The differential diagnosis of pelvic pain is extensive, with many patients having multiple etiologies contributing to their symptom burden. Table 33-2 lists common etiologies of CPP, all of which can be primary or comorbid causes of CPP. Select common gynecologic diagnoses are discussed in greater detail below:
| Category | Etiology | Mechanism | Testing/Diagnosis | Treatment |
|---|---|---|---|---|
| Cyclic/recurrent gynecologic | Endometriosis | Ectopic endometrial tissue infiltration and inflammation. Can be cyclic or noncyclic | ±imaging, laparoscopy with biopsy | Ovulation suppression (ie, OCPs, progestins, GnRH agonists/antagonists, surgical excision of endometriosis lesions, endometriomas, hysterectomy ± BSO |
| Adenomyosis | Endometrial stroma and glands deeper than 2 mm within the myometrium results in menorrhagia and dysmenorrhea | Ultrasound, MRI | NSAIDs, COC, progestins, GnRH agonists, uterine artery embolization, hysterectomy | |
| Primary/secondary dysmenorrhea | Primary = uterine menstrual pain Secondary = menstrual pain due to structural pathology | Rule out other causes | NSAIDs, OCPs, GnRH agonists, treatment of secondary causes, hysterectomy | |
| Ovarian remnant syndrome | FSH stimulation of incompletely excised ovarian tissue after oophorectomy | Surgical history, serum FSH, and estrogen in premenopausal range, ultrasound or MRI ± ovarian stimulation | Adhesiolysis and removal of all ovarian tissue may cure >90% | |
| Cervical stenosis | Blocked cervical os results in hematometra, retrograde menstruation | Ultrasound | Dilation of cervical os in the office or under sedation in operating room, may require hysterectomy if recurrent | |
| Noncyclic gynecologic | Abdominopelvic adhesions | Scar tissue from infection, trauma, endometriosis. | Laparoscopy | Laparoscopy/laparotomy and adhesiolysis, may use antiadhesion barriers (data equivocal) Adhesions may recur despite adhesiolysis |
| Uterine retroversion | Rare cause of deep dyspareunia and dysmenorrhea | Pelvic exam, ultrasound, pessary test for symptom relief | Hodge pessary or laparoscopic uterine suspension | |
| Chronic endometritis/chronic PID | Tubo-ovarian abscess, chronic chlamydial endometritis, Fitz–Hugh–Curtis syndrome | Gonorrhea/chlamydia PCR, endometrial biopsy, ultrasound, laparoscopy | Antibiotic therapy; azithromycin or doxycycline ×2 wk | |
| Chronic vulvovaginitis | Recurrent or chronic yeast, trichomonas, or fungal infections | Wet prep, culture, vaginal pH | Antibiotics treatment followed by a suppressive course, boric acid vaginal suppositories | |
| Vaginal cuff pain | Post hysterectomy chronic low-grade cuff cellulitis, seroma, neuroma, or nerve entrapment | Antibiotics, cuff resection/revision, local anesthetic injection, chemical neurolysis | ||
| Contact vulvitis | Contact irritant from lotion, soaps, clothing, etc. | Eliminate offending agents, ± apply topical steroids | ||
| Painful vulvar syndrome | Vulvar hyperalgesia | Cotton swab test, vaginal pH, wet prep, fungal culture, STI screening, biopsy if clinically indicated | Vulvar care, topical lidocaine, physical therapy, biofeedback, TCA, SSRIs, | |
| Vulvar vestibulitis | Subset of vulvodynia nonspecific vestibular inflammation; severe entry dyspareunia | Cotton swab test ± vulvar skin biopsy if clinically indicated | Similar to vulvodynia, vestibulectomy/perineoplasty if conservative management fails | |
| Pudendal neuralgia | Pudendal nerve injury or entrapment | Diagnostic nerve block | Avoid sitting for prolonged periods of time; pain medications, nerve block, or surgical decompression for severe cases | |
| Pelvic congestion syndrome | Pelvic vein insufficiency from pelvic varicosities, vascular stasis with tissue edema Pain with increased intra-abdominal pressure, prolonged standing Increased risk with collagen vascular disease (eg, Ehlers–Danlos) | Pelvic venography (transuterine contrast injection with real-time radiography), MRA, ultrasound | Ovulation suppression, endovascular embolization, hysterectomy | |
| Gastrointestinal | Irritable bowel syndrome | Functional bowel disorder Constipation or diarrhea predominant | Rule out other causes | Increase dietary fiber, loperamide, stool softeners, dicyclomine, Refer to gastroenterology |
| Inflammatory bowel disease (ulcerative colitis and Crohn's disease) | Chronic bowel inflammation | Cramping lower abdominal pain and bloody diarrhea, stool studies, colonoscopy, biopsies | Anti-inflammatory drugs, steroids, Refer to gastroenterology | |
| Diverticular disease | Colonic outpouchings of mucosa/submucosa due to muscularis weakness at sites of higher pressure; present in >10% of women over age 40; can become infected/inflamed | AXR, barium enema, colonoscopy | Antibiotics for infection, increased dietary fiber and hydration | |
