The Initial Management of

Chronic Pelvic Pain

Green-top Guideline No. 41 May 2012 ( evidence-based summary )
ACOG update recommendations 2021
Presented by : Dr. Ikram Ahmed
Academic day June 18th 2023
  This guideline provides an evidence-based framework for the initial assessment of women
Aim with chronic pelvic pain.
 To help in deciding when to refer the patient and to whom.
Definitions  Chronic pelvic pain can be defined as:
intermittent or constant pain in the lower abdomen or pelvis of a woman of at
least 6 months in duration , not occurring exclusively with menstruation
or intercourse and not associated with pregnancy.
 It is a symptom not a diagnosis.
 Chronic pelvic pain presents in primary care as frequently as migraine or
low-back pain
 May significantly impact on a woman’s ability to function.
Possible etiological factors in genesis of chronic pain :
 Multifactorial.
 Assessment should aim to identify contributory factors rather than assign causality to a single
pathology.
 At the initial assessment, it may not be possible to identify confidently the cause of the pain.
 The most common associated conditions are endometriosis and bladder pain syndrome, which affect
between 60% and 70% of patients with chronic pelvic pain. Nearly one-half of patients with chronic
pelvic pain have both conditions.
 Other common conditions that affect at least one in five patients with chronic pelvic pain are irritable
bowel syndrome, interstitial cystitis, pelvic floor muscle tenderness, and depression.
Pain :
 a sensory and emotional experience associated with actual or potential tissue damage.
 The experience of pain will inevitably be affected by physical ,psychological and social factors.
 Central and peripheral nervous system
 Acute pain reflects fresh tissue damage and resolves as the tissues heal.
 In chronic pain , additional factors come into play and pain may persist long after the original tissue injury or exist in the
absence of any such injury.
 ‘visceral hyperalgesia’ modified pain perception.
Alteration in visceral sensation and function eg. (nerve damage post surgery, trauma, inflammation, fibrosis or infection)
 ' neuropathic pain ’ Pain as a result of changes in the nerve itself.
 Endometriosis and Adenomyosis
 Pelvic pain which varies markedly over the menstrual cycle (endometriosis).
 The cardinal symptoms of dysmenorrhoea,dyspareunia and chronic pelvic pain are said to be
characteristic of endometriosis. (D Evidence)
 Pelvic congestion syndrome
 existence of pelvic venous congestion as a cause of chronic pelvic pain remains controversial.
 There is no diagnosis and management for pelvic congestion
 Ovarian suppression , GnRH analogue is shown to effectively reduce pain in randomized
controlled trials.
 with 50% of women experiencing a worsening of their symptoms in association with their period -
cyclical pain is likely to be gynaecological in nature.
Adhesions
Two distinct forms of adhesive disease are recognized :
 residual ovary syndrome
a small amount of ovarian tissue inadvertently left behind following oophorectomy which may become
buried in adhesions.
 trapped ovary syndrome
a retained ovary becomes buried in dense adhesions post-hysterectomy.
 Removal of all ovarian tissue or suppression using a GnRH analogue may relieve pain.
 IBS and interstitial cystitis
 Symptoms suggestive of IBS or interstitial cystitis are often present in women with chronic pelvic pain.
 These conditions may be a primary cause of chronic pelvic pain, a component of chronic pelvic pain or
a secondary effect caused by efferent neurological dysfunction in the presence of chronic pain
 Rome III criteria for the diagnosis of IBS
Continuous or recurrent abdominal pain or discomfort on at least 3 days a month in the last 3 months, with
the onset at least 6 months previously, associated with at least two of the following:
 improvement with defecation
 onset associated with a change in frequency of stool
 onset associated with a change in the form of stool.
Symptoms such as abdominal bloating and the passage of mucus are commonly present and are suggestive of
IBS.
Extraintestinal symptoms such as lethargy, back ache, urinary frequency and dyspareunia may also occur in
association with IBS.
 Musculoskeletal
 Musculoskeletal pain may be a primary
source of pelvic pain or an additional
component resulting from postural changes.
 Pain may arise from the joints in the pelvis or
from damage to the muscles in the abdominal
wall or pelvic floor and Pelvic organ
prolapse.
 Clear evidence regarding diagnostic tests and
therapeutic options is lacking.
 Spasm of the muscles of the pelvic floor is
proposed as a cause of pelvic pain which
can be reduced by botulinum toxin
injections.
 Nerve entrapment

