Chronic Pelvic Pain: Clinical Dilemma Or Clinician's Nightmare

Sex Transm Inf 2000;76:419–425 419

Chronic pelvic pain: clinical dilemma or clinician’s Sex Transm Infect: first published as 10.1136/sti.76.6.419 on 1 December 2000. Downloaded from Clinical nightmare knots Ahmos F F Ghaly, Patrick F W Chien

Chronic pelvic pain is a common problem presenting a major challenge to healthcare professionals. This is partly due to the lack of understanding of the aetiology and natural history of the disease. This condition is best managed using a multidisciplinary approach. In recent years, the emphasis in the clinical management has tended towards psychosocial or psychosexual involvement after organic disease has been excluded. (Sex Transm Inf 2000;76:419–425)

Keywords: pelvic pain

Introduction International Association for the Study of Pain Chronic pelvic pain (CPP) is a serious problem (IASP)1 defines CPP as chronic or recurrent aVecting the lives of many women during their pelvic pain that has a gynaecological origin but child bearing years. It is a recognised long term for which no definite lesion or cause is found. morbidity of sexually transmitted infections One of the criticisms of this definition is that it and pelvic inflammatory disease. The diVeren- implies absence of pathology, which may not be tial diagnosis of the underlying aetiology often the case. Reiter2 defined CPP as non-cyclical involves both psychological and organic fac- pelvic pain of greater than 6 months’ duration tors. The management of CPP constitutes a which is not relieved by narcotic analgesia. It is, major challenge to the clinician mainly because however, debatable whether non-cyclical in the of our lack of understanding of its natural his- above definition means continuous pain or tory, aetiology, and pathogenesis. pain with certain frequency and not related to The aim of this descriptive review is to iden- the menstrual cycle. The duration of 6 months tify the wide range of aetiological factors for as a criterion for the above definition is also CPP in order to illustrate the dilemma facing rather arbitrary. It has been suggested that a clinicians in investigating and managing this shortened duration of 3 months may be more condition. applicable and be more easily remembered by the patient.3 Literature search Electronic Medline search for all relevant arti- Incidence http://sti.bmj.com/ cles on CPP between 1980 and 1999 was per- CPP is the second most common gynaecologi- formed by one of the authors (AFFG). The cal presenting complaint and it accounts for search terms used were “dyspareunia,” “dys- 13%–20% of gynaecological consultations and menorrhoea,” and “pelvic/abdominal pain.” up to 52% of diagnostic laparoscopy.2 It also Other key words used in the search included represents a significant percentage of patients “endometriosis,” “pelvic inflammatory attending genitourinary medicine clinics with disease,” “pelvic adhesions,” “irritable bowel upper genital tract complaints. on October 2, 2021 by guest. Protected copyright. syndrome,” “gastro-intestinal symptoms,” In the United States, 12%–16% of hysterec- “genito-urinary pain/pelvic congestion,” and tomies were performed for CPP and the overall “urological pain.” The search was confined to financial cost has been estimated to exceed $2 articles published only in the English language. billion annually.2 The personal cost to the woman in terms of physical and mental Definition of CPP morbidity, relationship disharmony, and work Department of absenteeism cannot be calculated (table 1). Genito-Urinary Pelvic One of the main problems with CPP is that Medicine, Ninewells there is a wide variety of recognised definitions Hospital and Medical for this condition and they are all subject to Aetiology School, Dundee, diVerent interpretations and misunderstand- There are many aetiological factors that can Tayside DD1 9SY, UK A F F Ghaly ing. This also makes appraisal and comparison contribute to CPP. It is not uncommon to find of research data in the literature diYcult. The that more than one aetiological factor may be Department of Obstetrics and Table 1 Costs to society from chronic pelvic pain Gynaecology P F W Chien Healthcare and employment cost Personal cost United Kingdom Total NHS annual cost = £154.8 million Unsuccessful medical intervention Correspondence to: Approximately 0.6% of total NHS expenditure Dr Ahmos Ghaly Cost due to work absenteeism Social (loss of employment/absenteeism) [email protected] Psychological/psychiatric illness United States Total annual healthcare cost >$2 billion2 Psychosexual Accepted for publication Direct cost of medical consultations $9 million per annum Others 31 October 2000

