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Chronic pelvic pain (CPP), pelvic pain lasting longer than 6 months, is one of the most common gynecologic complaints. This pain may be episodic or continuous, with variations in intensity but never or rarely completely absent. Episodic pain may be associated with intercourse (dyspareunia), menstruation (dysmenorrhea), or ovulation (mittelschmerz).
Neuronal Pathways in the Pelvis
A review of the neuronal pathways is necessary in order to understand the pathophysiology of pelvic pain.
The pelvic viscera receive their innervation via the autonomic nervous system. The sympathetic portion originates from the thoracolumbar area of the spinal cord. The parasympathetic supply follows the distribution of the vagal nerve in combination with parasympathetic fibers from S-1, S-2, and S-3. The autonomic nerve fibers enter the pelvis by following several routes. Most of them contribute to the formation of the superior hypogastric plexus.
The fact that most of the pelvic viscera share their sensory innervation explains why pelvic pain is a nonspecific symptom for the dysmenorrhea.
The perception of pelvic pain, however, does not involve only the transmission of painful stimuli from the periphery to the center of the nervous system (brain). The gate-control theory was developed to explain the interaction between painful stimuli and the emotional and motivational state of the individual.
Table 1. Causes of Chronic Pelvic Pain
Reproductive system Mittelschmerz Primary dysmenorrhea Endometriosis Adenomyosis Leiomyomata Mullerian malformations Uterine retroversion Uterine prolapse Chronic pelvic inflammatory disease Adnexal tumors Pelvic congestion syndrome Cervical stenosis Pelvic adhesions |
Urinary system Nephrolithiasis Urinary tract infection Interstitial cystitis Urethral syndrome Cystocele Pelvic kidney |
Gastrointestinal system Constipation Irritable bowel syndrome Inflammatory bowel disease |
Musculoskeletal system Obturator syndrome Disorders of the lumbo-sacral spine Disorders of the hip joint Piriform syndrome Rheumatic polymyalgia Pelvic floor tension myalgia |
Diverticulosis Diverticulitis Neoplasms |
Neurologic disorders Diabetic neuropathy Multiple sclerosis |
Pelvic pain of unknown etiology |
Psychiatric disorders Affective disorders Munehausen syndrome |
Etiology of Chronic Pelvic Pain
Chronic pelvic pain may be associated with gynecologic disorders or with other conditions not related to the reproductive organs. For practical purposes we group the different causes of pelvic pain according to the functional system that they affect (Table 1). The most common pathologic conditions diagnosed laparoscopically in patients with pelvic pain are listed in Table 2.
Table 2. Laparoscopic Findings in Women with Chronic Pelvic Pain*
Endometriosis 31%
Adhesions 23%
Chronic PID 7%
Ovarian cyst 4%
Myomas <1%
Pelvic varicosities <1%
Other 4%
Negative laparoscopy 36%
Number of patients 1386
*Modified from Porpora MG, Gomel V. The role of laparoscopy in the management of pelvic pain in women of reproductive age. Fertil Steril 2006;68:675-79.
The most common reproductive disorder responsible for CPP is endometriosis. In several studies the incidence of endometriosis in women who have undergone laparoscopic evaluation of CPP was in the range of 38%.
Adenomyosis can also cause continuous pelvic pain. Adenomyosis frequently presents with only dysmenorrhea.
Uterine leiomyomas are found in approximately 30% of women of reproductive age.
Pelvic adhesions have been found in up to 23% of asymptomatic patients who underwent laparoscopic tubal sterilization. In several reports the incidence of adhesions in patients evaluated for pelvic pain varies.
Adnexal pathology (neoplasms, endometriomas, adnexal torsion) are more responsible for acute pelvic pain.
Chronic PID can be responsible for CPP, which is probably secondary to adhesion formation. The incidence of chronic PID.
Uterine prolapse and uterine retroversion have been described in patients with pelvic pain. The diagnosis of uterine prolapse is clinically obvious. A retroverted uterus can be associated with CPP, low back pain.
Pelvic congestion syndrome, in the absence of other pelvic pathology, may be responsible for dull pelvic pain with positional exacerbation. The pain may increase during menstruation and after intercourse.
Nongynecologic conditions frequently related to CPP include gastrointestinal disorders. Constipation and irritable bowel syndrome are the most common conditions encountered. Irritable bowel syndrome.
Urologic problems may also be responsible for CPP. Interstitial cystitis can present with pelvic pain associated with urgency, frequency, and urge incontinence. The diagnosis is established by cystoscopy during a intravenous pyelography.
Musculoskeletal disorders may contribute to pelvic pain. Spasm of the levator plate may represent a primary.
Diagnosis
In the evaluation of patients with CPP the history is of paramount importance.
Treatment
Treating patients with CPP represents a major challenge for the managing physician, especially when an extensive workup fails to yield a diagnosis. The development of good patient-physician rapport is of paramount.
Successfully used agents include oral contraceptives, danazol, progestational agents, and recently, gonadotropin-releasing hormone analogs (GnRHa). All these agents act by suppressing the development of ectopically positioned endometrial tissue. Progestational agents suppress the release of luteinizing hormone and thereby prevent ovulation and ovarian steroidogenesis. They also exert a direct effect on the endometriotic implants, inducing decidualization and atrophy. Medroxyprogesterone and megestrol acetate have been used with symptomatic relief in 80% of patients.
Danazol is a 17a-ethinyltestosterone derivative. Its mode of action includes (1) suppression of pituitary gonadotropin secretion, (2) direct binding to endome-trial cell receptors, (3) suppression of ovarian and adrenal steroidogenesis.
The GnRHa have been used successfully for several years in the treatment of endometriosis. Reversible suppression of gonadotropin production by the GnRHa eliminates ovarian steroid production. Ectopic endometrial tissue deprived of estrogen.
Serotoninergic antidepressants (trazodone and fluoxetine) as well as tricyclic antidepressants have been used successfully in combination with nonnarcotic medication in the management of these patients.
Alprazolam, a benzodiazepine derivative with mixed anxiolytic and antidepressive effects.