Chronic pelvic pain in adult females: Evaluation

INTRODUCTION — Chronic pelvic pain (CPP) is a symptom that can represent pathology in a specific organ system, a chronic pain syndrome, or both. As females with CPP may have more than one etiology for their pain, goals of the evaluation include identifying treatable causes of pain and differentiating specific peripheral causes from those overlapping with centralized pain syndromes, as the treatments can differ substantially.

This topic will present the evaluation of the adult woman who presents with CPP. Topics on the causes and treatment of CPP in adult females, as well as the evaluation of children and adolescents, are presented separately.

●(See "Chronic pelvic pain in nonpregnant adult females: Causes".)

●(See "Chronic pelvic pain in adult females: Treatment".)

●(See "Chronic abdominal pain in children and adolescents: Approach to the evaluation".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.

DEFINITION — While there is no consensus on the definition of CPP, it is generally defined as non-cyclic pain perceived to be in the pelvic area that has persisted for three to six months or longer and is unrelated to pregnancy [1-3]. These time frames are somewhat arbitrary and not data driven, but generally allow patients time to experience spontaneous resolution or to have completed an initial evaluation for acute problems. The pain can be constant, or episodic, but does not include pain that is only cyclic (ie, occurring only with menses, which is defined as dysmenorrhea) [4]. CPP generally refers to pain that is limited to the anatomic pelvis (between the umbilicus and the inguinal ligament) [5]. As such, perineal or vulvar pain disorders are typically categorized separately from CPP [6]. (See "Vulvar pain of unknown cause (vulvodynia): Clinical manifestations and diagnosis".)

EPIDEMIOLOGY AND PATHOGENESIS — An estimated 99 percent of all diagnostic laparoscopies for CPP done in the United States are performed on women [7]. Globally, female CPP has been reported to affect 6 to 25 percent of reproductive-age women, depending in part on the inclusion criteria [8-12]. CPP is a symptom with many potential underlying causes, including identifiable pathology (eg, endometriosis) or functional pain syndromes (table 1). In a cohort analysis of a primary care database, irritable bowel syndrome and cystitis were the most common diagnoses of women with pelvic pain across all age groups [13]. In a prospective observational study performed at a gynecology referral center, the most common diagnoses identified, in order, were irritable bowel syndrome, adhesions, musculoskeletal causes, and endometriosis [14]. For women in whom no specific etiology is identified, CPP appears to be part of the general family of functional somatic pain syndromes, with elements of heightened threat awareness and enhanced pain processing [15], although these chronic pain features are also present in many pain states with presumed "identifiable" causes [2,16,17]. A discussion of the types and mechanisms of functional chronic pain syndromes is presented in detail elsewhere. (See "Causes of abdominal pain in adults", section on 'Pathophysiology of abdominal pain'.)

Regardless of the initial source of pain, there is increasing awareness that persistence of pain, from any underlying etiology, is a risk factor for the development of a chronic pain syndrome as a result of central nervous system changes collectively referred to as central sensitization or nociplastic pain [2,18,19]. Research increasingly suggests an individual's genetic makeup, coupled with their individual sensory experience history, influences their relative pain output "set-point," analogous to how an audio speaker output is controlled by a volume knob [20,21]. This relative output explains why some pathological processes or sensory experiences do not result in pain in one woman, but cause dramatic pain in others (eg, acute labor pain, leiomyoma, or endometriosis). Further, problems in one organ can influence dysfunction in another organ, as evidenced by the high comorbidity of bladder pain syndrome, endometriosis, and irritable bowel syndrome with dysmenorrhea [22]. These and other mechanisms likely contribute to the enhanced sensitivity to pain and prolonged pain after sensation seen in women with CPP [23].

CLINICAL PRESENTATION — The hallmark symptom of women with CPP is non-cyclic pain localized to the pelvis of three to six months' duration or longer. Women with CPP may also have pain that radiates beyond the pelvis. Associated symptoms can include urinary or gastrointestinal symptoms, impaired quality of life (eg, no longer taking part in certain activities), and mental health changes (eg, depression, anxiety). As a result of these changes, women can also experience increased stress, or distress, in their personal and professional relationships. The precise nature of associated, distressing, non-pain symptoms often helps identify the CPP etiology and guide treatment.

OVERVIEW OF APPROACH — As CPP is an end symptom with multiple potential causes and contributing factors, the authors use a stepwise approach when evaluating these patients, including:

●Gather and review all available data, ideally prior to the initial patient visit (eg, visit notes, imaging studies, laboratory reports, and diagnostic tests), especially for protracted cases involving multiple prior clinical visits and years of unsuccessful treatment. This step allows us to spend more time developing a comprehensive differential diagnosis and educating patients during the actual visit.

●Recognize that initial clinical evaluation and counseling may require more than one office visit. Women with CPP may have had prolonged duration of symptoms, seen other clinicians, received conflicting information, and experienced uncoordinated care. Given the amount of information that needs to be obtained and multiple overlapping organ systems that must be evaluated, the patient may benefit from a separate visit to completely answer questions, provide counseling, and form a therapeutic plan.

●Utilize standardized questionnaires to elicit the history, associated symptoms, the successes and failures of prior treatments, and the physical examination. One such document is the history and examination form created by the International Pelvic Pain Society, which is available in English, French, Spanish, and Portuguese.

●Perform a physical examination, assess for mental health concerns, and complete targeted testing. A differential diagnosis is formulated based on the information from the history and examination, permitting systematic, stepwise treatment. Of note, women with multiple symptoms that are equally bothersome undergo different system evaluations simultaneously. There are no data supporting the specific order of symptom work-up. (See 'Targeted evaluation based on initial findings' below.)

INITIAL EVALUATION — CPP is a clinical syndrome based upon patient history of non-cyclic pelvic pain for at least three to six months' duration. Once the diagnosis of CPP is made, the clinician then begins the process of identifying and treating all possible causes of the pain, as there may be more than one underlying etiology [3]. The diagnostic process can be challenging as CPP from a specific cause can coexist with a centralized chronic pain syndrome.

Patients with alarm findings — In women with CPP, severe pain can represent worsening of the chronic pain syndrome or result from an acute abdominopelvic process. As with acute pelvic pain, women with unstable vital signs, peritoneal signs, or suspected life-threatening pathology (eg, ectopic pregnancy, bowel perforation) should be referred for emergency evaluation and management. Additionally, women whose clinical presentations are suspicious for acute appendicitis, pelvic inflammatory disease, obstructive renal stones, or ovarian torsion are also referred for expedient evaluation. (See "Evaluation of the adult with nontraumatic abdominal or flank pain in the emergency department" and "Acute pelvic pain in nonpregnant adult females: Evaluation" and "Evaluation of acute pelvic pain in female children and adolescents".)

History — The evaluation of women with CPP starts by taking a complete history that includes urinary, gastrointestinal, gynecologic, musculoskeletal, sexual, and psychosocial symptoms [24]. This ideally will identify all factors that could contribute to CPP (table 1). As noted above, the International Pelvic Pain Society has developed a detailed history and physical examination form for evaluation of women with CPP of any etiology.

As the history is obtained, the authors specifically listen for symptoms suggestive of five common etiologies of CPP: (1) musculoskeletal pelvic girdle pain/pelvic floor pain; (2) irritable bowel syndrome; (3) bladder pain syndrome/interstitial cystitis; (4) chronic uterine pain disorders (leiomyoma, endometriosis, adenomyosis); and (5) peripheral neuropathy. In addition, the patient is asked to identify all locations where she experiences chronic or persistent pain on anatomic diagrams (figure 1 and figure 2).

Pain characteristics — After the location and pattern of the pain is discussed, the authors use the mnemonic APQRST (associated, provocative/palliative, quality, radiation, setting, temporal aspects) to further characterize the woman's symptoms. Please note that the "A" for associated symptoms logically may be queried towards the conclusion of the patient interview. The table also provides a summary of the initial intake questions (table 2).

●Provocative and palliative factors – Understanding the factors that provoke (ie, worsen) or alleviate (ie, lessen) the pain helps contribute to a differential diagnosis. As examples:

•Pain that worsens with eating and/or improves with bowel movement is suggestive of a gastrointestinal process. (See "Causes of abdominal pain in adults" and "Evaluation of the adult with abdominal pain".)

