Sources
of Chronic Pelvic Pain
Chronic pelvic pain is a source of frustration to both the physician and the patient. Physicians have been ill
equipped by their training to confront the multifaceted nature of the complaints of patients with chronic pelvic
pain. Patients have experienced a repetitive dismissal of their complaints by physicians too busy in their practices
to address their problems comprehensively.
The approach to the patient with chronic pelvic pain must take into account six major sources of the origin
of this pain: 1) gynecological; 2) psychological; 3) myofascial; 4) musculoskeletal; 5) urological; and 6) gastrointestinal.
Only by addressing and evaluating each of these components by a very careful history and physical examination and
by approaching the patient in a comprehensive manner can the source of the pain be determined and appropriate therapy
provided.
This monograph was developed to provide the clinician with a set of tools and a methodology by which the patient
with this complaint can be approached.
Prevalence
of Chronic Pelvic Pain
Chronic pelvic pain is the reason for 10% of all office visits to a gynecologist1
and for over 40% of laparoscopies2 performed by gynecologists. There is increasing
awareness that chronic pelvic pain cannot be successfully managed using a simplistic approach.3
Technology has resulted in many advances in our ability to evaluate patients who complain of pelvic pain including
use of magnetic resonance imaging technology, vaginal probe with doppler flow ultrasound, hysteroscopy, and laparoscopy.
However, the lure is to use these increasingly expensive and invasive tests and procedures to evaluate all patients
with the complaint of chronic pain in the pelvic area. It is important for the gynecologist to recognize that patients
who complain of chronic pelvic pain may be afflicted by pathology in any one of the six areas. In fact a seventh
area of concern, that of neuropathic disorders, may also be considered in the differential in the patient with
chronic pelvic pain.
As this monograph will describe, a systematic approach to the patient with chronic pelvic pain can provide a
more accurate diagnosis while avoiding until absolutely required, those costly and frequently non-revealing technological
procedures which also may expose the patient to unnecessary risk while searching for the cause of her chronic pain.
This monograph has been prepared in the hope that the practitioner, both as an individual and as a part of the
healthcare system, will find some valuable information to assist in the evaluation and treatment of this very difficult
problem.
Definition
of Chronic Pelvic Pain
Chronic pelvic pain can be defined as nonmenstrual pain of 3 or more months duration that localizes to the anatomic
pelvis and is severe enough to cause functional disability and require medical or surgical treatment.2 Chronic dysmenorrhea or menstrual pain of 6 or more months duration that causes functional
disability and requires medical or surgical treatment is also appropriately included in the definition.
Laparoscopic
Findings in Chronic Pelvic Pain Patients
During the 1980s, laparoscopic evaluations for chronic pelvic pain revealed abnormalities that had a frequency
from as low as 2% to as high as 37%.2 In 1991, 74% of 227 women with the disorder
had laparoscopic findings consistent with endometriosis.4 The increase in the finding of
endometriosis is consistent with the increase in the association between the disease and infertility. The diagnosis
of endometriosis in infertile women rose from 42% in 1982 to 72% in 1992, an increase that is attributed to greater
awareness of subtle lesions of the disease.5
In 1984, laparoscopy was performed on 100 women who had pelvic pain in the same location for a minimum of 6
months. Eighty-three percent had abnormal pelvic organs compared with 29% of an asymptomatic group.6
Adhesions were the most common pathology, present in 38% of the subjects with pelvic endometriosis diagnosed in
32% of the symptomatic group.
In a 1994 study of 141 patients with a primary diagnosis of chronic pelvic pain, 67% were found to have endometriosis
which was associated with other abnormalities of the pelvis such as adhesions, leiomyomas, appendiceal abnormalities
and hernias. Thirteen percent had endometriosis as their only pathological finding.7
When focal tenderness was found on pelvic examination and titers for chlamydia were negative, 83% of these women
had endometriosis at the site of the tenderness.8
Reasons
for Increased Findings of Endometriosis in Pelvic Pain Patients
The increase in the findings of endometriosis at laparoscopy from as low as 2% to as high as 84% in pelvic pain
patients can be attributed to three improvements:
- The technical improvement in the instrumentation allowing better visualization at laparoscopy;
- An increased appreciation of abnormalities of the pelvis including all the subtle aspects of endometriosis
as well as the appearance of other abnormalities such as chronic appendicitis and hernia formation;
- Improvement in the manner in which patients who are provided with a laparoscopy are screened for the other
abnormalities that are important differentials.
According to a recent American Association of Gynecologic Laparoscopists (AAGL) survey 56% of all laparoscopies
are being performed for a diagnosis of chronic pain.9 However, according to an
analysis performed on 11 studies of patients with chronic pelvic pain, < 50% of patients with chronic pelvic
pain were helped by laparoscopic treatment and about 40% of the patients had no apparent pathology at laparoscopy.2
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