Version May 2024
INTRODUCTION — Chronic pelvic pain (CPP) refers to pain of three to six months' duration (or longer) that occurs below the umbilicus and is severe enough to cause functional disability or require treatment. The potential etiologies of CPP are diverse and can arise from pathology or dysfunction from any one of the multiple organ systems present in the pelvis. In addition, regardless of whether there is or is not identifiable anatomic pathology, CPP can also represent a centralized pain syndrome.
This topic will discuss the more common causes of CPP and is not meant to be exhaustive. Evaluation and treatment of CPP in adult women and adolescents are presented separately:
●(See "Chronic pelvic pain in adult females: Evaluation".)
●(See "Chronic pelvic pain in adult females: Treatment".)
●(See "Chronic abdominal pain in children and adolescents: Approach to the evaluation".)
DEFINITION — While there is no consensus on the definition of CPP, it is generally defined as noncyclic pain perceived to be in the pelvic area that has persisted for three to six months or longer, is severe enough to cause functional disability or require treatment, and is unrelated to pregnancy [1-3]. (See "Chronic pelvic pain in adult females: Evaluation", section on 'Definition'.)
Abdominal pain often overlaps with CPP but may be distinguished from pelvic pain by its location: the abdomen is the area at or above the umbilicus, while the pelvis is the area below the umbilicus. Some conditions that cause abdominal pain may also cause pelvic pain, and some conditions that cause pelvic pain may also cause abdominal pain. Abdominal pain is reviewed separately. (See "Causes of abdominal pain in adults".)
OVERVIEW OF EPIDEMIOLOGY AND PATHOGENESIS — The reported prevalence of CPP ranges from 4 to 16 percent in the general population, but only approximately one-third of women with CPP seek medical care [4-7]. The relative frequency reported for the various causes of CPP is significantly influenced by the local patient population, referral patterns, and specialty focus of the clinical practice. One population-based study reported that gastrointestinal and urologic problems were more common than gynecologic conditions in women with CPP; gynecologic conditions accounted for approximately 20 percent of cases of CPP in this population [8].
A detailed discussion of the epidemiology and pathogenesis of CPP is presented in related content. (See "Chronic pelvic pain in adult females: Evaluation", section on 'Epidemiology and pathogenesis'.)
COUNSELING POINTS FOR PATIENTS — CPP is an end symptom with multiple potential etiologies (table 1).
●One versus multiple causes – Although there are many causes of CPP, chronic pain is often the result of multiple overlapping pain conditions, with each contributing to the generation of pain, thus requiring management. As an example, a woman may have endometriosis, interstitial cystitis, and pelvic floor pain related to muscular spasm. Having more than one condition is more common than having only one, and women with more than one medical condition often have greater pain than women with only one disorder [9], although the severity of pain is not consistently associated with degree of anatomic pathology or number of pain conditions.
●Evaluation and treatment are a process – It is important that the clinician begin with a thorough history and physical examination to identify all conditions that are contributing to pain and decreased quality of life. Patients should be counseled that the evaluation takes time, many etiologies are considered chronic conditions, treatment is not always curative, and consultation with other providers may be warranted. (See "Chronic pelvic pain in adult females: Evaluation", section on 'Initial evaluation'.)
●Possible inability to make a diagnosis – In some women, no diagnosis other than chronic pain can be established; this is often a source of frustration for both the patient and clinician. These women are classified as having chronic pelvic pain syndrome, which is likely due to central sensitization, as discussed in the bullet below.
●Role of centralized pain syndrome – Central sensitization describes any central nervous system (CNS) dysfunction that plays a role in augmenting and maintaining pain as well as leading to other CNS-mediated symptoms [10]. This condition, generally characterized by multifocal pain and co-occurring somatic symptoms, such as fatigue, memory difficulties, and poor sleep, is found in subgroups of nearly every chronic pain condition. (See "Chronic pelvic pain in adult females: Evaluation", section on 'Epidemiology and pathogenesis' and "Approach to the management of chronic non-cancer pain in adults", section on 'General approach'.)
