Pelvic pain in the adolescent

Chronic pelvic pain (CPP) has been defined as pain that occurs constantly or recurrently for 3 months or longer.¹ Approximately 3% to 5% of all adolescent visits to a primary care provider involve abdominal pain.² A vast number of conditions can cause CPP and it is important to consider nongynecologic sources including the gastrointestinal (GI), urinary, and musculoskeletal systems. CPP in the adolescent is complicated by the psychosocial and developmental changes that occur in this age group.² Issues of privacy and confidentiality surrounding parental involvement must also be considered.

Aggressive diagnosis and management of CPP are important to avoid significant quality of life changes and a negative impact on future reproductive health of the adolescent. For that reason it has been suggested that evaluation begin if pain persists for 2 months.

History

The workup of CPP starts by establishing rapport with the adolescent in an effort to promote effective communication. Issues of privacy and confidentiality should be addressed at the initial visit.³ A thorough history, similar to that obtained from an adult, is essential (Table 1). In addition, a confidential gynecologic history should be taken with special emphasis on a detailed menstrual and sexual history. Questions surrounding sexual abuse should also be addressed. A thorough psychosocial history should be obtained and can be facilitated by using the Home, Education/Employment, Activities, Drugs/Dieting, Sexuality, Suicide, and Safety (HEADSSS) assessment, which is a screening tool for risk-taking behaviors (Table 2).^4,5 Nonthreatening questions are asked first and as the interview continues, the adolescent is questioned on more sensitive issues relating to sex and drug use.⁴ This assessment may reveal psychosocial triggers for pain. It may also give insight into the adolescent’s cognitive and developmental stage and, therefore, her capacity to understand and give consent for procedures.⁶

Physical exam

Fear and anxiety about pelvic exams are known barriers to evaluation of CPP in adolescents. Early reassurance that no painful examinations will be done or that the examination will be stopped if the adolescent feels pain can aid in reducing concern.³ Tailor the examination to the age and maturity of a patient and carefully explain the process. Table 3 outlines key points of the physical exam.^3,7 It has been our practice to avoid a bimanual or speculum exam in the virginal or sexually immature patient. In these cases, assessment of the vagina can be made with a small  moistened cotton swab; alternatively a rectoabdominal exam can
be performed.

Labs/Imaging

Laboratory and imaging studies are used to focus diagnoses and rule out common causes of pain. These should include a pregnancy test, urinalysis, urine culture, and gonorrhea/chlamydia cultures in the sexually active patient.³ Transabdominal pelvic ultrasound (U/S) in the young teenager is  beneficial if the pelvic exam is limited or a mass is palpated. Magnetic resonance imaging (MRI) is reserved for cases with high clinical suspicion of congenital anomaly. 

Pelvic pain specific to adolescents

Causes of CPP may be similar in adults and adolescents but specific problems are more common in the latter group. Here we present a brief discussion of 3 causes of CPP in the adolescent.

Endometriosis

The true incidence of endometriosis in adolescents is unknown but studies have reported a prevalence of 25% to 38% in adolescents with CPP and an incidence of 50% to 70% among adolescents undergoing laparoscopy for failed medical management.⁷ The presentation of endometriosis in adolescents differs from that seen in adults. Adolescents may present with cyclic or acyclic pain, often in association with GI and urinary complaints.² Stage I or II disease is typical in adolescents, but studies have shown that disease stage does not correlate with pain severity.⁷ In addition, clear and red lesions have been associated with more severe pain symptoms and they are more common in adolescents than typical “powder-burn” implants described in adults.⁸

In an adolescent with endometriosis, the pelvic exam may yield no abnormal findings or only minimal-to-moderate tenderness in the posterior cul-de-sac as opposed to nodules or masses.⁷ Therefore,
endometriosis should be considered in an adolescent with continued pelvic pain despite treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and combined hormonal contraception (CHC). If a patient fails to respond to a 3-month course of NSAIDs and CHC, a diagnostic laparoscopy is indicated. Lesions should be biopsied and removed at the time of laparoscopy with ablation, resection, or laser. Medical management is recommended for anyone with confirmed endometriosis in order to aid in pain relief and prevent disease progression (Table 4).^3,7,8

Congenital anomalies

Congenital anomalies with genital tract obstruction can present with severe cyclic pain. The incidence of congenital anomalies of the female reproductive tract has been estimated to be higher than 3% and most girls will present within a few months to years after onset of menses.⁶ These anomalies can be isolated to the vagina or part of a complex anomaly including the cervix and uterus.

