34 Chronic Pelvic Pain Robert L. Barbieri Chronic pelvic pain refers to menstrual or nonmenstrual pain of at least 6 months duration occurring below the umbilicus. Common gynecologic symptoms associated with chronic pelvic pain include dysmenorrhea (pain with menses), dyspareunia (pain with sexual intercourse), dyschezia (pain associated with bowel movements), and pain not associated with menses or intercourse. Vulvar and vaginal introitus pain occasionally occurs in combination with pelvic pain. Chronic pelvic pain is commonly associated with bladder and bowel symptoms including frequent and/or painful urination, diarrhea, constipation, and bloating. Chronic pelvic pain is a symptom, not a specific disease diagnosis. Chronic pelvic pain may be caused by gynecologic causes such as pelvic inflammatory disease, endometriosis, adenomyosis and uterine fibroids (Table 34.1). Nongynecologic causes of chronic pelvic pain include irritable bowel syndrome, bladder pain syndrome (interstitial cystitis), diverticulitis, and fibromyalgia. Mental health issues such as depression, anxiety, somatization, narcotic dependency, and a history of physical, psychological, or sexual abuse may contribute to the onset and severity of chronic pelvic pain. The gynecologic causes of chronic pelvic pain are reviewed in their individual chapters. The most common nongynecologic causes of chronic pelvic pain are reviewed below.
Definition
Diagnosis
| Gynecologic causes | Endometriosis |
| Pelvic inflammatory disease and adhesions | |
| Adenomyosis | |
| Fibroids (leiomyoma) | |
| Ovarian cancer | |
| Primary and secondary dysmenorrhea | |
| Urinary tract causes | Interstitial cystitis/painful bladder syndrome |
| Chronic urethral syndrome | |
| Bladder neoplasia | |
| Gastrointestinal causes | Irritable bowel syndrome |
| Inflammatory bowel disease | |
| Diverticular colitis | |
| Colon cancer | |
| Chronic intestinal pseudo-obstruction | |
| Constipation | |
| Celiac disease | |
| Musculoskeletal causes | Fibromyalgia |
| Pelvic foor muscle spasm | |
| Mental health issues related to chronic pain | Substance abuse |
| Sexual and physical abuse | |
| Depression and anxiety | |
| Somatization |
Irritable Bowel Syndrome
A diagnosis of irritable bowel syndrome is likely in patients who have abdominal or pelvic pain with two or more associated symptoms such as: pain relieved by defecation; pain associated with looser or more frequent stools; abdominal distention; mucus in the stool; or feeling of incomplete evacuation. About 35% of women with chronic pelvic pain also have irritable bowel syndrome.
Bladder Pain Syndrome (Interstitial Cystitis)
This syndrome is characterized by bladder pain of variable severity that persists over a prolonged period. It is diagnosed by the presence of chronic pain related to the urinary bladder accompanied by at least one additional urinary symptom such as daytime and nighttime urinary frequency, with exclusion of other causes such as urinary tract infection.
Musculoskeletal Causes
Fibromyalgia is a chronic pain condition that presents with diffuse musculoskeletal pain. Excessive tenderness in 11 or more of 18 musculoskeletal areas is considered diagnostic. Myofascial pain syndromes are a musculoskeletal cause of chronic pain that is confined to one anatomical region. Palpation of a trigger point produces a characteristic and reproducible pain pattern. About 15% of women with chronic pelvic pain meet the criteria for myofascial pain syndrome.
Prevalence and Epidemiology
In a survey of the medical records of 284 000 female patients, from 12 to 70 years of age in the United Kingdom, 3.8% had a diagnosis of chronic pelvic pain. Chronic pelvic pain accounts for about 10% of all referrals to gynecologists, 15% of all hysterectomy procedures, and 40% of gynecological laparoscopy procedures.
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