GYNECOLOGIC — Women whose complaints are mainly in the pelvis should be further evaluated for gynecologic causes of pain (table 1). (See "Chronic pelvic pain in adult females: Evaluation", section on 'Gynecologic'.)
Endometriosis — Endometriosis is the most common gynecologic cause of CPP. Endometriosis is defined as the presence of endometrial glands and stroma that occur outside the uterus. Endometriosis is the most common diagnosis made at the time of gynecologic laparoscopy for the evaluation of CPP [11]. Studies report that 20 to 80 percent of women who undergo surgery because of CPP are diagnosed with endometriosis; however, in practices specializing in the treatment of endometriosis, 70 percent or more of patients with CPP are given this diagnosis [12-14]. However, it is important to recognize that, in general, the presence and severity of endometriosis does not consistently correlate with symptom severity except in the case of posterior cul-de-sac disease and severity of dyspareunia. Even when endometriosis is present, endometriosis may not always be causal in CPP. Endometriosis has been identified in nearly 10 percent of women without pelvic pain [15-18], and some women with severe intractable pelvic pain may have minimal to no disease. Thus, it is important to treat endometriosis when identified in symptomatic women as well as diligently identify and treat all other possible sources of pain regardless of the presence of endometriosis. The coexistence of other pain syndromes in women and adolescents with endometriosis is higher than that in the general population [19,20]. Topics related to the diagnosis and treatment of endometriosis are presented in detail separately:
●(See "Endometriosis in adults: Pathogenesis, epidemiology, and clinical impact".)
●(See "Endometriosis: Treatment of pelvic pain".)
●(See "Endometriosis: Surgical management of pelvic pain".)
●(See "Endometriosis: Management of ovarian endometriomas".)
●(See "Endometriosis of the bladder and ureter".)
●(See "Endometriosis: Clinical manifestations and diagnosis of rectovaginal or bowel disease".)
Common — While CPP is not the hallmark symptom of adenomyosis, leiomyoma, intraabdominal adhesions, or pelvic inflammatory disease, the high prevalence of these conditions among women with CPP makes them important considerations when evaluating women with CPP.
●Intraabdominal adhesions – The relationship between CPP and intraabdominal adhesions is poorly defined. Peritoneal adhesions have been reported to develop following more than 90 percent of abdominal surgeries (general, vascular, gynecologic, and urologic) [21]. While most adhesions are often clinically silent, there is some evidence that dense adhesions that limit organ mobility cause visceral pain and that adhesions may account for pelvic pain based on pain mapping at the time of laparoscopy [22,23]. In a systematic review of 25 mostly observational studies evaluating the efficacy of adhesiolysis for treating chronic abdominal pain, pain improvement varied from 16 to 88 percent [24]. Twelve-year follow-up of one of the two trials in the systematic review reported no benefit to laparoscopic adhesiolysis compared with laparoscopy alone [25]. A meta-analysis also reported that, in general, patients with chronic pelvic pain and intraabdominal adhesions did not benefit long term from adhesiolysis [26]. (See "Postoperative peritoneal adhesions in adults and their prevention" and "Chronic pelvic pain in adult females: Evaluation", section on 'Role of laparoscopy' and "Chronic pelvic pain in adult females: Treatment", section on 'When to operate for suspected pelvic pathology'.)
