Chronic Pelvic Pain Case File

Chronic Pelvic Pain Case File

Eugene C. Toy, MD, Patti Jayne Ross, MD, Benton Baker III, MD, John C. Jennings, MD

CASE 37

A 42-year-old G2P2 woman complains of severe lower abdominal pain over the past 3 years, which is worsening. She states that the pain is worse with menses. She denied pain with intercourse. She had no medical problems. On examination, her blood pressure (BP) is 100/60 mm Hg, heart rate (HR) is 78 beats per minute (bpm), and temperature is 99°F (37.2°C). The heart and lung examinations are normal. Her abdomen is nontender and without masses. Her pelvic examination shows no tenderness or trigger points. Her pregnancy test is negative.

» What is the most likely diagnosis?

» What is the differential diagnosis?

» What is the next step?

ANSWER TO CASE 37:

Chronic Pelvic Pain                                           

Summary: A 42-year-old parous woman complains of a 3-year history of progressive lower abdominal and pelvic pain which worsened with menses.

• Most likely diagnosis: Chronic pelvic pain.
• Differential diagnosis: The differential diagnosis is broad and complex, and consists of gynecologic conditions such as endometriosis or adenomyosis, urinary conditions such as chronic urinary tract infections, GI conditions such as irritable bowel syndrome, neurologic conditions such as nerve entrapment, psychiatric conditions such as depression or sexual abuse, and rheumatologic conditions such as fibromyalgia.
• Next step: Careful history and physical examination to try to discern what general category the pain seems to belong, and if nongynecologic, refer to the appropriate consultant.

ANALYSIS

Objectives

1. Know the definition of chronic pelvic pain.
2. Describe the categories of conditions in the differential diagnosis of chronic pelvic pain (CPP).
3. List the evaluation of CPP.
4. Describe the treatment of CPP.

Considerations

This is a 42-year-old G2P2 woman with worsening lower abdominal/ pelvic pain of 3 years’ duration. The pain seems to be worse with menses. The physical examination appears to be normal. We are not given further information about the nature of the pain, but this is critically important to try to reach a presumptive diagnosis. For instance, pain that is associated with bloating, diarrhea/ constipation may be gastrointestinal (GI) in nature; urinary urgency or frequency suggests urinary etiology; a patient with a history of depression or sexual abuse may suggest a psychological disorder; pain that is burning or radiating may be neurologic. Finally, excessive vaginal bleeding associated with CPP may be adenomyosis or uterine fibroids, and dyspareunia or dyschezia may be endometriosis. A history of PID may be chronic pelvic inflammatory disease and adhesions. Pregnancy should be ruled out. If the pregnancy test is negative, then typically the baseline work-up would include chlamydia and gonorrhea assays, urinalysis and urine culture and sensitivity, complete blood count, and then pelvic ultrasound. After a diligent search, nonsteroidal anti-inflammatory drugs such as ibuprofen and/ or an oral contraceptive agent are usually initiated for a 3-month trial. If there is no response, an additional careful history and physical examination should be repeated. If there is no nongynecologic etiology noted, then a diagnostic laparoscopy is reasonable to assess for endometriosis.

APPROACH TO:

Chronic Pelvic Pain                                              

DEFINITIONS

ACUTE PELVIC PAIN: Pain in the lower abdomen and/ or pelvis region for less than 2 weeks’ duration.

SUBACUTE PELVIC PAIN: Pain in the lower abdomen and/ or pelvis between 2 weeks’ and 6 months’ duration.

CHRONIC PELVIC PAIN: Persistent pain in the lower abdomen or pelvis for at least 6 months’ duration, typically not related to pregnancy that has a significant effect on daily function and quality of life.

CHRONIC PELVIC PAIN SYNDROME: CPP without any obvious etiology or infection after diligent search, often associated with sexual or emotional consequences.

DYSPAREUNIA: Pain in the pelvis associated with penetrative sexual intercourse.

DYSMENORRHEA: Pain in the lower abdomen, pelvis, and/ or back that is associated with menses.

CLINICAL APPROACH

Background

CPP is a common complaint. Up to 20% of women between the age of 18 and 49 years have CPP that lasts more than 1 year. CPP comprises 20% to 30% of gynecologic visits and accounts for 15% of hysterectomies in the United States. Up to one-third of laparoscopies are performed for this complaint. Even after diligent investigation, up to one-third of women with CPP will have no underlying etiology. One-third of these patients will have endometriosis. Approximately 20% will have pelvic adhesions or chronic PID. The remaining 10% to 15% will have a variety of other causes such as genitourinary, gastrointestinal, neuromuscular, musculoskeletal, and psychological. Gynecologic causes are in Table 37– 1, and non-gynecologic causes in Table 37– 2.

