Chronic Pelvic Pain in Women

 

Am Fam Physician. 2016 Mar 1;93(5):380-387.

  Patient information: Handouts on chronic pelvic pain in women are available at http://www.aafp.org/afp/2008/0601/p1544.html and http://familydoctor.org/familydoctor/en/diseases-conditions/chronic-pelvic-pain.html.

Author disclosure: No relevant financial affiliations.

Chronic pelvic pain in women is defined as persistent, noncyclic pain perceived to be in structures related to the pelvis and lasting more than six months. Often no specific etiology can be identified, and it can be conceptualized as a chronic regional pain syndrome or functional somatic pain syndrome. It is typically associated with other functional somatic pain syndromes (e.g., irritable bowel syndrome, nonspecific chronic fatigue syndrome) and mental health disorders (e.g., posttraumatic stress disorder, depression). Diagnosis is based on findings from the history and physical examination. Pelvic ultrasonography is indicated to rule out anatomic abnormalities. Referral for diagnostic evaluation of endometriosis by laparoscopy is usually indicated in severe cases. Curative treatment is elusive, and evidence-based therapies are limited. Patient engagement in a biopsychosocial approach is recommended, with treatment of any identifiable disease process such as endometriosis, interstitial cystitis/painful bladder syndrome, and comorbid depression. Potentially beneficial medications include depot medroxyprogesterone, gabapentin, nonsteroidal anti-inflammatory drugs, and gonadotropin-releasing hormone agonists with add-back hormone therapy. Pelvic floor physical therapy may be helpful. Behavioral therapy is an integral part of treatment. In select cases, neuromodulation of sacral nerves may be appropriate. Hysterectomy may be considered as a last resort if pain seems to be of uterine origin, although significant improvement occurs in only about one-half of cases. Chronic pelvic pain should be managed with a collaborative, patient-centered approach.

Chronic pelvic pain in women is defined as persistent, noncyclic pain perceived to be in structures related to the pelvis.1 An arbitrary duration of six months is usually considered chronic. A systematic review found only seven studies that reported the prevalence of chronic pelvic pain among women worldwide, with rates of 6% to 27%, although there was a lack of consensus on the definition of chronic pelvic pain.2 Studies generally did not exclude dysmenorrhea.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

In the absence of a clear etiology, chronic pelvic pain should be considered a regional pain syndrome or functional somatic syndrome, and a biopsychosocial approach to care is indicated.

C

1, 6, 36

In patients with chronic pelvic pain, red flag findings requiring evaluation to exclude severe systemic disease or malignancy include postcoital bleeding, postmenopausal bleeding or onset of pain, unexplained weight loss, pelvic mass, and hematuria.

C

9

When chronic pelvic pain is severe, the patient should be referred for laparoscopy if the diagnosis remains unclear after the initial evaluation.

B

1, 9, 18

Limited evidence supports the use of nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, gabapentin (Neurontin), and serotonin-norepinephrine reuptake inhibitors for the treatment of chronic pelvic pain.

B

1, 21


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

In the absence of a clear etiology, chronic pelvic pain should be considered a regional pain syndrome or functional somatic syndrome, and a biopsychosocial approach to care is indicated.

C

1, 6, 36

In patients with chronic pelvic pain, red flag findings requiring evaluation to exclude severe systemic disease or malignancy include postcoital bleeding, postmenopausal bleeding or onset of pain, unexplained weight loss, pelvic mass, and hematuria.

C

9

When chronic pelvic pain is severe, the patient should be referred for laparoscopy if the diagnosis remains unclear after the initial evaluation.

B

1, 9, 18

Limited evidence supports the use of nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, gabapentin (Neurontin), and serotonin-norepinephrine reuptake inhibitors for the treatment of chronic pelvic pain.

B

1, 21


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

It usually is not possible to identify a single etiology or definitive cure for chronic pelvic pain. In at least one-half of cases, there are one or more associated entities, such as irritable bowel syndrome, interstitial cystitis/painful bladder syndrome, endometriosis, or pelvic adhesions.3,4 The presence of both endometriosis and interstitial cystitis is not unusual.5

Comprehensive guidelines for the diagnosis and treatment of chronic

The Authors

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LINDA M. SPEER, MD, is a professor and chair of the Department of Family Medicine at the University of Toledo (Ohio) College of Medicine and Life Sciencess....

