Resident Editor: Juliana Macri, MD

Faculty Editor: Jeannette Lager, MD

Background

• Definition: Continuous cyclic or non-cyclic pain in the lower abdomen or pelvis lasting ≥6 months and associated with a negative impact on quality of life. 
• Affects 6-27%  of the female population, depending on the definition used
• More prevalent in women, but also occurs in men
• In the absence of a clear single etiology, can be thought of as a complex pain syndrome, with neuromuscular and psychosocial components, requiring a multi-disciplinary approach 

Differential (most likely)

• Gynecologic: endometriosis, adenomyosis, ovarian cysts (hemorrhagic), adhesions (h/o PID, pelvic surgeries), vulvodynia, pelvic congestion syndrome 
• Gastrointestinal: IBS, constipation
• Urinary tract: interstitial cystitis (IC) 
• Neuromuscular: Low back/SI joint dysfunction, pelvic floor muscle dysfunction, hip or abdominal wall pathology, hyperesthesia/allodynia, fibromyalgia
• Psychological: PTSD (in one-third), trauma (in nearly one-half), depression (present in 12-35%), anxiety, depression, sexual dysfunction 

Evaluation

History (See International Pelvic Pain Society website (www.pelvicpain.org) for extensive history and PE forms in English, Spanish, French):

• Pain history/diary: quality, location (use pain mapping using body diagram), radiation, contributing or relieving factors, association with menses, urination, defecation, and sexual activity
• Medical/surgical history: chronic systemic medical problems, especially chronic pain conditions (e.g. IBS, chronic fatigue), meds, pelvic/abdominal surgeries
• Ob/Gyn history: menstrual, obstetric, and sexual 
• ROS:
  • Red flag symptoms: post-coital bleeding, post-menopausal bleeding or pain onset, weight loss, pelvic mass, hematuria, remote history of abnormal pap and no recent pap, acute abdomen
  • GI: abdominal pain, constipation, diarrhea, bloating, distention
  • Urinary: frequency, urgency, nocturia, bladder pain, or dysuria
• Health habits: substance abuse, nutrition/exercise
• Psych history:
  • Elicit patient’s view of illness, fears, and concerns
  • Quality of life: functioning, coping, support system
  • Screen for physical or sexual violence, current or prior, including events in childhood
  • Screen for depression  and PTSD
  • Assess sexual functioning: Desire, frequency, satisfaction, orgasm, and dyspareunia
• Spiritual health: what brings joy? What brings comfort? Gives meaning to life? What are your goals for treatment? 

Diagnostic tests

Physical exam:

• MSK
  • Examine the abdomen for scars, trigger points
  • Carnett’s sign: Differentiates abdominal wall versus an abdominal source of pain. The patient raises her head and shoulders from the examination table while the provider palpates the tender area on the abdomen. Positive if the pain remains unchanged or increases when the abdominal muscles are tensed. A positive test increases the likelihood of a myofascial or abdominal wall source of pain.  If pain is reduced, then pain may be intra-abdominal and reduced by “splinting.”
  • Assess lower back, SI joints, pubic symphysis, and hips for MSK source of pain
• GYN
  • External genitalia: 
    • Assess for discharge, erythema, lesions, pigmented changes, and other dermatologic changes, evaluate Bartholin’s glands (4 and 8 O’Clock)
    • Q tip test:  Identify and map changes in sensation including allodynia.  Gently touch with a q-tip starting at the thigh to perineum bilaterally including the clitoris and perianal areas. Proceed from labia majora to labia minora then the vestibule.
  • Urethra and bladder: mass or tenderness, prolapse, evaluate Skene’s glands (periurethral)
  • Vagina, cervix:  Inspection (lesion, trauma, infection, prolapse). Wet mount/STI screening if clinical suspicion.  Pap smear if > 3-5 years from last pap.
  • Pelvic floor muscles: with one finger with NO abdominal palpation. Just beyond hymen, mid-vagina, just before the cervix.  Assess for hypertonicity, tenderness, or trigger points 
  • Cervix: with one finger, assess for cervical motion tenderness
  • Uterus/adnexa – bimanual: Size, shape, consistency, mobility, mass, tenderness
  • Rectal or rectovaginal: Lesion, rectocele, uterine retroflexion, uterosacral nodules