 Nerve entrapment in scar tissue, fascia or a narrow foramen may result in pain and dysfunction in the
distribution of that nerve.
 The incidence of nerve entrapment (defined as highly localized , sharp, stabbing or aching pain,
exacerbated by particular movements, and persisting beyond 5 weeks or occurring after a pain
free interval) after one Pfannenstiel incision is 3.7%
 Psychology and social issues

 Depression and sleep disorders are common in women with chronic pain. This may be a consequence rather
than a cause of their pain, but specific treatment may improve the woman’s ability to function.
 women with chronic pain in general are more likely to report physical or sexual abuse as children than pain-
free women.
 Those who experience chronic pelvic pain specifically are more likely to report sexual abuse than women
with another chronic pain complaint.
 using multiple regression analysis, it appears that child sexual abuse may be a marker for continuing
abuse and the development of depression, anxiety or somatization , which then predispose the individual
to the development or presentation of chronic pelvic pain.
the initial assessment of chronic pelvic pain
 Adequate time should be allowed for the initial assessment of women with chronic pelvic pain.
 Women with chronic pelvic pain want their experience to be heard and validated and they want to
receive personal care to help them understand and manage their pain.
 The multifactorial nature of chronic pelvic pain should be discussed and explored from the
start.
 The aim should be to develop a partnership between the clinician and the woman to plan a
management program.
 consider referral when the pain has not been explained to the woman’s satisfaction or when pain is
inadequately controlled.
History
 The initial history should include questions about the pattern of the pain and its association with
other problems, such as psychological, bladder and bowel symptoms, and the effect of movement
and posture on the pain.
 Symptoms alone may be used to diagnose IBS positively in this group.
Long-term follow-up of women in whom a positive diagnosis of IBS is made suggests that the diagnosis is
unlikely to be changed.
 any ‘red flag’ symptoms:
 Bleeding per rectum
 New bowel symptoms over 50 years of age
 New pain after the menopause
 Pelvic mass
 Suicidal ideation
 Excessive weight loss
 Irregular vaginal bleeding over 40 years of age
 Postcoital bleeding
 Completing a daily pain diary for two to three menstrual cycles may help the woman and the
doctor identify provoking factors or temporal associations.
 to establish the woman’s level of function at the start of treatment (e.g. time off work, avoiding
activities), both to monitor progress and to emphasize the value of functional goals.
 tools are also available for the detection of psychological comorbidity. However, simply enquiring
generally about things at home and symptoms such as sleep or appetite disturbance and tearfulness
may be enough.
 If the history suggests to the woman and doctor that there is a specific non-gynaecological
component to the pain, referral to the relevant healthcare professional – such as
gastroenterologist, urologist, genitourinary medicine physician, physiotherapist, psychologist or
psychosexual counsellor.
 Examination
 The assessment should include abdominal and pelvic examination, looking particularly for:
 focal tenderness,
 enlargement, distortion or tethering, or prolapse.
 Highly localized trigger points may be identified in the abdominal wall and/or pelvic floor.
 The sacroiliac joints or the symphysis pubis may also be tender, suggestive of a musculoskeletal origin
to the pain.
 Investigations

1 2 3 4 5

If PID suspected, TVS : may MRI: helps in Diagnostic CA125 :

and all women identify if adnexal diagnosing laparoscopy: has If sx: bloating,
who are sexually mass present, may adenomyosis. been regarded in persistent pain
active with help in diagnosing the past as the >12 months, urine
chronic pelvic adenomyosis . ‘gold standard’ in urgency or in
pain >> do the diagnosis of women >50 yrs
screening for chronic pelvic
STI , including pain.. .
chlamydia and
gonorrhea
 Investigations
 Screening for infection- STIs
particularly Chlamydia trachomatis and gonorrhea , if there is any suspicion of pelvic inflammatory disease (PID).
If PID is suspected clinically, it is best managed in conjunction with a genitourinary medicine physician.
 Transvaginal scanning (TVS) and MRI
TVS is an appropriate investigation to identify and assess adnexal masses. (endometrioma, hydrosalpinges or fibroids)
 TVS has little value for the positive identification of other causes of chronic pelvic pain, including peritoneal
endometriosis.
 Role in identifying those women who are less likely to obtain a positive diagnosis from a diagnostic laparoscopy.
 While MRI lacks sensitivity in the detection of endometriotic deposits, it may be useful in the assessment
of palpable nodules in the pelvis or when symptoms suggest the presence of rectovaginal disease.
 The sensitivities of MRI and TVS for the diagnosis of adenomyosis are comparable in the best hands.

