Chronic Pelvic Pain

Clinical description

Chronic pelvic pain is defined as intermittent or constant pain that occurs in the lower abdomen or pelvis for at least six months. It may be associated with menses or intercourse; it is not associated with pregnancy.

Organ systems of aetiology include: gynaecologic (20% of cases; adenomyosis, adhesive disease, endometriosis, leiomyoma, PID), gastrointestinal (inflammatory bowel disease, irritable bowel syndrome, diverticulitis), urologic (interstitial cystitis), psychological, musculoskeletal (pelvic floor pain), or neurological (diabetic neuropathy, spinal cord injury).

Signs and symptoms

History Ascertain possible causes, covering every possible organ system of aetiology.

• Ask about frequency/timing of pain, location of pain, precipitating factors, prior surgeries, prior

diagnoses/treatments, abnormal vaginal discharge, menorrhagia, dysmenorrhea, dyspareunia, dysuria, hematuria, dyschechsia, tenesmus, association with food intake, diarrhea, constipation.

Exam

• Examine abdomen for evidence of scars from prior surgeries and palpate all 4 quadrants with superficial

and deep palpation.

• Performbimanual exam to assess for cervical motion tenderness (CMT), uterine tenderness or enlargement,

and adnexal tenderness/masses.

• Examine vulva for signs of irritation or lesions
• Perform speculum exam to assess for abnormal discharge and vaginal/cervical lesions.

Investigations UPT, urinalysis, gonorrhea/chlamydia screening if available, pelvic US for pelvic masses.

Treatment

Depends on possible aetiologies:

• Adenomyosis: dysmenorrhea, menorrhagia, bulky uterus on exam or ultrasound
• Hormonal treatment with either oral contraceptive pills, Provera, or Depo-provera injection
• Panadol and Bufren as needed
• If adnexal mass noted on exam or ultrasound, consider cystectomy/oophorectomy for possible

endometrioma

• Consider hysterectomy if done with childbearing
• Adhesive disease: history of prior surgeries, possibly with infection afterwards. Tenderness upon palpation

of scar.

• Panadol and Bufren as needed
• Consider injections with local anesthetic (Lidocaine, Marcaine, etc.) for trigger points.
• Endometriosis: dysmenorrhea; can also have dyspareunia, dysuria, dyschezia
• Hormonal treatment with either oral contraceptive pills, Provera, or Depo-provera injection
• Panadol and Bufren as needed
• If adnexal mass noted on exam or ultrasound, consider cystectomy/oophorectomy for possible

endometrioma

• Consider hysterectomy if done with childbearing
• Leiomyoma: menorrhagia; may feel pressure on bladder, rectum or spine; large bulky uterus on exam;

fibroids noted on ultrasound

• Hormonal treatment with either oral contraceptive pills, Provera or Depo-provera injection
• Panadol and Bufren as needed
• Consider hysterectomy if done with childbearing
• Pelvic inflammatory disease (PID): CMT and/or uterine/adnexal tenderness, possibly with abnormal

discharge or fever -> see Section onGynaecological Infections and Pelvic Inflammatory Disease.