Pelvic Pain

Rachel Worman, PT, DPT, MPT

Samir J. Sheth, MD

FAST FACTS

Chronic pelvic pain (CPP) can affect males as well as females, and the worldwide estimated prevalence is 2.1% to 24%.
When determining the cause of CPP, a thorough account of past surgical, psychological, and sexual history, including sexual abuse, should be identified.
CPP can arise from many different organ systems and as such, multidisciplinary management (gynecology, urology, gasteroenterology, pain medicine) is not uncommon.
Treatment usually begins with pelvic floor physical therapy, which is combined with behavioral health strategies. Pharmacologic and nonpharmacologic procedural interventions should be considered in patients with treatment-resistant CPP.

INTRODUCTION

Pelvic pain is a common disorder defined as a “pain located at the level of the lower abdomen, pelvis, or pelvic structures, which persists either intermittently or continuously for at least 3 to 6 months unassociated with menstrual cycle or pregnancy.”¹ Although much of the literature focuses on chronic pelvic pain (CPP) in females, it is a disorder that commonly affects males as well. The prevalence of CPP is thought to be anywhere from 2.1% to 24% of the worldwide population.²^,³ Despite its high prevalence, the exact diagnosis is unknown in up to two-thirds of patients⁴ owing to the complex nature of CPP and the various causes.

HISTORY

When taking a history of patients with CPP, it is important to be comprehensive. In addition to asking standard questions such as about pain intensity, quality, radiation, pain interference, and timing, it is important to ask the patient’s past surgical, psychological, and sexual history (including any sexual abuse history) (see later discussion). Patients with CPP have a rate of depression that may be 3 times higher than that of the general population.⁵ Surgical history also aids the initial workup and/or etiology. The International Pelvic Pain Society (IPPS) has a Pelvic Pain Assessment questionnaire available at http://pelvicpain.org/professional/documents-and-forms.aspx. Other surveys include the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI). The IPPS assessment questionnaire is more comprehensive and includes questions regarding surgical history and sexual history, along with mental health problems and/or history of sexual abuse. Prior surgery and history of
falls greatly facilitate etiology of the patient’s pain. For example, patients with prior inguinal herniorrhaphy can develop scar tissue, including neuroma, which can cause severe neuropathic pain. Patients who had surgery and/or trauma to the pelvic floor may have compression of the pudendal nerve, which leads to pain with sitting along with pain in perineum (see later discussion). If a questionnaire is not used, a thorough history as detailed later should be considered.

SUBJECTIVE

In the subjective interview, it is essential to focus on standard assessment models of pain (i.e., onset, quality, radiation, severity, and timing), especially the aggravating and alleviating factors. In pelvic pain, it is important to determine the changes occurring throughout the day as well as the cyclical nature on a monthly and/or seasonal basis.

Special questions in a pelvic pain interview include a thorough bowel, bladder, and dietary history. For the sake of time, it may be useful to have an intake form that can be completed by the patient before the visit.

Chief Complaints

Specifying the location of pelvic pain can be difficult, as visceral sensation is difficult to describe. When patients describe pain, it may be diffuse and poorly localized to areas such as the abdomen, groin, low back, and buttock. This information will support physical examination findings.

Aggravating factors in pelvic pain include activities, movements, positions, and dietary intake that trigger the pain. Alleviating factors in pelvic pain commonly include avoidance of certain foods, improved fiber intake, medications, positional changes, and rest.

Bowel, Bladder, and Diet Logs

Bowel, bladder, and diet logs can be completed via intake forms or interview. Bowel questions are outlined in Box 22-1, Bladder questions are outlined in Box 22-2 and Diet questions are outlined in Box 22-3.

