Abstract
Pelvic pain is one of the most difficult human conditions to diagnose and treat. The pelvis is composed of a complicated network of somatic and visceral nerves; connective tissues; as well as reproductive, urinary, and gastrointestinal organs. Pain in the pelvis can thus be from any of these areas. In order to diagnose and treat patient correctly it is very important to have a knowledge of all nongynecologic and gynecologic conditions leading to pelvic pain. Despite this knowledge, diagnosis may still be very difficult. Often very reexamining history and medical records may be helpful. In many patients pelvic floor is a main contributing factor to pelvic pain.
Editor’s Introduction
Pelvic pain is one of the most difficult human conditions to diagnose and treat. The pelvis is composed of a complicated network of somatic and visceral nerves; connective tissues; as well as reproductive, urinary, and gastrointestinal organs. Pain in the pelvis can thus be from any of these areas. In order to diagnose and treat patient correctly it is very important to have a knowledge of all nongynecologic and gynecologic conditions leading to pelvic pain. Despite this knowledge, diagnosis may still be very difficult. Very often reexamining history and medical records may be helpful. In many patients pelvic floor is a main contributing factor to the pelvic pain.
The pelvis has multiple functions such as providing support to the upper body, locomotion, evacuation of waste, childbirth, and sexual pleasure (from stimulation of both external and deep structures). The nerves innervating the pelvis and lower extremity often originate in the same segments of the spinal cord, such as in the case of pudendal and sciatic nerves; thus, by the mechanism of crosstalk, pain originating in one nerve may subsequently lead to pain in a neighboring nerve Additionally, muscles of the lower back and anterior and posterior thighs attach to the pelvis and often become affected themselves in patients with pelvic pain.
Coexistence and opposing functions (such as continence and evacuation) of the pelvic organs often make the diagnosis and treatment of pelvic pain difficult. For instance, patients often complain of pain related to their bladder; however, there is a big difference if pain is at the beginning of urination, during urination, or at the end. Each one of these is caused by a different condition.
Unlike in other parts of the body, coexistence of pain conditions in the pelvis is well described. In the mechanism of viscerosomatic convergence when a patient has a visceral source of pelvic pain, such as endometriosis implants on the pelvic organs, the surrounding muscles may become spastic and tender as the painful stimulus from the visceral organ travels. This is demonstrated by the high incidence of pelvic floor dysfunction and muscle spasm in women with endometriosis. In a similar vein, via the mechanism of viscerovisceral convergence, patients with one source of visceral pain may develop pain in another visceral organ, as seen in women with endometriosis and other coexisting pain syndromes such as interstitial cystitis/bladder pain syndrome (IC/BPS) or irritable bowel syndrome (IBS).
Another difficulty in treating pelvic pain is that there is no single medical specialty that routinely treats the condition. The majority of women with chronic pelvic pain see their primary gynecologist as the first provider for their complaint. Unfortunately, specialists in general obstetrics and gynecology receive minimal education in residency regarding pelvic pain. Thus, the majority of general gynecologists are most comfortable with medical management and simple surgery for endometriosis. Some may attempt to treat IC/BPS, but most rarely treat lesser known but common conditions such as pelvic floor dysfunction, intraabdominal adhesions, or pelvic congestion syndrome. Urologists are well trained to treat IC/BPS but very rarely address any other pain-causing conditions. Other physicians such as gastroenterologists, neurologists, general surgeons, and orthopedists rarely address pelvic pain at all. Physiatrists (physical medicine and rehabilitation physicians) and pelvic floor physical therapists with special training in the pelvic floor may in fact be the best equipped to address the needs of pelvic pain patients, as pelvic floor muscle spasm is the main cause of pain for the majority of these patients.
Despite best efforts, it has been shown that approximately 60% of women with chronic pelvic pain seen in a general Obstetrics and Gynecology practice do not receive a proper diagnosis and therefore cannot get proper treatment [1]. This percentage is possibly less for patients seen in a specialized pelvic pain practice or in a multidisciplinary practice; however, this number is unknown. Unfortunately, there are still some patients who will not receive the correct diagnosis even when seen at the most specialized practices. This chapter aims to provide guidance and suggestions on how to proceed when this occurs. In these cases, there is little scientific evidence on how to proceed and many statements in this chapter are from very extensive personal experience treating many patients with pelvic pain over several years.
Multiple Sources of Pain
Most patients with chronic pelvic pain have multiple sources of pain [2]. There are frequently coexisting conditions such as endometriosis with IC/BPS, IBS, and spastic pelvic floor syndrome or pudendal nerve injury with spastic pelvic floor syndrome. Ideally all sources of pain should be identified and treated in order to improve a patient’s pain. If all coexisting conditions are not addressed the patient will not be helped.