•Pain with urination or defecation can result from deep infiltrating endometriosis as well as functional and pathological disorders of the bladder or intestine (eg, bladder pain syndrome, irritable bowel syndrome, or inflammatory bowel disease). (See "Endometriosis of the bladder and ureter" and "Endometriosis: Treatment of rectovaginal and bowel disease".)

•Pain that is altered (increased or decreased) with specific activities or position changes suggests a musculoskeletal or vascular etiology (eg, pelvic girdle pain or pelvic congestion syndrome). (See "Myofascial pelvic pain syndrome in females: Clinical manifestations and diagnosis" and "Vulvovaginal varicosities and pelvic congestion syndrome".)

•Irritable bowel pain and bladder pain syndrome are typically associated with some degree of impaired visceral function. (See "Clinical manifestations and diagnosis of irritable bowel syndrome in adults" and "Interstitial cystitis/bladder pain syndrome: Clinical features and diagnosis".)

●Quality – The authors ask patients for words that describe their sensation of pain. For example, neuropathic pain tends to be described as burning, muscular pain as aching, and uterine pain as crampy in nature. However, it is important to note that these categories are not diagnostic, and have considerable overlap with other etiologies. More importantly, if patients use highly charged emotive descriptors to describe their pain (eg, affective-type elements such as punishing/cruel), this can be a clue that centralization of pain with cortical changes is an important contributor. We also ask women to quantify their pain intensity (best, average, and worst) on a numeric rating scale (figure 3), particularly for nonmenstrual pelvic pain, dysmenorrhea, dyschezia, dyspareunia, and dysuria in recent weeks. A monthly pain scale can be useful for tracking this information and provides an easy way to assess for progress at subsequent visits (form 1).

It is important for clinicians to be aware that many women experience low-level pain despite reporting the absence of any clinically concerning chronic pain symptoms to their health care provider. For example, in a study comparing individuals with moderate-to-severe dysmenorrhea, individuals with bladder pain syndrome, and healthy control women, nearly a quarter of those with dysmenorrhea tested positive for a dysmenorrhea plus bladder pain phenotype despite not presenting with such complaints [25]. In addition, those with dysmenorrhea, bladder pain, or both reported higher bodily pain and pelvic pain (in the last week) as determined by the self-reported PROMIS short forms compared with control individuals.

●Radiation – The woman is asked to identify all the primary locations where she experiences pain on a pain map (figure 1), and also to identify all the location(s) to which the pain/symptoms travel. Pelvic pain that isolates to a single area may be more commonly associated with an identifiable anatomic abnormality, such as an abdominal wall trigger point or ovarian cyst. The pattern of pain radiation can also indicate the cause. As examples:

•Pain that starts in the back and then wraps around the torso and/or radiates to the upper thighs may be suggestive of pelvic girdle dysfunction.

•Chronic nephrolithiasis, although uncommon, will have classic renal colic with radiation of the pain to the flanks.

•Chronic upper abdominal pain with radiation to the shoulders and back may be suggestive of chronic pancreatitis.

Radiating pain is a common feature of many pain states. While radiation of pain can reflect a radiculopathy when seen in classic dermatomes, the complexity of the changes that occur in the central and peripheral nervous systems with chronic pain allows for non-radiculopathy referred-pain states to also occur. Diagnostic nerve blocks can potentially help in identifying a purely peripheral process; if selective anesthesia of a nerve root or discrete peripheral nerve entirely ablates the radiating pain, then a peripheral neuropathy is likely [26].

●Setting – The canonical question for reproductive-age women is whether pain occurs only during menses. Pain limited to menses is defined as dysmenorrhea, which is classified as either primary or secondary. Primary dysmenorrhea is painful menstrual periods without an underlying anatomic cause, whereas secondary dysmenorrhea is due to anatomic pathology. Endometriosis is one of the common causes of secondary dysmenorrhea, but these symptoms may also be related to uterine fibroids or adenomyosis. However, cyclical flares following the menstrual cycle, that are superimposed on baseline symptoms, may reflect hormonal influences either on peripheral swelling or on nerve processing. (See "Endometriosis: Clinical features, evaluation, and diagnosis", section on 'Clinical features' and "Dysmenorrhea in adult females: Clinical features and diagnosis", section on 'Diagnosis'.)

It is also important to know if the patient experiences pain-related insomnia. Impaired sleep is common in centralized pain syndromes (eg, migraine headache, irritable bowel syndrome, and bladder pain syndrome), and strongly indicates the need to consider central neurologic therapies as well as specific efforts to improve sleep quality [27].

●Temporal – In discussing the timing of the patient's symptoms, the authors seek to understand the sequence of events that occurred before and after the onset of symptoms as well as the temporal course of the symptoms themselves (eg, is the pain constant, episodic, or cyclic). Specific examples include:

•Prior procedure or injury – The risk of chronic pain is increased in women who underwent a procedure or sustained a traumatic injury. In a prospective cohort study of women who underwent elective cesarean delivery, persistent surgical site pain was reported by 28 percent at 3 months and 20 percent at six months [28]. This may help with determining if a therapy to specifically reverse the acute process should be done, such as removing an IUD, a tubal sterilization microinsert, or a uterosacral vaginal vault stitch.

•Prior chronic pain episodes – Prior chronic pain episodes, particularly if they are multifocal, suggest a centralized pain syndrome, and if widespread, may include fibromyalgia. (See "Clinical manifestations and diagnosis of fibromyalgia in adults".)

•Prior visceral dysfunction – Visceral dysfunction that precedes pain or that has been present since childhood (such as chronic constipation or urinary urgency) suggests centralized sensory processing dysfunction, which can be relatively refractory to peripheral treatments. (See "Etiology and evaluation of chronic constipation in adults" and "Management of chronic constipation in adults".)

•Cyclical exacerbation – Cyclical exacerbation of symptoms around the menses, particularly for deep pelvic pain, raises the possibility of endometriosis. While knowing if a pain is constant or episodic pain may not be an informative distinction for the differential diagnosis, it does have implications for treatment. In patients with continuous pain, practitioners might consider empiric trials of daily neuromodulators (tricyclic antidepressants, gabapentinoids) for general pain suppression even during ongoing workup. (See "Approach to the management of chronic non-cancer pain in adults", section on 'General approach'.)

●Associated findings – Asking about associated findings can help identify the magnitude of organ system involvement. As examples, the authors ask about associated:

•Sexual symptoms – The authors inquire if the woman has pain with sex, and if so the location and timing of the pain. Pain that is isolated to the vaginal opening or vulva, and begins and is worsened with touch, is suggestive of vulvodynia or pelvic floor pain. In contrast, deep pain, particularly with thrusting, is more suggestive of endometriosis or other deep pelvic pathology. (See "Vulvar pain of unknown cause (vulvodynia): Clinical manifestations and diagnosis" and 'Gynecologic' below.)

•Urinary symptoms – Women with interstitial cystitis/bladder pain syndrome often note pain with urination or a full bladder, urinary urgency, and/or urinary frequency. These women do not typically have urinary incontinence. However, women with urethral diverticula often have urine leakage. Blood in the urine can indicate infection, stone, foreign body, or malignancy, but can also be found with interstitial cystitis. (See 'Urologic' below.)

•Bowel symptoms – Both deep infiltrating endometriosis and acute colitis can present with associated symptoms such as diarrhea, constipation, blood or mucus in the stool, and/or abdominal bloating, although these nonspecific findings can also be seen in women with functional gastrointestinal disorders such as irritable bowel syndrome [29]. Women whose primary symptoms are more related to intestinal dysfunction than pain are referred for a gastroenterology consultation. (See 'Gastrointestinal' below.)

•Myofascial symptoms – The authors ask women if there is weakness or loss of sensation in the pelvis, buttocks, perineum, or lower extremities to ensure no acute spinal process is occurring. Presence of a specific truncal movement that triggers the pain or if the patient can reproduce the action in the clinic can help identify the specific loci of pelvic girdle pain. (See 'Musculoskeletal' below.)

•Autonomic symptoms – Comorbid autonomic symptoms include nausea related to pain, bloating, and fatigue. While these symptoms do not help pinpoint the cause, they likely reflect the general activation of the autonomic nervous system with loss of normal homeostatic function. It can be reassuring for some patients to understand that these symptoms appear to be centrally mediated responses to pain, rather than separate disorders [30].

