Chronic Pelvic Pain

Original Editors - Nina Lefeber

Top Contributors - Nina Lefeber, Laura Ritchie and Andeela Hafeez  


[See also Pregnancy Related Pelvic Pain]

[See also Chronic Pelvic Pain Syndrome - Male]

Definition/Description

Pelvic Floor Muscles.jpg
Chronic pelvic pain (CPP) is commonly defined as nonmalignant intermittent or continuous pain in the lower abdomen, pelvis or intrapelvic structures, lasting at least 3–6 months.[1] If nonacute and central sensitization pain mechanisms are present, the condition is considered chronic, regardless of the time frame.[2] Central sensitization is characterized by amplification or increased sensory perception, where stimuli that are normally not painful are now perceived as painful.[3] CPP is in women not exclusively associated with the menstrual cycle, sexual intercourse or pregnancy[1], but is sufficiently severe to cause functional disability or to lead to medical care.[4]

Clinically Relevant Anatomy

Piriformis, gemmeli, obturator, quadratus femoris.PNG

Epidemiologically CPP has a greater incidence in women than in men, and is mostly present between the ages of 36 and 50 years.[2] The etiology of CPP however is not clear. It can be difficult and complex to determine the cause of pain; in fact, no specific cause may be discovered. Many women are not able to identify a specific set of problems which can cause the problems and allowing for the diagnosis to be made.[5] CPP may originate from one or more organ systems or pathologies and may have multiple contributing factors. It usually involves an interaction between the gastrointestinal, urinary, gynecologic, musculoskeletal, neurologic and endocrine systems. It can also be influenced by psychological and sociocultural factors.[4]

Characteristics/Clinical Presentation

Chronic pelvic pain has numerous presentations, and women with the same problem may exhibit different characteristics. Common symptoms include:

  • constant severe pelvic pain
  • intermittent pain
  • sharp or cramping pain
  • dull aching
  • pressure

Many women miss work, have difficulty doing non strenuous exercises, and have difficulty sleeping. The level of pain can vary greatly and can contrast from mild to disabling.[5]

Differential Diagnosis

Table 1.Selected Differential Diagnoses of Chronic Pelvic Pain by Organ System[6]
Gastrointestinal Celiac disease, colitis, colon cancer, inflammatory bowel disease, irritable bowel syndrome
Gynecologic Adhesions, adenomyosis, adnexal cysts, chronic endometritis, dysmenorrhea, endometriosis, gynecologic malignancies, leiomyomata pelvic congestion syndrome, pelvic inflammatory disease
Musculoskeletal Degenerative disk disease, fibromyalgia, levator ani syndrome, myofascial pain, peripartum pelvic pain syndrome, stress fractures
Psychiatric/neurologic          Abdominal epilepsy, abdominal migraines, depression, nerve entrapment, neurologic dysfunction, sleep disturbances, somatization
Urologic Bladder malignancy, chronic urinary tract infection, interstitial cystitis, radiation cystitis, urolithiasis
Other Familial Mediterranean fever, herpes zoster, porphyria

 

Diagnostic Procedures

[7]Pelvic exam. This can reveal signs of infection, abnormal growths or tense pelvic floor muscles. Your doctor checks for areas of tenderness and changes in sensation. Let your doctor know if you feel any pain during this exam, especially if the pain is similar to the discomfort you've been experiencing.
Cultures. Lab analysis of cell samples from your cervix or vagina can detect infections, such as chlamydia or gonorrhea.
Ultrasound. This test uses high-frequency sound waves to produce precise images of structures within your body.
Other imaging tests. Your doctor may recommend abdominal X-rays, computerized tomography (CT) scans or magnetic resonance imaging (MRI) to help detect abnormal structures or growths.
Laparoscopy. During laparoscopy, your doctor makes a small incision in your abdomen and inserts a thin tube attached to a small camera (laparoscope). The laparoscope allows your doctor to view your pelvic organs and check for abnormal tissues or signs of infection in your pelvis. This procedure is especially useful in detecting endometriosis and chronic pelvic inflammatory disease.Laparoscopy is an invaluable tool in the diagnosis of CPP in adolescents and should be performed before starting a psychiatric evaluation or prescribing long-term medical treatment.[7]

Outcome Measures

http://www.womenshealthapta.org/wp-content/uploads/2013/12/Pelvic-Girdle-Questionnaire.pdf

Medical Management

Treatment of chronic pelvic pain (CPP) is complex in patients with multiple problems.[8]

  • Initially, pain may respond to simple over-the-counter (OTC) analgesics such as paracetamol, ibuprofen, aspirin, or naproxen. If treatment results are unsatisfactory, the addition of other modalities or the use of prescription drugs is recommended.
  • If possible, avoid use of barbiturate or opiate agonists. Also discourage long-term use and overuse of all symptomatic analgesics because of the risk of dependence and abuse.
  • Tizanidine may improve the inhibitory function in the central nervous system and can provide pain relief. Therapy with tizanidine is not considered the standard of care
  • Amitriptyline (Elavil) and nortriptyline (Pamelor) are the tricyclic antidepressants (TCAs) used most frequently for chronic pain.
  • The selective serotonin reuptake inhibitors (SSRIs) fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) also are commonly prescribed. Other antidepressants such as doxepin, desipramine protriptyline, and buspirone also can be used.[9]

Physical Therapy Management

The optimal treatment of CPP is based on a biopscychosocial model delivered by a multidisciplinary approach. This multidisciplinary treatment concludes oral analgesics and other medications, pain management, pelvic floor rehabilitation, nerve stimulation therapies, teaching cognitive coping strategies, educate about the importance of planning and pacing exercise and activities.[3]

