Gynecology: Chronic Pelvic Pain

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I. Characteristics. Unpleasant sensation or discomfort in the lower abdomen or pelvis with a duration of greater than 6 months, causing enough physical or psychological suffering to impair the quality of life. Patients usually report incomplete relief by most previous treatments, significantly impaired function at home or at work, signs of depression, pain out of proportion to pathologic condition, altered family roles. Many have a history of past sexual abuse.

II. Etiology. The biopsychosocial model proposes that precipitating organic symptoms combine with psychosocial variables to produce chronic debilitating pain. In 5% of cases no identifiable somatic source of pain can be found.

III. Sources of noncyclic pain.

A. Gynecologic disorders. Pelvic inflammatory disease, pelvic adhesions, and cervical stenosis.

B. Musculoskeletal disorders. Poor posture, scoliosis, unilateral standing habits, lumbar lordosis, leg-length discrepancy, abnormal gait, abdominal wall trigger points, history of low back trauma, levator syndrome of pain/pressure in the perirectal area.

C. Gastrointestinal tract disorders. Irritable bowel syndrome, chronic constipation, and diverticulitis.

D. Urinary tract disorders. Chronic urethritis, detrusor instability, recurrent cystitis, interstitial cystitis. Other unusual diagnoses may also provide a source of pain.

IV. Sources of cyclic pain. Mittelschmerz, primary and secondary dysmenorrhea, endometriosis, adenomyosis, cervical stenosis, intrauterine device, leiomyomas, PMS, obstructive uterine/vaginal malformation in adolescents.

V. Psychosocial factors. Major depression or anxiety disorders, somatoform disorders, sexual or physical abuse, dissociation disorders, post-traumatic stress disorder, marital stress, spouse response to patient’s pain, familial model of handling pain.

VI. History. A comprehensive history of the pain including cyclicity, association with sexual activity, pinpoint pain (trigger point), associated GI (e.g., such as irritable bowel) or urologic symptoms including bowel and urinary habits. A pain diary may be helpful. 2) Detailed sexual history including physical or sexual abuse. 3) Screen for depression , 4) Psychologic response to pain and its effect on lifestyle, family, and friends, 5) Previous abdominopelvic surgical procedures or episodes of PID.

VII. Evaluation.

A. Physical examination focusing on the abdomen and pelvis. The examiner should probe for abdominal wall trigger points and evaluate for musculoskeletal disorders and tenderness of the bladder, urethra, and other pelvic organs.

B. Lab tests. UA and urine culture, stool guaiac, Pap smear, cervical cultures. Laparoscopy, endoscopy, colonoscopy, barium enema if indicated. Patient-assisted laparoscopy under local anesthesia can provide "pain mapping."

VIII. Management: Once a pathologic cause of chronic pelvic pain is ruled out, provide symptomatic relief. Focus on breaking the biopsychosocial cycle of pain and disability. Try to manage rather than eliminate the pain (which is usually unlikely).

A. Analgesics. Scheduled dosing of an NSAID (ibuprofen, naproxen). PRN dosing increases attention to pain. Avoid narcotics, which exacerbate dysmotility syndromes and are addictive.

B. Trigger points can be injected with 5 to 10 ml of 0.25%-0.5% bupivacaine (may mix with 40 mg of triamcinolone). Repeat this Q2-4 weeks at first, followed by successively longer intervals until the nidus of pain resolves. Alternatives include TENS, acupuncture, and physical therapy.

C. Antidepressants. Low doses of tricyclic antidepressants (imipramine, amitriptyline, doxepin 10-25 mg, titrate to 75 mg if needed) taken at bedtime will decrease pain intensity, promote sleep and reduce depressive symptoms. May exacerbate constipation. For treatment of major depression, consider using an SSRI in addition, or increasing the tricyclic.

D. Functional bowel disorders. Use daily psyllium supplements (6 g daily or more) with increased dietary fiber to reestablish normal bowel motility. Psychotherapy may be helpful. Use antispasmodics (dicyclomine) only after thorough GI evaluation.

E. Psychologic therapies. Cognitive-behavioral therapy to control pain: relaxation techniques, stress management, and pain-coping strategies. Psychotherapy for mood disorders, eating disorders, abuse survivors, etc. Marital/family counseling, sex therapy, substance abuse treatment as indicated.

F. Ovarian cycle suppression for cyclic pain. Monophasic oral contraceptives, medroxyprogesterone acetate either injectable (Depo-Provera 150-300 mg Q3 months) or oral (10-30 mg QD).

G. Antibiotics if evidence of chronic endometritis, (positive cultures or endometrial biopsy), or for urethritis with pyuria. See appropriate section for management.

H. Surgical management. Diagnostic laparoscopy, lysis of adhesions, uterine suspension, uterosacral nerve ablation, presacral neurectomy, hysterectomy (high recurrence rate of pain).