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pelvic pain

see chronic pelvic pain syndrome for chronic pelvic pain in men Etiology: 1) pregnancy-related pain a) ectopic pregnancy b) threatened or incomplete abortion c) corpus luteum cyst 2) non-pregnancy related gynecologic pain a) pelvic inflammatory disease b) dysmenorrhea c) ovarian pain - ovarian cyst - mittelschmerz - adnexal torsion (ovarian torsion) - ovarian cancer d) uterine leiomyoma - degeneration - torsion e) endometriosis (chronic pain) f) pelvic adhesions (chronic pain) g) pelvic varices [3] 3) non-gynecologic pelvic pain (80%) [8] a) gastrointestinal - appendicitis - irritable bowel syndrome - inflammatory bowel disease - diverticular disease b) urinary tract - urinary tract infection - interstitial cystitis - renal stones c) musculoskeletal - abdominal wall musculature - rib contusion or fracture - radicular pain secondary to herniated disc, fracture or arthritis of the spine - inguinal or abdominal hernia d) psychological - sexual dysfunction - sexual abuse (present or past) - physical abuse, emotional abuse - somatization disorder 4) risk factors for chronic pelvic pain* a) physical, sexual or emotional abuse b) pelvic inflammatory disease - intrauterine device (IUD) is risk factor for pelvic inflammatory disease (PID) & ectopic pregnancy c) pelvic surgery or abdominal surgery - bilateral tubal ligation (BTL) increases risk of ectopic pregnancy d) chronic pain syndrome e) psychiatric disorder: anxiety, depression [2] * oral contraceptives decrease the likelihood of ovarian cysts, ectopic pregnancy & pelvic inflammatory disease History: - character, intensity, location, radiation, onset, duration, frequency, remissions, exacerbations, aggravating factors, ameliorating factors, vaginal discharge, vaginal bleeding, dysuria, frequency, hesitancy, nausea/vomiting, diarrhea, constipation, hematochezia, melena, fever, last menstrual period, sexual activity, sexual partner(s), dysparunia, sexual trauma, IUD, birth control, vaginal douching, sexual abuse Clinical manifestations: 1) chronic pelvic pain is present for 3-6 months in the absence of pregnancy a) pelvic heaviness, abnormal uterine bleeding, infertility suggests uterine fibroids b) dysmenorrhea with pelvic pain just prior to & during menses suggests endometriosis c) urinary frequency, urinary urgency, nocturia, dysuria suggests interstitial cystitis d) absence of a diagnosis identifies this simply as chronic pelvic pain 2) missed menses suggests pregnancy-related pain 3) appendicitis moves from the epigastrium to the right lower quadrant - associated with abrupt increase in pain [2] 4) pelvic inflammatory disease is generally bilateral, occurring within 1st week of menstrual cycle 5) adnexal torsion is an intense, progressive pain often with preceding intermittent pain 6) ovarian cyst pain occurs mid cycle 7) pain with sexual intercourse may be present 8) associated symptoms of fever, vaginal discharge, urinary tract or GI symptoms may be present 9) pointing with 1 finger to pain is consistent with parietal peritoneum or skin involvement 10) pointing with entire palm is consistent with visceral involvement 11) rebound tenderness or involuntary guarding suggests parietal peritoneum irritation 12) pelvic examination a) vaginal or cervical erythema, discharge or bleeding b) cervical motion tenderness (CMT) 97% sensitive, but not specific for pelvic inflammatory disease (PID) c) adnexal tenderness suggests ectopic pregnancy, pelvic inflammatory disease (PID) & appendicitis d) uterine size & consistency abnormal in pregnancy,leiomyoma & endometriosis e) nodularity of uterosacral ligament & fixation of uterine structures is consistent with endometriosis f) adnexal masses 1] ectopic pregnancy (50% sensitive) 2] adnexal torsion (70-98% sensitive) 3] pelvic inflammatory disease (PID) (25-50% sensitive) g) rectal exam may detect retrocecal appendicitis Laboratory: 1) complete blood count (CBC) 2) urinalysis 3) pregnancy test (all women of reproductive age) 4) GenProbe for Neisseria gonorrhea & Chlamydia 5) Gram stain of cervical discharge Special laboratory: 1) culdocentesis 2) diagnostic laparoscopy a) diagnosis unclear after comprehensive evaluation b) surgical process (ectopic pregnancy or appendicitis) suspected Radiology: - transvaginal pelvic ultrasound a) essential in workup of pregnancy-related pelvic pain b) not as useful in workup of non pregnancy-related pelvic pain c) indicated pre-menopausal & perimenopausal pelvic pain d) more sensitive than CT for detecting pelvic masses [9] - plain film of the abdomen (upright) - computed tomography of the abdomen (postmenopausal) Differential diagnosis: - pelvic heaviness, abnormal uterine bleeding, infertility suggests uterine fibroids - dysmenorrhea with pelvic pain just prior to & during menses suggests endometriosis - urinary frequency, urinary urgency, nocturia, dysuria suggests interstitial cystitis - missed menses suggests pregnancy-related pain - absence of a diagnosis identifies this simply as chronic pelvic pain Management: 1) Strategy: a) consider surgical emergencies b) determine if the patient is pregnant c) assess whether the problem is acute or chronic 2) Evaluate for surgical emergency a) ectopic pregnancy b) incomplete abortion c) appendicitis d) adnexal torsion 3) Diagnosis and management of specific medical problem a) ovarian cyst b) pelvic inflammatory disease (PID) c) primary dysmenorrhea 4) patient is not pregnant, no cause for pain determine a) observation b) consider for referral if symptoms worsen 5) chronic pelvic pain a) integrated team approach may be indicated - cognitive behavorial therapy may be effective [2] b) often associated with history of psychosexual trauma; counseling is indicated c) diagnostic laparoscopy in any patient with pelvic pain in same location for 6 months b) women with non cyclic pain, migratory pain & normal pelvic exam are unlikely to benefit from surgery - routine laparoscopic adhesiolysis is not recommended [6] e) NSAIDs may be used short-term for most women with idiopathic chronic pelvic pain [2] f) gabapentin ineffective & associated with adverse effects [7]