Pelvic Floor Rehabillitation

Increasing evidence suggests that PFM dysfunction is associated with CPP. Montenegro et al found recently a significant difference between the prevalence of PFM pain in women with multiple CPP conditions and in women who were healthy. This suggests a relationship between the presence of an organic pain condition and PFM pain. A recent (2010) systematic review concluded that myofascial pain in the PFMs is associated with several different CPP conditions that occur in women.[2] (Level of evidence: 2C)

Therefore pelvic floor rehabilitation is a part of the treatment. Treatment interventions which are applied are[2]

  • manual therapy of the pelvic floor muscles
  • electromyographic biofeedback 
  • electrical stimulation
  • myofascial release of painful trigger points of the pelvic floor
  • Thiele massage techniques
  • relaxation
  • PFM exercises
  • specific stretches; although this may take in excess of six months to show any benefit[3]


Pain physiotherapy / management

Pain management and cognitive coping strategies should include education about how psychological factors, such as catastrophizing, pain related fear and anxiety, may affect sexual function and the perception of pain during intercourse and other activities for which patients may report pain.[6] (Level of evidence: 3A)

Pain management should also include educating patients about the importance of planning and pacing exercise and activities. The goal is to enable patients to pace their activity to achieve a similar amount each day. Overactive patients may experience constant pain with exacerbations called flare-ups, while others may have constant pain with flare-ups associated with minimal activity.[3] (Level of evidence : 2A)

In addition, therapy can include education about vulvodynia, dyspareunia (painful intercourse), muscle relaxation, Kegel exercises, and vaginal dilation. The goals of the therapy are reducing the fear of pain and other pain-related cognitions associated with intercourse, increase sexual activity level, and decrease pain.[6] (Level of evidence: 3A)

Resources

[10]
[11]

Recent Related Research (from Pubmed)


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Presentations

http://www.youtube.com/watch?v=w08iCzxnQBUKegel or not.png
Pelvic Physiotherapy - to Kegel or Not?

This presentation was created by Carolyn Vandyken, a physiotherapist who specializes in the treatment of male and female pelvic dysfunction. She also provides education and mentorship to physiotherapists who are similarly interested in treating these dysfunctions. In the presentation, Carolyn reviews pelvic anatomy, the history of Kegel exercises and what the evidence tells us about when Kegels are and aren't appropriate for our patients.

View the presentation

References

  1. 1.0 1.1 Díaz Mohedo E, Barón López FJ, Pineda Galán C, Dawid Milner MS, Suárez Serrano C, Medrano Sánchez E., Discriminating power of CPPQ-Mohedo: a new questionnaire for chronic pelvic pain, J Eval Clin Pract. 2011 Oct 26. doi: 10.1111/j.1365-2753.2011.01778.x. (Level of evidence : 2C)
  2. 2.0 2.1 2.2 2.3 Alappattu MJ, Bishop MD., Psychological factors in chronic pelvic pain in women: relevance and application of the fear-avoidance model of pain, Phys Ther. 2011 Oct;91(10):1542-50. doi: 10.2522/ptj.20100368. Epub 2011 Aug 11. (Level of evidence : 2C)
  3. 3.0 3.1 3.2 3.3 Cambitzi J, Chronic pelvic pain: causes, mechanisms and effects, Nursing Standard, 25, 20, 35-38. Date of acceptance: March 26 2010 (Level of evidence : 2A)
  4. 4.0 4.1 Silva GP, Nascimento AL, Michelazzo D, Alves Junior FF, Rocha MG, Silva JC, Reis FJ, Nogueira AA, Poli Neto OB., High prevalence of chronic pelvic pain in women in Ribeira˜o Preto, Brazil and direct association with abdominal surgery, Clinics (Sao Paulo). 2011;66(8):1307-12. (Level of evidence : 2B)
  5. 5.0 5.1 John D. Paulson, MD, Joseph N. Paulson, Anterior Vaginal Wall Tenderness (AVWT) as a Physical Symptom in Chronic Pelvic Pain, JSLS. 2011 Jan-Mar;15(1):6-9. (Level of evidence : 2B)
  6. 6.0 6.1 6.2 David D. Ortiz, MD, Chronic Pelvic Pain in Women, Am Fam Physician. 2008;77(11):1535-1542, 1544. (Level of evidence : 3A)
  7. 7.0 7.1 Chronic pelvic pain in women Tests and diagnosis ...fckLRwww.mayoclinic.org/.../chronic-pelvic-pain/.../tests-diagnosis/con-20030..
  8. Mathias SD, Kuppermann M, Liberman RF, et al. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol. Mar 1996;87(3):321-7. [Medline].fckLRfckLRJamieson DJ, Steege JF. The prevalence of dysmenorrhea, dyspareunia, pelvic pain, and irritable bowel syndrome in primary care practices. Obstet Gynecol. Jan 1996;87(1):55-8. [Medline].
  9. Chronic Pelvic Pain in Women Treatment & ManagementfckLRAuthor: Manish K Singh, MD; Chief Editor: Michel E Rivlin, M
  10. Stanford Health Care. Pelvic Pain Causes and Treatment. Available from: http://www.youtube.com/watch?v=xnJc-3M9NRQ [last accessed 29/11/15]
  11. innova fisioterapia. Chronic Pelvic Pain Syndrome - AUA 2015. Available from: http://www.youtube.com/watch?v=4dP_jtZvz9w [last accessed 29/11/15]