Pelvic Pain

Pelvic Pain

Rachel Worman, PT, DPT, MPT

Samir J. Sheth, MD


  • 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.


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.


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 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.


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.


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

Mar 10, 2020 | Posted by in PAIN MEDICINE | Comments Off on Pelvic Pain
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