Diagnosing chronic pelvic pain

Chronic pelvic pain is common in women. The broad differential diagnosis for chronic pelvic pain and overlap in symptoms among etiologies makes diagnosis challenging but underscores the need to conduct a detailed history and careful examination that considers the full spectrum of causes, according to Robert Moldwin, MD, associate professor of urology, Hofstra University School of Medicine, and director, Pelvic Pain Treatment Center, the Arthur Smith Institute for Urology, North Shore-LIJ Healthcare System, New Hyde Park, New York.

"The diagnoses for chronic pelvic pain in women include gynecologic, gastrointestinal, urologic, and neuromuscular-specific disorders, so clinicians must be careful not to limit their evaluation to entities falling only within their own specialty's realm. In addition, it is important to recognize chronic pelvic pain is associated with a high rate of various comorbid conditions. Therefore, both the diagnosis and effective management of chronic pelvic pain may necessitate a multidisciplinary approach," Moldwin told Contemporary OB/GYN.

A relatively high prevalence of chronic pelvic pain highlights the importance of developing expertise in evaluation. Estimates vary, but available epidemiologic data generally indicate that the frequency of diagnosis of some of the more common etiologies is increasing.

Medical history findings comprise about 90% of the diagnosis of chronic pelvic pain. The history should probe the specifics of the pain, including its location, nature, and radiation. However, because there is common innervation among urologic, gynecologic, gastrointestinal, and musculoskeletal structures, the report of pain location may be misleading in identifying the involved anatomy, Moldwin noted. The history should also elicit specific patterns, triggers, or factors that may bring relief and identify the presence of urinary and bowel voiding signs and symptoms.

Moldwin illustrated the role of obtaining a thorough history in arriving at an accurate diagnosis with the following case: A 42-year-old woman presents complaining of pelvic pain that is cyclical and exacerbated during sexual intercourse. Further questioning reveals that the patient has bladder-based signs and symptoms, including pain worsening with bladder filling and frequent nocturia. Urinalysis is negative, and no evidence of bladder cancer is found on cystoscopy.

"For the ob/gyn, a report of dyspareunia and cyclical pelvic pain might immediately bring to mind a diagnosis of endometriosis. However, the finding of urinary problems adds a new dimension to the clinical picture, and interstitial cystitis [IC] becomes the presumptive diagnosis based on the collective findings," Moldwin said.

A good pelvic examination to identify anatomic abnormalities or trigger points is also paramount in evaluating women complaining of chronic pelvic pain. For example, a finding of tenderness and fullness when palpating the course of the urethra suggests presence of a urethral diverticulum. Pain localizing directly on top of the bladder during an examination of the anterior vaginal vault suggests a bladder issue. Vulvar pain syndromes unrelated to infection, lichen sclerosis, or other well-defined pathologies should also be considered. In women with vulvar vestibulitis, severe pain can be elicited by pressing the end of a moist, cotton-tipped applicator into the vulvar vestibule. The physical exam may also identify taut bands of pelvic floor muscle containing trigger points and indicating pelvic floor dysfunction, a condition also known as levator ani syndrome, Hinman syndrome, or coccygodynia.

"The muscles of the pelvic floor are often overlooked during the physical examination, but pelvic floor dysfunction may coexist with many pelvic pathologic conditions," Moldwin explained. "In this condition, spasms arise as a guarding-type response of the body to some other organ- or tissue-specific pain. When present, pelvic floor dysfunction will also need to be addressed to achieve success in managing the patient's pain."

A urine sample may be obtained routinely for urinalysis and microbiologic assessment in women with complaints of chronic pelvic pain, but additional laboratory and diagnostic testing should be guided by the suspected pathology.

Accurate diagnosis of chronic pelvic pain is the foundation for initiating effective management. However, there are no simple treatment algorithms, and a multimodal approach is often necessary. For the various diagnoses, well-defined therapy may not exist, and some interventions are aimed at the global aspect of pain. Depending on the cause of the pain, women may benefit from muscle relaxants, botulinum toxin injections, physical therapy, behavioral therapy, neurostimulation, biofeedback techniques, control of constipation, or lifestyle and dietary interventions aimed at minimizing inciting triggers.

"In the distant past, chronic pelvic pain without a well-defined source was a ticket to psychiatric evaluation. We now understand that this pain is real and that in most instances, we can determine its etiology. In patients without an apparent cause, we believe that centralized pain originating in the central nervous system may be involved," Moldwin said. "However, for all patients, there are therapeutic options to minimize symptoms and improve quality of life."