SAUDIA MUSHKBAR, MD, is an assistant professor in the Department of Family Medicine at the University of Toledo College of Medicine and Life Sciences.

TARA ERBELE, MD, is an assistant professor in the Department of Family Medicine at the University of Toledo College of Medicine and Life Sciences.

Address correspondence to Linda M. Speer, MD, University of Toledo, 3000 Arlington Ave., Mailstop 1179, Toledo, OH 43614 (e-mail: linda.speer@utoledo.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

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1. Engeler D, Baranowski AP, Borovicka J, et al.; European Association of Urology. Guidelines on chronic pelvic pain. http://uroweb.org/wp-content/uploads/EAU-Guidelines-Chronic-Pelvic-Pain-2015.pdf. Accessed May 29, 2015....

2. Ahangari A. Prevalence of chronic pelvic pain among women: an updated review. Pain Physician. 2014;17(2):E141–E147.

3. Williams RE, Hartmann KE, Sandler RS, Miller WC, Steege JF. Prevalence and characteristics of irritable bowel syndrome among women with chronic pelvic pain. Obstet Gynecol. 2004;104(3):452–458.

4. Haggerty CL, Peipert JF, Weitzen S, et al.; PID Evaluation and Clinical Health (PEACH) Study Investigators. Predictors of chronic pelvic pain in an urban population of women with symptoms and signs of pelvic inflammatory disease. Sex Transm Dis. 2005;32(5):293–299.

5. Tirlapur SA, Kuhrt K, Chaliha C, Ball E, Meads C, Khan KS. The ‘evil twin syndrome’ in chronic pelvic pain: a systematic review of prevalence studies of bladder pain syndrome and endometriosis. Int J Surg. 2013;11(3):233–237.

6. Engeler DS, Baranowski AP, Dinis-Oliveira P, et al.; European Association of Urology. The 2013 EAU guidelines on chronic pelvic pain: is management of chronic pelvic pain a habit, a philosophy, or a science? 10 years of development. Eur Urol. 2013;64(3):431–439.

7. Potts JM, Payne CK. Urologic chronic pelvic pain. Pain. 2012;153(4):755–758.

8. Meltzer-Brody S, Leserman J, Zolnoun D, Steege J, Green E, Teich A. Trauma and posttraumatic stress disorder in women with chronic pelvic pain. Obstet Gynecol. 2007;109(4):902–908.

9. Royal College of Obstetricians and Gynaecologists. The initial management of chronic pelvic pain. May 2012. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_41.pdf. Accessed May 29, 2015.

10. Ortiz DD. Chronic pelvic pain in women. Am Fam Physician. 2008;77(11):1535–1542.

11. DynaMed Plus. Chronic pelvic pain in women. http://www.dynamed.com/topics/dmp~AN~T114601/Chronic-pelvic-pain-in-women [subscription required]. Accessed May 29, 2015.

12. Howard F. Evaluation of chronic pelvic pain in women. UpToDate. http://www.uptodate.com/contents/evaluation-of-chronic-pelvic-pain-in-women [subscription required]. Accessed May 29, 2015.

13. Burckhardt CS, Anderson KL. The Quality of Life Scale (QOLS): reliability, validity, and utilization. Health Qual Life Outcomes. 2003;1:60.

14. Nasr-Esfahani M, Jarrell J. Cotton-tipped applicator test: validity and reliability in chronic pelvic pain. Am J Obstet Gynecol. 2013;208(1):52.e1–52.e5.

15. Holland TK, Cutner A, Saridogan E, Mavrelos D, Pateman K, Jurkovic D. Ultrasound mapping of pelvic endometriosis: does the location and number of lesions affect the diagnostic accuracy? A multicentre diagnostic accuracy study. BMC Womens Health. 2013;13:43.

16. Meredith SM, Sanchez-Ramos L, Kaunitz AM. Diagnostic accuracy of transvaginal sonography for the diagnosis of adenomyosis: systematic review and metaanalysis. Am J Obstet Gynecol. 2009;201(1):107.e1–107.e6.

17. Cody RF Jr, Ascher SM. Diagnostic value of radiological tests in chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. 2000;14(3):433–466.

18. Jacobson TZ, Duffy JM, Barlow D, Koninckx PR, Garry R. Laparoscopic surgery for pelvic pain associated with endometriosis. Cochrane Database Syst Rev. 2009(4):CD001300.