History and Physical Exam

The approach to chronic pelvic pain begins with a careful history and physical examination. The physician should be patient, respectful, sensitive, and meticulous. Women often have been dismissed as histrionic or exaggerating, or “hormonal”; thus, the physician should be encouraging and validate the patient’s perception of the pain. The character of the pain, duration, frequency, severity, exaggerating and relieving factors, onset, and associated factors are important. The evolution of the pain over time and response to various treatments is likewise very important.

Pain that varies markedly over the menstrual cycle is likely due to a hormonal process such as endometriosis or adenomyosis. Pain that is constant in nature following a gynecologic surgery or pelvic infection (PID or ruptured appendicitis) may be caused by dense vascular adhesions. Cyclic pain in a patient who had undergone a bilateral oophorectomy may be due to residual ovarian syndrome, in which small amounts of ovarian tissue are trapped in the retroperitoneum. Suppression of ovulation can be confirmatory, and treatment with surgical excision is curative.

Gastrointestinal etiologies can include inflammatory bowel disease or irritable bowel syndrome. Associated symptoms of abdominal bloating are as follows.

Psychosocial Inquiries

In approaching possible psychological or psychosocial reasons, the physician must be very judicious in when and how these questions are asked. Affected patients may misperceive the line of query as “You think I’m crazy like the rest of the doctors”. Sometimes, these topics are reserved for the second visit, or put in the review of system. Because traumatic events such as sexual abuse or assault are very difficult to talk about, the manner of discussion is also important. A history of depression (or symptoms), anxiety, counseling are important.

Examination

The patient’s mood and posture are important to observe—flat affect or anxiety or in pain. She should be observed for mobility and flexibility. The extremities and joints are important to assess for arthritis or arthalgias. The back should be examined particularly, the paraspinous muscles and SI joints. The abdomen should be observed carefully for distension, surgical scars, and discoloration. Bowel sounds should be auscultated carefully. The abdomen should be mapped carefully for location, radiation, and severity; the abdominal wall should be palpated with and without abdominal wall flexion to try to discern musculoskeletal condition. There should be an evaluation of trigger points, which are tender points that cause the patient to “jump.” The legs should be raised to assess for sciatica or a herniated disc.

The vulva and vaginal area should be carefully palpated for tenderness, such as with a cotton-tipped applicator to assess for vulvodynia or vestibulitis, conditions of severe tenderness. Cervical motion tenderness should be sought, which may indicate PID. The adnexa and uterosacral ligaments should be palpated for endometriosis. The pelvic musculature such as the levator muscles, obturators, and periformis muscles should be carefully palpated. The examination should begin with the nontender regions initially and then moving toward the more painful areas. A painful, enlarged boggy uterus may indicate adenomyosis. Tender nodules of the uterosacral ligaments or a fixed retroverted uterus may suggest endometriosis.

Laboratories and Imaging

A reasonable panel of blood tests include a CBC, urinalysis, urine pregnancy test, and gonorrhea/ chlamydia assay. A pelvic transvaginal ultrasound examination is important to assess for uterine masses, adnexal masses, and peritoneal fluid.

Consultation

The patient should be referred to the appropriate consultant if the history, physical, laboratory, or imaging suggests a nongynecologic etiology. For instance, if the patient has abdominal bloating, nausea, or diarrhea, then a gastrointestinal consultation is indicated. If the patient has a history of depression, sexual abuse, or trauma, then a psychiatric consultation is important. If there is no definite organ system identified, then an empiric trial of 3 months of NSAID such as ibuprofen or naproxen, and/ or a low dose oral contraceptive course can be helpful. If a gynecologic etiology is suspected, then laparoscopy can be useful to establish a diagnosis: principally endometriosis or pelvic adhesions. If after a 3- to 6- month trial of medications there is no relief, and careful search does not reveal nongynecologic conditions, then a diagnostic laparoscopy is reasonable.