●Adenomyosis – Adenomyosis refers to a disorder in which endometrial glands and stroma are present within the uterine musculature. The ectopic tissue can induce hypertrophy and hyperplasia of the surrounding myometrium, which has been proposed as a cause of abnormal uterine bleeding and dysmenorrhea that is often reported in women with adenomyosis. Endometriosis and adenomyosis are widely believed to be associated, but the underlying etiology for their overlap remains unknown. Adenomyosis has been reported to be present in approximately 20 percent of women undergoing surgery for endometriosis and is most commonly seen in women with deeply infiltrative endometriosis [27]. In one imaging study of deeply infiltrative endometriosis, over 90 percent of women with deep endometriosis had concomitant adenomyosis, and 81 percent of women with adenomyosis had concomitant deep endometriosis [28]. While the mechanism of dysmenorrhea and chronic pain among women with adenomyosis is not entirely understood, theories include bleeding and swelling of endometrial islands confined by myometrium [29] and increased proliferation of nerve fibers in the endometrium [30]. However, it is important to recognize that, similar to nearly all anatomic pathologies, the relationship between adenomyosis and CPP is not fully understood. While some studies suggest that adenomyosis is related to abnormal bleeding and CPP, adenomyosis is also frequently identified in asymptomatic women. In one retrospective study of women who underwent hysterectomy, adenomyosis was identified in nearly 50 percent of women, but its presence is not correlated with pelvic pain, abnormal bleeding [31], or the likelihood that hysterectomy resolves CPP [32]. (See "Uterine adenomyosis".)
●Leiomyomas – Uterine leiomyomas may cause abnormal uterine bleeding or mass-related symptoms. Acute pain can occur with degeneration, torsion of pedunculated subserosal fibroids, or expulsion of pedunculated intracavitary myomas through the cervix. Chronic pain is not the most common symptom reported in women with leiomyomas but has been reported in women with leiomyoma as small as 2 cm3 [4]. The frequency of chronic pelvic pain in a population-based international survey of women was reported to be nearly 15 percent in women with fibroids compared with 3 percent for women without fibroids [33]. However, these data were based on self-report, and it is unknown if other causes of pain were also present. (See "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history".)
●Pelvic inflammatory disease (PID) – Pelvic inflammatory disease (PID) refers to acute and subclinical infection of the upper genital tract in women, involving any or all of the uterus, fallopian tubes, and ovaries. The self-reported lifetime prevalence rates of PID range from approximately 3 to 10 percent in the United States [34]. Women with PID can develop CPP as a long-term sequelae of infection or as a result of chronic subclinical infection. As many as 30 percent of women with PID subsequently develop CPP [35]. (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis".)
Two factors correlate with the likelihood of developing CPP after an episode of acute PID: (1) severity of adhesive disease and tubal damage (eg, hydrosalpinx) and (2) persistent pelvic tenderness 30 days after diagnosis and treatment [36]. However, the underlying reason that PID often leads to CPP has not been clearly established. In one study of 780 predominantly Black urban women with recently diagnosed PID, those most likely to develop CPP were smokers, women with a history of two or more episodes of PID, and women with a low composite mental health score on a graded chronic pain scale [37].
Less common
●Ovarian remnant and residual ovary syndrome – Ovarian remnant syndrome (ORS) occurs in patients who have undergone bilateral oophorectomy and subsequently present with symptoms related to ovulatory function from ovarian tissue inadvertently left behind. It should be distinguished from the residual ovary syndrome (ROS), in which the ovary was intentionally preserved and subsequently developed pathology. The typical patient presents with cyclic pelvic pain and a mass, although the pain may be chronic with acute flare-ups. Occasionally, an asymptomatic mass is detected on pelvic or sonographic examination. Rarely, ureteral obstruction may occur. (See "Ovarian remnant syndrome".)
●Malignancy – Gynecologic malignancies of the uterine body, cervix, ovaries, fallopian tubes, and vagina can cause diffuse pelvic symptoms, including pain. However, pain is a nonspecific symptom and most women with pelvic pain do not have cancer. Discussions of the various gynecologic malignancies are presented separately.
•(See "Endometrial carcinoma: Clinical features, diagnosis, prognosis, and screening".)
•(See "Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis".)
•(See "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical features and diagnosis".)
•(See "Vaginal cancer".)