Psychosocial History

High-quality studies exploring the psychosocial aspects of pelvic pain are limited. The current literature associates psychological factors such as stress, pain catastrophizing, personality factors, and social factors with the development of chronic prostatitis/chronic pelvic pain syndrome in men.¹² Moreover, psychologic factors including catastrophizing, hypervigilance, depression, fear of pain, and anxiety are correlated with provoked vestibulodynia in women.¹³^,¹⁴ Indeed, impaired sexual function is a frequent finding among women with vestibulodynia.¹³

Assessment and treatment of psychosocial factors is part of a multimodal pain management approach to pelvic pain. Box 22-4 outlines a list of potential questions for the interview.

Box 22-1 Bowel Interview Questions

Do you have any change in your bowel function?
What do you eat/drink for breakfast, lunch, dinner, and snacks?
How many bowel movements do you have per day or per week?
Do you have pain before, during, and/or after bowel movements?
How do you describe your stool on the Bristol stool scale?
Do you use any of the following (fiber supplements, stool softeners, stimulant laxatives, probiotics)?
Do you have any bowel incontinence (fecal smearing; mucous, watery stool; soft stool; pebbles)?
Does a strong urge precede any bowel disorder?
What is your position when defecating?
Do you have a history of irritable bowel syndrome? Type (constipated and/or loose)?
Do you have a history of irradiation in the pelvic region?

Box 22-2 Bladder Interview Questions

Do you have any change in bladder function?
How many times per day do you void?
- Is it frequent in the morning or afternoon?
How many times do you void at night?
Do you have urinary incontinence?
- With coughing, sneezing, lifting, and laughing was leaking unavoidable?
- How many episodes of incontinence per day or per week do you experience?
- Do you wear pads? (Depends, B-sure, Always incontinence pads)
  - Are the pads saturated (minimal [drops], moderate [50%], or maximal [100%])?
Fluid intake
- How many glasses of water do you drink every day?
- How much of each of the following do you drink? Coffee, tea (herbal or caffeinated), alcohol, soda, juice, milk?

Etiology

There are many potential causes to CPP. The overlap between somatic and visceral pain can be a diagnostic challenge. Therefore, it is important to be systematic
when assessing pelvic pain. The European Association of Urology recommends assessing multiple anatomical regions (urologic, gynecologic, colorectal, myofascial, and neurologic) when developing a differential diagnosis in patients with CPP.⁶

Anatomy and Physical Examination

Anatomy

The anatomical structures of the pelvis and its interconnections to the spine, trunk, and lower extremity make it a unique and complex relay center for function. Pelvic pain may arise from bone, joint, ligament, fascia, muscle, arterial, venous or lymphatic vessels, and visceral or nerve structures. Although pain may arise from one structure, other structures may respond and develop further dysfunction. Specialty clinicians must consider these functional anatomical interconnections when approaching the diagnostic and treatment process for pelvic pain.⁷

The pelvic perineum is the area overlying the pelvic outlet and includes the genitalia, perineal body, and urogenital and anal triangles. It is contained by bony and ligamentous borders between the pubic symphysis anteriorly, the pubic ramus anterolaterally, ischioramus laterally, sacrotuberous ligament posterolaterally, and the coccyx posteriorly (Figure 22-1).

In females, the perineum includes the vulva (female genitalia), which contains the labia majora and minora. Anteriorly, labia majora and labia minora form the hood of the clitoris, or prepuce and frenulum of the clitoris and its tissues may be implicated and must be tested in painful conditions such as clitorodynia. The labia minora contains sweat glands and joins posteriorly to become the posterior fourchette of the vagina, which is often torn during child delivery and may be a source of pain or dyspareunia due to decreased mobility with scar tissue (see Figure 22-2).

FIGURE 22-1 Pelvic anatomy. Reprinted with permission from Pillitteri A, Silbert-Flagg J. Maternal and Child Nursing. 4th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2003.

FIGURE 22-2 Female external genitalia. Reprinted with permission from Smith NE. Introductory Medical-Surgical Nursing. 12th ed. Philadelphia, PA: Wolters Kluwer; 2017.

