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Chronic pelvic pain is defined as a subacute, pelvic-focused process causing constant or cyclically persistent pain for 6 months or more. More than 10% of all gynecologic referrals are for chronic pelvic pain.
Taking a history from a patient with chronic pelvic pain is difficult. Information has to be evaluated at several levels. Not only must the physician develop a differential diagnosis, but he or she also must determine.
The patient needs time to discuss her problem in her own words. All follow-up sessions should be scheduled; they should not occur on an as-needed basis. Discussion with supporting family members to determine the extent of the effect of the problem on daily family function is important.
At the time of the physical examination, the physician must decide whether it is appropriate to perform a general physical examination or limit the evaluation only to a gynecologic examination. The examination needs to be performed meticulously, almost tissue layer by tissue layer, to determine the specific location of the problem. About one third of all patients will have no objective findings even after completion of the history, physical examination, and diagnostic laparoscopy of the pelvis.
Some degree of negative feeling, depression, and lowered self-esteem is already present in patients with chronic pelvic pain, but most patients resist inquiries about emotional and psychologic problems. Yet, early psychologic evaluation will help assess the extent to which these factors are a part.
Cyclic Chronic Pelvic Pain
Cyclic chronic pelvic pain is a special subset of chronic pelvic pain. It is more prevalent than noncyclic pelvic pain and affects up to one half of all menstruating females. It is not always associated with the uterus and ovaries. Although somewhat unusual, typically noncyclic types of chronic pelvic pain can appear in a cyclic pattern as well (eg, irritable bowel syndrome). Other forms of cyclic chronic pelvic pain include dysmenorrhea, mittelschmerz, and endometriosis.
LABORATORY STUDIES
In general, laboratory studies add little additional information to the investigative process. Pregnancy tests, sexually transmissible infection evaluations, urinalysis, complete blood counts.
IMAGING STUDIES
Imaging studies usually are not helpful in the diagnosis and management of chronic pelvic pain. Simple ovarian cysts are rarely the cause of chronic pelvic pain.
OPERATIVE MANAGEMENT OF CHRONIC PELVIC PAIN
Operative management is useful in the management of chronic pelvic pain when a specific preoperative diagnosis exists and the surgery is based on this diagnosis. Experience with acute pelvic pain surgery is not necessarily transferable to chronic pelvic pain problems. Excisional procedures (even if obvious lesions are present) may fail, and there are high recurrence rates. Excisional therapy of pain points may only serve to temporarily resolve the situation until reinnervation occurs.
Laparoscopy for Chronic Pelvic Pain
Laparoscopy for chronic pelvic pain may be indicated if no specific cause for the problem is discovered after a general history and a physical examination and gastrointestinal, urologic, and musculoskeletal causes have been ruled out. In well-selected series, one third of laparoscopies identify adhesions.
Adhesions
Adhesions may play a role in chronic pelvic pain, but that role is uncertain. In a large series of patients, more than 60% of patients who underwent adhesiolysis noted marked improvement. However, 12%
Hysterectomy for Chronic Pelvic Pain
Among all hysterectomies in the United States, 10-16% are for chronic pelvic pain. One study of 99 carefully selected patients who had hysterectomy for chronic pelvic pain reported that 75% of the patients had
NONOPERATIVE THERAPY
Trigger Point Pain
Muscle, fascial, and adipose tissue plains that are subjected to trauma may develop neural axon damage with end-bulb formation, leading to a nonpainful stimulus being perceived as painful (a trigger point). A careful
Irritable Bowel Syndrome
Irritable bowel syndrome is characterized by abdominal pain focused anywhere along the colon for 3 or more months in addition to any two of the following: 1) altered stool frequency, 2) altered stool form (hard or loose,
Pelvic Venous Congestion
Before the 1980s, chronic pelvic pain was often thought to be caused by dilation of the parauterine pelvic venous plexus, commonly called pelvic venous congestion syndrome. This pain is low in the pelvis and
Chronic Pelvic Pain and Sexual Victimization
Sexual victimization has the ability to produce lasting physical as well as psychologic symptoms. Sexual victimization is associated with but is not specific for the later development of chronic pelvic pain. Compared with matched control subjects, significantly more patients with chronic pelvic pain have been sexually
MEDICAL MANAGEMENT
Medication use in patients with chronic pelvic pain should be seen as part of a multiphasic approach and not as a treatment endpoint. The mainstay of pain management has been nonsteroidal anti-inflammatory drugs
NON MEDICAL TREATMENTS
Acupuncture, biofeedback (especially with distraction techniques), reinterpretation, relaxation, exercise, whirlpool/massage, hypnosis, transcutaneous electrical nerve stimulation, major nerve blocks, deep heat diathermy, and sexual and marital therapy have been shown to be helpful in controlling some forms of