Treatment

• Initial: Treat known GYN, GI, urologic or psychological issues.
• Medications depending on the type of pain
  • Acute exacerbations: analgesics, particularly those with an anti-prostaglandin effect, muscle relaxants. Consider opioids for acute use only.
  • Cyclic pain: hormonal therapy (e.g. OCPS, progestogen injections, levonorgestrel IUD, GnRH-agonist) especially effective if endometriosis
  • Neuropathic pain: Treat with centrally acting meds
    • If underlying mood disorder: SSRI
    • Otherwise tricyclic or SNRI antidepressants (e.g. amitriptyline, venlafaxine, duloxetine), and neuroleptics (e.g. gabapentin, pregabalin). Gabapentin +/- amitriptyline better than amitriptyline alone
  • Vulvodynia: topical lidocaine 5% ointment: apply ½ tsp to cotton ball then leave at vaginal opening nightly x 6-12 weeks. 
• Pelvic physical therapy:
  • Provides internal myofascial release, biofeedback, and home exercise program. Teach dilator use as needed.
  • Consider if pelvic floor tenderness. Effective for vulvodynia, myofascial pain/dyspareunia
• Surgical/procedural
  • Laparoscopic surgery for endometriosis. Hysterectomy as last resort though may benefit select patients with uterine tenderness 
  • Local steroid injections, nerve blocks, or implantable neuromodulatory devices if neuropathic pain (Pain anesthesia referral)
• Behavioral therapies/counseling
  • Treat anxiety, depression, and any physical or sexual trauma
  • Provide reassurance and counseling – CBT, pain psychology, or somatocognitive therapy (newer approach, which promotes body awareness and both cognitive and physical pain coping strategies)
  • Advice for sexual pain: Learn about your body, discover your pleasure spots, educate your partner, connect with your partner in sexual and non-sexual ways. Prepare for sex: relax the pelvic floor muscles, use lubricants, and take time for arousal. Reinvent your sex life. Avoid painful activities. Refer to a sexologist for education or a therapist for CBT and support.
  • Mind/body modalities (imagery, breathwork, mindfulness-based stress reduction)
• Other alternative therapies
  • Manual medicine (strain-counter strain, massage, chiropractic)
  • Movement therapies (yoga, Feldenkrais)
  • Acupuncture (limited evidence that ear acupuncture helpful for gynecologic pain)
  • Herbs (anti-inflammatory, adaptogens, relaxants), anti-inflammatory diet.
• Continually reassess patient for alternate diagnoses 

References

Abercrombie, P. D. and Learman, L. A. Providing Holistic Care for Women with Chronic Pelvic Pain. Journal of Obstetric, Gynecologic, & Neonatal Nursing. doi: 10.1111/j.1552-6909.2012.01403.x

Engeler D. et al. EAU Guidelines on CHroniic Pelvic Pain. European Association of Urology, 2014. Accessed at: https://uroweb.org/wp-content/uploads/26-Chronic-Pelvic-Pain_LR.pdf

Howard HS. Sexual Adjustment Counseling for Women with Chronic Pelvic Pain.

J Obstet Gynecol Neonatal Nurs. 2012 Aug 3. doi: 10.1111/j.1552-6909.2012.01405.x. 

Pastore EA, Katzman WB. Recognizing Myofascial Pelvic Pain in the Female Patient with Chronic Pelvic Pain.
J Obstet Gynecol Neonatal Nurs. 2012 Aug 3. doi: 10.1111/j.1552-6909.2012.01404.x. 

Speer et al. Chronic Pelvic Pain in Women. Am Family Physician. 2016; 93(5): 380-387.

Stein SL. Chronic pelvic pain. Gastroenterol Clin N Am 2013; 42:785 

Vercellini A, Somigliana E, Paola V, et al. Chronic pelvic pain in women: etiology, pathogenesis and diagnostic approach. Gynecological Endocrinology 2009; 25:149.

Yunker A, Sathe NA, Reynolds WS et al. Systematic review of therapies for noncyclic chronic pelvic pain in women. Obstetrical and Gynecological Survey 2012; 67:417.