Chronic pelvic pain

Prof. Sumaya T. S.

Chronic Pelvic Pain (CPP) 

is pain of 

apparent pelvic origin that has been 

present most of the time for the 

past six months

Definition

 Difficult to diagnose

 Difficult to treat

 Difficult to cure

Frustration for 

patient and 

physician

Definition

 Affects 15-20% of women of reproductive age 

 Accounts for 20% of all laparoscopies

 Accounts for 12-16% of all 

hysterectomies

 Associated medical costs of $3 billion 

annually 

Incidence

Gynecological 20%

Gastrointestinal 37%

Musculoskeletal

Urological 30%

Psychological

 25-50% of women had more than one diagnosis

 Severity and consistency of pain increased with 

multisystem symptoms 

 Most common diagnoses:

• endometriosis
• adhesive disease
• irritable bowel syndrome
• interstitial cystitis

Obtaining a 

COMPLETE and DETAILED HISTORY 

is the most important key to 

formulating a diagnosis 

Diagnosis

Diagnosis: Obtaining the History

 Associated with menses?

 Association with sexual activity? (Be specific)

 New sexual partner and/or practices?

 Symptoms of vaginal dryness or atrophy?

 Other changes with menses?

 Use of contraception?

 Detailed childbirth history?

 History of pelvic infections?

 History of gynecological surgeries or other problems?

Gynecological Review of Systems

Diagnosis: Obtaining the History

 Regularity of bowel movements?

 Diarrhea/ constipation/ flatus? 

 Relief with defecation?

 History of hemorrhoids/ fissures/ polyps?

 Blood in stools, melena, mucous?

 Nausea, emesis or change in appetite?

 Abdominal bloating?

 Weight loss?

Gastrointestinal Review of Systems

Diagnosis: Obtaining the History

 Pain with urination?

 History of frequent or recurrent urinary tract infxn? 

 Hematuria?

 Symptoms of urgency or urinary incontinence?

 Difficulty voiding?

 History of nephrolithiasis?

Urological Review of Systems

Diagnosis: Obtaining the History

 History of trauma?

 Association with back pain? 

 Other chronic pain problems?

 Association with position or activity?

Musculoskeletal Review of Systems

Diagnosis: Obtaining the History

 History of verbal, physical or sexual abuse?

 Diagnosis of psychiatric disease? 

 Onset associated with life stressors?

 Exacerbation associated with life stressors?

 Familial or spousal support?

Psychological Review of Systems

Diagnosis: The Physical Exam

Evaluate each area individually

 Abdomen
 Anterior abdominal wall
 Pelvic Floor Muscles
 Vulva
 Vagina
 Urethra
 Cervix
 Viscera 

– uterus, adnexa, bladder

 Rectum
 Rectovaginal septum
 Coccyx
 Lower Back/Spine
 Posture and gait

A bimanual exam alone is 

NOT sufficient for 

evaluation

Diagnosis: Objective Evaluative Tools

Basic Testing

 Pap Smear

 Gonorrhea and Chlamydia

 Wet Mount

 Urinalysis

 Urine Culture

 Pregnancy Test

 CBC with Differential

 ESR

 PELVIC ULTRASOUND

Specialized Testing

 MRI or CT Scan

 Endometrial Biopsy

 Laparoscopy

 Cystoscopy

 Urodynamic Testing

 Urine Cytology

 Colonoscopy

 Electrophysiologic studies

 Referral to Specialist

Differential Diagnosis: Gynecological Conditions

Cyclical

 Endometriosis

 Adenomyosis

 Primary Dysmenorrhea

 Ovulation Pain/ Mittleschmertz

 Ovarian Remnant Syndrome

Non-cyclical

 Pelvic Masses

 Adhesive Disease

 Pelvic Inflammatory Disease

 Pelvic Congestion Syndrome

 Symptomatic Pelvic Organ Prolaps

 Pelvic Floor Pain Syndrome

Pelvic Inflammatory Disease

 Description:  

Spectrum of inflammation and infection 

in the upper female genital tract

 Endometritis/ endomyometritis
 Salpingitis/ salpingoophritis
 Tubo-ovarian Abscess
 Pelvic Peritonitis

 Pathophysiology:  

Ascending infection of vaginal and 

cervical microorganisms

 Chlamydia and Gonorrhea (developed countries)
 Tuberculosis (developing countries)
 Acute PID usually polymicrobial infection

Pelvic Inflammatory Disease

 Risk Factors

 Adolescent
 Multiple sexual partners
 Greater than 2 sexual partners in past 4 weeks
 New partner in the past 4 weeks
 Prior history of PID
 Prior history of gonorrhea or chlaymdia
 Smoking
 None or inconsistent condom use
 Instrumentation of the cervix

Pelvic Inflammatory Disease

 Minimum Criteria (one required):

 Uterine Tenderness
 Adnexal Tenderness
 Cervical Motion Tenderness
 No other identifiable causes

 Additional criteria for dx:

 Oral temperature greater than 

101

 Abnormal cervical or vaginal 

discharge

 Presence of increased WBC in 

vaginal secretions

 Elevated ESR or C-reactive 

protein

 Documented of   CT

 Specific criteria for dx:

 Pathologic evidence of 

endometritis

 US or MRI showing 

hydrosalpinx, 

 Laparosopic findings  

consistent with PID

Pelvic Inflammatory Disease

 Treatment:

Multiple  outpatient antibiotic regimens; 

total therapy for 14 days.

