A 43-year-old woman has a one-year history of chronic pelvic pain that sometimes radiates to the thighs. She also experiences pelvic pain when the abdomen is palpated. Menstrual cycles are normal, with moderate-to-heavy flow. The pain is somewhat relieved with naproxen or propoxyphene and acetaminophen (Darvocet). No cysts or other abnormalities are seen within the vaginal vault. Annual Pap smears have been unremarkable. The uterus appears to be of normal size. Fallopian tubes and ovaries are without cyst(s). A pelvic and transvaginal ultrasound is nondiagnostic. What other tests can be performed? Are there any GI issues that could be causing the pain?

Chronic pelvic pain is a fairly common yet poorly understood syndrome. The differential diagnosis can be quite challenging and includes genitourinary, musculoskeletal, neurologic, and psychiatric disorders. The most common causes include endometriosis, pelvic-floor disorders (tension, prolapse, and levator ani spasm), pelvic congestion syndrome (varicosities around the uterus and/or ovaries), inflammatory disorders (chronic infection, inflammatory bowel disease), interstitial cystitis or bladder cancer, and psychological disorders (depression, somatization disorders, and personality disorders). Other possible causes include herniated disks, abdominal migraine, abdominal epilepsy, tuberculous salpingitis, and fibromyalgia. A detailed history is vital. Focus on the distribution and timing of pain, precipitating and alleviating factors, and quality of the pain over time. Review of systems should be meticulous and cover gynecologic, obstetric, urinary, GI, musculoskeletal, neurologic, and psychiatric symptoms. The pelvic exam should test for trigger points during the bimanual and rectovaginal exam and may narrow the differential. Imaging should be directed from the history and physical and may include cultures, ultrasonography, CT, or MRI. Colposcopy and/or laparoscopy may be indicated depending on presentation and exam findings. Laparoscopy can be done under local anesthesia, which will allow for directed pain mapping. