Chronic pelvic pain
Gynaecology
Gynaecology clinic
The first question
What pattern does the pain follow, and which systems are involved?
- 01
Map the pain
Cyclical or continuous; dyspareunia, dyschezia, dysuria; bladder and bowel symptoms; a pain diary.
- 02
Examine with care
Consent, pacing, one finger, the pelvic floor and the uterosacral ligaments, and the abdominal wall.
- 03
Image
Transvaginal ultrasound; MRI for deep endometriosis.
- 04
Treat in layers
Hormonal suppression, non-opioid analgesia, physiotherapy, psychology, and surgery for defined disease.
Where it is
Each opens the structure on the 3D pelvis.
History that discriminates
- Onset, pattern, cycle relation, progression
- Deep dyspareunia, dyschezia, dysuria with menses
- Bowel and bladder symptoms, irritable bowel, interstitial cystitis
- Prior infection, surgery, pregnancy, delivery trauma
- Mood, sleep, function
- Trauma history, asked with care and without assumption
Examination that discriminates
- Abdominal wall trigger points (Carnett's sign)
- Vulval and introital tenderness
- Pelvic floor muscle tenderness
- Uterosacral nodularity, fixed retroversion, adnexal masses
- Cervical motion tenderness
Investigations
- Transvaginal ultrasound
- MRI pelvis for deep infiltrating endometriosis
- Swabs if infection is possible
- Urinalysis
- Laparoscopy when it will change management
The differential
| Diagnosis | Favours | Against | Urgency |
|---|---|---|---|
| Endometriosis | Cyclical pain worsening over years, deep dyspareunia, endometrioma, nodularity | Non-cyclical, normal examination and scan (does not exclude it) | routine |
| Adenomyosis | Heavy painful periods, bulky tender uterus | Normal uterus | routine |
| Pelvic inflammatory sequelae and adhesions | Prior infection or surgery | No history | routine |
| Myofascial pelvic floor pain | Tender pelvic floor muscles reproducing the pain | Non-tender pelvic floor | routine |
| Irritable bowel syndrome | Pain with bowel habit change, relief with defecation | No bowel symptoms | routine |
| Bladder pain syndrome | Pain with bladder filling, frequency, relief on voiding | No urinary symptoms | routine |
| Central sensitisation | Widespread pain, poor sleep, mood disturbance, pain out of proportion to findings | Localised pain with a matching finding | routine |
Pitfalls this pathway refuses
- Reflex laparoscopy
- Dismissing the pain when the scan is normal
- Long-term opioids