 Diagnostic laparoscopy:
 ‘gold standard’ in the diagnosis of chronic pelvic pain.
 a second-line investigation if other therapeutic interventions fail.
 Diagnostic laparoscopy may have a role in developing the woman’s beliefs about her pain.
 it carries significant risks:
Estimated risk of death of 1 in 10 000, risk of injury to bowel, bladder or blood vessel of
approximately 2.4 in 1000, of whom two-thirds will require laparotomy
 One-third to one-half of diagnostic laparoscopies will be negative and much of the pathology
identified is not necessarily the cause of pain.
 Many women may feel disappointed that no diagnosis has been made leading to disengagement with
the medical process. (proper discussion and counselling)
showing women a photograph of their pelvis does not seem to affect their health beliefs or their
pain outcome.

CA125 :
 Women reporting any of the following symptoms persistently or frequently (more than 12 times per
month) :
bloating, early satiety, pelvic pain or urinary urgency or frequency.
 Particularly in women over the age of 50 years, any new IBS symptoms should prompt such action.
 Therapeutic options
 Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a
period of 3–6 months before having a diagnostic laparoscopy.
 Ovarian suppression can be an effective treatment for cyclical pain associated with endometriosis.
 achieved with the combined oral contraceptive, progestogens, danazol or GnRH analogues.
 The levonorgestrel-releasing intrauterine system, could also be considered, even in adolescents.
 Non-endometriosis-related cyclical pain also appears to be well controlled by these treatments.
 Women with IBS should be offered a trial with antispasmodics. and should be encouraged to amend
their diet to attempt to control symptoms.
Mebeverine hydrochloride - beneficial in the treatment where abdominal pain is a prominent feature.
 Analgesia :
 Women should be offered appropriate analgesia to control their pain even if no other therapeutic manoeuvres
are yet to be initiated.
 If pain is not adequately controlled, consideration should be given to referral to a pain management
team or a specialist pelvic pain clinic.
 Regular non-steroidal anti-inflammatory drugs with or without paracetamol may be particularly useful,
Compound analgesics such as co-dydramol may be appropriate.
 Adjuvant treatments such as amitriptyline or gabapentin may be useful in the treatment of neuropathic pain.
 Nonpharmacological modalities such as transcutaneous nerve stimulation, acupuncture and other
complementary therapies may be helpful for some women.
 Dietary modification may also relieve pain.
 Laparoscopic uterosacral nerve ablation (LUNA) is ineffective in the management of chronic pelvic pain.
SUMMARY
 Chronic pelvic pain is common, affecting 1/6 th of adult females.
 Etiology is unknown but could be multifactorial
 It’s a symptom not a diagnosis
 It is important to consider psychological and social factors
 Build good rapport, make patient feel they are heard, this may be therapeutic in itself
 Consider uncommon diagnosis, non gynecologic diagnosis and also possible IBS, STI
etc.
 Keeping a pain diary is helpful in tracking the pain
 If it seems cyclical>> try ovarian suppression and diagnostic laparoscopy to rule out
endometriosis and adenomyosis
 Other conditions such as IBS require specific treatment.
 Even if no explanation for the pain can be found initially, attempts should be made to
treat the pain empirically and to develop a management plan in partnership with the
woman.
QUESTIONS
 Chronic pelvic pain (CPP) is a common gynecologic problem.
Which of the following estimated percentages represents CPP prevalence in reproductive-aged
women?
A. 0.15 percent
B. 3 percent
C. 15 percent
D. 30 percent

ANSWER: C
 A 24-year-old diabetic woman undergoes a caesarean delivery o a healthy macrosomic baby girl. In the 2
years following delivery, the patient develops cyclic pain and swelling near her cesarean incision scar. This
suggests which o the following?
A. Vulvodynia
B. Endometriosis
C. Pelvic adhesions
D. Uterine leiomyoma

ANSWER: B
 In patients or whom specific pathology is not identified, medical management of chronic
pelvic pain can be directed toward alleviation o dominant symptoms. T is may involve the
use o which o the following?
A. Hormonal suppression
B. Antidepressants and anticonvulsants
C. Analgesics such as nonsteroidal anti-inflammatory drugs
D. All o the above

ANSWER: D
References

 GTG 2012
 ACOG 2021
 Williams gynecology – question bank