Related

abdominal pain chronic pelvic pain syndrome (CPPS)

Specific

prostadynia (prostatosis)

General

pain [odyn-]

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 394-397
  2. Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2018, 2022. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
  4. Benjamin-Pratt AR, Howard FM. Management of chronic pelvic pain. Minerva Ginecol. 2010 Oct;62(5):447-65. PMID: 20938429
  5. Mowers EL et al. Prevalence of endometriosis during abdominal or laparoscopic hysterectomy for chronic pelvic pain. Obstet Gynecol 2016 Jun; 127:1045 PMID: 27159755 http://journals.lww.com/greenjournal/pages/articleviewer.aspx?year=2016&issue=06000&article=00010&type=abstract
  6. Committee on Practice Bulletins - Gynecology. Chronic pelvic pain. Obstet Gynecol 2020 Mar; 135:e98. PMID: 32080051 https://journals.lww.com/greenjournal/Abstract/2020/03000/Chronic_Pelvic_Pain__ACOG_Practice_Bulletin,.48.aspx
  7. Horne AW et al. Gabapentin for chronic pelvic pain in women (GaPP2): A multicentre, randomised, double-blind, placebo-controlled trial. Lancet 2020 Sep 26; 396:909. PMID: 32979978 Free PMC article. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31693-7/fulltext
  8. Lamvu G, Carrillo J, Ouyang C et al Chronic Pelvic Pain in Women. A Review. JAMA. 2021;325(23):2381-2391. PMID: 34128995 https://jamanetwork.com/journals/jama/fullarticle/2781048
  9. NEJM Knowledge+