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Chronic pelvic pain is a common disorder of women that often presents a diagnostic dilemma. It is frequently difficult to cure or manage adequately. Many gynecologic and nongynecologic disorders appear to cause or be associated with chronic pelvic pain. Treatment usually is directed to specific diseases that cause chronic pelvic pain, but sometimes there is no clear etiology for pain, and treatment must be directed to alleviating the symptoms.
Definition and Prevalence
One proposed definition of chronic pelvic
pain is noncyclic pain of 6 or more months' duration that localizes to the
anatomic pelvis, anterior abdominal wall at or below the umbilicus, the
lumbosacral back, or the buttocks and is of sufficient severity to cause
functional disability or lead to medical care. A lack of physical findings does
not negate the significance of a patient's pain, and normal examination results
do not preclude the possibility of finding pelvic pathology.
Although the prevalence of chronic pelvic pain in the general population is not accurately established, available data suggest it is far more common than generally recognized. Approximately 15-20% of women aged 18-50 years have chronic pelvic pain of greater than 1 year's duration.
Etiology of Chronic Pelvic Pain
Potential sources of chronic pelvic
pain include the reproductive, genitourinary, and gastrointestinal tracts; the
pelvic bones, ligaments, muscles, and fascia. Chronic pelvic pain may result
from psychologic disorders or neurologic diseases, both central and peripheral.
Populations at Increased Risk of Chronic Pelvic Pain
Demographic
profiles of large surveys suggest that women with chronic pelvic pain are no
different from women without chronic pelvic pain in terms of age, race and
ethnicity, education, socioeconomic status, or employment status. Women with
chronic pelvic pain may be slightly more likely to be separated or divorced.
Women with chronic pelvic pain tend to be of reproductive age; however, age does
not appear to be a specific risk factor.
Physical and Sexual Abuse
Studies have found that 40-50% of women with
chronic pelvic pain have a history of abuse. Whether abuse (physical or sexual)
specifically causes chronic pelvic pain is not clear, nor is a mechanism
established by which abuse might lead to the development of chronic pelvic pain.
Endometriosis
Although endometriosis may be a direct cause of chronic
pelvic pain, it also may indirectly place women at increased risk for chronic
pelvic pain. For example, evidence suggests that women with endometriosis have
increased episodes and pain severity of urinary calculoses than women without
endometriosis. Similar results have been demonstrated for vaginal pain.
Interstitial Cystitis
Women with interstitial cystitis are at
significant risk of having chronic pelvic pain. Interstitial cystitis is a
chronic inflammatory condition of the bladder. It is clinically characterized by
irritative voiding symptoms of urgency and frequency in the absence of objective
evidence of another disease that could cause the symptoms.
Irritable Bowel Syndrome
Irritable bowel syndrome appears to be one of
the most common disorders associated with chronic pelvic pain. It seems to occur
much more commonly in women with chronic pelvic pain than in the general
population.
Obstetric History
Pregnancy and childbirth can cause trauma to the
musculoskeletal system, especially the pelvis and back, and may lead to chronic
pelvic pain. Although few well-designed trials have assessed the relationship,
historical risk factors associated with pregnancy and pain include lumbar
lordosis, delivery of a large infant, muscle weakness and poor physical
conditioning, a difficult delivery, vacuum or forceps delivery, and use of
gynecologic stirrups for delivery. Conversely, women who have never been
pregnant may have disorders that can cause both infertility and chronic pelvic
pain, such as endometriosis, chronic PID, or pelvic adhesive disease.
Past Surgery
A history of abdominopelvic surgery is associated with
chronic pelvic pain. Prior cervical surgery for dysplasia may cause cervical
stenosis, which has been associated with endometriosis. Additionally, among
women without preoperative pelvic pain, 3-9% develop pelvic pain or back pain in
the 2 years after hysterectomy. A recent case-control study suggests that
cesarean delivery also may be a risk factor for chronic pelvic pain.
Musculoskeletal Disorders
Musculoskeletal disorders as causes of or
risk factors for chronic pelvic pain have not been widely discussed in
gynecologic publications. They may be more important, however, than generally
recognized.
Diagnostic Studies
Up to two thirds of women with chronic pelvic pain
do not undergo diagnostic testing, never receive a diagnosis, and are never
referred to a specialist for evaluation or treatment.
Diagnostic Imaging
Transvaginal ultrasonography is particularly useful
for evaluation of the pelvis. In patients with a pelvic mass, ultrasonography
may help identify the origin of the mass as uterine, adnexal, gastrointestinal,
or from the bladder. Magnetic resonance imaging or computed tomography may be
useful in rare cases when ultrasound findings are abnormal.
Laparoscopy
Chronic pelvic pain is the indication for at least 40% of
all gynecologic laparoscopies. Endometriosis and adhesions account for more than
90% of the diagnoses in women with discernible laparoscopic abnormalities, and
laparoscopy is indicated in women thought to have either of these conditions.
When endometriosis is suspected on the basis of visual findings during
laparoscopy, biopsies and histologic confirmation of suspicious areas are
important because the visual diagnosis is incorrect in 10-90% of cases. Often,
adolescents are excluded from laparoscopic evaluation on the basis of their age,
but several series show that endometriosis is as common in adolescents with
chronic pelvic pain as in the rest of the population.
Clinical Considerations and Recommendations
Is there evidence to support the following medical approaches to treatment of chronic pelvic pain?