In males, the perineum has the same bony borders, with the external genitalia comprising the scrotum and penis.

Figure 22-3 details the visceral as well as muscular components for the pelvis and perineum in both males and females, respectively. These figures are especially helpful when performing a pelvic floor physical examination or when reading a report from a pelvic floor physical therapist.

Finally, Hart line (Figure 22-4) is an important female anatomical landmark for clinicians. It is the line between the labia minora and the vestibule. This is where the cotton swab test is performed (see section on pelvic examination). The vestibule is a space outlined by the urethra, inner labia minora, vagina, and Bartholin gland

posteriorly. Pain that is medial to Hart line yet distal to the introitus indicates the diagnosis of vestibulodynia. Lateral to Hart line sensation is normal (without pain).

FIGURE 22-3 Fasciae of perineum. A and B, Median sections, viewed from left, demonstrate the fasciae in the female (A) and male (B). The planes of the sections shown in parts (C)-(F) are indicated. C, This coronal section of the female urogenital triangle is in the plane of the vagina. Fibroareolar components of the endopelvic fascia (cardinal ligament and paracolpium) are shown. D, This coronal section of the male urogenital triangle is in the plane of the prostatic urethra. E, This coronal section of the anal triangle is in the plane of the lower rectal and anal canals. F, This coronal section demonstrates the subcutaneous tissue of the proximal penis and scrotum. Reprinted with permission from Moore KL, Dalley AF, Agur AM. Moore Clinically Oriented Anatomy. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.

FIGURE 22-4 Hart line. The vulvar vestibule and the position of Hart line. Hart line can be found on the medial aspect of the labia majora, extending in a curvilinear manner from the most inferior posterior portion of the labia minora to the vaginal fourchette. Reprined with permission from Mills SE. Histology for Pathologists. 4th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.

The neurovascular supply to the pelvic region arises from multiple different spinal levels. Blood is supplied to the external genitalia via the internal and external pudendal arteries, bilaterally. The bulb of the penis and the vestibule and labia drain to the internal pudendal vein.

Two main nerves provide the innervation to the external genitalia. Their course from the spine may provide the practitioner with information about other suspect structures.

The ilioinguinal nerve is mainly derived from the anterior rami of L1 nerve with contributions from T12. It pierces the psoas muscle before traversing laterally and anterior to the quadratus lumborum. It pierces the transverse abdominus at the anterior iliac crest and lies between the transverse abdominus and internal oblique muscle. Branches of the ilioinguinal nerve innervate the skin of anterior scrotum and base of the penis in males and the skin of the mons pubis and upper labia majora in females.²⁹

The genitofemoral nerve is derived from the L1-L2 nerve roots and travels inferior to pierce through psoas major muscle at the L3-4 intervertebral disc level and then runs along its anterior surface. It branches to become the femoral and genital nerves.²⁹

The femoral branch courses posterior to the inguinal ligament and innervates the skin of superior anterior thigh.²⁹

The genital nerve enters the inguinal canal by passing through the deep inguinal ring.²⁹ The genital branch provides sensory innervation to posterior scrotum in males as well as motor supply to the cremasteric muscle in males. In females, the nerve provides sensory innervation to the ipsilateral mons pubis and labia majora.³³

The pudendal nerve derives from the anterior rami of the sacral 2 to 4 nerve roots. The nerve travels through the greater sciatic foramen anteriorly before turning posteriorly to pass between the sacrospinous and sacrotuberous ligaments. The pudendal nerve then travels anteriorly through the lesser sciatic foramen into the perineal region via Alcock canal (obturator internus fascia) before giving off its 3 major branches: deep perineal, superficial perineal, and inferior rectal nerves (see Figure 22-5). The pudendal nerve supplies the skin of the penis and clitoris, the sensory innervation to the perineum along with the posterior aspect of the scrotum, and labia majora. It also provides motor innervation to the deep muscles of the pelvic floor along with the external anal sphincter.²⁹^,³⁰

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