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present in a single case and both organic and Pelvic congestion syndrome Sex Transm Infect: first published as 10.1136/sti.76.6.419 on 1 December 2000. Downloaded from non-organic causes may coexist. Table 2 shows Pelvic congestion syndrome can be defined as the various recognised aetiological causes for dilated pelvic veins with delayed disappearance this condition. of dye and is a common finding in women with no apparent cause for their pelvic pain.6 If congestion is suYciently severe, then it is likely that GYNAECOLOGICAL CAUSES pain will develop. Standing for long periods of Pelvic inflammatory disease time will increase pelvic congestion and hence Pelvic inflammatory disease (PID) is not pain in these women. Reginald et al7 have uncommonly seen in women attending the shown that a 30% reduction in pain can be genitourinary medicine clinic. It results from achieved following the intravenous administra- acute inflammation caused by micro- tion of the selective vasoconstrictor, dihydroer- organisms colonising the endocervix ascending gotamine. Pelvic congestion is largely confined to the endometrium, fallopian tubes, and to women in their reproductive years, and ovaries. PID is a clinical diagnosis implying therefore it seems likely that ovarian hormones, that the patient has upper genital tract probably oestrogen, are the cause of dilated infection. It involves cervicitis and progresses pelvic veins in these women. to endometritis and eventually salpingo- oophoritis. Hager et al4 have also proposed a set Endometriosis of clinical criteria to enhance the accuracy of Endometriosis is characterised by the presence the diagnosis and severity of PID. Most cases of and proliferation of functional endometrial tis- pelvic inflammatory disease are caused by sue containing both glands and stoma in sites sexually transmitted organisms, such as outside the endometrial cavity. The most Chlamydia trachomatis and Neisseria gonor- frequent sites of implantation are the pelvic rhoeae. Chlamydia infection may be asympto- viscera and peritoneum. On the other hand, matic and the resulting salpingitis is often adenomyosis is characterised by the presence referred to as “silent pelvic inflammatory of endometrial glands within the myometrium disease.” Endogenous micro-organisms found and this can also cause chronic pain, especially in the vagina, particularly the bacterial vagino- dysmenorrhoea. There is no single theory that can explain all sis micro-organisms (for example, Prevotella, clinical cases of endometriosis. The mech- Gardnerella vaginalis), are often also isolated anism of chronic pain from this condition is far from the upper genital tract of women with from clear and it probably involves not only PID. On a worldwide perspective, other organ- release of prostaglandins to the peritoneal sur- isms such as Mycobacterium tuberculosis and faces by the products of menstruation but also schistosomiasis are blood borne organisms that by swelling and stretching of the tissue as well can also cause PID. as nerve damage secondary to scarring that The mechanism of CPP following PID is occurs around the implants.8 Endometriosis likely to be related to the scarring, tissue dam- seems to be common among middle class age, and adhesions resulting from it. The women between the ages of 30 and 45 years.

nerves to the intra-abdominal pelvic organs The symptoms may range from deep dyspareu- http://sti.bmj.com/ and contiguous structures can be damaged or nia, dysmenorrhoea, and constant pelvic pain. the structures can adhere in such a way that painful stretching is produced by activities such Peritoneal adhesions as exercise, sexual intercourse, or passage of Pelvic peritoneal adhesions can sometimes be food through the bowel.3 A study conducted by responsible for pelvic pain although they are Heisterberg5 found that women with previous often asymptomatic. A single adhesion band

PID complained more of dyspareunia (14% which is under tension is likely to cause pain in on October 2, 2021 by guest. Protected copyright. versus 3% respectively) and CPP (6% versus certain positions or during movement. While 0.4% respectively) compared with controls. peritoneal adhesions are usually asymptomatic, they can cause pain, particularly when they are Table 2 Organic/non-organic “psychological” causes of pelvic pain extensive and involve sensitive structures like 9 Gynaecological Pelvic inﬂammatory disease the ovary. Adhesions are usually a complica- Endometriosis tion of PID, endometriosis, appendicitis, peri- Peritoneal adhesions tonitis, and/or previous pelvic surgery. The Others, eg pregnancy complications, ectopic pregnancy Ovarian remnant syndrome degree and the characteristic of the pain from Gastrointestinal Irritable bowel syndrome adhesions therefore depend on its extent and Diverticulitis location. Regional ileitis Others, eg chronic appendicitis Other gynaecological causes such as ovarian Urological Urethral syndrome Interstitial cystitis remnant syndrome, ovarian cyst, and retroverted Others, eg pelvic kidney, renal calculi uterus Musculoskeletal/neurological Nerve entrapment Ovarian remnant syndrome is sometimes seen Myofascial pain (“trigger points”) in patients following hysterectomy and bilateral Low back pain syndrome salpingo-oophorectomy for severe endometrio- Psychological Physical and/or sexual abuse sis or pelvic inﬂammatory disease. Ovarian Depression Anxiety remnant syndrome results from residual ovar- Child abuse ian cortical tissue that is left in situ after Rape Y Others, eg personality disorder di cult surgical dissection during oophorectomy.10 The patient usually has had multiple

