Pelvic Pain Syndrome in Women

Pelvic pain syndrome in women (chronic pelvic pain) is noncyclical or cyclical pain in the lower abdomen or pelvis lasting 6 months or longer, severe enough to cause functional disability or need treatment.

• It affects 15 to 25 percent of women of reproductive age and leads to a large share of gynaecological consultations and laparoscopies.
• Contributors: endometriosis, adenomyosis, adhesions, chronic pelvic inflammatory disease, pelvic venous congestion, fibroids, ovarian remnant, irritable bowel syndrome, interstitial cystitis (painful bladder syndrome), pelvic floor myofascial pain, pudendal and other neuropathies, abdominal wall pain, hernia, previous surgery, constipation, sexual and physical abuse, and depression.
• Central sensitisation often maintains the pain even after the initial cause resolves.

Constant or intermittent lower abdominal or pelvic pain, dysmenorrhoea, deep dyspareunia, dyschezia, urinary urgency, bloating, fatigue, sleep disturbance, depression and anxiety.

• Examination: abdominal wall tenderness (pain that increases when the abdominal wall is tensed), vulval allodynia, single finger examination of pelvic floor muscles (tender levator ani), uterine mobility and tenderness, adnexal masses, nodularity of uterosacral ligaments, tender scar.
• Differential diagnosis: endometriosis, adenomyosis, pelvic inflammatory disease, ovarian cyst, ectopic pregnancy, malignancy, appendicitis, diverticular disease, inflammatory bowel disease, urinary tract stone or infection, hernia, musculoskeletal disorders, pelvic floor dysfunction, psychological causes.
• Complications: disability, sexual dysfunction, work loss, depression, opioid dependence, repeated surgery, hysterectomy without cure.

Detailed history (pain map and diary, relation to menses, bowel and bladder, sex, trauma and abuse screen), mood assessment, and examination (abdominal wall, pelvic floor, bimanual).

• Pregnancy test, urinalysis and culture, cervical swabs for chlamydia and gonorrhoea, full blood count, C-reactive protein, CA 125 only if a mass is suspected.
• Transvaginal ultrasound (endometriomas, adenomyosis, fibroids, adnexal masses, venous dilation), magnetic resonance imaging for deep endometriosis, colonoscopy or cystoscopy if indicated.
• Diagnostic laparoscopy for persistent pain with unclear cause or suspected endometriosis (not as first test); Doppler or venography for pelvic congestion.

Supportive: multidisciplinary approach; explanation and reassurance, pain education, graded exercise, pelvic floor physiotherapy, cognitive behavioural therapy, treatment of depression, sleep hygiene, heat, regular follow-up.

Pharmacological

• Analgesia: paracetamol 1 g every 6 hours, naproxen 500 mg twice daily or ibuprofen 400 mg three times daily with food.
• Hormonal suppression (for endometriosis, adenomyosis and cyclical pain): combined oral contraceptive taken continuously, dienogest 2 mg daily, medroxyprogesterone acetate 30 mg daily or depot injection 150 mg IM every 12 weeks, levonorgestrel intrauterine system, or GnRH analogue (leuprorelin 3.75 mg IM monthly for 3 to 6 months) with add-back therapy (norethisterone 1 mg plus oestradiol 1 mg daily).
• Neuropathic pain: amitriptyline 10 mg at night increasing to 75 mg, gabapentin 300 mg daily increasing to 1800 mg daily in divided doses, pregabalin 75 mg twice daily increasing to 150 mg twice daily, duloxetine 30 to 60 mg daily.
• Irritable bowel features: mebeverine 135 mg three times daily and fibre; interstitial cystitis: amitriptyline and bladder training; constipation: macrogol 17 g daily.
• Avoid long term opioids.

Procedures: trigger point injection (bupivacaine 0.25 percent 5 to 10 mL), botulinum toxin to pelvic floor, nerve blocks; laparoscopic excision of endometriosis, adhesiolysis for dense adhesions; ovarian vein embolisation or ligation for pelvic congestion; hysterectomy (with excision of disease) as last resort; sacral neuromodulation.

Special groups: adolescents (exclude outflow obstruction), women with history of abuse (trauma-informed care), women desiring pregnancy (avoid hormonal suppression).

Red flags: postmenopausal bleeding, weight loss, pelvic mass, anaemia, rectal bleeding, suspected malignancy, acute pain with fever.

Follow-up: review every 4 to 8 weeks initially with pain scores; stop ineffective drugs after 3 months; refer to a pain clinic for persistent pain.