Chronic Pelvic Pain Chronic pelvic pain (>6 months in duration) is less likely to be associated with a readily identifiable

cause than is acute pain, and pain of less than 3 months duration. Acute pain is more likely to be associated with an identifiable pathophysiologic disorder. Clinical evaluation of chronic pelvic pain History The character, intensity, distribution, and location of pain are important. Radiation of pain or should be assessed. The temporal pattern of the pain (onset, duration, changes, cyclicity) and aggravating or relieving factors (eg, posture, meals, bowel movements, voiding, menstruation, intercourse, medications) should be documented. Associated symptoms. Anorexia, constipation, or fatigue are often present. Previous surgeries, pelvic infections, infertility, or obstetric experiences may provide additional clues. For patients of reproductive age, the timing and characteristics of their last menstrual period, the presence of non-menstrual vaginal bleeding or discharge, and the method of contraception used should be determined. Life situations and events that affect the pain should be sought. Gastrointestinal and urologic symptoms, including the relationship between these systems to the pain should be reviewed. The patient's affect may suggest depression or other mood disorders. Physical examination The patient should be asked to indicate the location of the pain. If the patient uses a single finger to indicate the location, it is more likely that the pain has a discrete source. Abdominal deformity, erythema, edema, scars, hernias, or distension should be noted. Abnormal bowel sounds may suggest a gastrointestinal process. Palpation should include the epigastrium, flanks, and low back, and inguinal areas. A thorough gynecologic examination should be completed with an attempt to reproduce the pain during the physical examination.

Postural and musculoskeletal alterations are assessed by viewing the patient's spine while she is sitting, standing, and walking. Neurologic testing of touch and reflexes is performed. Laboratory studies. Signs and symptoms may indicate the need for a urinalysis, urine culture, serum chemistry, or complete blood count. Diagnostic studies Ultrasonography may be useful when the pelvic examination is inconclusive. Diagnostic laparoscopy may be helpful when the pelvic examination is abnormal or when initial therapy is unsuccessful. Gynecologic causes of pelvic pain Symptoms that arise from genitourinary organs range from cramps to sharp pain; the pain is felt in the lower abdomen in the midline, and it occasionally radiates to the back. Bladder or ureteral pain may radiate to the vagina or groin. Endometriosis usually causes cyclical pelvic pain and dyspareunia. Urinary system. Interstitial cystitis, cystitis, urethritis, and urethral syndromes all may cause chronic pelvic pain. Gastrointestinal causes of pelvic pain Irritable bowel syndrome (IBS) is the most common GI cause of pelvic pain, responsible for one half of all cases of chronic pelvic pain. IBS usually causes pain that is colicky in character and associated with a sensation of rectal fullness or incomplete emptying; it improves after a bowel movement, but is intensified by meals. The symptoms of lBS often wax and wane, often in association with emotional stress. Constipation with intermittent diarrhea is common; however, in some cases pain is the only symptom of IBS. Bulk-forming agents with ample fluids, anxiolytics, and low doses of antidepressants are used to treat IBS. Anticholinergics lack effectiveness. Inflammatory bowel disease

Most patients with Crohns disease or ulcerative colitis report poorly localized pain and diarrhea. Fever and bloody stool are common in inflammatory bowel disease but not in irritable bowel syndrome. Cramping that is relieved by voluminous, often bloody diarrhea, is typical of ulcerative colitis. Diverticular disease can cause abdominal pain and diarrhea in older patients. Bleeding, perforation, and abscess formation may occur. The pain is usually located in the left lower quadrant and improves with bowel movements and the passage of flatus. Musculoskeletal causes of pelvic pain Herniation of an intervertebral disk, spondylolisthesis, or exaggerated lumbar lordosis may all cause pelvic pain. Pain over the distribution of a peripheral nerve may be caused by herniation of a disk. Management of chronic pelvic pain Therapy should be directed toward relieving the underlying condition. Pharmacologic therapy Processes that involve inflammation usually will respond to a nonsteroidal anti-inflammatory drug (NSAID). Mild analgesics such as acetaminophen, propoxyphene, and NSAIDs may be appropriate for mild pain. Stronger pain may warrant the use of narcotics. Brief use of these agents generally does not present a significant potential for abuse. The use of combination medications (NSAIDs and opiates) increases analgesic potency. Suppression of the menstrual cycle may be indicated in individuals with cyclic menstrual pain. Antidepressants or sleeping aids are useful adjunctive therapies. Amitriptyline ( Elavil), in low doses of 25-50 mg qhs, may be of help in improving sleep and reducing the severity of chronic pain complaints. Muscle relaxants may prove useful in patients with guarding, splinting, or reactive muscle spasms. Surgical therapy Laparoscopic uterosacral nerve ablation and presacral neurectomy have high complication rates. Surgery has a role in the treatment of endometriosis and pelvic adhesions.

If significant pathology is not detected by laparoscopy, hysterectomy for chronic pelvic pain may be considered if the pain has persisted for more than 6 months, does not respond to analgesics, and impairs the patient's normal function.