| Intermittent bowel obstruction | Mechanical partial obstruction, usually secondary to adhesions | AXR (upper GI with small bowel follow-through study), CT scan, biopsy of any mass | Bowel decompression and conservative management or surgical adhesiolysis | |
| Urologic | Bladder pain syndrome (BPS)/Interstitial cystitis (IC) | Chronic noninfectious cystitis and hyperesthesia | Cystoscopy, hydrodistension | Dietary changes/bladder training Hydrodistension, intravesical DMSO, oral pentosan polysulfate, low-dose TCA, antihistamines, hydroxyzine |
| Chronic/recurrent urinary tract infection | Bacterial or fungal infection, often due to anatomic abnormalities, causes irritative voiding symptoms, increases with age and PMP status | Urinalysis, urine culture, test of cure | Antibiotics ± prophylactic suppression | |
| Urethral syndrome | Chronic urethral inflammation, infection, or obstruction, similar to IC/BPS | History of dysuria, frequency, urgency, and slow painful urine stream; exam, cystoscopy, urine culture, chlamydia PCR | Hormone replacement therapy in PMP women, biofeedback, DMSO, NSAIDs, muscle relaxants, and alpha antagonists may be useful | |
| Urethral diverticulum | Herniation of the urethral lining; pocket may become infected/inflamed; a rare cause of chronic pain | History of dysuria, dyspareunia, and postvoid dribbling Anterior vaginal wall mass Urinalysis, urine culture, ± cytology, voiding cystourethrography, double-balloon positive pressure urethrography, ultrasound, MRI, urethroscopy | Antibiotics for infection, surgical excision | |
| Detrusor–sphincter dyssynergia | Urethral sphincter relaxation does not occur in coordination with detrusor activity causing increased bladder pressure and urine retention; often from CNS injury or multiple sclerosis | Urodynamics, EMG study | Urethral stent, transurethral sphincterotomy, botulinum toxin injection, and catheterization are possible treatments | |
| Musculoskeletal | Myofascial pain syndrome/pelvic floor dysfunction/levator ani, piriformis syndromes | Irritability, spasm, pain of pelvic floor or abdominal muscles Levator ani syndrome includes chronic or recurrent rectal or vaginal pain or dyspareunia Piriformis syndrome includes sciatic nerve impingement by piriformis muscle spasm or overuse syndrome; buttock, thigh, leg pain; running, and biking can exacerbate | Pain reproduction or trigger point detection on vaginal or rectal exam Rule out lumbar disk herniation (ie, sciatic root impingement), complete neurologic exam, spinal imaging EMG testing | Heat packs, muscle relaxants, massage, physical therapy, relaxation techniques, trigger point, or botulinum toxin injections |
| Fibromyalgia | Global myofascial pain syndrome due to abnormal pain processing/signaling | 11 of 18 painful diagnostic trigger points | Exercise, physical therapy, warm packs, massage, NSAIDs, biofeedback, relaxation techniques, low-dose SSRIs, muscle relaxants, trigger point injections | |
| Coccydynia | Trauma to the coccyx can cause S1–S4 nerve pain referred to pelvic floor | Dynamic spine/coccygeal x-rays, MRI, diagnostic local anesthetic injection | Local anesthetic or steroid injections, NSAIDs, TCAs, physical therapy, rarely coccygectomy | |
| Hernia | Inguinal, obturator, spigelian, umbilical, etc. | CT scan | Manual reduction, binders, avoiding increased intra-abdominal pressure, surgical correction | |
| Neurologic | Nerve entrapment | Surgical injury of ilioinguinal or iliohypogastric nerve can cause neuroma formation Obturator internus can press on obturator nerve Mechanical nerve impingement or stretch can lead to neuropathy | Anatomic correlation, and diagnostic nerve block | Transcutaneous neurolysis, myofascial release procedure, local anesthetic injection, or surgical neurectomy if medical therapy fails |
| Peripheral neuropathy/neuritis/neuralgia | Numerous local and systemic processes that damage peripheral nerves; persistent numbness, burning, tingling pain | Evaluate for systemic disease and infectious causes (eg, herpes zoster) | TCAs, gabapentin, pregabalin, valproate, transcutaneous electrical nerve stimulation | |
| Abdominal migraine | Neuronal hyperexcitation; paroxysmal abdominal pain ± nausea/vomiting/flushing; usually in children, rare in adults | H&P, family history, rule out other causes, consider neuroimaging | Sleep, antiemetics, TCAs, refer to neurology | |
| Psychiatric | Somatization disorder | Internal psychological conflict and hypersensitivity to pain stimuli | Four different sites of pain plus two GI, one sexual, and one pseudoneurologic symptom (per diagnostic criteria) Rule out organic pathology | Psychiatry referral, cognitive-behavioral therapy, antidepressants |
This list is not exhaustive but represents the multiple systems and variety of diagnoses in the workup of CPP. General treatments are listed only to indicate possible therapies used for each condition.