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pelvic operations with the uterus and adnexa Myofascial pain Sex Transm Infect: first published as 10.1136/sti.76.6.419 on 1 December 2000. Downloaded from removed sequentially. Ovarian cysts can also Myofascial syndrome has been documented in cause unilateral pelvic pain. An acutely retro- approximately 15% of patients with CPP.17 verted uterus can sometimes contribute to the Slocumb has termed certain spots in the pelvic pain syndrome. However, there is still no abdominal wall as “trigger points.”18 Trigger convincing evidence that ventrosuspension is points are believed to be initiated by patho- eVective in relieving such symptoms. genic autonomic reflex of visceral or muscular origin and can sometimes be observed during GASTROENTEROLOGICAL CAUSES examination. The sites of the referred pain A significant proportion of woman with CPP from trigger points are in a dermatome section can subsequently be found to have a gastro- and are the result of nerves from the muscle or intestinal disorder, either pathogenic or func- deeper structures sharing a specific neuron in tional. The location of the referred pain from the spinal cord. Injections of local anaesthetics the gastrointestinal tract overlaps that of the into these painful points can temporarily oblit- reproductive organs. erate the pain. Trigger points are often present in woman with CPP, irrespective of the presence or type of the underlying pathology. Irritable bowel syndrome 18 This is one of the most common causes of In a conducted study by Slocumb, trigger lower abdominal pain and may account for up points were present on the abdomen in 89%, to 60% of referrals to the gynaecologist for vagina in 71%, and sacrum in 25% of cases. CPP.11 The exact cause of irritable bowel Other aetiological factors may also contrib- syndrome is still unknown although visceral ute to this symptom. These include psychologi- hypersensitivity or hyperalgesia has been pos- cal, hormonal, and biomechanical factors tulated as a possible cause for the pain.12 which are believed to predispose the patient to Patients with this syndrome have pain which is chronic myofascial syndrome when pathology associated with smaller bower distention vol- is absent. ume compared with controls.13 Low back pain syndrome Low back pain may accompany gynaecological Other gastrointestinal causes such as chronic pathology and pelvic pain. The underlying appendicitis, diverticulitis aetiology can involve vascular, neuralgic, psy- Chronic inflammatory conditions involving the chogenic, or musculoskeletal causes. gastrointestinal tract such as appendicitis with an atypical presentation and diverticulitis can NON-ORGANIC (PSYCHOSOCIAL) CAUSES also occasionally present as CPP.14 There are many observational studies suggest- ing that women with pelvic pain are signifi- UROLOGICAL CAUSES cantly more likely to have histories of depres- Urethral syndrome sion, somatisation, sexual and physical abuse, Urethral syndrome is a complex of various and chronic psychological distress compared symptoms such as dysuria, frequency and with controls.19 Childhood sexual and physical urgency of urination, suprapubic pelvic dis- abuse have also been shown to subsequently http://sti.bmj.com/ comfort, and dyspareunia. The diagnosis is lead to somatisation, anxiety, and depression. usually made by excluding any abnormality in The intensity of these psychosocial sequelae the urethra or bladder. The cause of urethral also appears to be correlated with the duration syndrome is uncertain but it has been attrib- and severity of the abuse.20 When organic uted to subclinical infection, urethral obstruc- disease has been excluded, these patients often tion, cold, stress, and psychogenic and allergic have a characteristic psychological pattern: sad factors.