19. Kang SB, Chung HH, Lee HP, Lee JY, Chang YS. Impact of diagnostic laparoscopy on the management of chronic pelvic pain. Surg Endosc. 2007;21(6):916–919.

20. Swanton A, Iyer L, Reginald PW. Diagnosis, treatment and follow up of women undergoing conscious pain mapping for chronic pelvic pain: a prospective cohort study. BJOG. 2006;113(7):792–796.

21. Cheong YC, Smotra G, Williams AC. Non-surgical interventions for the management of chronic pelvic pain. Cochrane Database Syst Rev. 2014(3):CD008797.

22. Sator-Katzenschlager SM, Scharbert G, Kress HG, et al. Chronic pelvic pain treated with gabapentin and amitriptyline: a randomized controlled pilot study. Wien Klin Wochenschr. 2005;117(21–22):761–768.

23. Allen C, Hopewell S, Prentice A, Gregory D. Nonsteroidal anti-inflammatory drugs for pain in women with endometriosis. Cochrane Database Syst Rev. 2009(2):CD004753.

24. Harada T, Momoeda M, Taketani Y, Hoshiai H, Terakawa N. Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis: a placebo-controlled, double-blind, randomized trial. Fertil Steril. 2008;90(5):583–1588.

25. Schlaff WD, Carson SA, Luciano A, Ross D, Bergqvist A. Subcutaneous injection of depot medroxyprogesterone acetate compared with leuprolide acetate in the treatment of endometriosis-associated pain. Fertil Steril. 2006;85(2):314–325.

26. Brown J, Pan A, Hart RJ. Gonadotrophin-releasing hormone analogues for pain associated with endometriosis. Cochrane Database Syst Rev. 2010(12):CD008475.

27. Bayoglu Tekin Y, Dilbaz B, Altinbas SK, Dilbaz S. Postoperative medical treatment of chronic pelvic pain related to severe endometriosis: levonorgestrel-releasing intrauterine system versus gonadotropin-releasing hormone analogue. Fertil Steril. 2011;95(2):492–496.

28. Saarto T, Wiffen PJ. Antidepressants for neuropathic pain. Cochrane Database Syst Rev. 2007(4):CD005454.

29. Hartmann KE, Ma C, Lamvu GM, Langenberg PW, Steege JF, Kjerulff KH. Quality of life and sexual function after hysterectomy in women with preoperative pain and depression. Obstet Gynecol. 2004;104(4):701–709.

30. Lamvu G. Role of hysterectomy in the treatment of chronic pelvic pain. Obstet Gynecol. 2011;117(5):1175–1178.

31. Fritz J, Chhabra A, Wang KC, Carrino JA. Magnetic resonance neurography-guided nerve blocks for the diagnosis and treatment of chronic pelvic pain syndrome. Neuroimaging Clin N Am. 2014;24(1):211–234.

32. Martellucci J, Naldini G, Carriero A. Sacral nerve modulation in the treatment of chronic pelvic pain. Int J Colorectal Dis. 2012;27(7):921–926.

33. Tu FF, Holt J, Gonzales J, Fitzgerald CM. Physical therapy evaluation of patients with chronic pelvic pain: a controlled study. Am J Obstet Gynecol. 2008;198(3):272.e1–272.e7.

34. Fitzgerald MP, Anderson RU, Potts J, et al.; Urological Pelvic Pain Collaborative Research Network. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. J Urol. 2013;189(1 suppl):S75–S85.

35. Loving S, Nordling J, Jaszczak P, Thomsen T. Does evidence support physiotherapy management of adult female chronic pelvic pain? A systematic review. Scand J Pain. 2012;3(2):70–81.

36. Haugstad GK, Kirste U, Leganger S, Haakonsen E, Haugstad TS. Somatocognitive therapy in the management of chronic gynaecological pain. A review of the historical background and results of a current approach. Scand J Pain. 2011;2(3):124–129.

37. Haugstad GK, Haugstad TS, Kirste UM, et al. Continuing improvement of chronic pelvic pain in women after short-term Mensendieck somatocognitive therapy: results of a 1-year follow-up study. Am J Obstet Gynecol. 2008;199(6):615.e1–615.e8.

38. Zhu X, Hamilton KD, McNicol ED. Acupuncture for pain in endometriosis. Cochrane Database Syst Rev. 2011(9):CD007864.

39. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–613.


 

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