Pain pattern phenotype — The authors attempt to broadly classify the patient's pain pattern phenotype. Research on interstitial cystitis/bladder pain syndrome has suggested that women with pelvic pain can be separated into groups based on those with pelvic pain only (ie, with a focal, unrecognized peripheral pain generator, or tier 1) and those with pelvic pain and beyond (ie, with more central sensitization of their pain, or tier 2) [31]. In our experience, women with tier 2 pain exhibit long-standing pain and may have significant comorbid psychological dysfunction (depression, anxiety, history of posttraumatic stress disorder). In addition, visceral pain disorders can be influenced (increased or decreased) by the emotional state of the patient [21]. Although preliminary, the authors find the phenotype distinction useful and counsel women with tier 2 pain that they will likely need a multi-modal and longer duration of treatment for their pain. Other types of pelvic pain symptom phenotypes or scores have also been suggested, including a proposal for the clinical profiling of endometriosis pain that can be done specifically for deeply infiltrating forms or endometriomas [32-34]. (See "Chronic pelvic pain in adult females: Treatment".)

Psychosocial assessment — The authors assess for mental health confounders such as depression, anxiety, substance abuse, and somatization as well as evaluate for active or past abuse. Depression and anxiety have been associated with increasing severity of other pain disorders [35-38]. The National Institutes of Health Patient-Reported Outcomes and Measurement Information System (PROMIS) scales are available without cost for functional assessment of key outcomes in multiple domains. These can be administered as short forms for either depression or anxiety, sleep impairment, function, and multiple other relevant domains (representative examples are included for depression (table 3) and anxiety (table 4), and scoring information is provided separately). These translate into standardized scores anchored to the United States population, and may be particularly relevant for assessing anxiety, depression, sleep, pain interference, and social satisfaction [39,40].

Some women who present with CPP have histories of primary psychiatric comorbidity. However, it is thought that most patients who experience chronic pain develop secondary psychological problems as a consequence of their pain. Since nociceptive pathways are modulated by psychological processes, this mechanism probably plays an important role in amplifying pain symptomatology [41].

Patients are screened for the following issues, and those who screen positive are referred for further evaluation and treatment:

●Psychiatric disorders – Women with CPP have been reported to have increased pain-catastrophizing thinking and greater anxiety, somatization, and depression compared with women without chronic pain [42-48]. It is not clear if depression and CPP are causally related, but there is increasing evidence that pain may be a more important risk factor for developing depression or anxiety than the inverse [49,50]. Certainly, experiencing intense repetitively stressful situations, such as childhood sexual abuse, could increase biological vulnerability to both CPP and depression [51]. It is likely that pain and mood disorders mutually influence each other and likely co-occur in part due to common neurobiologic vulnerabilities [48]. (See "Screening for depression in adults" and "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis".)

Both depression and anxiety can generally worsen health outcomes and intensify pain independently of the actual biological process. In addition to screening for depression and anxiety, the authors also ask patients if they have other signs of heightened sensory awareness, as this finding can be critical for educating the patient that her pain is not just peripheral, but also an alteration in normal pain processing. Examples of questions that assess for increased sensory awareness include asking the woman if she finds odors/smells unpleasant, dislikes bright lights, or finds textured clothing very irritating. These patients can benefit from adding targeted therapy to recognize and de-escalate this hypervigilant response, potentially through cognitive behavioral therapy methods of reframing and mind-body methods that have been used to treat other chronic pain conditions [52].

●Sleep disorder – Sleep disturbance is very common in chronic pain states and thus is crucial to identify. Women with CPP can have sleep disorders that both result from and contribute to their pain and/or depression [53]. Induction of sleep disturbance experimentally worsens pain sensitivity in college students, and studies suggest that normal sleep is a period where the brain restores balanced function [54]. In addition, poor sleep has been associated with lower quality of life and decreased ability to work and perform daily tasks [55]. Studies of populations with chronic pain have reported rates of disturbed sleep from 50 to nearly 90 percent [56]. In a cohort study assessing sleep quality in women with CPP compared with unaffected control women, more women with CPP reported poor sleep quality (80 versus 55 percent) [27]. Chronic pain and sleep disorders can become a vicious cycle. Women who note significant sleep interference are referred to their primary care physician for a sleep evaluation. (See "Stages and architecture of normal sleep" and "Insufficient sleep: Definition, epidemiology, and adverse outcomes" and "Insufficient sleep: Evaluation and management".)

●Abuse – A history of abuse (physical, emotional, sexual, or related to childhood neglect) appears to be more common in patients with chronic pain, particularly CPP, although this may reflect some higher overall prevalence of trauma history in patients seeking care in tertiary care clinics. Studies of CPP have reported up to 47 percent of women with CPP disclose a history of physical and/or sexual abuse [57-59]. In a questionnaire study of over 700 women referred to a CPP clinic, nearly one-half reported a history of physical or sexual abuse, and nearly one-third screened positive for posttraumatic stress disorder [59]. Thus, the authors also ask all patients if they have ever been, or currently are, in a threatening relationship. Screening tools are also available [60]. (See "Intimate partner violence: Diagnosis and screening" and "Intimate partner violence: Intervention and patient management".)

Past traumatic experiences may alter neuropsychological processing of pain signals and can permanently alter pituitary-adrenal and autonomic responses to stress. Studies in animal models support that states of deprivation (eg, early maternal separation or early experimental visceral injury) disturb adult visceral perception [61]. Screening for such past occurrences is not done to suggest the experiences are the sole cause of CPP, but rather to allow patients with more complex pain presentations to understand why they have enhanced pain awareness. Studies in other trauma populations have reported that cognitive behavioral therapy (ie, mind-body methods) may reduce hypervigilance and autonomic response to peripheral stimuli [62]. (See "Overview of psychotherapies" and "Overview of psychotherapies", section on 'Cognitive and behavioral therapies'.)

●Opiate or substance dependency – Cross-sectional studies have reported that the prevalence of opioid dependence and/or abuse among patients treated with long-term opioids for chronic pain ranges from 3 to 26 percent [63-65]. Thus, women with CPP are asked about their use of medications and other substances to treat pain. (See "Prescription drug misuse: Epidemiology, prevention, identification, and management", section on 'Identification and management' and "Opioid use disorder: Epidemiology, clinical features, health consequences, screening, and assessment".)

Additionally, patients with chronic pain often have a decreased responsiveness to opioid analgesics, such that higher than normal doses are required for adequate analgesia. Because of these factors, the decision to treat women with CPP with chronic opioids should be contemplated only after a thorough evaluation; aggressive, deliberate use of multiple non-opioid treatment modalities; and appropriate counseling of risks. Notably, the published literature does not support a meaningful benefit of chronic long-term opioid management as monotherapy for the majority of pain patients.

If a patient has substantial use of high doses of opioids (the Centers for Disease Control and Prevention suggest heightened caution with all levels of prescribing, but especially beginning at >50 mg oral morphine equivalents), worsened pain that is not improved significantly despite these escalating opioid doses may actually reflect opioid-induced hyperalgesia [66]. Referral to a psychologist and addiction pain physician for one-on-one cognitive behavioral therapy and potential elimination of opioids from the treatment regimen can enhance outcomes by addressing maladaptive cognition and behaviors and provide alternative self-directed strategies to address pain. (See "Approach to the management of chronic non-cancer pain in adults".)

●Somatic sensitivity – Historically, somatization has been defined as a syndrome of nonspecific physical symptoms, such as fatigue, widespread pain, and/or sleep disturbance, that are distressing and may not be fully explained by a known medical condition after appropriate investigation. Increasingly, many researchers view somatic sensitivity as a trait that exists on a continuum and makes individuals more vulnerable to experiencing pain-related distress, and less as a condition that they develop [67]. As an example, in a study comparing women with provoked vulvodynia (n = 18) and bladder pain syndrome (n = 21) with healthy control women (n = 20), women in the pain groups had pro-nociceptive pain profiles on experimental sensory testing, including hyperalgesia in the reference body area, inefficient pain inhibition, enhanced pain ratings during trigger point examination, and higher Brief Pain Inventory ratings [68].

It is important to note any adverse experience related to sensation may influence where an individual's pain set-point threshold operates. This explanation can help provide an etiology as well as motivate women to engage in mind-body methods to reduce threat hypervigilance and reduce autonomic response to peripheral stimuli. (See "Somatic symptom disorder: Epidemiology and clinical presentation" and "Somatic symptom disorder: Assessment and diagnosis".)