childhood, lack of parental interest and aVec- on October 2, 2021 by guest. Protected copyright. tion. Resentment is generally directed prima- Interstitial cystitis rily against the patient’s mother who is often Interstitial cystitis is a chronic non-bacterial perceived as having a negative attitude towards inﬂammation of the bladder. Hypersensitivity sexuality.21 The patient’s marital and/or sexual or hyperalgesia has been postulated as the relationship has often been unsuccessful with cause of the pain although the underlying aeti- various psychosexual dysfunctions such as loss ology remains unclear.15 of libido, lack of orgasm, and dyspareunia. Russo et al22 have shown that the number of NEUROLOGICAL AND MUSCULOSKELETAL CAUSES non-organic causes of pelvic pain is linearly Nerve entrapment correlated with both the number of lifetime Nerve entrapment usually follows an abdomi- anxiety disorders, agoraphobia, and the degree nal cutaneous nerve injury. Entrapment may of neuroticism. Walker et al23 highlighted the occur spontaneously or within weeks to years importance of recognising that medically after transverse suprapubic or laparoscopic unexplained physical symptoms may be a skin incisions.16 The ilioinguinal or iliohypogas- proxy for psychiatric distress. They emphasised tic nerves may become trapped between the that a simple review of various medical systems transverse and the internal oblique muscles, may be a convenient tool to provide an estimate especially during muscular contractions. Alter- of the degree of psychopathology which would natively, the nerve may be ligated or trauma- provide a balance of the medical and psycho- tised during surgery. The clinical picture is logical therapy oVered to these patients. The usually suggestive of long term postoperative following psychological and/or psychiatric con- symptoms with an onset following surgery. ditions are not uncommonly found.

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Depression Management Sex Transm Infect: first published as 10.1136/sti.76.6.419 on 1 December 2000. Downloaded from Pain and depression can be closely linked The current management strategy for CPP is together. Both may be mediated by the same somewhat characterised by lengthy investiga- neurotransmitters such as noradrenaline (nor- tions before any form of eVective management epinephrine), serotonin, and endorphine.24 is oVered to patients (ﬁg 1). In order to avoid a They also give rise to similar behaviour, such as fragmented approach, a multidisciplinary ap- behavioural and social withdrawal with limited proach addressing both organic and psycho- interaction. Depression was found to predate logical aspects has been adopted as the main the symptom of pain in 75% of cases.24 Nolan management philosophy of this clinically com- et al25 found that 51 (72%) out of 71 patients plicated condition. This includes investigation with pelvic pain reported sleep disorders and and treatment of organic disease as well as 37 (51%) out of 72 patients were clinically clinical psychological and/or psychiatric input. depressed as determined by the Beck Depres- DiVerent healthcare professionals may have a sion Inventory. Slocumb et al26 found gynaeco- part to play in the management of the patient logical patients with pelvic pain to be more depending on the underlying aetiology. The anxious, depressed, hostile, and had more ﬁrst author runs a genital uropelvic dysfunc- somatic symptoms than controls. Although tion clinic within the department of genitouri- there appears to be an association between nary medicine which acts as a tertiary referral chronic pelvic pain and depression, in many clinic designed to coordinate the multidiscipli- cases it is still unclear as to whether the depres- nary management of this condition. The sive symptoms precede the development of following are preliminary investigations carried pain or result from it. out for all patients attending the clinic.

MICROBIOLOGY Somatisation disorders Microbiological studies are very important in Patients with CPP have an increased incidence the management of such patients. Vaginal and of upper abdominal pain, diarrhoea, constipa- cervical swabs would reveal lower genital infection, low back pain, dyspareunia, dysmenor- tion. Although these results cannot be univer- rhoea, nausea, bloating, breathlessness, dizzi- sally extrapolated to the upper genital tract, ness, weakness, and menstrual irregularity.27 one can assume that a woman who has lower There is also an association between somatisa- abdominal pain with chlamydial or gonococcal tion and a history of sexual trauma in women endocervical infection will probably have PID. with non-somatic pelvic pain.19 Immediate microscopy as well as culture is routinely available within the clinic for this purpose. Physical and sexual abuse Childhood physical and sexual abuse has been noted to be more prevalent in women with PELVIC ULTRASOUND CPP compared with those with other types of Ultrasound can play a major part in diagnosing pain and control groups (52% versus 12% pathology as well as oVering psychological 28 reassurance to many patients without disease.