●Pelvic congestion syndrome – Pelvic congestion syndrome is a controversial entity that does not currently have validated diagnostic criteria. It refers to a condition in which characteristic symptoms of pelvic pain, pelvic pressure, deep dyspareunia, postcoital pain, and exacerbation of pain after prolonged standing are associated with radiologic findings of pelvic varicosities (dilated uterine and ovarian veins) that display reduced blood flow [38]. The incidence of pelvic congestion syndrome has not been established since there are no validated diagnostic criteria. The presence of pelvic varices has been reported in up to 10 percent of the general population. Among these, approximately 40 percent will develop pelvic vein insufficiency [39]. 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 [40], similar to changes described in CPP and multiple other centralized pain conditions [41].
●Other – Dysmenorrhea is defined as recurrent, crampy, lower abdominal pain occurring shortly before and during menses. It is further classified as primary dysmenorrhea, which is recurrent menstrual pain that occurs in the absence of demonstrable pelvic disease, versus secondary dysmenorrhea, which occurs in association with other pelvic pathology such as endometriosis, adenomyosis, or uterine fibroids. Although women with CPP often experience exacerbation of their pain during menses, dysmenorrhea is considered a distinct entity in which women do not have bothersome pain when they are not menstruating. In contrast to most chronic pain conditions characterized by almost daily pain, dysmenorrhea has not been traditionally considered a chronic pain condition because pain is limited to a few days of each month. However, emerging evidence suggests that dysregulation of central nervous system pain processing is present in women with dysmenorrhea [42].
Other pelvic pain symptoms that often co-occur with CPP include vulvar pain and dyspareunia:
•(See "Dysmenorrhea in adult females: Clinical features and diagnosis".)
•(See "Vulvar pain of unknown cause (vulvodynia): Clinical manifestations and diagnosis".)
•(See "Female sexual pain: Evaluation".)
•(See "Female sexual pain: Differential diagnosis".)
GASTROINTESTINAL TRACT — Gastrointestinal processes that can cause chronic pelvic and abdominal pain include irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), diverticular colitis, celiac disease, chronic constipation, and cancer (table 1). The evaluation of women with CPP and gastrointestinal symptoms is reviewed separately:
●(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 intestinal pseudo-obstruction: Etiology, clinical manifestations, and diagnosis".)
●(See "Clinical presentation, diagnosis, and staging of colorectal cancer".)
More common
●Irritable bowel syndrome (IBS) – IBS is a gastrointestinal pain syndrome characterized by chronic or intermittent abdominal pain that is associated with altered bowel function in the absence of any organic cause. Approximately 10 percent of the general population has symptoms compatible with IBS; women are diagnosed with IBS more than twice as often as men [43-45]. IBS is probably the most common etiology of CPP in primary care populations and has been reported as occurring in up to 35 percent of these women [9,46]. However, in many women with CPP and IBS, the IBS has not been diagnosed or treated [46].
It is important to note that IBS is highly prevalent in women with endometriosis and CPP [47,48]. However, the presence of symptoms such as bowel pain or bowel upset (ie, constipation, diarrhea) do not correlate with the severity of endometriosis. In a study of nearly 1000 women with surgically confirmed endometriosis, symptoms of constipation, diarrhea, and bowel pain were reported by 29 percent of women with stage I/II disease compared with 36 percent of women with III/IV disease, which were not statistically different [49].
The diagnosis of IBS is based upon specific criteria in the patient's history; physical examination is generally unremarkable. The clinical manifestations, diagnosis, and treatment of IBS are discussed in detail separately. (See "Clinical manifestations and diagnosis of irritable bowel syndrome in adults" and "Treatment of irritable bowel syndrome in adults".)
●Inflammatory bowel disease (IBD) – Fatigue, diarrhea with crampy abdominal pain, weight loss, and fever, with or without gross bleeding, are the hallmarks of Crohn disease. The transmural nature of the inflammatory process leads to fibrotic strictures that often lead to repeated episodes of small bowel or less commonly colonic obstruction. Ulcerative colitis, as well as other causes of colitis, have a similar presentation; however, rectal bleeding is more common with ulcerative colitis than with Crohn disease. (See "Clinical manifestations, diagnosis, and prognosis of Crohn disease in adults" and "Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults".)