Physical examination

Planning — The physical examination is an essential component in the evaluation of pelvic pain but can also be painful and emotionally stressful for the patient. To reduce stress, the authors find it helpful to conduct the examination in a systematic, gentle, and interactive approach. After explaining the components of the examination (table 5), the examiner should proceed slowly through the chaperoned examination, begin with the least threatening and least painful areas, maintain eye contact with the patient, and ask whether each maneuver elicits the same pain experienced by the patient. The primary goal is to identify the anatomic locations and structures that reproduce the patient's pain. In rare cases, it may be critical for highly pain-sensitive patients to have a pelvic examination done at a later visit once a rapport is established. (See "The gynecologic history and pelvic examination", section on 'Preparing for the examination'.)

Back, abdomen, and extremities — The table provides a summary of the physical examination (table 5). After reviewing vital signs and making an overall assessment of the patient's demeanor and posture, the examination begins with the back while the patient is seated. The examiner should apply focal pressure to the sacrum, coccyx, sacroiliac joints, and paraspinal muscles. Tenderness in the area of palpation as well as referral or radiation to the back and/or abdominal wall suggests a musculoskeletal cause of pain. Spinal curvature, abnormal posture, or asymmetry of the pelvic girdle or gait also suggest a musculoskeletal component to pain [69]. In a small study comparing iliac crest height in women with CPP with control women, women with CPP had two- to fivefold more asymmetry in iliac crest height and symphyseal malalignment [70].

The abdominal examination is then performed with the woman supine. The authors ask the woman to first point to all the areas of pain and then the area of maximal pain. Cotton swab and gentle pin prick can be used to detect allodynia (pain with only a light touch) and hyperalgesia (exaggerated pain to noxious stimulus), suggesting a possible abdominal wall neuropathy. Particularly for women with low or lateral abdominal wall incisions, the authors evaluate the pathways of the ilioinguinal and iliohypogastric nerves for evidence of neuropathy. In order to distinguish between visceral and myofascial pain generators, the authors then palpate the abdominal wall by pressing a single finger firmly and systematically across and down the abdominal wall. The pattern (diffuse versus focal), severity of pain, and association with the patient's primary daily symptoms is noted. The examiner must be able to differentiate diffuse lower abdominal pain from focal pain associated with a taut band of muscle or trigger point. Differentiation of visceral versus myofascial pain can also be made by applying pressure to the abdominal wall in the area of maximal pain while the patient flexes her abdominal wall. Worsened pain during flexion, a "positive Carnett's sign," is more likely a result of pain in the abdominal wall, whereas improved pain during flexion suggests an underlying visceral etiology. In our experience, somatic structures, including the pelvic floor, truncal stabilizers like the iliacus and psoas muscles, and the abdominal wall, are underappreciated sources of pain.

The authors palpate the inguinal area to evaluate for a possible hernia and the pubic symphysis to evaluate for conditions such as symphysis pubis dysfunction (pelvic girdle pain) and osteitis pubis. Of note, reproductive organs are not normally palpable above the pelvic brim, and any palpable mass noted on abdominal examination should be considered abnormal and evaluated further. (See 'Targeted testing' below.)

Lastly, when there is suspicion for musculoskeletal involvement, the authors examine the lower extremities and hips while the patient is still supine. The authors test passive and active range of motion and muscle strength, including hip flexion, extension, internal and external rotation, abduction, and adduction. An evaluation of resting muscle tone or spasticity should be included, and bilateral examination allows for identification of subtle asymmetries.

Pelvic examination — The pelvic examination is typically performed in the lithotomy position. The components of the examination are reviewed in the table (table 5). (See "The gynecologic history and pelvic examination", section on 'Components of the examination'.)

●Visual inspection of the external genitalia – The authors look for vulvar scars, lesions, skin changes, swelling, cysts, or asymmetries in the vulvar architecture and gently palpate scars to assess for tenderness. A mirror can be used to explain the findings to the patient and provide education regarding normal anatomy.

●Cotton swab test – The cotton swab test is suggested specifically for women with vulvar pain or symptoms of painful intercourse (dyspareunia), particularly if the pain occurs with entry. The moistened soft end of a cotton swab should be used to press lightly, beginning at the lateral thighs and moving medially to include evaluation at the 1-, 4-, 6-, 8-, and 11-o'clock locations of the vestibule (figure 4). Focal pain to light touch of the vulvar vestibule is the hallmark finding of vulvodynia (ie, vulvar pain of unknown cause). (See "Vulvar pain of unknown cause (vulvodynia): Clinical manifestations and diagnosis".)

●Examination of pelvic floor – Prior to performing a traditional bimanual examination, the authors palpate the pelvic floor, anterior vaginal wall, cervix, uterus, and vaginal fornix with a well lubricated single finger to assess for contracted or painful muscles and trigger points. The authors systematically, and gently palpate the levator ani (3 to 5 o'clock and 7 to 9 o'clock positions), internal transverse perineal, and obturator internus (2 to 3 o'clock and 9 to 10 o'clock) muscles [71]. The bladder, urethra, and rectum (if high suspicion for disease is present) are then palpated independently with a single digit to assess for tenderness, followed by the cervix, posterior lower uterine segment, adnexa, and lateral vaginal fornices. This is helpful to distinguish uterine, cervical, or adnexal pain from abdominal wall or bladder pain noted on the traditional bimanual examination. (See "Myofascial pelvic pain syndrome in females: Clinical manifestations and diagnosis", section on 'Pelvic floor musculature'.)

If the woman reports pain with palpation of the pelvic floor muscles, the authors ask if the pain is similar to her typical pain (daily pain, pain with intercourse, etc) or a new pain (ie, one that is not familiar to the patient). Some experts have suggested using a four-point scale to rate relative tenderness, which has good inter-rater reliability, but the modest reliability of this pelvic floor muscle hyperalgesia scale (ICC between 0.4 and 0.8) suggests that repeat evaluation during a follow-up visit may be helpful to improve precision [72].

●The bimanual examination is then performed by placing one or two fingers in the vagina and examining for uterine/adnexal size, mobility, and tenderness. In addition to the knowledge gained by performing a single-digit examination, alternating pressure between the abdominal hand and the vaginal hand, while asking the patient which areas are most tender, can help distinguish among pain arising from the pelvic floor, bladder, uterus, and adnexa (vaginal fingers) versus the abdominal wall. The authors palpate the urethra and bladder; reproducible pain can suggest a diagnosis of bladder pain syndrome. Rectovaginal examination should be considered selectively for deep pelvic pain presentations, to identify nodularity or tenderness in the rectovaginal septum or uterosacral ligaments, which may occur with deep infiltrating endometriosis (figure 5). During that examination, the authors also assess for rectovaginal mobility, as obliterative cul-de-sac endometriosis can cause tethering of the uterus and rectum. (See "The gynecologic history and pelvic examination", section on 'Bimanual examination'.)

●The speculum examination is performed after the bimanual examination. The authors use the smallest speculum that allows adequate visualization of the cervix, posterior fornix, and vaginal walls. Cervical (and possibly vaginal) cultures are obtained if there is a concern for cervicitis, vaginitis, or pelvic inflammatory disease (ie, abnormal vaginal or cervical discharge). Careful inspection of the posterior fornix is particularly important if the patient has symptoms of endometriosis, as transmural deep infiltrative endometriosis lesions can occasionally be seen in this area. (See "The gynecologic history and pelvic examination", section on 'Speculum examination'.)

TARGETED TESTING — There are no standardized laboratory or imaging studies for women with CPP. Rather, the selection of tests and imaging studies is guided by the information gained during the above history and physical examination. However, most women will undergo a urinalysis to exclude urinary tract infection and microbiologic tests for sexually transmitted infections if they are sexually active.

●Laboratory tests – CPP itself does not cause laboratory abnormalities. Laboratory evaluation is done to exclude other causes for the patient's symptoms. For example, women with pelvic pain often have a pregnancy test (if applicable), urinalysis, and tests for gonorrhea, chlamydia, and trichomonas. Women with a urinalysis suggestive of infection then undergo urine culture. Women with a recent travel history and gastrointestinal symptoms undergo testing for intestinal infection.

