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Chronic Pelvic Pain Diagnosis and Management
Once this very extensive history has been completed, the physician is ready to undertake a physical examination of this patient. The physical examination for the chronic pelvic pain patient should be conducted in a manner which provides for the maximum amount of information relating to the possible non-gynecologic causes of pelvic pain.
Musculoskeletal Evaluation
The musculoskeletal examination includes history and interview, postural examination, active and passive range of motion, palpation exam, muscle strength testing, neurologic screening and gait evaluation. The physician determines whether pain is altered by positional changes and whether there is history of low back injury or pain.14
The physician should evaluate structural findings such as exaggeration of the lumbar lordotic curve and anterior pelvic tilt. In addition to pelvic obliquity, unequal iliac crest height, should be determined. Slouch standing or sitting habits should be determined. Patients who are obese will often have exaggerated lumbar lordosity and anterior pelvic tilt. An exam for scoliosis should be performed.14
Mobility is evaluated, especially reversal of the concave lumbar lordotic curve on forward bending. Gait habits are determined. The lumbar and lower thoracic musculature is evaluated by palpation for tenderness. Trigger points in the abdominals, pelvic floor and hip musculature are checked for. Strength testing is performed.
Musculoskeletal dysfunctions contribute to the signs and symptoms of chronic pelvic pain. Musculoskeletal dysfunction resulting from the prolonged assumption of a posture that enhances the lordotic curve in the lumbar and lower thoracic spine and exaggerates the anterior tilt of the pelvis are most commonly associated with the development of chronic pelvic pain symptoms. This lordotic anterior pelvic tilt posture has been described as typical pelvic pain posture because of its significant occurrence in this population.14
This common pattern of faulty posture is associated with typical patterns of muscle imbalance involving the abdominal muscles, thoracolumbar fascia, lumbar extensors, hip flexors and hip abductors and extensors as well as the muscles of the pelvic floor. Pelvic pain may result from local musculoskeletal dysfunction, for example, the abdominal iliopsoas, and anterior hip capsule or it may be referred from any dysfunctional structure enervated by Tll, T12, L1, L2, L3 or L4 such as thoracolumbar joints and muscles.14
The addition of musculoskeletal screening procedures in the gynecologic examination of chronic pelvic pain patients by practitioners with expertise in the examination and management of musculoskeletal dysfunction such as orthopedic physical therapists, is strongly recommended.14
Musculoskeletal screening involves evaluating the spinal column for any evidence of scoliotic curve, evaluation of the bony pelvis for any evidence of inflammation such as osteitis pubis and evaluation of the stability of the bony pelvis especially in those patients who have had previous childbearing. Potential areas of joint or skeletal inflammatory processes should be carefully assessed in this portion of the evaluation.
Myofascial Evaluation
Hernias
Patients with myofascial pain may in fact have a hernia. To diagnose a hernia the patient must be examined in a standing position. It is also best to examine the patient after she has been on her feet for prolonged periods of time.
Anterior and posterior perineal hernias are usually limited to cystocele, rectocele or enterocele and can cause lower abdominal or perineal pain in women. This pain is usually not severe and will usually respond to surgery.
Abdominal wall hernias may involve protrusions of abdominal viscera through the abdominal fascia. Abdominal wall hernias include umbilical, epigastric, lumbar, spigelian, ventral and incisional hernias. Umbilical hernia in the adult can lead to incarceration or strangulation of intestinal contents. Patients with abdominal wall hernias can present with symptoms even if an abdominal mass may not be detected.15
Incisional hernias are usually iatrogenic and can occur in any abdominal incision. Transverse incisions are associated with a lower incidence of incisional hernias than are vertical incisions. Incisional hernias can occur after laparoscopic surgery especially at trocar sites 10 mm or larger.16
Spigelian hernias are spontaneous lateral ventral hernias and consist of a protrusion through the transverse abdominal aponeurosis lateral to the edge of the rectus muscle but medial to the spigelian line. The spigelian line is the point of transition of the transverse abdominal muscle to its aponeurotic tendon. This fascia begins at the level of the ninth costal cartilage and extends to the pubic tubercle. Most spigelian hernias tend to occur just below the umbilicus. It is possible to diagnose and repair this hernia surgically through laparoscopy.17
Nerve Entrapment and Referred Pain
The ilioinguinal and iliohypogastric nerves are frequently found to be involved in pelvic pain patients. Some patients will have pain along the entire demarcation of these nerves along the anterior aspect of the abdominal wall. Pain from the lateral femoral cutaneous nerve has been named meralgia paresthetica and is usually from either direct abdominal wall nerve entrapment or from disk disease at the level of L2-L3. Whether this pain is nocioceptive or neuropathic can frequently be difficult to determine.
