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 2 physicians previously, tried an oral contraceptive pill and ibuprofen, and has had 2 laparoscopies in an attempt to relieve her pain. She currently rates her pain as 8/10 using a visual analog scale. She is otherwise healthy, but slightly depressed and sleeps poorly. Physical exam 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 multifactorial and complex.[1] When there is only one diagnosis, it is most commonly gynecologic-based pain (endometriosis or adenomyosis) when seen by a gynecologist, 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 pathologic 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 magnetic resonance imaging or ultrasound may be able to detect higher-stage disease.
Interstitial cystitis (also called painful bladder syndrome) may be suspected based on history, physical exam, 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 alkalinized 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 exam 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 exam. Most patients can distinguish the pressure of a pelvic exam from pain on palpation. Pain in multiple locations suggests the presence of a central pain syndrome. Injection of local anesthetic (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 American College of Rheumatology 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 underemphasized and will require additional treatment 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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