respectively). There is a specific association http://sti.bmj.com/ between major sexual abuse and CPP and a Ultrasonic features of PID such as peritoneal more general association between physical free fluid, dilated fallopian tubes, and tubo- abuse and chronic pain.19 Walker et al29 30 found ovarian abscess are well recognised. Other that women with pelvic pain who had a gynaecological pathology such as ovarian cyst previous history of sexual abuse had a signifi- and fibroid can also easily be detected by this cantly higher risk for having a current diagno- non-invasive imaging. It can also confirm or sis of major depression and somatiform pain on October 2, 2021 by guest. Protected copyright. disorder compared with those with no abuse or Stage 1 31 less severe abuse. Toomey et al also found that General practitioner 19 (53%) out of 36 patients with CPP reported ? Pelvic inflammatory disease previous abuse and that sexual abuse was Course of antibiotic Short term relief reported more frequently than physical abuse. Moreover, other forms of abuse need to be Stage 5 Patient still suffering identified since there was a significantly greater from the condition incidence of childhood physical abuse in Stage 2 patients with CPP compared with patients with Weeks later pain recurs 32 19 other pain or with controls. Rapkin et al General practitioner Flare up of pain reported that 39% of patients with CPP had Stage 4 been physically abused during childhood and Another course Pain persists of antibiotic in this study physical abuse was more common Psychiatric referral TRANSIENT TREATMENT than sexual abuse in the majority of these cases. Analgesics However, many studies have failed to adopt Management comparative groups of patients with pain of Stage 3 equivalent chronicity. It is therefore diYcult to Pain persistent Gynaecological referral exclude the possibility that psychological dis- Ultrasound scan/laparoscopy turbances may have arisen from long term No pelvic pathology experiences of pain. Furthermore, the possi- Reassurance and discharge bility of selection bias being operative cannot Figure 1 Diagnostic cul de sac for the management of also be ruled out in these studies. chronic pelvic pain.

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exclude early pregnancy problems such as important to obtain swabs for microbiology Sex Transm Infect: first published as 10.1136/sti.76.6.419 on 1 December 2000. Downloaded from ectopic pregnancy in those patients with an studies from the pouch of Douglas, fallopian irregular or delayed menstrual cycle. tubal fimbriae, and adnexal abscess. If the Transvaginal ultrasound is useful for imag- microbiological results are positive, the appro- ing dilated pelvic veins in cases with pelvic priate antibiotics should be prescribed and the congestion syndrome.33 It has been reported relevant contact tracings carried out as soon as that clinical evaluation of patients with CPP possible. combined with ultrasound is highly predictive of pelvic pathology but the best information is OTHER INVESTIGATIONS still achieved with diagnostic laparoscopy.34 (1) Urine analysis and midstream urine speci- Ultrasound, however, has limitations in diag- men for culture and sensitivity should be nosing peritoneal endometriosis. The predic- obtained to investigate for urinary tract tive ability of ultrasound for the diagnosis of infections. PID depends on several factors such as opera- (2) Sigmoidoscopy is important for conditions tor skills, the quality of the ultrasound machine such as irritable bowel syndrome or diver- used, and the presence or absence of previous ticulitis. This procedure is usually carried pelvic surgery. out in the outpatient clinic. (3) Radiological imaging studies can be help- OUTPATIENT ENDOMETRIAL BIOPSY ful to exclude pathology related to low The procedure may be useful in diagnosing back pain syndrome. endometritis especially plasma cell type which (4) Psychometric instruments such as the is characteristic of chlamydial infection. Blind Minnesota Multiphasic Personality Inven- endometrial biopsy is an easy procedure which tory41 can be used to diVerentiate patients can be carried out with the minimal discomfort with non-organic chronic pain from those and harm to the patient. It is important that with pelvic pathology. such a procedure is performed after a negative (5) Other investigations are requested depend- sexually transmitted disease screen in order to ing on the provisional diagnosis—for prevent any iatrogenic PID. The biopsy can be example, cystoscopy, intravenous pyelo- sent for microbiological as well as histopatho- gram. logical studies. Hysteroscopically directed endometrial biopsy, however, may be indicated in Multidisciplinary management patients with irregular menstrual bleeding in All patients with CPP should be managed by a order to improve the detection of intrauterine multidisciplinary team addressing the diVerent pathology such as polyp, fibroid, and carci- aspects of the problem. Gambone et al42 advo- noma.35 cated such an approach, which incorporates the skills of the genitourinary physician, the LAPAROSCOPY gynaecologist, psychologist, anaesthesiologist, Laparoscopic abnormalities have been re- urologists, and gastroenterologists. Women ported in patients who had a primary diagnosis with clinical depression should be treated with of CPP.35 These findings include endometriosis an appropriate antidepressant.43 A useful algo-

