1. Chronic Pelvic Pain: A Multifactorial Problem
Tony Thomas MD MRCOG
Consultant O&G. Minimal Access Gynaecologic Surgeon &
RCOG College Tutor
Manor Hospital
Walsall Healthcare NHS Trust.

2. Aims Define chronic pelvic pain
Cite the prevalence and common etiologies of chronic pelvic pain
Describe the symptoms and physical exam findings associated with chronic pelvic pain
Discuss the psychosocial issues associated with chronic pelvic pain
Discuss the steps in the evaluation and management options for chronic pelvic pain

3. Definition
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

4. Chronic Pelvic Pain Difficult to diagnose Frustration for patient and
Doctor
Difficult to treat
Difficult to cure

5. Prevalance
Chronic pelvic pain presents in primary care as frequently as migraine or low-back pain and may significantly impact on a woman’s ability to function.
Overall 15-20% of women aged 18 to 50 yrs have chronic pelvic pain
10-30% of gynecologic visits
10-20% of hysterectomies
30-40% of laparoscopy indications

6. Etiology
frequently more than one component to chronic pelvic pain

7. Etiology Psychological Gastrointestinal Urological Gynecological
Musculoskeletal

8. Diagnosis Distribution
Chronic Pelvic Pain
25-50% of women had more than one diagnosis
Severity and consistency of pain increased with multisystem symptoms
Most common diagnoses:
endometriosis
adhesive disease
irritable bowel syndrome
interstitial cystitis
Gastrointestinal
Urinary
Gynecological
Unknown
20-30%
Diagnosis Distribution
Found that diagnoses related to the urinary and GI tracts were more common than gynecological diagnoses.
For example, 43% of women with CPP without GI or urologic symptoms had moderate to severe pain; whereas 71% of women with both GI and urological symptoms had moderate to severe pain.

9. Gynaecologic Endometriosis Adhesions Chronic PID
Ovarian remnant syndrome
Pelvic congestion syndrome
Recurrent hemorrhagic ovarian cysts
Myomata uteri (degenerating)
Uterine retroversion
Adenomyosis
Pelvic floor and hip muscle pain
Visceral hyperalgesia

14. Non Gynaecologic Genitourinary Gastrointestinal
Urinary retention
Urethral syndrome
Interstitial cystitis
Gastrointestinal
Penetrating neoplasms
Irritable bowel syndrome
Irritable bowel disease
Partial small bowel obstruction
Diverticulitis
Hernia
Neuro muscular and Psychological(Higher incidence in victims of abuse/anxiety disorders)

15. Psychological and social issues
Enquiry should be made regarding psychological and social issues which commonly occur in association with chronic pelvic pain; Addressing these issues may be important in resolving symptoms

16. Etiology
Many women present because they want an explanation for their pain.
Often they already have a theory or a concern about the origin of the pain.
These ideas should ideally be discussed in the initial consultation.

17. 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.

18. Examination Abdominal and pelvic examination
Focal tenderness, enlargement, distortion or tethering
Highly localised 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 symptoms

19. Investigations
All sexually active women with chronic pelvic pain should be offered screening for sexually transmitted infections (STIs).
TVS is an appropriate investigation to identify and assess adnexal masses
MRI :Second line investigation useful mainly to identify adenomyosis /mass lesions

20. Diagnostic laparoscopy
Regarded in the past as the ‘gold standard’ in the diagnosis of chronic pelvic pain.
Becoming a second-line investigation if other therapeutic interventions fail.
Diagnostic laparoscopy may have a role in developing the woman’s beliefs about her pain.

21. Role of CA 125
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 – should have a serum CA125 measurement taken.
Particularly in women over the age of 50 years, any new IBS symptoms should prompt such action.

22. Therapeutic Options
Women often present because they seek an explanation for their pain
The assessment process should allow enough time for the woman to be able to tell her story . This may be therapeutic in itself
A pain diary may be helpful in tracking symptoms or activities associated with the pain
Where pain is strikingly cyclical and no abnormality is palpable at vaginal examination, a therapeutic trial of ovarian suppression may be more helpful than a diagnostic laparoscopy
In suspected IBS : trial with antispasmodics and dietary modification
Appropriate analgesia

23. Treatment Analgesics NSAIDS including COX-2 inhibitors
Few adequately powered clinical trials have addressed chronic pelvic pain
Opioids are increasingly used but randomized trials suggest no improvement in functional or psychological status with increased risk in addiction

24. The Pelvic Witch Hunt

25. Surgical Arsenal Excision/Ablation of endometriosis
Division of Dense/Vascular Adhesions
Ovarian cystectomy
Unilateral/Bilateral Salphingo oophorectomy
Total Laparoscopic Hysterectomy
Unlikely to be beneficial :LUNA, Presacral neurectomy, uterine suspension

26. Combined OCP
Consider the combined oral contraceptive (COC) pill, first-line.
Monophasic COCs containing 30–35 micrograms of ethinylestradiol, and either norethisterone or levonorgestrel, are usually the first choice.
NICE suggests a three month trial of conventional treatment, then switching to tricycling after three months if necessary. Some women may find continuous use helpful.

27. Combined OCPs Suppress ovulation
Stabilize estrogen and progesterone levels
Abrogate menstrual increases in prostaglandin levels
Useful for endometriosis-associated chronic pelvic pain

28. Progestins
Effectively decreases pain from endometriosis and pelvic congestion syndromes
Medroxyprogesterone acetate(10 to 20 mgs /day continuous) proven for pain suppression
Adverse effects include weight gain, fluid retention, depression, breakthrough bleeding
Mirena® intrauterine device shown to be effective in reducing pain and may be considered alternative to hysterectomy in adenomyosis patients

29. Physiotherapy
Electrotherapy, fast and slow twitch exercises of the striated muscles of the pelvic floor, manual therapy of myofascial trigger points

30. Psychotherapy
Many suggest various modes of psychotherapy including cognitive therapy, operant conditioning, and behavioral modification appear to be helpful
Significant numbers of women with chronic pelvic pain have a history of physical or sexual abuse

31. If the only tool you have is a hammer, you tend to see every problem as a nail
Abraham Maslow

32. Summary Multifactorial Problem
Women often present because they seek an explanation for their pain
The assessment process should allow enough time for the woman to be able to tell her story. This may be therapeutic in itself
Often need combination therapies
Chronic Pelvic Pain requires patience, understanding and collaboration from both patient and physician
Treatment options often multi modal – medical, surgical, physio therapy, cognitive

33. Organisations providing further information and/or support
Endometriosis UK [
IBS Network [
Cystitis and Overactive Bladder foundation [
Women’s Health [ or [womenshealth.gov]
Pelvic Pain Support Network [
Department of Health Expert Patient Initiative [

34. Questions ? Thank you