Case history
Case history
A 37-year-old woman (gravida 2, para 2) presents with a 4-year history of chronic pelvic pain, including dyspareunia and dysuria. She has seen two physicians previously, tried an oral contraceptive pill and ibuprofen, and had two laparoscopies in an attempt to relieve her pain. She currently rates her pain as 8/10 using a visual analogue scale. She is otherwise healthy, but slightly depressed and sleeps poorly. Physical examination reveals point tenderness in the lower abdomen, pain with palpation of the levator muscles on one side, moderate bladder tenderness, and pain with manipulation of the uterus or cervix.
Other presentations
Chronic pelvic pain represents a spectrum of disease. Visceral, neuromuscular, and psychosocial factors combine to produce a presentation that can vary from straightforward to multi-factorial and complex.[1] When there is only one diagnosis, it is most commonly gynaecological-based pain (endometriosis or adenomyosis) when seen by a gynaecologist, or interstitial cystitis (painful bladder syndrome, which rarely occurs alone) when presenting to a urologist. Other pain diagnoses that present themselves in isolation with an intermediate frequency include fibromyalgia, levator ani syndrome, irritable bowel syndrome, and vestibulitis.
Endometriosis and adenomyosis classically present with cyclic pain, often worse during menses, but may develop into constant pain. Advanced endometriosis can involve the bowel and induce a range of bowel-related symptoms.[2] Adenomyosis generally requires pathological examination of the uterus to diagnose accurately. Endometriosis can be diagnosed at laparoscopy, but requires biopsy confirmation due to the low accuracy of visual identification. Limited evidence suggests that high resolution MRI or ultrasound may be able to detect higher-stage disease.
Interstitial cystitis (also called painful bladder syndrome) may be suspected based on history, physical examination, and normal urinalysis, but requires cystoscopy with hydrodistension to diagnose according to research-based (but not clinical) criteria.[3] A patient who experiences pain relief with alkalinised lidocaine bladder instillation has a high likelihood of having interstitial cystitis. A typical patient has had at least two negative urine cultures while complaining of urinary tract infection symptoms.
A physical examination is the only way to accurately diagnose myalgia of any muscle (abdominal or levator ani) or vulvodynia through direct palpation and reproduction of the patient's pain. Upon palpation, the levators will feel very stiff and the patient will complain of pain beyond the usual discomfort of a pelvic examination. Most patients can distinguish the pressure of a pelvic examination from pain on palpation. Pain in multiple locations suggests the presence of a central pain syndrome. Injection of local anaesthetic (lidocaine 1%) into a tender point of a muscle suspected of being a pain generator can lead to immediate and surprisingly prolonged relief (trigger-point injection). The full diagnostic criteria for fibromyalgia may not be present.[4][5][6]
Irritable bowel syndrome is diagnosed based solely on history, which should include the Rome IV criteria. See Irritable Bowel Syndrome.
Pelvic adhesions from previous surgery, scarring from previous infections, or hernias may also cause constant pain, but surgical management is not always effective.
The occurrence of psychiatric comorbidity cannot be underemphasised and will require additional treatment in order to succeed in the management of chronic pain. Patients with higher degrees of pain will have greater levels of neuroticism-axis personality traits and traumatic stress symptoms.
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