●Diverticular colitis – Patients with diverticular disease can develop segmental colitis, most commonly in the sigmoid colon, that results in CPP. The endoscopic and histologic features vary, ranging from mild inflammatory changes with submucosal hemorrhages (peridiverticular red spots on colonoscopy) to florid, chronic active inflammation resembling (histologically and endoscopically) inflammatory bowel disease. The pathogenesis is incompletely understood. The cause may be multifactorial, related to mucosal prolapse, fecal stasis, or localized ischemia. (See "Segmental colitis associated with diverticulosis".)
●Celiac disease (sprue) – Celiac disease (or sprue) is a disorder caused by an immune reaction to gluten. Impaired absorption and digestion of nutrients by the small intestine typically result in recurrent diarrhea and weight loss or symptoms that resemble IBS [50,51]. CPP can also be a presenting complaint. The presentation, diagnosis, and management of celiac disease in adults is reviewed separately:
•(See "Epidemiology, pathogenesis, and clinical manifestations of celiac disease in adults".)
•(See "Diagnosis of celiac disease in adults".)
•(See "Management of celiac disease in adults".)
Less common
●Chronic intestinal pseudo-obstruction – Pseudo-obstruction is a syndrome characterized by signs and symptoms of a mechanical obstruction of the small or large bowel in the absence of an anatomic lesion that obstructs the flow of intestinal contents. The clinical symptoms of chronic intestinal pseudo-obstruction include distension (75 percent), abdominal pain (58 percent), nausea (49 percent), constipation (48 percent), heartburn/regurgitation (46 percent), fullness (44 percent), epigastric pain/burning (34 percent), early satiety (37 percent), and vomiting (36 percent). (See "Chronic intestinal pseudo-obstruction: Etiology, clinical manifestations, and diagnosis".)
●Chronic constipation – Although chronic constipation is common in women, chronic pain is not a diagnostic criterion for this condition. Women with chronic constipation who have pain as a prominent symptom, in the absence of other anatomic intestinal pathology, are defined as having IBS with the constipation subtype. (See "Etiology and evaluation of chronic constipation in adults" and "Clinical manifestations and diagnosis of irritable bowel syndrome in adults", section on 'Constipation'.)
●Colon cancer – The majority of patients with colorectal cancer have hematochezia or melena, abdominal pain, and/or a change in bowel habits. CPP can be an additional component. (See "Clinical presentation, diagnosis, and staging of colorectal cancer".)
●Hernia – Abdominal wall, inguinal, and obturator hernias can cause CPP, although a bulge presenting with intermittent pain is more common. (See "Overview of abdominal wall hernias in adults".)
URINARY TRACT — Urologic causes of CPP include interstitial cystitis/painful bladder syndrome, renal stones, bladder foreign bodies, recurrent urinary tract infection, or urethral diverticulum (table 1). The evaluation of women with CPP and urinary tract symptoms is reviewed separately. (See "Chronic pelvic pain in adult females: Evaluation", section on 'Targeted evaluation based on initial findings'.)
●Interstitial cystitis/painful bladder syndrome – Interstitial cystitis/bladder pain syndrome (IC/BPS) is a diagnosis that applies to patients with chronic bladder pain and urinary urgency and frequency in the absence of other etiologies and is a common cause of CPP [52]. Chronic urethral syndrome also presents with symptoms resembling those of IC/PBS and is often viewed as part of the same syndrome. (See "Interstitial cystitis/bladder pain syndrome: Clinical features and diagnosis".)
●Other – Other less common urinary causes of CPP include recurrent renal stones, bladder or urethral foreign bodies, recurrent urinary tract infections, urethral diverticulum, and, rarely, bladder cancer. Renal stones more commonly present with waxing and waning pain. Bladder foreign bodies commonly present in association with irritative voiding symptoms. Chronic suprapubic pain, especially in association with frequency, urgency, and/or hematuria requires evaluation for recurrent urinary tract infection. The possibility of a urethral diverticulum should be considered if there is a suburethral mass, fullness, or tenderness. Bladder neoplasia (carcinoma-in-situ and carcinoma) may present with symptoms similar to those of interstitial cystitis. Neoplasia should be considered in women with hematuria, a history of smoking, or in any person with irritative bladder symptoms over 60 years of age.
