54 Janesh Gupta Centre for Women’s and Newborn Health, Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham Women’s Hospital, Birmingham, UK Pain perception is subjective, multifactorial and involves complex physical, biochemical, emotional and social interactions. Somatic pain is usually sharp and unilateral whereas visceral pain is duller, aching, bilateral or localized to the midline. Chronic pelvic pain (CPP) is defined as non‐cyclical pain lasting for more than 6 months, localized to the anatomical pelvis and anterior abdominal wall, at or below the umbilicus, or to lumbo‐sacral back and buttocks of sufficient severity to cause functional disability or lead to medical intervention [1]. CPP is a broad term with varied presentations and has a significant impact on quality of life. It may present as dysmenorrhoea, dyspareunia, vulvodynia, non‐specific pelvic pain, musculoskeletal pain, intestinal cramps or dysuria [2]. CPP is associated with long‐standing mental health problems, with reported increased rates of anxiety, depression, somatic disorders, disturbed concentration and insomnia [3]. In primary care settings, CPP has a similar prevalence to migraine, back pain and asthma [4] and postmenopausal women have also reported a substantial burden of CPP [5]. In the literature the incidence and prevalence of CPP are reported in an inconsistent manner which makes comparison and discussion difficult. It is recognized that in England it can take several years for a patient’s persistent chronic pain condition to be recognized and even longer before management is provided in a secondary care setting [6]. Chronic post‐surgical pain may develop after any surgical procedure, and is a common feature after abdominal and pelvic surgery, with a prevalence varying between 10 and 40% [7]. CPP is a symptom and not a diagnosis but it has to be regarded as a disease in its own right and requires attention accordingly. This involves multidisciplinary care, which differs from the organ‐centred view. Pain associated with a well‐described disease process requires that the disease be treated as a priority. Pain management is therefore a vital component and may reduce chronicity. In most instances the diagnosis is derived from clinical history rather than relying upon examination and investigations. An empathic consultation and acknowledging the presenting complaints can in themselves be therapeutic; furthermore, a comprehensive neurological, myofascial and postural assessment should be carried out. Overall, pain relief, though paramount, is not the only goal of treatment. Improvement in quality of life is also equally important. Clinical history is an integral part of management as it not only helps to find the possible cause or predisposing factor but also helps in understanding the impact on quality of life and the patient’s expectations from treatment. Table 54.1 presents a classification of causes of CPP that should be borne in mind while undertaking the clinical assessment. Table 54.1 Classification of the causes of chronic pelvic pain. Clinical history needs to include the onset and duration of symptoms, the location and radiation of pain, factors associated with exacerbation and relief, and the relationship of pain to the menstrual cycle. Dysmenorrhoea may be a separate or related symptom. The intensity of dysmenorrhoea can sometimes warn of the possibility of specific pathology such as endometriosis. Dyspareunia may include pain during intercourse, but for many women a particularly unpleasant symptom is post‐coital pain and a specific enquiry about this should be made. One should also explore the temporal relationship of pain with events like labour and delivery, which could have damaged the pelvic floor, or surgery which could have caused adhesions or nerve damage leading to pain. A history of subfertility hints at a diagnosis of endometriosis. Earlier studies showed a history of sexual abuse in more than half of patients with CPP [8]. Many women with chronic abdominal or pelvic pain will turn out to have irritable bowel syndrome (IBS) as their primary problem [9]. These patients do not have good outcomes following (inappropriate) gynaecological referral and investigation [10]. Therefore, it is particularly important that a detailed history is taken of bowel symptoms. The Rome II criteria [11] for the clinical diagnosis of IBS in those with chronic pain include at least two of: Abdominal bloating in association with acute exacerbations of pain is indicative, but needs to be distinguished from menstrual cycle‐related bloating. While dyspareunia is not likely to be due solely to IBS, bowel spasm may account for the experience of those patients who describe an interval between the end of intercourse and the onset of acute pain associated with the urge to defecate and abdominal distension [12]. Bladder symptoms also form an important part of the systems review. Urinary frequency and urgency, but most importantly exacerbation of pain associated with a full bladder, may indicate