A)CEFTERIAXON 500 mg im single dose and 
doxycycline 100 mg twice daily plus metronidazole 400 
mg twice daily.
B )ofloxacin 400 mg twice daily plus metronidazole twice 
daily.

Inpatient regimens in form of i.v. cefteriaxon 2g daily plus 
i.v. or oral doxycycline 100 mg BD followed by oral 
doxycycline 100 mg BD plus metronidazole 400 mg BD.

*laparoscopy to confirm the diagnosis

*drainage of abscess 

*treatement of concomitent diseases.

Infertility
Ectopic Pregnancy
Chronic Pelvic Pain
Occurs in 18-35% of women who develop PID
May be due to inflammatory process with development of pelvic 
adhesions

Pelvic Congestion Syndrome

 Description:  

Retrograde flow through incompetent 

valves venous valves can cause tortuous and 
congested pelvic and ovarian varicosities; Etiology 
unknown.

 Symptoms:  

Pelvic ache or heaviness that may 

worsen premenstrually, after prolonged sitting or 
standing, or following intercourse

 Diagnosis:  

Pelvic venogrpahy, CT, MRI, ultrasound, 

laparoscopy  

 Treatment:  

Progestins, GnRH agonists, ovarian vein 

embolization or ligation, and hysterectomy with 
bilateral salpingo-oophorectomy (BSO)

Pelvic Floor Pain Syndrome

 Description:  

Spasm and strain of pelvic floor muscles

 Levator Ani Muscles 
 Coccygeus Muscle
 Piriformis Miscle

 Symptoms:  

Chronic pelvic pain symptoms; pain in 

buttocks and down back of leg, dyspareunia

 Treatment:  

Biofeedback, Pelvic Floor Physical 

Therapy, TENS  (Transcutaneous Electrical Nerve 
Stimulation) units, antianxiolytic therapy, cooperation 
from sexual partner

Differential Diagnosis: 

Urological Conditions that may Cause or 

Exacerbate Chronic Pelvic Pain



Bladder Carcinoma



Interstitial Cystitis



Radiation Cystitis



Urethral Syndrome



Detrussor Dyssynergia



Urethral Diverticulum



Chronic Urinary Tract Infection



Recurrent Acute Cystitis



Recurrent Acute Urethritis



Stone/urolithiasis



Urethral Caruncle

Source: ACOG Practice Bulletin #51, March 

2004

Interstitial Cystitis

 Description:  

Chronic inflammatory condition of the bladder

 Etiology: 

Loss of mucosal surface protection of the 

bladder and thereby increased bladder permeability

 Symptoms:  

 Urinary urgency and frequency
 Pain is worse with bladder filling; improved with urination
 Pain is worse with certain foods
 Pressure in the bladder and/or pelvis
 Pelvic Pain in up to 70% of women
 Present in 38-85% presenting with chronic pelvic pain 

Interstitial Cystitis

 Diagnosis: 

 Cystoscopy with bladder distension 

 Presence of glomerulations (Hunner Ulcers) 

 Treatment:  

 Avoidance of acidic foods and beverages
 Antihistamines
 Tricyclic antidepressants
 Elmiron (pentosan polysulphate)
 Intravesical therapy: DMSO (dimethyl sulfoxide)

Differential Diagnosis: 

Gastrointestinal Conditions that may Cause or 

Exacerbate Chronic Pelvic Pain



Colon Cancer



Constipation



Inflammatory Bowel Disease



Colitis



Chronic Intermittent Bowel 
Obstruction



Diverticular Disease

Source: ACOG Practice Bulletin #51, March 

2004



Irritable Bowel Syndrome 

Irritable Bowel Syndrome (IBS)

 Description:  

Chronic relapsing pattern of abdominopelvic

pain and bowel dysfunction with diarrhea and constipation

 Prevalence

 Affects 12% of the U.S. population
 2:1 prevalence in women: men
 Peak age of 30-40

’s

 Rare on women over 50
 Associated with elevated stress level

 Symptoms

 Diarrhea, constipation, bloating, mucousy stools 
 Symptoms of IBS found in 50-80% women with CPP

Irritable Bowel Syndrome (IBS)

 Diagnosis based on Rome II 

criteria

 Treatment

 Dietary changes
 Decrease stress
 Cognitive Psychotherapy
 Medications

 Antidiarrheals
 Antispasmodics
 Tricyclic Antidepressants
 Serotonin receptor (3, 4) 

antagonists

 40 

– 50% of women with CPP have a history of 

abuse (physical, verbal , sexual)

Psychological Associations 

 Psychosomatic factors play a prominent role in CPP

 Approach patient in a gentle, non-judgmental manner

• Do not want to imply that “pain is all in her head”

 Psychotropic medications and various modes of 

psychotherapy appear to be helpful as both primary and 
adjunct therapy for treatment of CPP

 Chronic Pelvic Pain requires patience, understanding 

and collaboration from both patient and physician

 Obtaining a thorough history is key to accurate 

diagnosis and effective treatment

 Diagnosis is often multifactorial

– may affect more 

than one pelvic organ

 Treatment options often multifactorial

– medical, surgical, 

physical therapy, cognitive

Conclusions