Chapter 35
Pelvic and urogenital pain

Anjali Martinez

Obstetrics and Gynecology, George Washington University, Washington, DC, USA

Introduction

Chronic pelvic pain is a common disorder in women, with a prevalence of about 4% [1]; similar to the prevalence of migraine headaches and asthma. It is a frequent reason for outpatient visits to doctors. Women with chronic pelvic pain not infrequently also have limited function or disability, marital problems or divorce, and often have been subjected to multiple surgical treatments without much benefit.

Chronic pelvic pain is defined as non‐cyclic pelvic or lower abdominal pain of greater than 3–6 months’ duration. Traditionally, chronic vulvar pain is not included based on its anatomic location, but it is discussed in this chapter as part of genital pain. Note that a specific diagnosis is not necessary for the diagnosis of chronic pelvic pain, and indeed sometimes chronic pain itself is the only or best diagnosis. Chronic pelvic or urogenital pain may have multiple etiologies, and often multiple etiologies exist at once. Some of these disorders have no cure so naturally lead to the chronic nature of chronic pelvic pain, but why other etiologies lead to chronic pain are less understood. Although most etiologies of pelvic pain may start as visceral or somatic nociceptive pain, neuropathic pain or centralization of pain may occur, so that the pain is maintained regardless of the status of the original source of pain.

Etiology

The differential diagnoses of the disorders associated with chronic pelvic pain are very broad. Visceral sources of pain include the gastrointestinal tract, the urologic system and the reproductive system. Somatic sources of chronic pain in this area include the musculoskeletal system and the neurologic system. In a large British primary care study, chronic pelvic pain was more often related to the gastrointestinal tract and urinary system than to the reproductive system [1]. Although many etiologies of chronic pelvic pain are not gender‐specific, this discussion focuses on chronic pelvic pain in women. Disorders that have strong evidence of a causal relationship with chronic pelvic pain include interstitial cystitis/bladder pain syndrome, irritable bowel syndrome (IBS), constipation, endometriosis and abdominal wall myofascial pain. For many disorders, there is only limited evidence that the disease leads to chronic pain. For a list of diagnoses commonly associated with chronic pelvic pain see Table 35.1.

Evaluation

Diagnosis is mostly based on a thorough history and physical examination. Because the etiologies of pain are diverse, both the history and examination must cover multiple organ systems. A good history will include details of the pain itself including quality, severity, timing and location, preferably mapped by the patient on a diagram of the body; a psychosocial history; questions regarding bowel and bladder symptoms and a depression screen. Details in the patient’s history often suggest which organ systems are involved (gastrointestinal, urologic, musculoskeletal, gynecologic, neuropathic) and can guide further evaluation and care. Depression or anxiety often co‐exist with chronic pelvic pain [2], and psychosocial factors may contribute to a patient’s interpretation of pain and response to treatment.

Table 35.1 Conditions that may cause or exacerbate pelvic and urogenital pain, by level of evidence.

Level of evidence	Gastrointestinal	Gynecologic	Urologic	Musculoskeletal
Level A	Irritable bowel syndrome	Endometriosis	Interstitial cystitis Bladder Pain syndrome	Abdominal wall Myofascial pain (trigger points)
	Constipation	Gynecologic malignancies	Bladder malignancy	Pelvic floor tension myalgia
	Inflammatory bowel disease	Ovarian retention syndrome (residual ovary syndrome)	Radiation Cystitis	Neuralgia of iliohypogastric, ilioinguinal, and/or genitofemoral nerve
	Carcinoma of the colon	Ovarian remnant syndrome		Peripartum pelvic pain syndrome
		Pelvic congestion syndrome
		Pelvic inflammatory disease
		Vestibulodynia
		Vulvodynia
Level B		Adhesions	Urethral diverticulum	Neoplasia of spinal cord or sacral nerve
		Benign cystic mesothelioma		Coccydynia
		Leiomyomata		Lumbar disk herniation
		Postoperative peritoneal cysts
Level C	Colitis	Adenomyosis	Chronic urinary tract infection	Compression of lumbar vertebrae
	Chronic intermittent bowel obstruction	Atypical dysmenorrhea	Recurrent acute cystitis	Degenerative joint disease
	Diverticulosis	Adnexal cysts	Recurrent acute urethritis	Hernias (ventral, inguinal, femoral, spigelian)
		Cervical stenosis	Urolithiasis	Thoracolumbar facet syndrome
		Chronic endometritis
		Residual accessory ovary
		Genital prolapse
		Endosalpingiosis

Level A: good and consistent scientific evidence of causal relationship to chronic pelvic pain.

Level B: limited or inconsistent scientific evidence of causal relationship to chronic pelvic pain.

Level C: causal relationship to chronic pelvic pain based on expert opinions.

The physical examination is performed to identify any anatomic sources of the patient’s pain. It is important to isolate and examine the musculoskeletal, gastrointestinal, urinary, reproductive and neurological systems during the evaluation to pinpoint specific diagnoses if present. In particular, the pelvic examination for chronic pelvic pain is different from the traditional bimanual pelvic examination in that it is performed with one finger of one hand so that focal areas of tenderness that reproduce the patient’s baseline pain can be sought in bony, nervous, muscular and visceral structures (referred to as a “pain‐mapping exam”). For details on conducting the physical examination, see Chronic Pelvic Pain in Adult Females: Evaluation [3].

Presentations of some of the most common disorders associated with chronic pelvic pain are outlined here.