Approach to chronic pelvic pain (GYN): Clinical sciences

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Introduction0:00–1:01

Chronic pelvic pain arises from pelvic and other structures in non-pregnant patients, and lasts more than 6 months. It can affect quality of life and negatively impact the ability to participate in other daily activities, such as school or work.
In addition to physical pain, many patients have associated symptoms of anxiety, distress, or even depression. The diagnosis of chronic pelvic pain is often difficult because there can be more than one condition causing it, and sometimes there’s overlap between several coexisting causes of pain.
So be sure to complete the evaluation and don’t stop just because one possible etiology is found. Gynecologic causes include endometriosis, adenomyosis, leiomyomas, adnexal masses, and pelvic organ prolapse.
On the other hand, non-gynecologic causes can be urinary, musculoskeletal, psychosocial, or gastrointestinal. When a patient presents with chronic pelvic pain, the first step is to perform a focused history and physical examination, and obtain an hCG to assess for pregnancy.

Pregnancy1:01–1:30

If hCG is positive, your patient is pregnant. Thus, consider diagnoses associated with pregnancy, such as ectopic pregnancy or musculoskeletal pain.
On the other hand, if the hCG is negative, assess for causes of chronic pelvic pain. Let’s start with gynecologic causes, and the first one is endometriosis.

Endometriosis1:30–3:06

This is characterized by endometrium-like tissue outside of the endometrial cavity. A focused history may reveal the 4 “Ds” of endometriosis: dysmenorrhea, dyspareunia, dyschezia, or dysuria.
These symptoms, as well as generalized pelvic pain, are often exacerbated by menses and can be cyclic in nature. On physical exam, you might find lower abdominal or pelvic tenderness, a pelvic mass, reduced uterine mobility, a tender posterior vaginal fornix, and rectovaginal nodularity.
If this is the case, consider endometriosis. Next, obtain a pelvic ultrasound, and consider performing a diagnostic laparoscopy to confirm your diagnosis.
Here’s a clinical pearl! The definitive diagnosis of endometriosis is made with laparoscopy.
However, given surgical risks and costs, many clinicians make a presumptive diagnosis of endometriosis based on clinical history, physical exam, and ultrasound.
If you see an endometrioma on ultrasound, or if the laparoscopy reveals an endometrioma, endometriotic implants, or scarring, this supports the diagnosis of endometriosis.Here’s a high-yield fact!
An endometrioma can also be referred to as a "chocolate cyst" because it contains old blood that, when expressed, looks like chocolate syrup.Our next gynecologic cause is adenomyosis.

Adenomyosis3:06–3:50

Here, the glandular endometrial tissue extends into the uterine myometrium. The patient might report dysmenorrhea, heavy vaginal bleeding, and intermenstrual spotting.
Physical exam findings may include lower abdominal or pelvic tenderness, and an enlarged globular uterus. In this case, consider adenomyosis and obtain a pelvic ultrasound.
If ultrasound shows a heterogeneous myometrium, myometrial cysts, and asymmetric myometrial thickness, the diagnosis is likely adenomyosis.Next, consider leiomyomas, aka fibroids.

Uterine leiomyoma3:50–5:13

These are common benign smooth muscle tumors. The history might reveal dysmenorrhea and heavy vaginal bleeding, as well as the sequelae of uterine enlargement, which includes pelvic pressure, low back pain, urinary frequency, and constipation.
The physical examination might demonstrate abdominal or pelvic tenderness and an enlarged uterus with an irregular contour.
With these findings, consider a uterine leiomyoma and obtain a pelvic ultrasound. If ultrasound reveals an enlarged uterus with at least one myometrial mass, the likely diagnosis is a leiomyoma.Here’s a high-yield fact!
Uterine leiomyomas are the most common gynecologic pelvic neoplasm; but without surgical removal and histologic analysis, they’re difficult to distinguish from the rare but aggressive leiomyosarcoma.
Most patients with leiomyosarcoma don’t have any predisposing risk factors; however some may have a hereditary cancer syndrome such as Li-Fraumeni or retinoblastoma, while others may have a history of pelvic radiation exposure or using tamoxifen for more than 5 years.
Okay, let’s move on to adnexal pathology. In this case, the patient may describe intermittent unilateral pain that’s indolent or progressive in nature.

Benign or malignant adnexal mass5:13–6:38

They may also report abdominal distension or bloating and pelvic pressure. Physical exam might reveal abdominal or pelvic tenderness and a pelvic mass.In these patients, consider an adnexal mass and obtain a pelvic ultrasound.
If the ultrasound demonstrates a cystic or solid adnexal mass, your diagnosis is either a benign or malignant adnexal mass.
As a quick reminder, adnexal masses can be cystic or solid; simple or complex; as well as unilateral or bilateral. Time for another clinical pearl!
The diagnosis and management of adnexal masses is complicated and is determined by multiple factors, including patient history, risk factors for malignancy, and ultrasound findings.
The differential diagnosis is broad and includes simple ovarian cysts, endometriomas, cystadenomas, teratomas, hydrosalpinx, tubo-ovarian abscess, an adnexal leiomyoma, or ovarian or tubal malignancy.
Surgical evaluation is necessary for those with significant pain, adnexal masses that don’t resolve, and in cases suspicious for malignancy.Okay, our last gynecologic cause is pelvic organ prolapse.