•(See "Kidney stones in adults: Diagnosis and acute management of suspected nephrolithiasis".)
•(See "Chronic urinary retention in females", section on 'Anatomic'.)
•(See "Recurrent simple cystitis in women".)
•(See "Urethral diverticulum in females".)
•(See "Clinical presentation, diagnosis, and staging of bladder cancer".)
MUSCULOSKELETAL — Musculoskeletal causes of CPP include myofascial pelvic pain syndrome, fibromyalgia, poor posture, hernia, and osteitis pubis.
●Myofascial pelvic pain syndromes – Myofascial pain is pain that arises from dysfunction, spasticity, and/or hypersensitivity of the muscle, fascia, or joints in the abdominal wall, pelvic floor, and/or low back. This is an extremely common but under-recognized source of pain in women with CPP, in part because diagnostic criteria and consistent study designs are lacking [53].
Trigger points, a type of myofascial pain, are palpable nodules that are markedly painful to firm palpation. These nodules are associated with referred pain, motor dysfunction, and occasionally autonomic symptoms [54]. Myofascial pain may develop after an injury (direct muscular injury or overuse strain), or it may be related to scoliosis or other postural/joint abnormalities. (See "Myofascial pelvic pain syndrome in females: Clinical manifestations and diagnosis".)
Coccydynia, pelvic floor tension myalgia, or pelvic myofascial pain appear to be specific types of MPPS and are caused by involuntary contraction and shortening of the pelvic floor muscles (eg, piriformis, levator ani, iliopsoas, obturator internus). In particular, the levator ani muscle group can undergo pain processes observed in other muscle groups, such as hypertonus, myalgia, overuse, and fatigue. While the etiology includes any inflammatory painful disorder, childbirth, pelvic surgery, and trauma, many women with this condition do not have an identifiable risk factor or cause of pelvic floor muscle dysfunction. In addition to dyspareunia, there may be aching pelvic pain, which is aggravated by physical activity, and is often worse by the end of the day. Symptoms are often described as improved by heat and lying down with the hips flexed. There is evidence that women with CPP have decreased thresholds to pain in the pelvic floor muscles and that pelvic floor tension myalgia is commonly identified in women with CPP, including those with and without endometriosis or interstitial cystitis/bladder pain syndrome [55]. Treatment is primarily pelvic floor physical therapy. However, medication, trigger point, and/or botox injections may be indicated in some women. (See "Myofascial pelvic pain syndrome in females: Pelvic floor physical therapy for management" and "Myofascial pelvic pain syndrome in females: Treatment".)
●Fibromyalgia – Women with fibromyalgia may sometimes present for evaluation with CPP as the primary complaint. Fibromyalgia is a clinical diagnosis characterized by widespread pain and is often accompanied by fatigue, memory problems, and sleep dysfunction [56]. Although the original diagnostic criteria include the identification of tender points, the most recent diagnostic criteria are entirely symptom based and do not include tender point counts. Fibromyalgia is recognized as a centralized pain syndrome characterized by central nervous system amplification of sensory processing. (See "Clinical manifestations and diagnosis of fibromyalgia in adults".)
●Posture – Faulty posture can cause muscle imbalance involving the abdominal muscles, thoracolumbar fascia, lumbar extensors, or hip flexors and abductors leading to local or referred pain. Consultation with a physical therapist can be helpful for both a diagnosis and treatment.
●Osteitis pubis – Osteitis pubis refers to lower abdominal and pelvic pain due to noninfectious inflammation of the pubic symphysis. It can be a complication of surgery (eg, urogynecologic procedures) or related to pregnancy/childbirth, athletic activities, trauma, or rheumatologic disorders. The pain is aggravated by movements such as walking, stair climbing, and coughing. Osteitis pubis is distinguished from other pain syndromes by demonstrating the pubis symphysis tenderness with direct palpation. (See "Sports-related groin pain or 'sports hernia'" and "Maternal adaptations to pregnancy: Musculoskeletal changes and pain".)