with adhesions (48%), leiomyomas (42%), and rithm that summarises the management path- http://sti.bmj.com/ enlarged globular uterus (24%). In addition, way for CPP is shown in ﬁgure 2. A patient appendiceal abnormalities were present in 2% with an organic pathology is treated by the rel- and hernia in 1% of cases. Hysterectomy was evant specialist without losing sight of the also performed on these patients and reported potential psychological need. as abnormal in 30% of cases with ﬁndings that The approach to women with CPP must be include leiomyomas (18%), interuterine polyps therapeutic, supportive, and sympathetic. Fol-

(6%), and cervical stenosis (3%). low up appointments should be given because on October 2, 2021 by guest. Protected copyright. Howard36 reported that laparoscopy revealed requesting patients to return only if pain pathology such as endometriosis, pelvic adhe- persists can reinforce pain behaviour. sions, pelvic inflammatory disease, and ovarian Strategies such as relaxation techniques, stress cysts in only 61% of women with CPP. This management, sexual and marital counselling, survey also found similar abnormalities in 28% and other psychotherapeutic approaches have of asymptomatic women presenting for infertil- been found to be useful. Studies of multidisci- ity investigations. The author therefore sug- plinary pain management have shown that pain gested that laparoscopy is not the ultimate relief in such patients can be achieved in 85% investigation since it is diYcult to be certain if of cases.44 Pain clinics can oVer an alternative the laparoscopic findings are the cause of CPP approach for women in whom organic pathol- in all cases. Ozaksit et al34 reported that 82% of ogy has been excluded. Such alternative adolescents with CPP had abnormal findings at treatments such as acupuncture, transcutane- laparoscopy. This result is in contrast with ous electrical stimulation, hypnosis, exercise, those obtained from other studies37 38 where biofeedback therapy, and intensive psycho- 35%–40% of patients suVering from CPP were therapy have been shown to achieve 71% found to have abnormal laparoscopic findings. reduction in pain in patients who continued to Vercellini et al39 and Goldstein et al40 examined attend these clinics.45 Anxiety and depression the value of laparoscopy in 47 adolescent can also be reduced with psychosocial func- women with CPP; endometriosis was found to tioning improved, including return to work, be the most frequent pathology (38%) present increased social activities, and improved sexual and the authors suggested that endometriosis activity. Therefore, the multidisciplinary pain in adolescents is not a rare condition. It is also management approach is eVective in achieving

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symptomatic relief from pain as well as A recently conducted randomised controlled Sex Transm Infect: first published as 10.1136/sti.76.6.419 on 1 December 2000. Downloaded from palliative reduction in pain which is due to trial in a health maintenance organisation organic causes that have not responded to con- showed that routine screening for genital ventional therapy. Chlamydia trachomatis in a sexually active The mechanism by which hypnosis appears population between the ages of 15–35 years to be eVective is still unclear. However, there resulted in a significant reduction of almost are various reports which suggest that it helps 60% in the incidence of PID.47 This may lead to in breaking up the harmful and well established a reduction in the incidence of CPP. The pain reflexes through “synaptic ablation.” second preventative strategy is the administra- Hypnotherapy is contraindicated in the psy- tion of single dose antibiotic therapy to index chotic patient, who should be referred to a psy- patients and relevant partners in order to chiatrist. Presacral neuroectomy is one of the ensure compliance. This strategy has to be last surgical approaches to control persistent supported by eYcient contact tracing in which midline CPP. The reported success rate is 75% health advisers has a major role. The third vital and it is usually carried out by a specialist preventative strategy is the availability of high anaesthetist or neurosurgeon.46 quality diagnostic facilities such as ultrasound scans within the CPP clinics to look for sexual Prevention strategies transmitted infections of the upper genital Our focus in the clinical arena must also be tract. Finally, public awareness and education eVective preventative strategy by screening and are also vital in ensuring early recognition of treatment of avoidable conditions such as lower the condition and early self referral to a multi- genital tract infection which can result in PID. disciplinary clinic in order to ensure adequate management. Multidisciplinary consultation Other preventive measures can also follow a similar approach. For example, irritable bowel syndrome can be minimised by ensuring a History healthy and high fibre diet and the incidence of Patient consent for disclosure leaflet if there is no GP referral letter nerve entrapment can be reduced by adapting Baseline McGill pain score hospital anxiety and depression questionnaire Assessment of sexual function (Hudson 82 ISS) surgical techniques which avoid the relevant Quality of life questionnaire (Eurocol) nerves being damaged during surgery. Pre- ventative measures will also be needed to tackle the growing incidence of childhood physical Examination and sexual abuse. Clinical examination including Speculum and vaginal examination Examination of partner (if appropriate) Conclusion Management of chronic pelvic pain is a major challenge for the health service. It represents a Investigation clinical dilemma for many clinicians. This is Screening for genital tract infection (urethral, endocervical, vaginal swabs) Urinanalysis and dipslide partially due to the usual presence of multiple Pregnancy test factors in its aetiology and partly because of

