Chronic Pelvic Pain

 

Chronic pelvic pain is described as intermittent or constant pain in the lower abdomen or pelvis of at least 6 months’ duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy.  It is a symptom not a diagnosis and presents in primary care as frequently as migraine or low-back pain and may significantly impact on a woman's ability to function

.

Exclude Red Flag Symptoms

Women reporting any of the following symptoms persistently or frequently (more than 12 times per month) should have a serum CA125 measurement taken; particularly in women over the age of 50 years, any new IBS symptoms should prompt such action:

  • bloating
  • early satiety
  • pelvic pain
  • urinary urgency or frequency

.

Causes

The following conditions are known to cause and/or contribute to chronic pelvic pain:

  1. Endometriosis and adenomyosis - Pelvic pain which varies markedly over the menstrual cycle is likely to be attributable to a hormonally driven condition such as endometriosis
  2. IBS and interstitial cystitis - Symptoms suggestive of IBS or interstitial cystitis are often present in women with chronic pelvic pain.  These conditions may be a primary cause of chronic pelvic pain, a component of chronic pelvic pain or a secondary effect caused by efferent neurological dysfunction in the presence of chronic pain
  3. Musculoskeletal - Musculoskeletal pain may be a primary source of pelvic pain or an additional component resulting from postural changes
  4. Nerve entrapment - Nerve entrapment in scar tissue, fascia or a narrow foramen may result in pain and dysfunction in the distribution of that nerve
  5. Psychological and social issues - Enquiry should be made regarding psychological and social issues which commonly occur in association with chronic pelvic pain; addressing these issues may be important in resolving symptoms

.

Assessment

There is frequently more than one component to chronic pelvic pain. Assessment should aim to identify contributory factors rather than assign causality to a single pathology

  1. Explore the pattern of the pain and any association with other problems, such as psychological, bladder and bowel symptoms, and the effect of movement and posture on the pain
  2. If the history suggests that there is a specific non-gynaecological component to the pain, refer to the relevant healthcare professional – such as gastroenterologist, urologist, genitourinary medicine physician, physiotherapist, psychologist or psychosexual counsellor – should
    be considered

.

Investigations

Use the following investigations to aid diagnosis:

  1. Sexually active women with chronic pelvic pain should be offered screening for STIs - HVS, MSU, Chlamydia screening
  2. Order a pelvic ultrasound to determine if there is any underlying pathology
  3. If Pelvic inflammatory disease (PID) is suspected clinically, manage in conjunction with a genitourinary medicine physician in order that up-to-date microbiological advice and contact tracing can be arranged
  4. Transvaginal scanning (TVS) is an appropriate investigation to identify and assess adnexal masses
  5. TVS and MRI are useful tests to diagnose adenomyosis

.

Treatment

Consider the following therapeutic options:

  1. Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of 3–6 months before having a diagnostic laparoscopy
  2. Women with IBS should be offered a trial with antispasmodics
  3. Women with IBS should be encouraged to amend their diet to attempt to control symptoms
  4. Women should be offered appropriate analgesia to control their pain even if no other therapeutic manoeuvres are yet to be initiated. If pain is not adequately controlled, consideration should be given to referral to a pain management team or a specialist pelvic pain clinic

.

Information to include in referral letter

Include the following information when making a referral:

  • Symptoms and possible triggers
  • Current contraception/hormonal therapy
  • Examination findings
  • PMH
  • Smear history – do not perform smear if outside screening programme
  • Current regular medication
  • Smoking status
  • Blood test results FSH/LH TFT Prolactin
  • Pelvic USS

.

Abdominal Pain Poster

.

Blood tests / Phlebotomy

If your practice does not have a practice nurse who is trained to take bloods, you can refer a patient to the Pathology Department at East Kent Hospitals for a blood test (find details here)

Alternatively, Buckland Hospital (Dover) and the Royal Victoria Hospital (Folkestone) both operate a walk-in service where no appointment is necessary, except for if the patient requires a Glucose Tolerance Test (GTT).  In the event that a GTT is required, please call 01304 222552 (for Buckland) and 01303 854484 (for Royal Victoria) to arrange a suitable appointment

Please ensure that the patient remembers to take with them their blood test form to the walk-in centres

.

Microbiology

Please send cultures to the Microbiology Department at East Kent Hospitals (find details here)

.

Ultrasound

For ultrasonography investigations you refer a patient to one of the following acute or community ultrasound providers (find details here)

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

Have a question or query?

Get in touch