Antidepressants
Tricyclic antidepressants, such as imipramine,
amitriptyline, desipramine, and doxepin, have been shown in placebo-controlled
studies to improve pain levels and pain tolerance in some, but not all, chronic
pain syndromes. It is not clear how effective other antidepressants, such as
SSRIs, are in the treatment of chronic pain syndromes.
At this time, evidence is insufficient to substantiate efficacy of antidepressants for the treatment of chronic pelvic pain. Nonetheless, the substantial association of depression with chronic pelvic pain supports the use of antidepressants for the specific treatment of depression.
Local Anesthetic Injection of Trigger Points
Chronic pain
syndromes associated with myofascial trigger points have been clinically
recognized for quite some time. Observational data on the use of local
anesthetic injection of trigger points of the abdominal wall, vagina, and sacrum
for relief of chronic pelvic pain have demonstrated a response rate of 68%.
Analgesics
Extensive evidence demonstrates that nonsteroidal
antiinflammatory drugs relieve various types of pain. No clinical trials have
addressed chronic pelvic pain specifically, but moderate analgesic efficacy, as
shown for other types of pain, would be anticipated.
Is there evidence to support the use of hormonal therapy for treatment of chronic \ pelvic pain?
Combined Oral Contraceptives
Oral contraceptives provide
significant relief from primary dysmenorrhea. They suppress ovulation, markedly
reduce spontaneous uterine activity, stabilize estrogen and progesterone levels,
abrogate menstrual increases in prostaglandin levels, and reduce the amount of
pain and symptoms associated with menses. These effects also are thought to make
oral contraceptives effective in the treatment of other gynecologic pain
disorders. Oral contraceptives often are recommended for
endometriosis-associated chronic pelvic pain, but there are limited data from
clinical trials to support this recommendation.
Gonadotropin-Releasing Hormone Agonists
Gonadotropin-releasing
hormone agonists available in the United States are nafarelin, goserelin, and
leuprolide. Numerous clinical trials show GnRH agonists are more effective than
placebo and as effective as danazol in relieving endometriosis-associated pelvic
pain.
Progestins
Clinical trials suggest progestins are effective in the
treatment of chronic pelvic pain associated with endometriosis and pelvic
congestion syndrome.
What is the evidence for efficacy of proposed nonmedical treatments? Many modalities of treatment other than medications and surgery have been recommended for chronic pelvic pain, including exercise, physical therapy, and dietary modifications. Very few of these treatments have been studied in clinical trials.
Physical Therapy
Observational studies suggest various physical
therapy modalities are effective for pain relief. Electrotherapy, fast- and
slow-twitch exercises of the striated muscles of the pelvic floor, and manual
therapy of myofascial trigger points in the pelvic floor have shown improvement
of pain in 65-70% of patients.
Are surgical approaches effective for treatment of chronic pelvic pain?Various surgical treatments aimed primarily at treating endometriosis, including excision or destruction of endometriotic tissue and hysterectomy, have been proposed to relieve chronic pelvic pain. Other surgical approaches also have been considered.
Excision or Destruction of Endometriotic Tissue
It is suggested
that conservative surgical treatment of endometriosis results in significant
pain relief for 1 year in 45-85% of women.
Hysterectomy
Although based only on observational studies, it
appears that at least 75% of women who have a hysterectomy for chronic pelvic
pain thought to be caused by gynecologic disease experience pain relief at 1
year of follow-up.
Adhesiolysis
Adhesions are commonly thought to be a potential
cause of chronic pelvic pain, and evidence from conscious laparoscopic pain
mapping suggests some women have painful adhesions. Observational studies
suggest that up to 85% of women improve after adhesiolysis.
Nerve Stimulation
Sacral nerve stimulation is beneficial in the
treatment of chronic voiding dysfunction. Its use in women with voiding
dysfunction and chronic pelvic pain has suggested potential efficacy for
treatment of chronic pelvic pain. Uncontrolled studies of sacral nerve
stimulation in women with chronic pelvic pain and no voiding disorder suggest
that 60% of women show significant improvement in their pain levels.
Is counseling or psychotherapy effective for treatment of chronic pelvic
pain?
Psychosomatic factors appear to have a prominent role in chronic
pelvic pain, which suggests that psychiatric or psychologic evaluation and
treatment should be routine in women with chronic pelvic pain. Various modes of
psychotherapy, including cognitive therapy, operant conditioning, and behavioral
modification, appear to be helpful in women with chronic pelvic painbut most of
the data are observational or include psychotherapy as part of multidisciplinary
treatment.
Are complementary or alternative medicine therapies effective for treating chronic pelvic pain?
Herbal and Nutritional Therapies
Treatment of dysmenorrhea has
been studied in clinical trials of magnesium, vitamin B6, vitamin B1, omega-3
fatty acids, and a Japanese herbal combination (Japanese angelica root, peony
root, hoelen, atractylodes lancea root, alisma root, cnidium root). Vitamin B1
and magnesium were significantly more effective than a placebo in numerous
studies, but data were insufficient to recommend the other therapies for
dysmenorrhea.
Magnetic Field Therapy
The application of magnets to abdominal
trigger points appears to improve disability and reduce pain when compared with
placebo magnets. However, only one clinical trial evaluated the use of magnet
therapy, and it had significant methodologic flaws.
Acupuncture Clinical trials evaluating the efficacy of acupuncture, acupressure, and transcutaneous nerve stimulation therapies have been performed only for primary dysmenorrhea, not for nonmenstrual pelvic pain. All 3 modalities are better than placebo in the treatment of dysmenorrhea.