●Imaging studies – Imaging techniques can be useful to identify structural causes of CPP, such as uterine leiomyomas or ovarian cysts. When imaging is deemed to be an appropriate next step, the authors generally begin with pelvic ultrasound as it provides detailed information of the pelvis, is relatively inexpensive, widely available, and avoids ionizing radiation. For women in whom the pelvic ultrasound is unclear or who need further investigation, the authors typically request magnetic resonance imaging for soft tissue abnormalities and computed tomography for evaluation of bony structures, the intestines, or ureters.

•Ultrasound – A pelvic ultrasound is typically performed for females with acute or chronic pelvic pain who also have an enlarged uterus, an adnexal mass, other structural abnormality on physical examination, or symptoms of heavy or irregular bleeding [73]. Uterine leiomyomas or ovarian cysts/masses can cause pain. A complex adnexal mass can be the result of endometriosis (ie, endometrioma), although a normal ultrasound does not exclude endometriosis of the peritoneal surface [74]. Adenomyosis can cause pain with abnormal uterine bleeding and can be suggested by ultrasound findings, although sonography cannot provide a definitive diagnosis. The authors counsel women with a history that places them at risk for intra-abdominal adhesions or postoperative changes (eg, prior pelvic inflammatory disease, surgery) that incidental findings may be discovered that do not need surgery. Simple or complex cysts of the peritoneum or other structures are relatively common following pelvic surgery but are not typically associated with pain. Deep infiltrating endometriosis (DIE) can be identified by routine transvaginal ultrasound. In women with DIE, uterorectal adhesions can fix the posterior uterus to the anterior rectal wall and thus the sliding of rectum against posterior uterine wall is absent or impaired. This "negative sliding sign" when assessed with dynamic ultrasound, has a sensitivity of 85 percent and specificity of 96 percent for the presence of DIE [75]. The accuracy of ultrasound for diagnosis of DIE also is likely operator dependent. Thus, the choice between magnetic resonance imaging (MRI) and transvaginal ultrasound should be made based on the experience of the local radiologist. (See "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on 'Clinical features' and "Approach to the patient with an adnexal mass" and "Endometriosis: Clinical features, evaluation, and diagnosis", section on 'Imaging'.)

•Magnetic resonance imaging – The authors find MRI helpful in women suspected of having deep infiltrating endometriosis either by history (eg, dyschezia or deep dyspareunia) or physical examination (eg, rectovaginal nodules). In a Cochrane review of six studies with 266 participants, MRI had excellent sensitivity (94 percent, 95% CI 90-97 percent) and specificity (77 percent, 95% CI 44-100 percent) for the diagnosis of DIE, thus approaching the criteria for a replacement diagnostic test in lieu of surgical biopsy [74]. As with sonography, absence of MRI findings does not exclude peritoneal endometriosis and findings suggestive of endometriosis, while highly consistent with the disease, are not definitive [74,76]. (See "Endometriosis: Clinical features, evaluation, and diagnosis", section on 'Imaging'.)

Some experts also find MRI data helpful in women suspected of having adenomyosis (eg, enlarged, boggy uterus on examination), although others prefer ultrasound imaging. While imaging can be suggestive of adenomyosis, imaging is not diagnostic. (See "Uterine adenomyosis".)

•Ionizing radiation – Studies delivering ionizing radiation are employed cautiously in women with CPP if no clear acute process is present. Computed tomography (CT) scans are infrequently utilized unless there is evidence of acute enteritis or colitis. Pelvic venography is very controversial, as the diagnosis of pelvic venous congestion for which it is used (based largely on ovarian vein diameter, subjective scoring of tortuosity of pelvic veins, and persistence of injected dye in these veins) has not been appropriately determined [77]. The authors advise use of pelvic venography only in centers with experience in performing imaging for pelvic congestion syndrome and the ability and commitment to follow outcomes prospectively [78].

●Provocative testing – The purported purpose of provocative tests is to stimulate the involved organs with the goal of identifying the source of the woman's pain. Such tests include potassium chloride challenge and urodynamic testing for women with bladder pain and anal manometry for women with irritable bowel syndrome. While these tests have a role in research protocols to characterize visceral hypersensitivity as a risk factor for developing chronic pain, the authors believe the available data do not support their use in the clinical setting [79,80].

ROLE OF LAPAROSCOPY — Laparoscopy can be used for both diagnosis and treatment in women with some causes of CPP (eg, endometriosis, adhesions) but is also associated with surgical risks (eg, bleeding, infection, visceral organ injury). A major challenge for clinicians who care for women with CPP is deciding when to pursue an operative procedure. While performing laparoscopy on all women with CPP is unnecessary, underutilization can also result in a delay in diagnosis and appropriate treatment. As there are insufficient data to guide the optimal timing of laparoscopy in this population, the decision is left to the patient and her care team. For women who do not have findings that are highly suggestive of a surgically-treatable process such as deep infiltrating endometriosis, large leiomyoma, hydrosalpinges, or large endometriomas, the authors typically offer initial management for two to three months with medical, physical, and/or cognitive behavioral therapy. Laparoscopy is then offered to women who decline or do not benefit from these therapies. However, the exact timing of when to offer laparoscopy is a collaborative decision with the patient and there are no consistently accepted guidelines.

TARGETED EVALUATION BASED ON INITIAL FINDINGS — The clinical features identified in the initial history, physical examination, and targeted testing guide the subsequent evaluation. The authors aim to identify signs, symptoms, and/or test results that indicate that one or more organ systems may be involved.

Gynecologic — Women whose complaints are mainly in the pelvis, with minimal or no urologic and gastrointestinal symptoms, are further evaluated for common gynecologic causes of pain. Of note, the most common cause of prolonged pelvic pain is dysmenorrhea, which is characterized by cyclic symptoms and not considered CPP. However, repeated bouts of intense dysmenorrhea have been hypothesized to potentially sensitize the nervous system and facilitate development of other causes of CPP, potentially through cross-organ sensitization mechanisms [81,82]. The treatment of dysmenorrhea is presented in detail separately. (See "Dysmenorrhea in adult females: Treatment".)

Common causes — Common gynecologic causes of CPP include endometriosis, prior pelvic inflammatory disease, ovarian cysts, adhesions, adenomyosis, and leiomyoma (table 1).

●Endometriosis – As endometriosis prevalence rates of up to 70 percent have been reported in referral populations of women and adolescents with pelvic pain, teams involved in CPP evaluation and management ideally include a pelvic surgeon who is well versed in clinical pelvic assessment and a radiologist who is experienced in reviewing ultrasound and magnetic resonance imaging studies suggestive of endometriosis [83-90]. Similar to other experts, the authors typically offer medical management consisting of hormonal suppression and nonsteroidal anti-inflammatory drugs (NSAIDs) to women with diagnosed or presumed endometriosis who do not desire pregnancy and who do not have an adnexal mass suspicious for an endometrioma [91,92]. For women whose symptoms do not improve after three to four months of hormonal suppression, or in whom medical management is not appropriate, the authors perform laparoscopy for diagnosis and excision of endometriosis lesions, when identified. Particularly in women who present with typical endometriosis symptoms (ie, a reproductive-age woman with dysmenorrhea and/or dyspareunia, infertility, or an ovarian mass), laparoscopy is performed to avoid delay in diagnosis of a disease that for some women requires life-long management [29,93,94]. However, it is also important to recognize that endometriosis may not always be causal in CPP, and can also be identified in women without pelvic pain. Thus, it is important to treat endometriosis when identified in symptomatic women but diligently identify and treat all other possible sources of pain in women regardless of the presence of endometriosis. Medical and surgical treatment options for women with endometriosis, or presumed endometriosis, is presented in detail separately. (See "Endometriosis: Treatment of pelvic pain".)

Not all gynecologic surgeons have the surgical expertise required to perform complete surgical excision, particularly of deep infiltrative disease, at the time of diagnostic laparoscopy. A major unresolved issue for gynecologists is how to minimize the number of procedures performed per chronic pain patient while also ensuring that patients with symptomatic endometriosis, in need of surgery, have the optimal surgical intensity of treatment. A key unknown worthy of further study is the long-term relative efficacy of comprehensive nonsurgical treatment versus excisional treatment, for both stage I/II and stage III/IV disease. In the absence of these data, we generally offer full excisional treatment of peritoneal disease, especially when conservative treatments have already failed. (See "Endometriosis: Surgical management of pelvic pain".)