Pain Persisting Without Identifiable Cause

A significant portion of patients with CPP will have persistent pain and no discernible etiology. In these instances, it is often helpful to have a multidisciplinary team, such as a gynecologist, physical therapist, psychologist, sex therapist, pain specialist, and anesthesiologist. Sometimes acupuncture can be helpful. A trial of nonnarcotic analgesics, SSRIs, tricyclic antidepressants, and perhaps ovulation suppression such as oral contraceptives or depolupron can be helpful. Excisional surgical procedures such as hysterectomy, oophorectomy, or salpingectomy should be used judiciously, since pelvic pain may persist or even worsen if there is no clear indication for these operations. Ablation of endometrioic implants and/ or hysterectomy and BSO is helpful for endometriosis. Acupuncture, nerve blocks and trigger point injections can alleviate pain.

CASE CORRELATION See also Cases 31 (Domestic/ Sexual Abuse) and 36 (PID).

COMPREHENSION QUESTIONS

37.1 A 17-year-old G0P0 female complains of severe pain with menses for 3 years, which seems to be worsening. She has tried oral contraceptives and NSAIDs for 2 years without relief. Her pregnancy test is negative. Which of the following is the best next step?

A. GnRH agonist therapy

B. Opiate medical therapy

C. Psychiatric evaluation

D. Laparoscopy

E. Trigger point injection

37.2 A-42-year old G2P2 woman complains of a 3-year history of chronic pelvic pain. By history, it seemed as though it would be neuropathic pain. Which of the following is the best therapy?

A. Vitamin B6 supplementation

B. H2 antihistamine therapy

C. Tricyclic antidepressant therapy

D. Oral hypoglycemic therapy

37.3 A-16-year-old G0P0 female complains of severe pain with menses which began within her first year of menses. The physical examination is normal. The pregnancy test is negative. Which of the following is the most likely mechanism?

A. Pelvic adhesions

B. High prostaglandin levels

C. Tubal inflammation

D. Endometriosis

ANSWERS

37.1 D. Even in an adolescent, when there is severe dysmenorrhea that persists despite oral contraceptive and NSAID use, a likely etiology is endometriosis and laparoscopy is an important next step. GnRH agonist therapy should not be used without a diagnosis, and particularly not in an adolescent, since this will induce a hypoestrogenic state and predispose to osteoporosis. Opiate medications should be used with extreme caution since addiction is common. Psychiatric evaluation should be obtained when there is a reason, such as depression or a history of abuse. Trigger point injection is efficacious with fibromyalgia.

37.2 C. In cases of neuropathic pain, tricyclic antidepressant therapy can be helpful. Additionally, acupuncture has been shown to have efficacy in clinical trials.

37.3 B. This 16-year-old nulliparous female has primary dysmenorrhea, which is a condition with pain usually starting within 6 months of menarche. The mechanism is elevated prostaglandin F2 alpha levels, leading to intense uterine contractions, causing the pain with menses. The best treatment is NSAIDs, prostaglandin synthetase inhibitors which reduces the endogenous prostaglandin levels.

    CLINICAL PEARLS    

» Chronic pelvic pain is defined as lower abdominal or pelvic pain of 6 months’ duration or more and leading to a significant debilitation. » In approximately one-third of CPP patients, no etiology is found. » Nongynecologic causes include GI, GU, psychological, and neuromuscular disorders. » A history of depression, sexual abuse or trauma is important to seek when treating a patient with CPP. » Primary dysmenorrhea is due to elevated endometrial prostaglandin F compounds leading to strong uterine contractions with menses. » CPP which markedly worsens during menses suggests a gynecologic etiology. » After a trial of NSAIDs and oral contraceptive, it is reasonable to consider laparoscopy to assess for endometriosis or pelvic adhesive disease.

REFERENCES

APGO. Chronic Pelvic Pain: An Integrated Approach. APGO Educational Series on Women’s Health Issues. Washington, DC: APGO; January 2000. 

APGO Medical Student Educational Objectives. 9th ed. Educational Topic 39; 2009:82-83. 

Beckmann CRB, Ling FW, Barzansky BM, Herbert WNP, Laube DW, Smith RP, eds. Obstetrics and Gynecology. 6th ed. 2010, Chap. 30, 279-282. 

Hacker NF, Gambone JC, Hobel CJ. Hacker and Moore’s Essentials of Obstetrics and Gynecology. 5th ed. 2009, Chap. 21, 259-264. 

Katz V, Lentz G, Lobo R, Gershenson D. Comprehensive Gynecology. 5th ed. 2007, Chap. 8.

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