Chronic Pelvic Pain

Key Points

• Chronic pelvic pain is an indication for 40% of the laparoscopies in the United States.

• The four most common causes of chronic pelvic pain are endometriosis, pelvic adhesions, interstitial cystitis, and irritable bowel syndrome.

• Up to 70% of women with chronic pelvic pain have more than one cause for their pain.

Chronic pelvic pain is defined as noncyclic pain that lasts longer than 6 months. It occurs frequently, affecting up to 15 % of all women at some point in their reproductive years. Chronic pelvic pain is a diagnosis associated with up to 10%

of all outpatient gynecologic consultations, 40% of all lapa-roscopies, and 18% of all hysterectomies performed each year in the United States (Zondervan and Barlow, 2000). In 1990 the estimated cost of services related to chronic pelvic pain was $2 billion (Reiter, 1990).

Almost half of all women with chronic pelvic pain have a history of past sexual abuse or depression (Latthe et al., 2006). Women with a history of trauma have more severe symptoms (Meltzer-Brody et al., 2007). A recent meta-analysis of women with a history of abuse found an increased prevalence of functional bowel disorders, nonspecific chronic pain, and chronic pelvic pain (Paras et al., 2009). Drug and alcohol abuse are associated with an increased likelihood of pain (Latthe et al., 2006). There is no difference in prevalence based on race, ethnicity, education, or socioeconomic status (ACOG, 2004).

The etiology of chronic pelvic pain is frequently multifactorial and comes from multiple organ systems. Up to 70% of women have more than one cause of pain (Butrick, 2007). The most common gynecologic causes of chronic pelvic pain are endometriosis and pelvic adhesions. The most common gastrointestinal cause is irritable bowel syndrome, and the most common urologic cause is interstitial cystitis (Bordman and Jackson, 2006). In addition, many women who have chronic pelvic pain also have some myofascial pain from the pelvic floor muscles (Box 25-6).

Initial evaluation of a woman with chronic pelvic pain includes a careful history to determine any pattern of the pain that would lead to a possible diagnosis. For example, history of abdominal surgery increases the risk of pelvic adhesions. A complete medical, surgical, family, sexual, and psychological history should also be completed. It is important to determine how the pain is affecting the woman's daily life. The physical examination should include a general exam in addition to a thorough pelvic assessment. Every effort should be made to replicate the pain through a bimanual or rectovaginal examination.

Laboratory evaluation is focused on the likely diagnosis. Many women have a pelvic ultrasound for further evaluation of the pelvic anatomy. Ultimately, many women undergo a diagnostic laparoscopy to evaluate the etiology of the pain. Laparoscopy is normal in 35% to 40% of these women. Endometriosis is diagnosed in about 30% of women at laparoscopy, and adhesions are diagnosed in about 25% (Howard, 2000).

Treatment of a woman with chronic pelvic pain should be multimodal to address the multifactorial nature of her pain (ACOG, 2004; Stones et al., 2009). A strong physician-patient relationship is imperative as a basis for successful treatment. First-line treatment includes pain control with nonnarcotic medication. Hormonal manipulation with medroxypro-gesterone acetate, combined hormonal contraception, or gonadotropin-releasing hormone (GnRH) analogues can be effective treatments for endometriosis-related pain. GnRH analogues can only be used for up to 6 months because of side effects (e.g., menopausal symptoms, osteoporosis).

Laparoscopic treatment of endometriosis and lysis of dense adhesions are helpful in a subset of women. Lysis of adhesions that are not severe has not consistently decreased pain (ACOG, 2004). Hysterectomy is performed in women with untreatable pain and is most effective if accompanied by bilateral oophorectomy. Hysterectomy is major surgery with many potential complications but can cure some cases of pain related to endometriosis. Uterosacral nerve ablation

Box 25-6 Common Causes of Chronic Pelvic Pain

Gynecologic

Endometriosis

Pelvic adhesions

Pelvic congestion

Pelvic inflammatory disease

Adenomyosis

Vulvodynia

Uterine myomas

Gastrointestinal

Irritable bowel syndrome Inflammatory bowel disease Chronic constipation Colitis

Diverticulitis

Urologic

Interstitial cystitis Chronic urinary tract infections Urethral syndrome Radiation cystitis Urinary calculi

Musculoskeletal

Myofascial pain (abdominal wall or pelvic floor muscles) Fibromyalgia

Coccygeal or low back pain Nerve pain

Modified from Bordman R, Jackson B. Below the belt: approach to chronic pelvic pain. Can Fam Physician 2006;52:1556-1562; and Reiter RC. Chronic pelvic pain. Clin Obstet Gynecol 1990;33:117-118.

is not an effective method for treating idiopathic chronic pelvic pain (Daniels et al., 2009).

None of the above treatment modalities addresses the physiology of chronic pain. Several newer anticonvulsants (gabapentin, topiramate, valproic acid, pregabalin) and antidepres-sants, such as tricyclic antidepressants and selective serotonin reuptake inhibitors, have been successful in treating neuropathic pain from other sources. However, limited data are available in women with pelvic pain. Trigger point injections and botulinum toxin (Botox) injections in pelvic floor muscles show promise for treating myofascial pain (Gomel, 2007). Mul-tidisciplinary treatment teams should include mental health professionals and physical therapists as well as physicians.

KEY TREATMENT

Treatment of chronic pelvic pain should be multidisciplinary and include a mental health professional (Stones et al., 2009) (SOR: A). Uterosacral nerve ablation is not an effective method for treating idiopathic chronic pelvic pain. (Daniels et al., 2009) (SOR: A). First-line treatment includes pain control with nonnarcotic medication (ACOG, 2004) (SOR: A).

Hormonal manipulation with medroxyprogesterone acetate, combined hormonal contraception, or GnRH analogues can be effective treatments for endometriosis-related pain (ACOG, 2004) (SOR: A).

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