●Prior pelvic inflammatory disease (PID) – Up to 30 percent of women with prior PID will develop CPP [95]. Women with CPP (particularly uterine pain), a history of PID, and no other identified causes of CPP, are offered neuromodulators, consistent with guidelines for chronic pain syndromes (strategy similar to treatment of general neuropathic pain outlined in algorithm, although opioid analgesia is generally avoided) (algorithm 1) [96,97]. However, some patients may benefit from selective removal of hydrosalpinges. In the authors' experience, hysterectomy that is performed as a final option can be curative for some patients. The timing of when that hysterectomy should be done is an urgent research question as persistent pain may be a trigger for developing centralized pain syndromes. (See "Chronic pelvic pain in adult females: Treatment", section on 'When to perform additional surgical procedures aimed to reduce pain'.)

●Adhesions – While adhesions are often asymptomatic, most patients with symptomatic adhesions have a history of prior surgery or an intraabdominal or pelvic inflammatory process. The role of adhesions as a cause of CPP is less clear [98]. In a randomized double-blind controlled trial of 100 patients with chronic abdominal pain and adhesions comparing laparoscopic lysis of adhesions versus diagnostic laparoscopy alone, no difference was identified between the groups after 12 years of follow-up (27 percent of patients in each group noted initial pain relief), but the data suggested that the group undergoing diagnostic laparoscopy alone overall did better [99]. In a separate prospective observational study of 68 patients (59 women and 9 men) with chronic abdominal pain who underwent laparoscopic adhesiolysis, 90 percent reported resolved or improved pain at 15 years of follow-up, but nearly one-quarter also underwent reoperation because of some abdominal disease and 68 percent underwent further abdominal evaluation during the followup period. All of the above suggests that there remains a long-term vulnerability to sensory abnormalities in these patients, and that laparoscopic lysis of adhesions is not always a useful or durable therapy [100]. (See "Postoperative peritoneal adhesions in adults and their prevention", section on 'Indications for adhesiolysis'.)

Unless there is a specific suspicion that an ovary or tube is badly distorted from prior infection, or there is cul-de-sac obliteration from stage IV endometriosis, the authors are very cautious about performing diagnostic laparoscopy for the sole treatment of pelvic and/or abdominal adhesions. For patients who repeatedly ask about the role of adhesions and adhesiolysis, the authors conservatively present the low likelihood of significant benefit for pain reduction solely from bowel adhesiolysis, at the very least until a discussion about the role of central factors in pain amplification has been had with the patient and ideally an extensive trial of neuromodulators and physical therapy been attempted.

●Adenomyosis – Women with adenomyosis typically present with painful, heavy periods, but CPP can also occur. Findings suggestive of adenomyosis include an enlarged, boggy uterus on examination and imaging studies demonstrating endometrial tissue within the myometrium. MRI can be very helpful for further suggesting the diagnosis. Evidence-based initial treatments are limited to hormonal manipulation (including the levonorgestrel-releasing IUDs) or hysterectomy (when medical therapy fails). However, the presence of adenomyosis does not predict the success of hysterectomy in curing pelvic pain. Approximately 25 percent of women who undergo hysterectomy for the indication of adenomyosis and CPP have persistent pelvic pain that does not resolve postoperatively [101]. (See "Uterine adenomyosis".)

In rare cases a discrete adenomyoma can be identified. These can be meticulously removed by expert surgeons and potentially preserve fertility, but success rates are not well known from small case series and the risk of uterine rupture in pregnancy is considered much higher than with other uterine preserving procedures [102].

●Leiomyoma – Leiomyoma, or fibroids, typically cause heavy or irregular vaginal bleeding and can cause mass-related symptoms such as pelvic pressure, urinary frequency, urinary retention, and/or constipation. Acute pain can occur with degeneration. While chronic pain is uncommon, pelvic pain associated with leiomyoma volumes as small as 2 cm³ has been reported [103]. Leiomyoma can be diagnosed on physical examination or imaging studies. (See "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on 'Clinical features'.)

As there are no clear diagnostic criteria to prove a leiomyoma is the source of pelvic pain, it requires a judgement call to surgically treat leiomyoma that are not clearly painful to palpation on repeated assessment, especially when the leiomyoma are less than 3 cm in size. However, women who have not responded to conservative therapy may benefit from leiomyoma removal, and thus leiomyoma remain on the differential diagnosis for CPP. The authors have occasionally seen patients who failed to respond to years of conservative neuromodulator and physical therapy treatment dramatically respond, with durable results, to a last-ditch simple myomectomy.

Less common causes — Less common gynecologic causes include pelvic congestion syndrome, ovarian remnant syndrome, and malignancy (table 1).

●Pelvic congestion syndrome – Pelvic congestion syndrome, while controversial, refers to a condition in which characteristic symptoms of shifting location of pain, deep dyspareunia, postcoital pain, and exacerbation of pain after prolonged standing are associated with radiological findings of pelvic varicosities (dilated uterine and ovarian veins) that display reduced blood flow [104]. One theory is that damage to the valves in the ovarian veins results in valvular incompetence leading to reflux and chronic dilation; however, incompetent and dilated pelvic veins are a common finding in asymptomatic women [105]. Unfortunately, the ideal diagnostic test cut-off values, whether using MRI, venography, or ultrasound, have not been definitively established [106]. (See "Vulvovaginal varicosities and pelvic congestion syndrome", section on 'Pelvic congestion syndrome'.)

●Ovarian remnant and residual ovary syndrome – Ovarian remnant syndrome occurs in patients who have undergone bilateral oophorectomy and subsequently present with symptoms related to ovulatory function from ovarian tissue inadvertently left behind. Ovarian remnant syndrome is distinguished from the residual ovary syndrome, in which the ovary was intentionally preserved and subsequently develops pathology. The typical patient presents with cyclic pelvic pain and a mass, although the pain may be persistent with acute flare-ups. Occasionally, an asymptomatic mass is detected on pelvic or sonographic examination. Premenopausal levels of estradiol and follicle-stimulating hormone, and an adnexal mass in a woman with a history of bilateral oophorectomy support the diagnosis of ovarian remnant syndrome. However, it is important to note that not all women with ovarian remnant syndrome have premenopausal levels of estradiol and follicle-stimulating hormone, and menopausal values do not exclude the diagnosis. Prior to surgical treatment, preoperative stimulation with clomiphene citrate can improve the surgeon's ability to adequately visualize the mass. However, despite seemingly complete surgical treatment, recurrences have been reported. Rarely, ureteral obstruction may occur [107]. (See "Ovarian remnant syndrome".)

●Malignancy – While gynecologic malignancies can affect the uterine body, cervix, ovaries, fallopian tubes, and vagina, ovarian cancer is the one that is most likely to cause diffuse pelvic symptoms, such as lower abdominal pain/discomfort/pressure/bloating, increased abdominal girth, constipation, lack of appetite, nausea or indigestion, irregular menstrual cycles or abnormal vaginal bleeding, low back pain, fatigue, urinary frequency, and/or dyspareunia. Careful pelvic examination for pelvic nodularity along with pelvic ultrasound is generally sufficient to rule out disseminated disease. (See "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical features and diagnosis".)

Urologic — Urologic causes of CPP include interstitial cystitis/bladder pain syndrome, renal stones, bladder foreign bodies, or urethral diverticulum (table 1). Presenting symptoms can include pain with voiding, urinary urgency and/or frequency (bladder pain syndrome, stone, foreign body, or neoplasia), urethral mass and urinary incontinence (urethral diverticulum), and hematuria (chronic recurrent infection or neoplasia). Cystourethroscopy can diagnose bladder stone or foreign body, urethral diverticulum, and bladder neoplasia, but is not required for the diagnosis of bladder pain syndrome, which can be made based on clinical symptoms alone. (See "Interstitial cystitis/bladder pain syndrome: Clinical features and diagnosis", section on 'Clinical features' and "Urethral diverticulum in females", section on 'Clinical presentation' and "Clinical presentation, diagnosis, and staging of bladder cancer".)

