pelvic pain

Introduction

see chronic pelvic pain syndrome for chronic pelvic pain in men

Etiology

• pregnancy-related pain
  • ectopic pregnancy
  • threatened or incomplete abortion
  • corpus luteum cyst
• non-pregnancy related gynecologic pain
  • pelvic inflammatory disease
  • dysmenorrhea
  • ovarian pain
    • ovarian cyst
    • mittelschmerz
    • adnexal torsion (ovarian torsion)
    • ovarian cancer
  • uterine leiomyoma
    • degeneration
    • torsion
  • endometriosis (chronic pain)
  • pelvic adhesions (chronic pain)
  • pelvic varices
• non-gynecologic pelvic pain (80%)
  • gastrointestinal
    • appendicitis
    • irritable bowel syndrome
    • inflammatory bowel disease
    • diverticular disease
  • urinary tract
    • urinary tract infection
    • interstitial cystitis
    • renal stones
  • musculoskeletal
    • abdominal wall musculature
    • rib contusion or fracture
    • radicular pain secondary to herniated disc, fracture or arthritis of the spine
    • inguinal or abdominal hernia
  • psychological
    • sexual dysfunction
    • sexual abuse (present or past)
    • physical abuse, emotional abuse
    • somatization disorder
• risk factors for chronic pelvic pain*
  • physical, sexual or emotional abuse
  • pelvic inflammatory disease
    • intrauterine device (IUD) is risk factor for pelvic inflammatory disease (PID) & ectopic pregnancy
  • pelvic surgery or abdominal surgery
    • bilateral tubal ligation (BTL) increases risk of ectopic pregnancy
  • chronic pain syndrome
  • psychiatric disorder: anxiety, depression

* oral contraceptives decrease the likelihood of ovarian cysts, ectopic pregnancy & pelvic inflammatory disease

History

• character, intensity, location, radiation, onset, duration, frequency, remissions, exacerbations, aggravating factors, ameliorating factors, vaginal discharge, vaginal bleeding, dysuria, frequency, hesitancy, nausea/vomiting, diarrhea, constipation, hematochezia, melena, fever, last menstrual period, sexual activity, sexual partner(s), dysparunia, sexual trauma, IUD, birth control, vaginal douching, sexual abuse

Clinical manifestations

• chronic pelvic pain is present for 3-6 months in the absence of pregnancy
  • pelvic heaviness, abnormal uterine bleeding, infertility suggests uterine fibroids
  • dysmenorrhea with pelvic pain just prior to & during menses suggests endometriosis
  • urinary frequency, urinary urgency, nocturia, dysuria suggests interstitial cystitis
  • absence of a diagnosis identifies this simply as chronic pelvic pain
• missed menses suggests pregnancy-related pain
• appendicitis moves from the epigastrium to the right lower quadrant
  • associated with abrupt increase in pain
• pelvic inflammatory disease is generally bilateral, occurring within 1st week of menstrual cycle
• adnexal torsion is an intense, progressive pain often with preceding intermittent pain
• ovarian cyst pain occurs mid cycle
• pain with sexual intercourse may be present
• associated symptoms of fever, vaginal discharge, urinary tract or GI symptoms may be present
• pointing with 1 finger to pain is consistent with parietal peritoneum or skin involvement
• pointing with entire palm is consistent with visceral involvement
• rebound tenderness or involuntary guarding suggests parietal peritoneum irritation
• pelvic examination
  • vaginal or cervical erythema, discharge or bleeding
  • cervical motion tenderness (CMT) 97% sensitive, but not specific for pelvic inflammatory disease (PID)
  • adnexal tenderness suggests ectopic pregnancy, pelvic inflammatory disease (PID) & appendicitis
  • uterine size & consistency abnormal in pregnancy,leiomyoma & endometriosis
  • nodularity of uterosacral ligament & fixation of uterine structures is consistent with endometriosis
  • adnexal masses
    • ectopic pregnancy (50% sensitive)
    • adnexal torsion (70-98% sensitive)
    • pelvic inflammatory disease (PID) (25-50% sensitive)
  • rectal exam may detect retrocecal appendicitis

Laboratory

• complete blood count (CBC)
• urinalysis
• pregnancy test (all women of reproductive age)
• GenProbe for Neisseria gonorrhea & Chlamydia
• Gram stain of cervical discharge

Diagnostic procedures

• culdocentesis
• diagnostic laparoscopy
  • diagnosis unclear after comprehensive evaluation
  • surgical process (ectopic pregnancy or appendicitis) suspected

Radiology

• transvaginal pelvic ultrasound
  • essential in workup of pregnancy-related pelvic pain
  • not as useful in workup of non pregnancy-related pelvic pain
  • indicated pre-menopausal & perimenopausal pelvic pain
  • more sensitive than CT for detecting pelvic masses
• plain film of the abdomen (upright)
• computed tomography of the abdomen (postmenopausal)

Differential diagnosis

• pelvic heaviness, abnormal uterine bleeding, infertility suggests uterine fibroids
• dysmenorrhea with pelvic pain just prior to & during menses suggests endometriosis
• urinary frequency, urinary urgency, nocturia, dysuria suggests interstitial cystitis
• missed menses suggests pregnancy-related pain
• absence of a diagnosis identifies this simply as chronic pelvic pain

Management

• Strategy:
  • consider surgical emergencies
  • determine if the patient is pregnant
  • assess whether the problem is acute or chronic
• Evaluate for surgical emergency
  • ectopic pregnancy
  • incomplete abortion
  • appendicitis
  • adnexal torsion
• Diagnosis and management of specific medical problem
  • ovarian cyst
  • pelvic inflammatory disease (PID)
  • primary dysmenorrhea
• patient is not pregnant, no cause for pain determine
  • observation
  • consider for referral if symptoms worsen
• chronic pelvic pain
  • integrated team approach may be indicated
    • cognitive behavorial therapy may be effective
  • often associated with history of psychosexual trauma; counseling is indicated
  • diagnostic laparoscopy in any patient with pelvic pain in same location for 6 months
  • women with non cyclic pain, migratory pain & normal pelvic exam are unlikely to benefit from surgery
    • routine laparoscopic adhesiolysis is not recommended
  • NSAIDs may be used short-term for most women with idiopathic chronic pelvic pain
  • gabapentin ineffective & associated with adverse effects

More general terms

• pain [odyn-]

More specific terms

• prostadynia (prostatosis)

Additional terms

• abdominal pain
• chronic pelvic pain syndrome (CPPS)