Expert Commentary

Chronic pelvic pain: 11 critical questions about causes and care

OBG Manag. 2009 August;21(8):27-40

References

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Urinary tract disorders

Interstitial cystitis/painful bladder syndrome is the most common urologic diagnosis among women who have CPP. Recent evidence suggests that 38% to 81% of women who are given a diagnosis of a reproductive-tract disorder may in fact have IC/PBS.^17,18 Much of the recent evidence regarding interstitial cystitis suggests that inflammatory and neuropathic mechanisms are crucial in the generation of CPP; therefore, much of the treatment focuses on inflammatory and neuropathic pain.^19,20

For example, among the treatments that alleviate IC/PBS to some degree are:

amitriptyline, widely used for neuropathic pain²¹
gapabentin, an anticonvulsant used to treat neuropathic pain²²
antihistamines directed at inflammation²³
intravesical instillation of a local anesthetic agent, which may target both inflammatory and neuropathic pain mechanisms.²⁴

Although these therapies have not been widely studied for their efficacy in gynecologic disorders, they are likely to produce similar results.

Disorders of the GI tract

Irritable bowel syndrome is the most common GI diagnosis in women who have CPP. It is a clinical diagnosis, usually based on the Rome III criteria (TABLE 3). (Sara B. was evaluated when Rome II criteria were in use.)

Data from a primary-care database in the United Kingdom suggest that irritable bowel syndrome may be the most common diagnosis in women who have CPP (about 38% of patients).²⁵ In some cases, irritable bowel syndrome presents primarily with lower abdominal or pelvic pain, so it must be considered in the differential diagnosis of CPP. It seems likely that the pain in irritable bowel syndrome is not simply nociceptive, but that inflammatory and nociceptive mechanisms play an important role, as well.^26,27

TABLE 3

Rome III criteria for irritable bowel syndrome

*Two or more criteria must be present to make the diagnosis.*
Over the past 3 months, have you had at least 3 days when you have had abdominal pain or discomfort that: was relieved with a bowel movement? began with a change in how often you were having a bowel movement? began with a change in the form or appearance of the stool or bowel movement?

8. What are the main somatic causes of chronic pelvic pain?

Abdominal wall myofascial pain syndrome

When there are trigger points and myofascial pain of the lower abdominal wall muscles or pelvic floor muscles, they often present as CPP.

The underlying mechanisms responsible for myofascial pain syndrome are not clear. Nociceptive pain seems to be an important mechanism, but it is not clear whether inflammatory and neuropathic changes occur in some patients with this syndrome.

Many women who have myofascial pain syndrome and CPP respond poorly to traditional treatment with physical therapy and trigger-point injections; this may be due to inflammatory or neuropathic changes, or both.

Pelvic floor tension myalgia

Pain due to abnormal tension of the pelvic floor muscles is well-described. In many cases, pelvic floor tension myalgia is a secondary phenomenon, as pelvic floor muscles react to the persistent presence of pelvic pain, which often has a visceral basis. In other cases, pelvic floor tension myalgia is a primary phenomenon and most likely represents myofascial pain syndrome of one or more of the pelvic floor muscles.

9. Are multiple anatomic sites and mechanisms the “norm”?

They may not be the norm, but it is not unusual to discover multiple diagnoses when evaluating a patient for CPP. Most published studies of women from primary-care practices suggest that 25% to 50% of patients have more than one diagnosis,^5,25,28 and anecdotal experience from referral practices suggests that most women in such practices have more than one diagnosis. The most common diagnoses in most published series are endometriosis, adhesions, irritable bowel syndrome, and interstitial cystitis.^18,29-31 The absence of somatic diagnoses in these series probably reflects the gynecologist’s tendency to concentrate on visceral elements in CPP.

10. When multiple systems are involved, is the pain greater?

Yes. Women who have more than one organ system involved in CPP have greater pain than women who have only one system involved. For example, 43% of patients who have CPP without GI or urologic symptoms had moderate or severe pain (mean visual analog score of 3.8), whereas 71% of women who had CPP and both GI and urologic symptoms had moderate to severe pain (mean visual analog scale score of 5.4).²⁸

Pain is also more consistent in women who have multisystem symptoms. Women who have CPP are more likely than the general population to have dysmenorrhea (81% versus 58%) and dyspareunia (41% versus 14%). The severity of pain with intercourse and with menses is greater in women who have CPP and GI and urologic symptoms than in those who have no GI and urologic symptoms.