the presence of interstitial cystitis, a neurogenic inflammatory condition of the bladder associated with chronic pain. As with IBS, it has been suggested that a proportion of women with CPP seen by gynaecologists are in fact suffering from unrecognized interstitial cystitis on the basis of potassium chloride sensitivity testing [13]. As pain is subjective, attempts to quantify can be made using a number of validated pain assessment measures, such as a 10‐cm visual analogue scale (VAS) where one end is marked ‘no pain’ and the other end is the ‘worst imaginable pain’ [14]. There are also specific questionnaires available from the International Pelvic Pain Society (https://pelvicpain.org/home.aspx). Health‐related quality of life can be measured using a generic instrument such as EuroQoL EQ‐5D (measured on a scale of −0.59 to 1 based on responses to five questions about life quality) or the EQ‐VAS scale (measured on a 0–100 scale) [15]. Other generic quality‐of‐life measures such as the SF‐36 (http://www.sf‐36.org/tools/sf36.shtml) or the shorter SF‐12 can also be used. Observing how a patient walks into the consulting room can provide a clue to the diagnosis. Pelvic pain that is predominantly secondary to musculoskeletal origins can lead to the typical pelvic pain posture, with lordosis and concomitant kyphosis. On examination, musculoskeletal symphysial tenderness may be noted in such women. Abdominal wall pain has been proposed as a defining new test, where there is abdominal wall tenderness with a positive Carnett test (i.e. tenderness that worsens or remains the same with abdominal wall contraction). The prevalence in women with pelvic pain was 67% and was independently associated with CPP (odds ratio, OR 13.8, 95% CI 3.71–51.2; P <0.001) but not with other symptoms including dysmenorrhoea, deep and superficial dyspareunia, or bowel and bladder symptomology. The women with abdominal wall pain were more likely to require opioids or pain adjuvants than women without it (P = 0.015 and P <0.001) [16]. Careful inspection of the abdomen can reveal previous surgical scars, which could suggest pain from adhesions or nerve entrapment. ‘Trigger point’ tenderness elicited by palpation with one finger suggests a nerve entrapment, often involving the ilioinguinal or iliohypogastric nerves. Hernial sites should be examined carefully. On palpation, abdomino‐pelvic masses may be noted. It is useful to ask the patient to point to the area of maximum pain and encircle the area where the pain spreads. The diagnosis is confirmed by infiltration of local anaesthetic such as bupivacaine into the tender area. Interestingly, the duration of relief is often much longer than the action of the local anaesthetic, perhaps because surrounding muscles are induced to relax and are no longer pulling on the sensitive area. Local examination of the perineum should be carried out after obtaining verbal consent and in the presence of a chaperone. Vulval erythema may suggest infection, whilst thinning is suggestive of lichen sclerosus. In cases of vulvar vestibulitis, there can be local redness near the vestibular gland. The presence of vulval or lower limb varicosities is associated with pelvic vein incompetence. During vaginal examination, tenderness on palpation of the pelvic floor muscles could suggest myofasciitis of the pelvic musculature, whereas deep fornicial tenderness with nodularity on palpation could suggest chronic inflammatory disease or endometriosis. The uterus should be palpated for size, mobility and tenderness. Palpation of the adnexa may reveal masses like endometriomas or there can be tenderness in the adnexa due to pelvic congestion syndrome (see later). Investigations largely depend on the diagnosis suggested by history and examination. A few basic tests may be required, such as urine microscopy and sensitivity to rule out infection and a full blood count to rule out anaemia and infection. Culture swabs to exclude sexually transmitted infections such as Chlamydia are useful. If symptoms suggest, tests may be required to rule out diabetes or hypothyroidism. An ultrasound examination may be useful in identifying uterine or adnexal pathology and has been shown to be an effective means of providing reassurance [17,18]. Laparoscopy has commonly been undertaken as the primary investigation for CPP. The aims are to give a diagnosis but also to provide ‘one‐stop’ treatment for endometriosis and adhesions where these are identified. This approach is cost‐effective for endometriosis treatment, as the expense of a second procedure or hormonal treatment is obviated [19]. This method is being challenged by a current study to assess if MRI can replace or triage the need for laparoscopy in women presenting with CPP (MEDAL study: http://www.nets.nihr.ac.uk/projects/hta/092250). The results are awaited. Conscious pain mapping by laparoscopy has been used at some centres and found useful in cases where examination and imaging were inconclusive, with a majority of patients showing some