Armando Hasudungan
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Chronic Pelvic Pain


Overview Chronic Pelvic Pain is an intermittent or constant pain in pelvic area for at least 6 months, not exclusively related to menstruation, intercourse or pregnancy. CPP is a symptom not a diagnosis. It accounts for approximately 10 percent of all ambulatory referrals to a gynecologist and is a common indication for diagnostic and therapeutic surgery. Patients typically present with at least two of several common pain-related diagnoses: interstitial cystitis, irritable bowel syndrome, fibromyalgia, levator ani syndrome (pelvic floor tension myalgia), endometriosis, adenomyosis, leiomyoma, or vulvodynia. Common comorbid conditions include depression, anxiety, and traumatic stress disorder. Refer immediately to gynaecology all patients with a pelvic mass, abnormal cervix, or persistent bleeding. The definitive diagnosis is not made for 50% of women with chronic pelvic pain

Remember the four most commonly diagnosed etiologies are endometriosis, adhesions, irritable bowel syndrome and interstitial cystitis.
Chronic pelvic pain (CPP): refers to pain of at least six months’ duration that occurs below the umbilicus and is severe enough to cause functional disability or require treatment.
Acute pelvic pain: generally defined as pain in the lower abdomen or pelvis lasting less than three months.

Differential Diagnosis

Remember in Pregnancy woman these differential will be different as the pain might be due to the obstetric complications

Chronic Pelvic Pain – Gyaenacological causes

  • Endometriosis
  • Adenomyosis
  • Fibroids
  • Adhesions – Post-hysterectomy ovary becomes trapped within dense adhesions at the pelvic side wall (trapped ovary syndrome)
  • Pelvic Inflammatory Disease
  • Acute pelvic pain becoming chronic

More info on Acute Pelvic Pain

Side note While the commonest causes of chronic pelvic pain are endometriosis and chronic pelvic infections, over one-third will have an identifiable pathology. It is important to call a halt to unnecessary investigations: accept chronic pelvic pain syndrome.

Chronic Pelvic Pain – non-gyaenacological causes

  • Irritable Bowel Syndrome
  • Inflammatory Bowel Disease
  • Fibromyalgia
  • Neuropathic pain
  • Interstitial cystitis
  • Psychological (i.e depression)
Condition History Examination
Gastrointestinal Malignancy Haematochezia
Adhesions Non-hormonal pain fluctuation, history of pelvic surgery, pelvic infections or use of intrauterine device
Irritable bowel syndrome Non-hormonal pain fluctuation
Interstitial cystitis Non-hormonal pain fluctuation
Endometriosis Dysmenorrhoea, Dyspareunia, Pain fluctuates with menstrual cycle Adnexal mass
Pelvic inflammatory disease Bilateral pelvic pain, Dysuria, Vaginal Discharge, post coital bleeding Adnexal mass, bilateral adominal examination, cervical motion, uterine or adnexal tenderness, Fever, vaginal discharge
Fibromyalgia Positive Carnett’s sign
Cervical Malignancy Postcoital bleeding, unexplained weight loss
Endometrial Malignancy Perimenopausal or postmenopausal irregular vaginal bleeding, unexplained weight loss


Evaluation and Approach

  • History
  • Examination
  • Psychological Assessment
  • Investigations (be careful not to over investigate initially)
    • FBC
    • Urinalyss
    • STI screening
    • Pregnancy tests (bHCG serum and urine)
    • Pelvic ultrasound
    • MRI
    • Diagnostic laproscopy – Gold Standard
Remember Gastrointestinal, urological, gynecological, psychological, and musculoskeletal sources should be considered in evaluating women with chronic pelvic pain (CPP)


  • Analgesia – Opiates, Neuropathic pain?
  • Hormonal treatments – Oral contraceptives, progestagens, GnRH analogues
  • Complementary therapy
  • Surgery – Hysterectomy

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