is there a history of domestic violence or sexual or other physical abuse? |
| Any history of substance abuse, including alcohol? |
| Family history of relevant clinical conditions |