CLINICAL CASE
Unit 3: Gynecology
Section A: General Gynecology
Objective 39: Chronic Pelvic Pain
A 24-year old woman presents to you as a self-referral for pelvic pain. She describes a
four-year history of intermittent lower abdominal and pelvic pain that is now
constant in nature. The pain is always present, sometimes sharper in the left lower
quadrant and not related to menses. She has occasional nausea and is sometimes
constipated. Nothing makes the pain better or worse. Over the years, she has used
acetaminophen and ibuprofen, and has not found any relief. She began her menses at
age 13 and they have come on a regular monthly basis. She experiences some
premenstrual bloating and has cramps with her periods, and reports discomfort at
other times of the month. She had a trial of oral contraceptives and then a subsequent
laparoscopy by a prior gynecologist. She was told that everything looked normal. She
is otherwise a healthy non-smoker, but reports that this pain is making her life
miserable.
She has a bachelor’s degree from a local college, works as computer processor and lives
at home with her parents. She has never been sexually active. Upon further
questioning, she reports that her oldest brother sexually abused her as a child.
Physical exam
Somewhat flattened affect, but smiles occasionally. 5 feet 4 inches; 142 pounds.
Trapezius and paraspinous muscles tender on palpation. No costovertebral angle
tenderness. Abdomen is soft with 2 well-healed pelviscopy incisions. There is no
rebound or guarding or mass. Tenderness is elicited with deep palpation of the lower
quadrants. External genitalia, vagina and cervix are normal. Uterus is mid-position,
mobile and the adnexa are mildly tender. The rectal vault is palpably normal with
soft stool that is heme negative.
Differential diagnosis of chronic pelvic pain
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Gynecologic origin
Gastrointestinal disorders
Urinary problems
Musculoskeletal disease
Pain processing disorders
Psychiatric and psychological
Management plan
The patient was counseled about the multiple possible causes of chronic pelvic pain.
The provider was empathic and sensitive in regards to this challenging problem. A
plan of care was devised jointly and she was scheduled for a follow-up. The patient’s
previous records and operative report was obtained and reviewed. On a subsequent
visit, the patient did note that the pain worsens when her older brother returns home
for family holidays. She reports that she has never mentioned this to the therapist
that she has recently started seeing. A trial of low dose tricyclic antidepressants was
initiated which helped the patient with sleeping, but did not make the pain go away.
The patient continued to follow up at regularly scheduled intervals with her
gynecologist and therapist, and had less emergency room visits.
Teaching points
Chronic pelvic pain can be defined as cyclic pain of 6 months duration or non-cyclic
pain of 3 months duration and the pain interferes with normal activities. The problem
of chronic pelvic pain is under-recognized. It may affect 15% to 24% of American
women and accounts for a large proportion of office visit time and many invasive
surgical procedures.
Chronic pelvic pain can be derived from a variety of sources, including gynecologic,
gastrointestinal, rheumatologic, musculoskeletal, urologic or psychiatric. It can be
difficult to diagnose the etiology and can be challenging to treat. The health care
provider must perform a thorough history and physical exam, which are often much
more valuable in making a diagnosis than any laboratory or radiologic tests.
Patients present to different specialists based on their belief of what is causing the
pain. Gastrointestinal diseases may cause symptoms such as nausea, vomiting,
bloating or changes in bowel habits. Urinary tract disorders my cause dysuria,
urgency or vague pelvic discomfort. Patients need to be asked about fatigue, sleep
disturbances, or mood disorders and fibromyalgia and depression considered. Patients
also need to be queried about physical and sexual abuse, or any history of substance
abuse. Musculoskeletal disorders can be determined by a thorough motor and sensory
examination, with attention to the back, hips and legs.
Possible gynecologic causes of chronic pelvic pain include endometriosis, adenomyosis,
chronic pelvic infection or adhesions. A normal laparoscopy does not completely rule
out endometriosis, as the changes can be subtle and occasionally missed. Providers
can consider an empiric trial of oral contraceptives or GnRH agonists after nongynecologic causes have been ruled out. Some providers recommend a trial of
antibiotics or non-steroidal anti-inflammatories for potential infectious causes. In the
case of depression, whether overt or covert, antidepressants should be initiated.
Even when the etiology is determined, chronic pelvic pain can be difficult to treat.
The patient may need to be seen regularly and provided with much support. Comanagement with a psychologist, social worker or therapist may be helpful.