From etiology to treatment, get a quick review of the latest guidance for managing chronic pelvic pain in our new slideshow.
Chronic pelvic pain (CPP) is common, affecting up to 26% of women worldwide. In the US, the frequency of CPP is approximately 15% and it is twice as common in women as it is in men. Although CPP in women is thought to be related to gynecologic disorders, the origin is nongynecologic in 80% of patients. Musculoskeletal pain and dysfunction are found in 50%-90% of patients with CPP.
Many treatments lack high-quality evidence to support their use, however, there is now a greater understanding of the factors influencing the development of CPP and consensus recommendations are emerging for the evaluation and management of CPP. A new review published in the June issue of JAMA aimed to summarize those guidelines and provides an approach for physicians when treating patients with CPP. In the slides below, find key points from the review that could help in clinical practice.
The most common conditions known to cause CPP in women include IBS, bladder pain syndrome or interstitial cystitis, endometriosis, and myalgias.
It is unclear how much of the observed overlap is related to similar etiologies (eg, innervation) underlying different disorders and how much is related to inter-relationship among physical structures in the pelvis, where the presence of one disorder may cause or exacerbate another.
In some cases CPP etiology may be clear, however, in-depth physical and psychological histories are essential given the many potential and potentially complex etiologies. A multidisciplinary team approach involving subspecialties may be needed.
Diagnostic testing should be individualized and limited to a pregnancy test in women of childbearing age; vaginitis and sexually transmitted infection screenings for abnormal discharge in sexually active women; urinalysis for urinary tract symptoms; and an endometrial biopsy for chronic abnormal bleeding.
Psychosocial history is essential. Although the role of childhood abuse in the development of CPP remains controversial, there is little doubt that for some patients it is a contributing factor. If identified in the history, it will need to be addressed as part of successful pain management. It is very important to make clear to a patient that identifying psychological factors in no way calls into question the presence or severity of the pain.
Transvaginal pelvic sonography is the most useful diagnostic test for identifying physical pathology and transvaginal ultrasonongraphy is useful for detecting myomas. The usefulness of laparoscopy remains controversial; the test appears to be overused. No underlying pathology for the pain is identified via laparoscopy in up to 40% of women who undergo the procedure.
Research indicates that comorbidity is frequent between CPP and other chronic pain conditions more common among women than men, including fibromyalgia and migraine headaches. The nature of the relationship between disorders remains unclear.
Because of the many disorders that can cause CPP, there is no single “best” treatment. It is critical for physicians to recognize that the etiology of CPP is likely multifactorial and avoid attributing the pain to a single disorder; appreciate that psychosocial factors may play a role and need to be identified and addressed for successful pain management.
Unfortunately, in the absence of overt signs of another disorder (eg, an infection), CPP is often by default attributed to uterine or ovarian disorders. This may result in women undergoing unnecessary surgery that can have a detrimental effect on their lives.
Reference: Lamvu G, Carillo J, Ouyang C, Rapkin A. Chronic pelvic pain in women: A review. JAMA. 2021;325:2381-2391.