improvement in VAS pain scoring [20–22]. However, these studies have been small and there are no randomized controlled trials to suggest that this technique should be implemented into routine practice. Medroxyprogesterone acetate (MPA) has been used extensively but is only effective after 4 months’ treatment as reflected in pain scores (OR 2.64, 95% CI 1.33–5.25; N = 146] and a self‐rating scale (OR 6.81, 95% CI 1.83–25.3; N = 44), but benefit was not sustained 9 months after treatment [23,24]. MPA plus psychotherapy was effective in terms of pain scores (OR 3.94, 95% CI 1.2–12.96; N = 43) but not the self‐rating scale at the end of treatment. Benefit was not sustained following treatment. Venography scores, symptom and examination scores, mood and sexual function were improved to a greater extent 1 year after treatment with the GnRH analogue goserelin compared with progestogen [25]. No improvement in pain scores was seen in women taking the selective serotonin reuptake inhibitor sertraline compared with placebo. The SF‐36 subscale ‘health perception’ showed a small improvement in the sertraline arm, while the ‘role functioning–emotional’ subscale showed a large fall in the sertraline arm [26]. Previously, laparoscopic uterosacral nerve ablation (LUNA) was commonly performed for the treatment of CPP. However, a large and well‐designed randomized controlled trial showed that this technique did not lead to any improvement in pain, dysmenorrhoea, dyspareunia or quality of life [27]. Intraperitoneal adhesions can form de novo or following a surgical procedure. Diamond et al. [28] distinguished two types of postoperative peritoneal adhesions. Type 1, or de novo adhesion formation, involves adhesions formed at sites that did not have previous adhesions, and includes type 1A (no previous operative procedure at the site of adhesion) and type 1B (previous operative procedures at the site of adhesion). Type 2 involves adhesion reformation, with two separate subtypes: type 2A (no operative procedure other than adhesiolysis at the site of adhesion) and type 2B (other operative procedures at the site of adhesions). Each surgeon defines adhesions on an individual basis contingent on the surgeon’s own experience and capability. A peritoneal adhesion index has been described and is based on the macroscopic appearance of adhesions and their extent in the different regions of the abdomen. The abdomen is divided into nine quadrants and bowel‐to‐bowel adhesions are also noted. Each area is given a grade: grade 0, no adhesions; grade 1, flimsy adhesions requiring blunt dissection; grade 2, strong adhesions requiring sharp dissection; and grade 3, very strong vascularized adhesions requiring sharp dissection with damage hardly preventable. Using specific scoring criteria, clinicians can assign a peritoneal adhesion index ranging from 0 to 30, thereby giving a precise description of the intra‐abdominal condition [29]. There is no definite relationship between adhesions and pain. Usually, peritoneal adhesions, or flimsy adhesions which allow movement between two structures, cause little pain [30]. Traditionally, laparoscopy has been the only way of diagnosing and treating adhesions. Recently, transvaginal ultrasound has been suggested for the diagnosis of adhesions based on ovarian mobility [31,32]. It is controversial to surgically treat adhesions to decrease pain as adhesiolysis itself has an inherent risk of adhesiogenesis. A large Dutch trial randomizing both men and women to adhesiolysis or no treatment found no difference between the groups. There was a small possible difference in those undergoing adhesiolysis with dense vascular adhesions but the sample size was small for conclusive results [33]. A recent systematic review examining the efficacy of adhesiolysis for the treatment of chronic pain showed that the benefit of intervention varied from 16 to 88%, with the majority of studies reporting pain relief in more than 50% of cases. However, there was a high risk of bias in most of the studies [34,35]. Therefore, it is important to take steps to minimize adhesion formation in the first place. The use of hyaluronic acid derivatives, polyethylene glycol (PEG)‐based derivatives and solid barrier agents derived from oxidized regenerated cellulose (Interceed) during laparoscopy or laparotomy in benign gynaecological surgery is supported by only limited evidence and their use should perhaps not be continued [36,37].
Chronic Pelvic Pain
Clinical history
Inflammatory, infective: chronic salpingitis
Inflammatory, non‐infective: endometriosis, vulvodynia with dermatosis
Mechanical: uterine retroversion, adhesions
Functional: pelvic congestion, irritable bowel syndrome
Neuropathic: post‐surgical, dysaesthetic vulvodynia, vulval vestibulodynia (‘vestibulitis’)
Musculoskeletal: pelvic floor myalgia, abdominal and pelvic trigger points, postural muscle
Examination
Investigations
Management
Medical therapy
Surgical therapy
Adhesiolysis
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
