Contents
Introduction
Non-cyclic pain lasting for ≥ 6 months, that localizes to the anatomic pelvis, anterior abdominal wall at/below the umbilicus, the lumbosacral back, or the buttocks and is of sufficient severity to cause functional disability or lead to medical care
American College of Obstetricians and Gynaecologists definition
- Form of chronic regional pain syndrome (CRPS)
- Seen in an estimated 4-16% women. Only a third of women suffering from chronic pelvic pain seek medical care
Aetiology
Somatic component:
In over half of the cases cases there is a comorbid condition present. As the patient’s pain becomes chronic, it centralizes, leading to chronic pelvic pain.
- Irritable bowel syndrome
- Musculoskeletal pelvic floor pain
- Painful bladder syndrome
- Peripheral neuropathy
- Chronic uterine pain disorders (eg. endometriosis)
Psychiatric component:
Chronic pelvic pain has a strong association with previous physical or emotional trauma. Thus the etiology of chronic pelvic pain may also be related to a functional somatic pain syndrome. Emotional state and stress levels influence visceral pain, such as chronic pelvic pain
- Posttraumatic stress disorder (PTSD)
- Major depressive disorder
Clinical features
Centralized pain:
Chronic pelvic pain is a form of centralized pain, where the body develops a low threshold for pain, often a result of chronic pain.
- Hyperalgesia: Previously mild to moderate pain is experienced as severe pain
- Allodynia: Tactile sensations can be interpreted as painful
Case study:
Diagnosis
Carnett test:
Patient is asked to raise both of their legs off the exam table while in a supine position. The provider places their finger on the patient’s painful abdominal to determine whether the patient’s pain increases with the legs are flexed, and the abdominal muscles have contracted. In myofascial pain, the patient is likely to experience more considerable pain with leg flexion, while visceral pain improves with leg flexion.
Differential diagnosis:
A list of the various possible etiologies for chronic pelvic pain are listed below:
- Gynecological: Endometriosis, pelvic inflammatory disease, pelvic adhesion disease, recurrent ovarian cysts, leiomyoma, adenomyosis, hydrosalpinx, and post-tubal ligation pain syndrome
- Gastroenterological: Irritable bowel syndrome, celiac disease, inflammatory bowel disease, colorectal carcinoma, and hernias
- Urological: Interstitial cystitis (painful bladder syndrome), recurrent cystitis, radiation cystitis, chronic urolithiasis, bladder cancer, and urethral syndrome
- Musculoskeletal: Abdominal wall myofascial pain, fibromyalgia, coccygodynia, pelvic floor tension myalgia, piriformis syndrome
- Neurological/vascular: Ilioinguinal nerve entrapment, iliohypogastric nerve entrapment, pudendal neuralgia, spinal cord injury, pelvic congestion syndrome, peripheral neuropathy, and vulvar varicosities
Management
Treatment of chronic pelvic pain is often complicated, with limited evidence-based treatment options. Treatment is usually focused on the suspected etiology of the chronic pelvic pain, such as treating a comorbid mood disorder, neuropathy, or uterine dysfunction.