A physician needs to remember that L1-L2 neuropathies which can cause bilateral, abdominal discomfort radiating down through the inguinal area are much more frequently diagnosed in men than women with no known reason for this variation. In the process of this exam, it is also important that the physician realize that the L1-L2 spinal cord segment enervates the genital-femoral, the L1 segment the ilioinguinal and the T12, L1 segment, the iliohypogastric nerve. In addition, the lateral femoral cutaneous nerve is enervated from L2-L3. There is a dorsal root ganglionic reflex that can create referred pain related to skin vs a visceral origin of the pain. For instance, the uterus has referred elements to the hypogastric region, the ovary to the inguinal area and the cervix to the iliac fossa.18 After a careful examination of the skeletal system, the physician should proceed to a careful examination of the abdominal wall with these relationships in mind. It is frequently necessary to perform an examination with point pressure or even at times with a needle point to identify areas of potential abdominal wall nerve entrapment or myofascial segments which are causing pain referred into the pelvic area. A very careful abdominal wall evaluation performed with the patient flexing the abdominal muscles allows the physician to distinguish between abdominal wall discomfort and pain vs internal pelvic pain. Abdominal wall pain can be both identified and treated by the process of trigger point blocks.19 Once a trigger point is identified which reproduces the pain, this is injected with a solution of 0.25% bupivacaine hydrochloride until the pain has been significantly diminished.
Neuralgia
Patients with previous surgery, such as a previous Pfannenstiel or appendectomy incision may suffer from deafferentiation. During the time of the surgery a form of a sympathectomy occurs. It is possible for a neuroma to form allowing for somatosensory afferents to generate signals initiating a sensation of neurologic pain from a neuralgia rather that a causalgia.
Urological Evaluation
A careful urologic exam must be performed with emphasis on the conditions of interstitial cystitis and urethral syndrome. In general, painful bladder syndrome contains these two main categories.
Urethral Syndrome
The urethral syndrome is comprised of the classic symptoms of urinary tract infection with a negative urinary culture. Symptoms commonly including pressure, urgency and frequency but not nocturia. The etiology of urethral syndrome includes chlamydia, mycoplasma, herpes simplex virus, urethral trauma, atrophy, stenosis, and functional obstruction.
The physical examination for the patient with urethral syndrome includes evaluation for a tender rope-like urethra, a careful examination of the pelvic floor muscle status and evaluation for a hypersensitive urethra with manipulation such as catheterization.
The clinical course of the urethral syndrome is oftentimes acute in onset and there is good response to therapy with frequent remission.
Interstitial Cystitis
Interstitial cystitis patients have a classic history of chronic urinary tract infections with negative cultures. Their common symptoms include pressure, urgency, and frequency with nocturia two or more times. They have suprapubic pain that decreases with voiding. The etiology is unknown but it is felt that there may be abnormal bladder mucosa, neurologic insult to the nerves of the lower urinary tract, chronic infection, and anatomic disturbance such as postoperative surgical trauma or dysfunctional voiding.
The examination for interstitial cystitis includes findings of bladder base tenderness. Again, the pelvic floor muscle status must be carefully evaluated and other pelvic pathology such as adhesive disease, endometriosis and atrophy must be ruled out. Frequently, patients with interstitial cystitis are found to also have vestibulitis and vulvitis. Patients with suspected interstitial cystitis should complete a careful bladder diary, have a urine culture, and have the lower genital tract evaluated for infection. The urethra should be calibrated and tenderness of the urethra and bladder neck area should be carefully evaluated before and after treatment.
A urethral pressure profile is important to rule out urethral instability or urethral spasticity. A cystometrogram is important to rule out detrusor instability. A uroflow study should be performed to determine whether the patient is experiencing high-resistance, low-flow conditions. To diagnose interstitial cystitis, perform cystoscopy to look for petechial hemorrhage on second fill, to evaluate for neovascular changes, and to evaluate areas of tenderness.
