Approach

Because chronic pelvic pain is a collection of associated diagnoses, there is no overall definitive test, except for the patient's subjective complaint of pain.

The optimal approach to chronic pelvic pain is with a structured history and physical examination designed to diagnose many of the common associated conditions.[1]​ A history and physical examination form is available free from the International Pelvic Pain Society. International Pelvic Pain Society: history and physical form Opens in new window​ Guidelines are available that provide algorithms for the assessment of chronic pelvic pain; remember that multiple causes may be present in some patients.[26]​​

History

Previous caesarean sections, miscarriages, a history of endometriosis, adhesions, or pelvic inflammatory disease provide a pathological basis for chronic pain symptoms.

Key elements of the history are a thorough description of the course of a patient's pain, with particular attention to aggravating factors, such as menses, physical activity, and stress.[1][26]​​

  • Pain that varies with the menstrual cycle is more likely to be adenomyosis or endometriosis.

  • Pain that worsens later in the day or with activity may represent fibromyalgia.

  • Pain that worsens following intercourse may represent pelvic congestion syndrome.

  • Pain with initial penetration at intercourse may represent vulvodynia.

  • Bladder pain or irritative voiding symptoms may represent interstitial cystitis once bladder infection has been ruled out. Interstitial cystitis is typically considered a diagnosis of exclusion, and a number of other urological conditions can present in a similar manner.[27]

  • Irritable bowel syndrome is diagnosed solely on historical criteria.

Other symptoms include:

  • Dysuria

  • Dyspareunia

  • Dysmenorrhoea

  • Abdominal pain

  • Nocturia

  • Incomplete voiding

  • Dyschezia

  • Low back pain

  • Headache.

A history of poor vulvovaginal hygiene, sexual abuse, drug use, anxiety, or depression can indicate a higher risk of developing chronic pelvic pain.[8][9][20]​​​​[21]​ A thorough psychiatric evaluation is extremely helpful in assessing common comorbidities.

Physical examination

The objective of the examination is to isolate each part of the pelvis and determine whether it is involved in pain generation.[1]

The physical examination should be carefully and systematically performed, usually with one finger. The standard fibromyalgia syndrome trigger points should be palpated, followed by a careful lower abdominal and pelvic examination. Trigger points are those sites that cause pain when 4 kg of pressure is applied. Starting with non-tender areas first will improve the patient tolerance and accuracy of the examination.

Vulvodynia is diagnosed solely on the basis of a careful physical examination of the introitus.[28]​ Using a cotton tip swab to gently indent the skin of the vestibule can localise areas of pain, which frequently include only the posterior portion (fossa navicularis).[1]

For myalgia, either levator ani or of the abdominal wall, palpation of a tender trigger point, and infiltration with a local anaesthetic provides both a diagnostic and therapeutic approach.

Tenderness of the urethra may represent a chronic infection and tenderness of the bladder is common in interstitial cystitis.

Pain with manipulation of the uterus is common in adenomyosis and pain or nodularity of the uterosacral ligaments is found in endometriosis. Pain in the adnexa can represent adhesions or endometriosis.

Laboratory evaluation and imaging

Once the pain-generating organs have been isolated, further testing of these organ systems may be useful.

A basic urinalysis and/or culture is useful to rule out the possibility of infective cystitis or urethritis.[3][26]​ Nucleic acid amplification tests for gonorrhoea, chlamydia, mycoplasma and trichomonas are useful to rule out chronic infections.[1][26][29]​

Imaging studies including pelvic ultrasound may be useful to find fibroids, adenomyosis, or large ovarian cysts.[1][30]​​ Pelvic computed tomography can be used to further characterise any pelvic masses found on ultrasound. Magnetic resonance imaging (MRI) is a more sensitive diagnostic test than ultrasound for the identification of adenomyosis and endometriosis.[31][32]​​ MRI does not have a routine place in the diagnosis of most chronic pelvic pain.[33][34]​​

Endometriosis can be confirmed only with laparoscopic biopsy. Similarly, although adenomyosis may be suggested by pelvic ultrasound, pathological diagnosis is the definitive test.

Interstitial cystitis is also diagnosed in the operating room based on the findings of glomerulations or Hunner's ulcers following instillation or hydrodistension. Whether a laparoscopy or cystoscopy is warranted is based on the patient's symptoms and the expected course of therapy.[3][35]​​

Trigger-point injection can be used to diagnose abdominal wall myalgias or levator ani syndrome.[36][37]

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