Nonmenstruating girls with congenital anomalies: An adolescent with imperforate hymen or a transverse vaginal septum will present with cyclic or persistent pelvic pain and primary amenorrhea. If significant hematometra is present, an abdominal mass may also be palpable.⁹ Table 5 compares diagnoses and management of imperforate hymen and transverse vaginal septum.

Menstruating girls with congenital anomalies: These include unicornuate uterus with a noncommunicating obstructed uterine horn and uterine didelphys with obstructed hemivagina, which is associated with ipsilateral renal anomaly
(Figures 1-4).^6,10 These patients present with normal menses and pain due to obstruction of menstrual flow from the noncommunicating horn or obstructed hemivagina. Both conditions are diagnosed with U/S and may be confirmed with MRI. Surgical management is required for both conditions with either laparoscopic resection of the noncommunicating horn or excision of the vaginal septum with creation of a single vaginal vault.^6,10

Pelvic inflammatory disease

Pelvic inflammatory disease (PID) is an infection of the upper genital tract caused by a polymicrobial infection comprising both sexually transmitted pathogens and bacteria from vaginal flora.¹ CPP is a well-known sequelae of PID. In the United States, 16% to 20% of cases of PID are diagnosed in teenagers, with the highest rates occurring in those aged 15 to 19 years.¹¹ Adolescents are particularly at risk because of their high rates of exposure to chlamydia, low levels of protective antibodies, incidence of cervical ectropion, and exposure to smoking and risky sexual behaviors.^2,11 PID should be considered in any adolescent who is sexually active. Aggressive diagnosis and treatment of PID is essential to prevent significant morbidity.

Conclusion

Diagnosis and treatment of CPP is complex and further complicated by psychosocial changes during adolescence. Expeditious diagnosis and appropriate management are essential in an effort to preserve functioning and reproductive health.² This is often a long-term process, and a multidisciplinary approach to management has been shown to be beneficial.¹² It is also essential to set reasonable goals and consider alternative therapies. Consideration of causes that are more common in adolescents is essential in the initial evaluation.

Take-home messages

Fear and anxiety about pelvic exams are known barriers to evaluation of CPP in adolescents.

Expeditious diagnosis and appropriate management are essential to preserve functioning and reproductive health.

The North American Society for Pediatric and Adolescent Gynecology (NASPAG) is a nonprofit organization dedicated to educating healthcare professionals in pediatric and adolescent gynecology. For more information, visit www.naspag.org.

References

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2. Song AH, Advincula AP. Adolescent chronic pelvic pain. J Pediatr Adolesc Gynecol. 2005;18(6):371-377.

3. Damle LF, Gomez-Lobo V. Pelvic pain in adolescents. J Pediatr Adolesc Gynecol. 2011;24(3):172-175.

4. Ehrman WG, Matson SC. Approach to assessing adolescents on serious or sensitive issues. Pediatr Clin North Am. 1998;45(1):189-204.

5. Sacks D, Westwood M. An approach to interviewing adolescents. Paediatr Child Health. 2003;8(9):554-556.

6. Grover S. Pelvic pain in the female adolescent patient. Aust Fam Physician. 2006;35(11):850-853.

7. Laufer M. Gynecologic pain: dysmenorrhea, acute and chronic pelvic pain, endometriosis, and premenstrual syndrome. In: Emans SJ, Laufer MR. Emans, Laufer, Goldstein’s Pediatric and Adolescent Gynecology. 6th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2012:238-271.

8. Dovey S, Sanfilippo J. Endometriosis and the adolescent. Clin Obstet Gynecol. 2010:53(2):420-428.

9. Miller RJ, Breech LL. Surgical correction of vaginal anomalies. Clin Obstet Gynecol. 2008;51(2):223-236.

10. Laufer M. Structural abnormalities of the female reproductive tract. In: Emans SJ, Laufer MR. Emans, Laufer, Goldstein’s Pediatric and Adolescent Gynecology. 6th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2012: 188-237.

11. Shrier LA. Sexually transmitted infections: chlamydia, gonorrhea, pelvic inflammatory disease, and syphilis. In: Emans SJ, Laufer MR. Emans, Laufer, Goldstein’s Pediatric and Adolescent Gynecology. 6th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2012:325-348.

12. Economy KE, Laufer MR. Pelvic pain. Adolesc Med. 1999;10(2):291-304.