Urodynamic testing can be employed selectively when urgency/frequency is present to identify women with obstructed voiding (anatomic or functional), such as may occur with a urethral stricture. These women more typically note slow urine stream, sensation of incomplete emptying, and difficulty voiding. Women with acute causes such as a compressing mass or urethral lesion can present with pain. (See "Chronic urinary retention in females", section on 'Clinical presentation'.)

Gastrointestinal — Gastrointestinal processes that can cause CPP include irritable bowel syndrome, inflammatory bowel disease, diverticular colitis, celiac disease, chronic constipation, and cancer (table 1). To diagnose or exclude these entities, we refer women with a significant component of gastrointestinal symptoms (diarrhea, constipation, rectal bleeding, urgency, and tenesmus) for a gastroenterology evaluation. While all consultants benefit from the referring provider's insight as to possible causes for the woman's pain, additional detail is particularly important for gastroenterology consultations because both deep infiltrating endometriosis and intestinal disorders can present with similar symptoms. In one study of women who underwent laparoscopy, dyschezia was reported by 44 percent of those with endometriosis and up to 24 percent of patients without pelvic findings [108]. In those with hematochezia, the authors alert the consultant to the possibility of deep endometriosis invading the bowel as lesions may be visualized on colonoscopy.

●(See "Clinical manifestations and diagnosis of irritable bowel syndrome in adults".)

●(See "Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults".)

●(See "Clinical manifestations, diagnosis, and prognosis of Crohn disease in adults".)

●(See "Clinical manifestations and diagnosis of acute colonic diverticulitis in adults".)

●(See "Segmental colitis associated with diverticulosis".)

●(See "Epidemiology, pathogenesis, and clinical manifestations of celiac disease in adults".)

●(See "Chronic pelvic pain in nonpregnant adult females: Causes".)

●(See "Chronic intestinal pseudo-obstruction: Etiology, clinical manifestations, and diagnosis".)

●(See "Clinical presentation, diagnosis, and staging of colorectal cancer".)

Musculoskeletal — Musculoskeletal processes that can cause CPP include myofascial pelvic pain syndrome and fibromyalgia (table 1).

●Myofascial pelvic pain syndrome – Women with myofascial pelvic pain syndrome generally present with pain in the pelvis, vagina, vulva, rectum, or bladder, or in more distant referral areas such as the thighs, buttocks, hips, or lower abdomen. These women can also have heaviness, symptoms of bladder urgency or frequency, and tenesmus. Physical examination findings of tender pelvic muscles and trigger points are highly suggestive of myofascial pelvic pain syndrome. Trigger points are hyperirritable, palpable nodules that are painful to compression [109,110]. These women typically benefit from treatment by specialized physical therapists, and possibly from multidisciplinary treatment from specialists in physiatry. Myofascial pain is often comorbid with the other pain syndromes seen in CPP. (See "Myofascial pelvic pain syndrome in females: Clinical manifestations and diagnosis" and "Myofascial pelvic pain syndrome in females: Pelvic floor physical therapy for management".)

●Fibromyalgia – Fibromyalgia is a clinical diagnosis characterized by widespread pain, typically in the muscles and joints, and multiple tender points on examination. (See "Clinical manifestations and diagnosis of fibromyalgia in adults".)

Psychosocial — As noted above, the authors screen for mental health confounders such as depression, anxiety, somatization, substance misuse, and abuse (physical, sexual, and/or emotional) (table 1). Women with concerning symptoms or who screen positive are referred to a specialist for further evaluation and treatment. (See 'Psychosocial assessment' above.)

Poorly understood causes — Poorly studied conditions such as sacral Tarlov cysts, cauda equina syndrome, pelvic varicosities entrapping sacral nerve roots, or pelvic adhesions at the site of symptoms have been implicated as causes of CPP [111-114]. The role of these entities in CPP is not well studied. Other poorly understood diagnoses from complementary health care providers can include leaky gut syndrome or dysbiosis. While evidence supports that gut dysfunction and altered gut microbiota likely contribute to obesity, it is not known if these are causes of chronic pain as well [115]. When patients inquire about the possibility of these conditions causing their symptoms, it is important to acknowledge the limits of current knowledge, but also to consider the potential risks associated with treating these hypothesized disorders, many of which require complex procedures with associated risks.

Unknown etiology — Some women will complete the evaluation above and still not have clear signs, symptoms, or test results that help identify the cause of their pelvic pain. As endometriosis typically requires surgery for definitive diagnosis, the clinician and patient must decide if a diagnostic, and possibly operative, laparoscopy is indicated when no other pain etiology has been identified by less invasive measures. Women with a negative laparoscopy are diagnosed with idiopathic CPP that is generally managed like other centralized chronic pain syndromes. Over time, many of these patients will eventually develop more explicit symptoms that place them in discrete categories like irritable bowel syndrome, bladder pain syndrome, myofascial pelvic pain syndrome, or vulvodynia. (See "Chronic pelvic pain in adult females: Treatment".)

SPECIAL POPULATIONS

Pain flare or exacerbation — Women with known CPP who present with a pain flare can be challenging because the clinician must find a balance between repeating the entire evaluation to identify a possible new problem or assuming the flare is an exacerbation of the existing CPP and providing only supportive management. It is particularly problematic to support a patient's motivation to work on mind-body techniques to treat entrenched central pain processing abnormalities, when the surgeon and patient are both concerned about a flare representing a possible new structural problem (cyst, enlarging leiomyoma) or acute pathology in a nongynecologic organ system (eg, appendicitis, kidney stone, cholecystitis, acute entrapped spinal nerve).

In general, women with worrisome signs (fever, blood in urine or stool, pain with loss of sensation, and acute signs of intestinal obstruction or ovarian torsion) should be brought in for an evaluation. Over time, the clinician and patient may be able to establish a pain flare pattern and avoid repeated evaluations. However, symptoms that continue to escalate, even if they have been present in the past, warrant new evaluation. As an example, one of the authors evaluated a woman with persistent increasing abdominopelvic pain and escalating opioid use in the setting of gastric bypass that had been performed years earlier. After weeks of repeated examinations, the woman underwent a computed tomography scan and was diagnosed with multifocal spontaneous pelvic abscesses, without any evidence of systemic illness or acute abdomen.

Postmenopausal women — While the components of the evaluation of CPP in postmenopausal women are not significantly different compared with premenopausal women, the differential diagnosis narrows, which can alter the ordering of specific tests or interventions. For example, there is greater concern for malignancy, including ovarian, uterine, and colon cancer, as a cause of CPP in postmenopausal women who present with deep visceral features. Endometriosis symptoms largely resolve for most postmenopausal women, but in rare cases can still be functional and lead to pain or other complications [116-118]. While benign ovarian cysts still occur in postmenopausal women, physiologic cysts that result from ovulation are no longer present.

As higher rates of musculoskeletal pain are seen in some studies of older patients, these women may benefit from more aggressive attention to pelvic girdle issues [119]. The role of reduced sex hormone levels on pain processing is complex, and there is not good evidence to suggest that hormone replacement therapy dramatically improves CPP outcomes in postmenopausal women.

Adolescents — The evaluation of adolescents with CPP is discussed separately. Because early treatment of pain may reduce the chances of chronification, it is particularly important to be responsive to pain in this population. Adolescents with pain from dysmenorrhea can be counseled that one prospective observational study of 74 individuals with severe dysmenorrhea reported nearly 30 percent had no menstrual pain as adults while 18 percent were subsequently diagnosed with endometriosis [120]. (See "Chronic abdominal pain in children and adolescents: Approach to the evaluation".)

Obesity — Higher rates of chronic pain are seen in the obese and super-obese [121]. The exact etiology for the increased risk is not well understood, but some suggestions include increased load on the pelvic girdle and muscles, as well as increased systemic inflammation which can have direct effects of elevated circulating chemokine levels on pain processing. Aggressive physical therapy and weight optimization can be effective initial treatments before moving to any surgical approach. (See "Obesity in adults: Prevalence, screening, and evaluation" and "Patient education: Health risks of obesity (The Basics)".)