If patients are found to have conditions consistent with interstitial cystitis they should have their hypoestrogenic state corrected, be placed on a low acid diet and have bladder retraining. Hydrodistention, DMSO, heparin and other therapies can assist with the treatment of this condition.20
Gastroenterologic Causes of Chronic Pelvic Pain
Gastroenterologic causes of chronic pelvic pain include irritable bowel syndrome, inflam-matory bowel disease, (either Crohn’s disease or ulcerative colitis), infectious enterocolitis, diverticulitis, intestinal obstruction, intestinal neoplasms, hernia, recurrent appendiceal colic, abdominal angina and intestinal endometriosis. Of these, irritable bowel syndrome, chronic appendicitis, and intestinal endometriosis are the most common.15
Irritable Bowel Syndrome
Up to 50% of visits to gastroenterologists are for irritable bowel syndrome. The pain of irritable bowel syndrome is cramping, colicky pain usually in the lower abdominal region. Pain is often improved after a bowel movement and most typically is worst 1 - 1.5 hours post-prandially. Complaints of constipation consisting of hard pellet-like stools or the passage of stools less than three times per week are a common complaint of patients with irritable bowel syndrome.15
Ninety-one percent of irritable bowel syndrome patients had two or more symptoms including abdominal distention, relief of pain with bowel movement or frequent bowel movement with the onset of pain, or looser bowel movements with the onset of pain. Thirty percent of patients with organic disease have two or more of these symptoms. On physical examination the finding of a palpable tender sigmoid colon or discomfort during the insertion of the finger into the rectum as well as finding hard pieces in the rectum is suggestive of irritable bowel syndrome.15
Chronic Appendicitis
Chronic appendicitis or appendicopathy does exist and can be the cause of chronic lower abdominal pain.
In 55 laparoscopic appendectomies performed for chronic right lower quadrant abdominal and pelvic pain, the pathological conditions included entrapping adhesions in 38, chronic appendicitis in 12, and endometriosis in five patients. Forty-four of these patients had complete relief, nine had satisfactory improvement, and two had no relief.21
In 63 patients who had an appendectomy for chronic lower abdominal pain, 79% had pain localized to the right lower quadrant. All of these patients had undergone previous surgery for pain without relief and 54% had sought psychologic intervention or pain clinic treatment to no avail. Histologically, 92% of the removed appendixes revealed abnormality and 95% of these patients were completely cured.22
In 103 patients with chronic right lower quadrant pain appendiceal abnormality was noted laparoscopically in 62 (60%), and these appendixes were removed. Histology was abnormal in 30 of them (48%). After pelvic reconstructive surgery and appendectomy, 60 out of 62 patients (97%) reported complete relief of symptoms.23
Visual pathology is not found to correlate with histopathology. In 85 women undergoing laparoscopy for pelvic pain, pelvic adhesions, and endometriosis, pathology of the appendix was visible in 16.8%, and histopathology revealed abnormalities in 42.4%. Because of the high frequency of pathology in patients with these conditions, appendectomy at the time of laparoscopy for chronic pelvic pain may be both a preventative and a therapeutic measure.24
Psychological Factors in Patients With Chronic Pelvic Pain
Because chronic pelvic pain consists of many different diagnostic categories which involve the pelvis and abdomen, a large number of chronic pelvic pain patients are misdiagnosed. This problem is exacerbated by the limited training of any individual who attempts to diagnose and treat chronic pelvic pain alone. A misdiagnosis can result in ineffective treatment and sometimes unnecessary operative procedures. Unfortunately when the medical diagnosis or treatment modality has not been successful, women with chronic pelvic pain have been told that the pain is "in their head" with an implication that they are "crazy."25
Psychological Differential Diagnosis
Psychological diagnosis and treatment is important to the recovery of women with chronic pelvic pain. Depression, anxiety, history of sexual and physical abuse, and even personality disorders have been found to be important diagnostic considerations for managing chronic pelvic pain. Second, women with chronic pelvic pain are more likely to develop depression, anxiety disorders, substance abuse, somatization, and/or sexual dysfunction. Furthermore, women with chronic pelvic pain often experience decreasing social support with escalating relationship disruption and possible divorce. The partners of chronic pelvic pain patients become more unsupportive with time, especially if a diagnosis is not found and multiple treatments are ineffective. Chronic pelvic pain as a conversion reaction with secondary gain appears to be rare and can frequently be differentially diagnosed when psychological and medical techniques are used together. Psychological evaluation of a chronic pelvic pain patient should involve a complete review of records and questionnaires, detailed description of pain location and characteristics, brief history with patient and partner, current psychological status and coping, list of medications, psychological testing when pertinent, and a team conference with the medical personnel. A complete and appropriate psychological evaluation of the patient is best performed by trained psychologists with experience in pain and possible sexual dysfunction.25
Gynecologic Evaluation
The next portion of the examination evaluates the specific gynecologic presentation of pain.