Think Pelvic Floor
The majority of physicians who see women for pelvic pain (gynecologists, urologists, gastroenterologists) are not familiar with pelvic floor muscle spasm, which is often a source or a contributing factor to pelvic pain [3]. Often patients with chronic pelvic pain undergo multiple laparoscopies and even hysterectomy, but their pain persists. More often than not they have spasm of the levator ani, obturator internus, and superficial pelvic muscles that is unrecognized and thus has never been addressed. Unfortunately, physicians don’t know what questions to ask, nor are they taught to properly examine for pelvic floor muscle spasm. If there is any doubt if the patient has pelvic floor muscle spasm she should be referred to a pelvic floor physical therapist.
| Causes of pelvic floor muscle spasm | Possible mechanism |
|---|---|
| Endometriosis | Viscerosomatic conversion. Visceral organs with implants of endometriosis are innervated through the same segment of the spinal cord as the pelvic muscles. If the viscera is irritated, the pelvic muscle may develop a spasm in response. |
| Pelvic trauma/surgery/mesh implantation | Direct trauma and irritation of the muscles. |
| Sexual and psychological trauma | Protective mechanism against penetration/rape. |
| Laxity of pelvic ligaments/joints | Increased laxity of pelvic joints may lead to overactivity and spasm of pelvic muscles to stabilize the joint. |
| Physical activity | Certain physical activity (gymnastics, ballet) may lead to overgrowth and increased tone of pelvic floor muscles. |
| Nerve compression | Nerve compression leads to significant pain that then causes reflex muscle spasm in the area close to the injured nerve (somatosomatic reflex). |
| Unknown | Possible genetic or anatomical predisposition to muscle spasm |
Repeat History
The most important component of diagnosis and evaluation of chronic pelvic pain is the history (Figure 21.1). Questions regarding the events that lead to the onset of pain are central to the diagnosis. Often, at the patient’s initial visit, when the history is taken for the first time, she may not remember all the events leading up to the start of her pain (Figure 21.2). Thus, it may be very beneficial to retake the history from the very beginning. Patients who complain of pain since menarche are more likely to have endometriosis. On the other hand, if their pain started with pregnancy, delivery, surgery, athletic activity, or trauma they most likely have another etiology causing their pain. Many patients with complex pain conditions have several reasons to have pain, and it is very important to identify all the sources of pain. Often pain from different sources may begin at different chronological points; thus obtaining a detailed history with a precise timeline is crucial. For example, pain caused by endometriosis, which often starts with onset of menstrual periods, with time may become related to physical and sexual activity. This usually signifies involvement of pelvic floor muscles. As time progresses the bladder may become affected and patients may begin complaining of nocturia and pain with a full bladder. In addition to taking a repeat history from the patient it is sometimes very helpful, with the patient’s permission, to talk to family members, especially parents or partners. People close to the patient may notice patterns that the patient herself may be unaware of. Another good technique, especially if the patient is referred from another physician, is to “start clean.” It may be more helpful to first obtain a full history directly from the patient before reviewing notes from another provider. This may allow the clinician a broader perspective and may prevent the clinician from coming to the same conclusion as prior providers.
Figure 21.1 Simplified diagnosis of pelvic pain based on the initial incident. IC/BPS, interstitial cystitis/bladder pain syndrome; PCFN, posterior cutaneous femoral nerve; PCS, pelvic congestion syndrome; PFTM, pelvic floor tension myalgia; PNE, pudendal nerve entrapment.
Figure 21.2 Simplified diagnosis of pelvic pain based on the nature of pain and additional symptoms.
Table 21.3 Review of patient’s history
| Onset of pain |
|
| Location |
|
| Aggravating factors |
|
| Alleviating factors |
|
| Sexual symptoms |
|
| Urinary symptoms |
|
IC/BPS, interstitial cystitis/bladder pain syndrome.
Determine if Pain Is Somatic or Visceral
If the etiology of the pain cannot be determined, it may be helpful to determine if pain is somatic or visceral. This may help later on to narrow down the pain to a specific location.
Pelvic pain may be nociceptive somatic, nociceptive visceral, or peripheral neuropathic. Often if pain has persisted for a long period of time through previously described mechanisms of viscerosomatic and viscerovisceral convergence, patients may have a mix of all of the above.
Reexamine Medical Records
Pelvic pain patients are usually seen by many providers before being seen by a pelvic pain specialist. In the process of working up their pain condition patients often undergo multiple tests, consultations, and procedures. Often, at the time of the first visit, patients will provide hundreds of pages of records from other providers and it is almost impossible to review those records in the allocated time for their visit. It is thus important to choose which records should be reviewed first, and those that may need to be reviewed at a later time.
| Nociceptive somatic | Nociceptive visceral | Peripheral neuropathic | |
|---|---|---|---|
| Location | Localized | Diffuse | Radiating |
| Characteristics | Pinprick, stabbing, sharp | Ache, pressure or sharp | Burning, shooting, tingling, numb, electric shock-like, or lancing |
| Mechanism | A-delta fiber located in the periphery | C fiber | Dermatomal innervation |
| Examples of medical treatment | Opioids and NSAIDs | Opioids and NSAIDs | Antidepressants, anticonvulsants, local anesthetics |
| Examples of surgical treatment | Trigger point injections | Resection of endometriosis, adhesiolysis | Neurolysis neurectomy |
| Examples in the pelvis | Spastic pelvic floor syndrome | Endometriosis, IC/BPS, IBS, abdominal/pelvic adhesions | Pudendal nerve entrapment |
IBS, irritable bowel syndrome; IC/BPS, interstitial cystitis/bladder pain syndrome; NSAIDs, nonsteroidal antiinflammatory drugs.
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