Chronic Pelvic Pain

Abstract

Chronic pelvic pain (CPP) is a common pain syndrome in women worldwide, which can be difficult to manage by individual providers. CPP can result in significant debilitation and suffering for patients. A focused, systematic approach to the history and physical exam ensures that the patient’s clinical history is collected in an organized and thorough fashion. The differential diagnosis for CPP is extensive, and the causes of chronic pelvic pain are often complex and multifactorial. A systems-based approach to the differential diagnosis, guided by the patient’s clinical presentation, ensures that the provider does not miss a potential diagnosis. Treatment of CPP should target the most likely contributing causes. A trusting and caring primary care provider-patient relationship, a patient-centered approach, and the coordination of care with a team of specialists offer the best chance for successful treatment. These components are critical to ensure that all aspects of the patients’ symptoms are appropriately addressed and that treatment choices are complementary across disciplines. Patients should be counseled to understand that eradication of pain symptoms is unlikely to be a realistic outcome, but improvement in baseline pain level and quality of life are achievable with appropriate management.

Review Questions

• 1. A 30-year-old woman comes to your office reporting pelvic pain and vulvar irritation for the last 10 years that has been worsening over the last several weeks. She researched her symptoms online and took an over-the-counter antifungal for a presumed yeast infection. She is married and denies new sexual partners. She does report a long-standing history of burning pain with intercourse. There are no lesions on her external genitalia and bimanual exam is unremarkable. She reports severe pain from 4 o’clock to 7 o’clock along the posterior fourchette on cotton swab testing. Wet mount with 10% KOH of the vaginal discharge shows no evidence of candidal vaginitis. What is the first-line treatment of vulvodynia?

  • A. Nonsteroidal anti-inflammatory drugs

  • B. Vulvar care measures: wearing cotton underwear and avoiding vulvar irritants

  • C. Vestibulectomy

  • D. Topical lidocaine cream

  • E. Tricyclic antidepressants

  The correct answer is B. Vulvodynia is a chronic pain disorder that is defined as burning vulvar pain in the absence of relevant visible findings or a specific clinically identifiable neurological disorder. This is a diagnosis of exclusion, and treatable causes of vulvar pain, such as candidal vaginitis, must be ruled out. Other chronic skin conditions, such as lichen sclerosus, lichen planus, and vulvovaginal atrophy, should be first ruled out by careful visual examination of the vulva and perineum. Vulvar lesions may warrant biopsy in order to obtain a tissue diagnosis. Cotton swab testing along the perineum allows for mapping of the location and severity of the patient’s vulvodynia symptoms. First-line treatment for suspected vulvodynia includes lifestyle modifications with vulvar care measures that avoid vulvar irritants. Such measures include wearing 100% cotton underwear, avoiding perfumes/dyes in detergents or soaps, avoiding douching, cleaning the vulva with water only, keeping the vulvar area dry throughout the day and applying a preservative-free emollient daily, and rinsing and gently drying the vulva after urination. If lifestyle modifications do not result in improvements, then topical local anesthetics, estrogen cream, or topical tricyclic antidepressants may provide symptomatic relief. Oral tricyclic antidepressants or anticonvulsants may be incorporated as a third-line treatment. Nonsteroidal anti-inflammatory drugs usually provide minimal relief for chronic pain associated with vulvodynia. Surgical resection of the vestibule, or vestibulectomy, should be reserved for patients who have tried and failed medical management options [80, 87].

• 2. A 45-year-old multiparous woman presents to your office reporting pelvic pain since the birth of her last child 7 years ago. The pain is constant and sharp and radiates to her lower back. Her past medical history is significant for chronic constipation. She has not been sexually active for multiple years due to significant dyspareunia. Pelvic exam is limited due to discomfort. She has point tenderness along her left and right levator ani muscles. Which of the following is the most appropriate next step in the management of this patient?

  • A. Recommend strict pelvic rest.

  • B. Initiation of oral muscle relaxants.

  • C. Initiation of low-dose long-acting narcotics.

  • D. Referral to pelvic floor physical therapy.

  The correct answer is D. Pelvic floor muscle dysfunction or myofascial pain can often be diagnosed with history and physical exam. Often, the patient will report a history of painful intercourse, painful urination, and/or pain with defecation. Pelvic floor muscle dysfunction may result from either increased muscle tone (muscle spasms) or decreased muscle tone (myofascial laxity). The most commonly affected muscles are the levator ani, obturator, and piriformis muscles which are found deep within the pelvic floor. Patients with pelvic floor dysfunction may require an interdisciplinary team including a pelvic floor physical therapist, urogynecologist, primary care physician, and psychologist. The most important first step in the management of patients with suspected pelvic floor muscle dysfunction is referral of the patient to a certified pelvic floor physical therapist for confirmation of the diagnosis and treatment. Directed therapeutic exercise or myofascial release is recommended over strict pelvic rest, which may actually worsen the pelvic floor dysfunction. Oral muscle relaxants do not specifically target the pelvic floor muscles and are often associated with increased sedation; therefore, their use should be limited. Narcotics in general are unlikely to be effective in treating pelvic floor muscle dysfunction and may worsen the patient’s chronic constipation. Patients with pelvic floor muscle spasms, who are refractory to physical therapy, may benefit from pelvic floor injections [27, 28, 55, 56].

• 3. A 34-year-old multiparous woman presents to your office with progressively worsening lower abdominal and pelvic pain over the past year. She has a medical history significant for fibromyalgia and irritable bowel syndrome. She states that although she experiences the pain daily, her symptoms are worst during her menses and with intercourse. She also reports a history of heavy menstrual bleeding that has been increasing in severity over the past year. On pelvic exam, her uterus is normal size/shape and non-tender. However, she has tenderness in the posterior cul-de-sac and you appreciate tender fullness along the right adnexal region. Her pregnancy test is negative. What imaging study should be ordered first to evaluate her chronic pelvic pain?

  • A. Transvaginal ultrasound

  • B. Computed tomography of the abdomen and pelvis

  • C. Magnetic resonance imaging of the pelvis

  • D. Abdominal x-ray

  The correct answer is A. This patient’s symptoms of dysmenorrhea and acute worsening of her chronic pelvic pain with cul-de-sac tenderness and adnexal fullness is concerning for endometriosis. The gold standard for diagnosis of endometriosis is histologic confirmation with tissue biopsy. Radiographic evaluation for pelvic pain should identify structural causes for patient’s pain while minimizing unnecessary exposure to ionizing radiation. Transvaginal ultrasound is the optimal initial imaging modality for the evaluation of female pelvic pain because ultrasonography can delineate structural abnormalities within the uterus and adnexae without exposing the patient to radiation. Specifically, ultrasound can distinguish the characteristics of adnexal cysts as simple, complex, hemorrhagic, or endometrioma or exhibits features concerning for malignancy. Additionally, transvaginal ultrasound can be used to detect deep infiltrating endometriosis along the rectovaginal septum. Computed tomography (CT) rarely adds useful additional information to a pelvic ultrasound and exposes the patient to ionizing radiation and significantly increases cost. CT may be useful for further evaluation of patients with an adnexal mass with features concerning for malignancy. Magnetic resonance imaging (MRI) may provide better imaging of deep tissue structures; however, it is significantly more expensive than transvaginal ultrasound and unlikely to be an ideal first imaging study. None of the reproductive organs can be visualized with abdominal x-ray [88,89,90].