Pelvic Floor Myalgia (Coccydynia, Prostadynia, Pelvic Floor Spasm, Levator Spasm, Pyriformis Syndrome)
Pelvic floor tension myalgia presents with findings of a negative wink reflex (already severely contracted pelvic floor) with spastic fasiculation seen on gross exam. The pubococcygeal muscle will be tightly contracted on vaginal exam. There will be tenderness with muscle palpation. Trigger points will be found and there will be limited range of motion with poor pelvic floor muscle awareness and poor voluntary relaxation of the pelvic floor. These patients most commonly respond favorably to pelvic muscle relaxation techniques such as the Kegel exercises and biofeedback training. At times they will need diathermia and physical therapy, trigger point injection or sacral nerve stimulation.20
Posthysterectomy Syndrome
If the patient has had a previous hysterectomy and has recurrence of pain, this may be associated with a very low-grade cuff cellulitis or a seroma or hematoma of the cuff or bladder flap. However they may have a neuralgia related to the transection of the nerve tissue. For these patients, it may be necessary to resect a portion of the vaginal cuff to affect complete relief.20
Pelvic Exam for Pain
The gynecologic examination specific for the patient with chronic pelvic pain involves: 1) examination of the introitus and vulva for vaginismus and vulvadynia; 2) the vagina for stricture or shelves from previous surgery; 3) the cervix for cervical tenderness; 4) the right and left uterosacral ligaments, the posterior cul-de-sac, and the rectovaginal septum for nodularity; 5) the round ligaments for tenderness; 6) the uterus for tenderness, fibroids or globularity consistent with adenomyosis; 7) the right and left ovaries for ovarian masses and tenderness; and 8) and the rectum for tenderness and focal areas of pain.
Gynecologic Differential for Pelvic Pain
This examination must be carried out thoroughly and carefully. With a complete history and physical as described and an understanding of the complete differential diagnoses of patients with chronic pelvic pain, the performance of the gynecologic examination provides an opportunity for the physician to concentrate on those potential findings that would be later confirmed by laparoscopic examination and excisional biopsies. The differential diagnoses includes endometriosis, adhesions, leiomyomas, infection, ovarian disease, pelvic congestion, adenomyosis and endosalpingiosis.25
Accuracy of Physical Exam
When nodularity is found in the uterosacral ligaments, in the cul-de-sac or in the rectovaginal septum, laparoscopy may not reveal the disease even if near contact laparoscopy is utilized. Even if near contact laparoscopy is performed in patients in whom nodularity is felt, only 50% of those patients will have visible disease on the peritoneal surface. In addition, MRI will miss half of the lesions. However, resection of the uterosacral ligaments and biopsies in the rectovaginal septum will reveal the presence of endometriosis in 80% of those patients in whom the physical exam locates a tender nodule.26
Laboratory Studies in Patients with Pelvic Pain
In patients with chronic pelvic pain, laboratory studies such as chlamydia titers and cultures, gonorrhea cultures, and cultures for mycoplasma and ureaplasma are routinely performed. However, cultures are frequently negative for mycoplasma and ureaplasma when these organisms can, in fact, be detected by more sensitive studies. Therefore, many centers no longer perform these tests in spite of the fact that they are related to pelvic pain. Chlamydia cultures are also performed. Chlamydia can be found three times more frequently by performing a laparoscopy, and testing the peritoneal fluid in the pouch of Douglas, than by performing an endocervical culture.27 Therefore, in patients with chronic pelvic pain one may consider empiric treatment with antibiotics for chlamydia, mycoplasma and ureaplasma as a reasonable course.