AXR, abdominal x-ray; BSO, bilateral salpingo-oophorectomy; DMSO, dimethyl sulfoxide; DEXA, dual-energy x-ray absorptiometry; EMG, electromyography; NSAIDs, nonsteroidal anti-inflammatory drugs; OCP, hormonal oral contraceptive pills; PCR, polymerase chain reaction; PID, pelvic inflammatory disease; PMP, postmenopausal; SSRI, selective serotonin reuptake inhibitors; STD, sexually transmitted disease; TCA, tricyclic antidepressants.
Dysmenorrhea is reported in up to 80% of women with CPP (see Chapter 44).
Endometriosis is the most common cause of secondary dysmenorrhea; 6% to 10% of women of reproductive age have endometriosis, and up to 70% of women with CPP have endometriosis. The symptoms of endometriosis are extremely variable, ranging from no symptoms, minimal to severe pain, or manifestations in other organ systems (ureteral obstruction, bowel obstruction, constipation, hematuria, etc.) (see Chapter 44).
Adenomyosis is the benign invasion of endometrium into the myometrium often resulting in an enlarged uterus. Prevalence rates estimate that up to 50% of women who undergo hysterectomy for CPP will have evidence of adenomyosis. As the gold standard for adenomyosis is tissue diagnosis, it is often an incidental finding at time of hysterectomy for other conditions. For patients who are symptomatic, the most common presenting symptom is painful and/or heavy menses (see Chapter 32).
Painful vulvar syndrome (previously vulvodynia) is a spectrum of vulvar hyperalgesia whose diagnosis relies on patient history and features of hypersensitivity on clinical exam. The pathophysiology is not well understood but mechanisms under investigation include injury/irritation of nerves that transmit vulvar pain sensation to the spinal cord, increase sensitivity or number of vulvar nerve fibers, local inflammatory cytokine production, pelvic floor muscle dysfunction (see Chapter 36).
Central pain sensitization (CPS) is a complex process of amplification of neuronal signaling within the central nervous system (CNS) which elicits pain hypersensitivity. CPS can manifest as hyperalgesia (increased response to painful stimulus) or allodynia (pain from a nonpainful stimulus). Patients with CPP related to CPS have a high co-occurrence of other central pain syndromes included in the COPCs discussed earlier.
Pelvic congestion syndrome (symptomatic varicose veins of the pelvis) can be objectively diagnosed by pelvic venogram. This diagnosis can also be suggested by pelvic ultrasound or MRI. Randomized trials show correlation between venogram scores and pain, with improvement after treatment.
Pelvic adhesions are eventually diagnosed in about 25% of women with CPP, but a causal relationship is debatable. Pain localization, but not intensity, correlates with the presence of isolated adhesions detected during laparoscopy.
Myofascial pain is comorbid with 10% to 20% of cases of CPP.
Functional bowel disorders, such as IBS and chronic constipation are a primary or secondary diagnosis in 40% to 60% of patients with CPP. Associated symptoms of IBS include abdominal distention, bloating, fatigue, and headache. Symptoms are sometimes worse before menses. While IBS is often comorbid with CPP, it is often a diagnosis of exclusion when considering a primary etiology for CPP.
BPS (previously described as interstitial cystitis [IC]) is a clinical diagnosis that is defined by symptoms of suprapubic pain that are exacerbated by bladder filling and are often accompanied by increased urinary urgency or frequency in the absence of urinary infection (see Chapter 48).