Pelvic organ prolapse6:38–7:26

This can involve the bladder, bowel, vagina, or uterus. In addition to pelvic pain, the patient may report pelvic or vaginal pressure, a vaginal bulge or protrusion, urinary incontinence, or defecatory dysfunction.
The physical exam may reveal a cystocele, rectocele, or cervical or uterine descent. Consider pelvic organ prolapse, and assess the pelvic anatomy and pelvic floor muscle tone with a validated instrument, such as the pelvic organ prolapse quantification system, or POP-Q.
If you find measurable pelvic organ prolapse and possibly weak muscle tone, that’s your diagnosis.Now that we have assessed gynecologic causes of chronic pelvic pain, let's talk about urinary causes.

Interstitial cystitis/bladder pain syndrome7:26–9:06

The history will include discomfort, pain, pressure, or spasms with bladder filling and relief of pain with voiding. Patients also often report urinary frequency and urgency, and possibly dyspareunia.
Physical exam will reveal bladder wall tenderness, urethral tenderness, and may demonstrate pelvic floor tenderness. With these findings, consider interstitial cystitis, also known as bladder pain syndrome.
Next, obtain a urinalysis, and possibly perform a cystoscopy with hydrodistention. The urinalysis will be negative for infection, but may demonstrate microscopic hematuria.
The cystoscopy might demonstrate inflammatory Hunner lesions, which are erythematous lesions with scarring that are visualized on the bladder mucosa, as well as petechiae.
In this case, the likely diagnosis is interstitial cystitis or bladder pain syndrome.And now a clinical pearl! Cystoscopy is not required to make the diagnosis of interstitial cystitis, but can rule out other reasons for urinary symptoms, such as bladder stones or malignancy.
You can also consider evaluating for interstitial cystitis by using a validated questionnaire known as the pelvic pain, urgency, and frequency, or PUF scale.
An elevated PUF score highly correlates with positive findings of interstitial cystitis, without the need for invasive diagnostic testing.

Possible myofascial syndrome, fibromyalgia, or neuropathic pain9:06–10:11

Next, assess for musculoskeletal causes. The patient’s history may reveal dull, achy, or crampy pain that’s not related to menses or eating but increases throughout the day.
They may also report positional discomfort or dyspareunia. On physical exam, you might note abdominal wall tenderness, as well as pelvic floor muscle tenderness or hypertonicity.
If this is the case, consider musculoskeletal causes of chronic pelvic pain, such as myofascial syndrome, fibromyalgia, and neuropathic pain.Here’s another clinical pearl!
Abdominal wall pain caused by nerve entrapment can be identified by palpating the painful site while your patient tenses their rectus abdominis muscles, either by raising their legs or their head.
A painful response, caused by irritation of the entrapped nerve, is known as a positive Carnett sign. Nerve entrapment can be further evaluated by injecting an anesthetic at the painful site.
Now, let’s discuss psychosocial causes of chronic pelvic pain. These patients may report symptoms of depression, anxiety, or an inciting traumatic event.

Possible depression, anxiety, PTSD, intimate partner violence10:11–11:38

Physical exam may reveal an abnormal mental status and, in cases of trauma or abuse, unexplained bruising or injuries. Keep in mind that bruising may occur in hidden or unexpected areas, such as on the breast, abdomen, or perineum.If you see these findings, you may want to use a screening tool or questionnaire for intimate partner violence, such as the Partner Violence Screen, or PVS.
There are also many screening tools for depression and anxiety, such as the Patient Health Questionnaire-9, or PHQ-9, which is a depression screening instrument, and the Generalized Anxiety Scale-7, or GAD-7, that screens for anxiety.
A careful interview, plus the use of a questionnaire, may lead you to the diagnosis of intimate partner violence, depression, anxiety, or posttraumatic stress disorder.Here’s a final clinical pearl!
Anxiety and depression can be a primary cause of chronic pelvic pain, or may be the result of living with pain. It’s important to avoid dismissing the physical symptoms when a psychiatric diagnosis is present.
Be sure to address the physical symptoms and psychosocial factors with equal concern and sensitivity. Finally, after assessing common causes of chronic pelvic pain, consider and assess for alternative diagnoses.

Other diagnoses11:38–12:04

Possible diagnoses include pelvic adhesions, pelvic congestion syndrome, chronic pelvic inflammatory disease, celiac disease, inflammatory bowel disease, and colorectal cancer.

Review12:04–12:53

Alright, as a quick recap… Chronic pelvic pain is pain that persists for more than 6 months and arises from pelvic and other structures in non-pregnant patients.
Common gynecologic causes include endometriosis, adenomyosis, uterine leiomyomas, adnexal masses, and pelvic organ prolapse.
Non-gynecologic cases include interstitial cystitis, myofascial syndrome, fibromyalgia, or neuropathic pain. Psychosocial factors like intimate partner violence, depression, anxiety, or PTSD, can also contribute to chronic pelvic pain.
Finally, consider other causes like celiac disease, inflammatory bowel disease, or colorectal cancer.