CHAPTER 23 CHRONIC PELVIC PAIN
1. What is chronic pelvic pain?
Chronic pelvic pain is pain that is recurrent or persistent for 6 months or longer. There may or may not be an identifiable causative lesion. (The time frame is a measurement used to categorize most types of chronic pain, not just chronic pelvic pain.)
2. What are some other hallmarks of chronic pelvic pain?
With chronic pelvic pain, pain and disability appear out of proportion to physical abnormalities, and are unrelieved by usual medical or surgical therapies. There may be signs of depression, such as loss of appetite, weight change, and sleep disturbance. Pain interferes with daily lifestyle, causing inability to perform normal household or job-related tasks, exercise, or sexual intercourse. A history of physical or sexual abuse may be elicited.
3. Describe the impact of chronic pelvic pain on family interaction
Pain may become an interpersonal device through which family members communicate. Caregivers may infantilize the patient, and the patient may use the pain to manipulate the family. Although the process is difficult, patient and family education is needed to interrupt this cycle.
4. Is chronic pelvic pain purely a disease of women?
No. Men may have a syndrome that mimics prostatitis but does not include acute infection or inflammation. Objective findings may be absent. These patients are similar in many ways to women with interstitial cystitis.
5. Identify important information that can be obtained from the history
Findings from the history should include the following: What aggravates or alleviates the pain? Is it related to the menstrual cycle or stress? Is it continuous, or intermittent? Characteristics such as quality, severity, and location of the pain are all important factors to elicit.
Age, parity, and use of contraception are important in respect to the ovulatory cycle, as well as the possibility of prolapse of the uterus.
Menstrual history may give insight as to duration of discomfort and at which point of the menstrual cycle the pain occurs.
A history of endometriosis may be significant, because this may cause scarring and adhesions that give rise to pain.
Sexual history may reveal introital pain, dyspareunia, or sexual abuse. Vaginal spasm may be due to an inflammatory reaction or scarring or may have a psychologic origin. A history of sexually transmitted infection or pelvic inflammatory disease is relevant because these can lead to adhesion formation.
Any associated pain in other areas of the body, including the lower back, gastrointestinal tract, and the urinary tract should be discussed. Radiation of pain is important in ruling out other etiologies of pain, including a neuropathy or radiculopathy.
Previous operative procedures may be significant for adhesion formation and scarring in the area.
6. How can the physical examination contribute to the diagnosis?
A vaginal, rectal, and rectovaginal examination with direct visualization, where possible, should be performed in an attempt to reproduce the pain. A Pap smear and cervical cultures for Chlamydia trachomatis and Neisseria gonorrhoeae should be done, as well as a pregnancy test, if warranted. During bimanual and rectovaginal examination, evaluate areas of tenderness by assessing the uterosacral ligaments, which are commonly thick and tender in endometriosis. Also, assess adnexal or uterine tenderness, and mobility. Infection and scarring from endometriosis can affect normal mobility, as well as thicken and damage tissue.
7. From what pelvic structures can chronic pelvis pain arise?
Vagina (e.g., atrophy, chronic infection)
Cervix (e.g., tumor, cervical stenosis)
Fallopian tube (e.g., chronic infection)
Ovary (e.g., cyst, tumor, adhesions, torsion)
Uterine ligaments (e.g., endometriosis)
Bowel (e.g., IBS, constipation, diverticulitis, obstruction)
Bladder (e.g., interstitial cystitis)
Nonpelvic structures (e.g., nerve, joint, and ligament) can give rise to radiated and referred pain to the pelvic area.
8. Is a retroflexed uterus a cause for pain?
Approximately 20% of normal women have a uterus in the retroflexed position. A retroflexed uterus may be due to adhesions from a postoperative or postinflammatory process or to endometriotic lesions. Pain in these patients is not due to the position of the uterus but rather to the primary disease. On occasion, anterior displacement of the uterus alleviates the pain. In this case, a pessary or uterine suspension may be considered.
9. What are the common signs and symptoms of endometriosis?
Pain tends to follow the menstrual cycle. Pain on defecation and intercourse may occur because the disease affects the cul-de-sac and/or uterosacral ligament. In severe cases, the bowel wall may be involved, causing cramping or even obstruction.
10. What is the pelvic congestion syndrome?
This syndrome is due to pelvic vascular engorgement, which presents as heaviness and pain. Symptoms start after arising in the morning and worsen as the day continues. The diagnosis is made by laparoscopy: the uterus looks dusky and mottled, and the broad ligament veins demonstrate varicosities.
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