NEUROLOGIC — Neurologic causes of CPP include nerve injury or entrapment and chronic pain syndromes.
●Nerve injury or entrapment – CPP may be related to nerve injury or entrapment of abdominal or pelvic nerves, such as the iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous, or pudendal nerves. A history of a prior surgical procedure with subsequent pain in the anatomic distribution of a peripheral nerve is suggestive of nerve injury or entrapment. For example, chronic abdominal wall pain occurs in 7 to 9 percent of women after a Pfannenstiel incision and can be due to injury of the ilioinguinal or iliohypogastric nerves [57]. A history of a repetitive activity, such as bicycle or horseback riding, with persistent pain in the pelvis and perineum is suggestive of pudendal neuralgia. (See "Anterior cutaneous nerve entrapment syndrome" and "Nerve injury associated with pelvic surgery".)
●Central sensitization – After a thorough evaluation for the etiology of CPP, some women will have no identified cause of pain and others will have persistent pain despite treatment of presumed etiologies. These women are presumed to have a chronic pain syndrome, which is characterized by central sensitization [58]. (See "Evaluation of chronic non-cancer pain in adults" and "Approach to the management of chronic non-cancer pain in adults", section on 'General approach'.)
OTHER CONSIDERATIONS — Psychosocial disorders, opioid dependency, physical and sexual abuse experiences, and depression and other mood disorders are commonly identified in women with CPP. It is important to recognize that these conditions may not be the initial or underlying cause of CPP but should be appropriately treated in order to improve quality of life.
●Opioid dependency – Patients with opioid dependency can present with complaints of CPP, both to obtain more opioids and also a result of opioid-induced hyperalgesia and/or opioid-induced bowel dysfunction. In the United States, nearly half of new pain patients who take opioids for more than 30 days in the first year of treatment continue to do so for three or more years [59]. Additionally, patients with chronic or persistent opioid use can experience opioid-induced hyperalgesia with decreased responsiveness to opioid analgesics [60,61]. The most common side effect of opioid use is constipation, but some patients may also have associated abdominal pain. Given the risks and limited benefit of opioids for the treatment of chronic, nonmalignant pain, we discourage the use of opioids for the treatment of CPP. (See "Substance use disorders: Clinical assessment" and "Prevention and management of side effects in patients receiving opioids for chronic pain" and "Approach to the management of chronic non-cancer pain in adults", section on 'General approach'.)
●Abuse – Women with chronic pain, including CPP, appear to have a higher incidence of prior physical or sexual abuse: up to 47 percent of women with CPP disclose a history of physical and sexual abuse [62-64]. (See "Intimate partner violence: Epidemiology and health consequences".)
•In a questionnaire study of 713 consecutive women seen in a referral-based pelvic pain clinic, 47 percent reported having either a sexual or physical abuse history and 31 percent had a positive screen for posttraumatic stress disorder [64].
•A different self-reported questionnaire study of over 1900 multiethnic women in California reported current bladder pain was associated with a lifetime history of sexual assault (OR 1.39, 95% CI 1.02-1.88) and current PTSD symptoms (OR 1.96, 95% CI 1.5-2.65) [65].
•In one study of women with CPP, a history of abuse was not associated with a difference in pelvic pain intensity, but a history of sexual abuse was associated with greater pain-related disability. Furthermore, a history of physical or sexual abuse appeared to hold a stronger relationship with current depressive symptoms than pain experienced by women with CPP [66].
Past traumatic experiences may alter neuropsychological processing of pain signals and can permanently alter pituitary-adrenal and autonomic responses to stress. In one study, women with a childhood history of sexual or physical abuse had a fivefold greater increase of adrenocorticotropic hormone to a standardized social stress intervention compared with women without a history of abuse [67].