EXTIRPATIVE SURGERY — Regardless of initial diagnosis, many women with CPP will ultimately undergo multiple laparoscopic procedures (eg, for ablation of stage I endometriosis or lysis of adhesions) and may ultimately undergo extirpative surgery (hysterectomy, oophorectomy) with the hope improving their symptoms. However, CPP often persists despite multiple surgeries and/or removal of all pelvic organs. Thus, a critical area for future research is to understand the true abnormality in pain processing pathways in these women and preemptively distinguish those patients who will benefit from surgery and those who will not, so that repetitive surgery and its associated risks can be avoided. Until then, CPP practitioners need to reassure patients when enough procedural treatments have been done and direct the treatment focus to pain education and desensitization of these abnormal pathways. (See "Chronic pelvic pain in adult females: Treatment", section on 'When to perform additional surgical procedures aimed to reduce pain'.)

The authors find the following questions helpful when discussing organ removal with a patient:

●Does the pain have a deep location? If so, deep infiltrating endometriosis is a significant possibility. The authors pursue imaging, and possibly laparoscopy, to identify deep infiltrating endometriosis, which may allow organ-sparing approaches for those desiring fertility preserving strategies. (See "Endometriosis: Treatment of rectovaginal and bowel disease" and "Endometriosis of the bladder and ureter".)

●Has reasonable musculoskeletal treatment been attempted? If not, the authors refer the woman for evaluation with a specialist in pelvic floor physical therapy. It is important to directly communicate with the therapist to see if an adequate trial has been completed. (See "Myofascial pelvic pain syndrome in females: Clinical manifestations and diagnosis" and "Myofascial pelvic pain syndrome in females: Treatment" and "Myofascial pelvic pain syndrome in females: Pelvic floor physical therapy for management".)

●Do symptoms seem to be more cyclical? If so, a hormone-mediated process is more likely. The authors encourage these women to try hormone manipulation (eg, hormonal contraceptives, gonadotropin-releasing hormone analogues) before performing removal of both ovaries.

●Is there imaging evidence of a specific lesion that corroborates to the patient's pain or physical examination findings? As examples, women may have hydrosalpinges or ovarian cysts that may, or may not, be contributing to their pain. The presence of an anatomic abnormality that does not correspond to the woman's symptoms makes removal less likely to improve her symptoms.

●Has the woman undergone prior surgery or does she have a history of endometriosis in the area of pain? For example, endometriosis or surgery to treat it can lead to tethering of an ovary and resultant pain. If the uterus is the location of pain, does the region where a leiomyoma or adenomyoma sits correspond to where palpation-related pain can be reproduced, and could that foci be treated conservatively?

●If there is clear evidence of multi-focal pain or widespread pain (eg, fibromyalgia), is the patient prepared to accept that part of their pain represents altered central pain processing, that will require adjunctive treatment in the event that extirpative surgery is not helpful?

In all cases, it is essential to be supportive of the patient's concerns about the option of surgery, and the prospects of success, but they also need to know this may only treat a related symptom (eg, abnormal uterine bleeding), and/or only provide partial relief, no relief, or even worsen symptoms of pelvic pain.

RESOURCES FOR PATIENTS AND CLINICIANS

●Pelvic pain:

•International Pelvic Pain Society – A non-profit organization dedicated to the diagnosis and treatment of women with CPP that provides patient education materials and resources for clinicians.

•The International Association for the Study of Pain information from special-interest groups (SIGs) focused on specific types of pain.

•American College of Obstetricians and Gynecologists FAQ sheet – A free handout that answers questions about CPP.

•The Society of Obstetricians and Gynecologists of Canada provides consensus guidelines for the management of pelvic pain.

•Facing Pelvic Pain: A Guide for Patients and Their Families. Eds Elise De, MD, and Theodore A. Stern, MD. Boston: Mass Gen Hosp Psych Academy, 2021.

●Functional gastrointestinal disorders:

•The Rome Foundation provides statements from related work-groups as well as presentations and videos

●Functional urologic pain disorders:

•The American Urological Association Diagnosis and Treatment Interstitial Cystitis/Bladder Pain Syndrome (2014) provides guidelines for the management of bladder pain syndrome.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Female pelvic pain".)

SUMMARY AND RECOMMENDATIONS

●Definition – While there is no consensus on the definition of chronic pelvic pain (CPP), it is generally defined as non-cyclic pain perceived to be in the pelvic area that lasts for three to six months, or longer, and is unrelated to pregnancy. These time frames generally allow patients time to experience spontaneous resolution or have completed an initial evaluation for acute problems. (See 'Definition' above.)

●Incidence and etiologies – CPP has been reported to affect up to approximately 25 percent of reproductive-age women. CPP can be the result of identifiable pathology (eg, endometriosis), can persist without an identifiable cause (eg, functional/nociplastic pain syndrome, or be a combination of the two processes (table 1). (See 'Epidemiology and pathogenesis' above.)

●Clinical presentation – The hallmark symptom of women with CPP is pain localized to the pelvis of three to six months duration or longer. Women with CPP may also have pain that radiates beyond the pelvis, urinary or gastrointestinal symptoms, impaired quality of life (eg, no longer taking part in certain activities), and mental health changes (eg, depression). (See 'Clinical presentation' above.)

●Step-wise evaluation – As CPP is an end symptom with multiple potential causes and contributing factors, the authors use a stepwise approach for the initial evaluation of women with CPP. As with acute pelvic pain, women with unstable vital signs, peritoneal signs, or suspected life-threatening pathology (eg, ectopic pregnancy, bowel perforation) should be referred for emergency evaluation and management. (See 'Overview of approach' above and 'Patients with alarm findings' above.)

•History – The evaluation of women with CPP starts by taking a complete history that includes urinary, gastrointestinal, gynecologic, musculoskeletal, sexual, and psychosocial symptoms (table 2). In the history, the authors attempt to identify all factors that could contribute to CPP. The International Pelvic Pain Society has developed a detailed history and physical examination form for evaluation of women with CPP of any etiology. (See 'History' above.)

•Physical examination – The physical examination is an essential component in the evaluation of pelvic pain but can also be painful and emotionally stressful for the patient. While the examination is necessary to identify the anatomic locations and structures that reproduce the patient's pain, it may be critical for highly pain sensitive patients to have a pelvic examination done at a later visit, once a rapport is established. (See 'Planning' above.)

-Tenderness map – During the examination of the back, abdomen, and extremities, the examiner maps sites of tenderness and evaluates for abnormalities of multiple systems that could be contributing to the woman's CPP, including peripheral nerves, musculoskeletal tissues, and the gastrointestinal, urological, and reproductive organs (table 5). (See 'Back, abdomen, and extremities' above.)

-Pelvic examination – The pelvic examination includes inspection, cotton-swab testing for hyperalgesia or pain, and assessment of the pelvic musculature and reproductive organs, which is performed with a single-digit to minimize patient discomfort (table 5). (See 'Pelvic examination' above.)

●Additional testing – Unless there is a focal finding (eg, mucopurulent cervical discharge, suspected pelvic mass), there is generally a limited role for ancillary laboratory or imaging tests. Exceptions include urinalysis to exclude urinary tract infection and microbiologic tests for sexually transmitted infections if patients are sexually active. Likewise, provocative organ testing (anal manometry, potassium chloride bladder challenge) is generally not helpful. (See 'Targeted testing' above.)

●Role of laparoscopy – Laparoscopy can be used for both diagnosis and treatment in women with some causes of CPP (eg, endometriosis, adhesions) but is also associated with surgical risks (eg, bleeding, infection, visceral organ injury). While performing laparoscopy on all women with CPP is unnecessary, underutilization can also result in a delay in diagnosis and appropriate treatment. The optimal timing for performing laparoscopy has not been determined and, if contemplated based on initial assessment, requires a discussion of the individual benefits and risks with the patient. (See 'Role of laparoscopy' above.)

●Subsequent evaluation – The clinical features identified in the initial history, physical examination, and targeted testing guide the subsequent evaluation. The clinician aims to identify signs, symptoms, and/or test results that indicate that one or more organ systems may be involved, and then further evaluate that organ system. Groups who require additional consideration include adolescents and women who have an acute pain flare in addition to baseline CPP, are postmenopausal, or are obese. (See 'Targeted evaluation based on initial findings' above and 'Special populations' above.)

●Role of extirpative surgery – Many women with CPP will ultimately undergo extirpative surgery (eg, hysterectomy or oophorectomy) to improve their symptoms. However, CPP often persists despite removal of all pelvic organs. CPP practitioners need to reassure patients when enough procedural treatments have been done and direct the treatment focus to pain education and desensitization of these abnormal pathways. (See 'Extirpative surgery' above.)