Ultrasound scan our lack of our understanding of the natural http://sti.bmj.com/ Endometrial biopsy (after negative screen for genital tract infection) history of the condition. It is described by some Laparoscopy clinicians as a nightmare to provide eVective management and such patients are usually Treatment sucked into a fragmented treatment strategy. A multidisciplinary approach seems to be the way Negative investigations Endometriosis forward where the condition is not only inves- Psychological assessment and Continuous combined oral contraceptive pill psychosexual, anxiety and depression Continuous progestogens tigated properly but therapeutic strategy takes on October 2, 2021 by guest. Protected copyright. therapy if appropriate Danazol, gestrinone into account both physical and psychological LHRH analogue plus or minus add-back HRT management oVered by various medical and Analgesics with NSAIDs for trigger point Laparoscopic surgical ablation/excision non-medical health professionals. injection Benign ovarian cyst Other experimental interventions, eg Laparoscopic ovarian cystectomy/ Conﬂict of interest: none. Source of funding: none. acupuncture, hypnosis, biofeedback, oophorectomy laparoscopic uterine nerve ablation, Laparoscopic assisted pelvic clearance in presacral neurectomy older women and family is complete 1 Campbell F, Collet BJ. Chronic pelvic pain. Br J Anaesth 1994;73:571–3. 2 Reiter RC. Chronic pelvic pain. Clin Obstet Gynecol Surgical pelvic clearance + HRT Pelvic inflammatory disease 1990;33:117–8. (only as last resort) Antibiotics and contact tracing 3 Bonica JJ. General consideration of pain in the pelvis and perineum. In: Bonica JJ, Loeser JD, Chapman CR, Fordyce Laparoscopic adhesiolyis plus or minus WE, eds. The management of pain. Vol 2. Pennsylvania: Lea Infection adnexal or pelvic clearance and Febiger, 1990:1283–301. Antibiotics therapy and contact training 4 Hager WD, Eschenbach DA, Spence MR, et al. Criteria for diagnosis and grading of salpingitis. Obstet Gynecol Urological/general surgical problem 1983;61:113–4. Irritable bowel syndrome Refer to appropriate specialty 5 Heisterberg L. Factors inﬂuencing spontaneous abortion, High fibre diet, Fybogel or alternative dyspareunia, dysmenorrhoea and pelvic pain. Obstet Gyne- col 1993;81:594–7. 6 Fry RP, Beard RW, Crisp AH, et al. Sociopsychological fac- Early pregnancy/ectopic pregnancy tors in women with chronic pelvic pain with and without Gynaecological referral pelvic venous congestion. J Psychsom Res 1997;42:71–85. 7 Reginald PW, Beard RW, Kooner JS, et al. Intravenous dihy- droergotamine to relieve pelvic congestion with pain in Pelvic congestion syndrome young women. Lancet 1987;2:351–3. High dose medroxyprogesterone acetate 8 Vercellini P, Fedele L, Bianchi S, et al. Pelvic denervation for chronic pelvic pain associated with endometriosis: fact or Figure 2 Management algorithm for chronic pelvic pain. fancy? Am J Obstet Gynecol 1991;165:745–9.

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