●Depression – Depression, which is prevalent in the general population, appears to occur even more frequently in patients with chronic pain, including women with CPP [68]. The relationship between depression and chronic pain is complex and intertwined. However, most studies suggest that mood disorders are a consequence of chronic pain. A population-based study reported that moderate to severe pain is a strong risk factors for incident or recurrent mood and anxiety disorders, independent of other mental health disorders [69]. Furthermore, studies suggest that depression and chronic pain share common, but not entirely overlapping neurobiological and psychosocial underpinnings [70,71]. Thus, it is clear that chronic pain is not simply a consequence or manifestation of depression or other mood disorders, and the optimal treatment for comorbid pain and depression should adequately address both the physical and psychological symptoms of both conditions. (See "Unipolar depression in adults: Epidemiology".)
●Psychiatric comorbidity – Some women presenting with CPP have histories of primary psychiatric comorbidity. It is important to distinguish them from patients who are developing secondary mood disorders, that is, patients who are developing symptoms of anxiety, depression, or other expressions of psychopathology in reaction to their persistent pain. Since nociceptive pathways are modulated by psychological processes, this mechanism probably plays an important role in amplifying pain symptomatology [72]. (See "Unipolar depression in adults: Assessment and diagnosis".)
●Sleep disorders – Women with CPP can have sleep disorders that both result from and contribute to their pain and/or depression [73]. (See "Classification of sleep disorders".)
●Stress – Human and animal data suggest that stress, particularly early life stress, is associated with increased pain sensitivity [74-76]. More studies are needed to understand the mechanisms and potential therapeutic options.
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: Endometriosis" and "Society guideline links: Chronic pain management" and "Society guideline links: Female pelvic pain".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Chronic pelvic pain in females (The Basics)" and "Patient education: Bladder pain syndrome (interstitial cystitis) (The Basics)")
●Beyond the Basics topics (see "Patient education: Chronic pelvic pain in females (Beyond the Basics)" and "Patient education: Diagnosis of interstitial cystitis/bladder pain syndrome (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Definition – Chronic pelvic pain (CPP) refers to pain below the umbilicus of at least three to six months' duration that is severe enough to cause functional disability or require treatment. (See 'Definition' above.)
●Epidemiology – The relative frequency of the various causes of CPP is significantly influenced by the local patient population, referral patterns, and specialty focus of the practice. Prevalence rates from 4 to 16 percent have been reported. (See 'Overview of epidemiology and pathogenesis' above.)
●Counseling points for patients – As chronic pelvic pain has multiple potential etiologies, more than one cause may be present. It is important that the clinician begin with a thorough history and physical examination. Patients should be counseled that diagnosis and treatment take time, may not be curative, and consultation with other providers may be warranted. Patients for whom a specific etiology is not identified are presumed to have a centralized pain syndrome.
•(See 'Counseling points for patients' above.)
•(See "Chronic pelvic pain in adult females: Evaluation".)
•(See "Chronic pelvic pain in adult females: Treatment".)
●Common causes of CPP by organ system – Potential causes of CPP in nonpregnant women and associated symptoms are listed in the table (table 1).
•Gynecologic – Endometriosis (see 'Gynecologic' above)
•Gastrointestinal – Irritable bowel syndrome, inflammatory bowel disease, diverticular colitis, and celiac disease (see 'Gastrointestinal tract' above)
•Urologic – Interstitial cystitis/painful bladder syndrome (see 'Urinary tract' above)
•Musculoskeletal – Myofascial pelvic pain syndrome (see 'Musculoskeletal' above)
•Neurologic – Nerve injury or entrapment (see 'Neurologic' above)
●Additional conditions – Psychosocial disorders, including physical and sexual abuse experiences, opioid dependency, and depression and other mood disorders are commonly identified in women with CPP and should be appropriately treated in order to improve quality of life. (See 'Other considerations' above.)
ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledge Fred Howard, MD, who contributed to an earlier version of this topic review.
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
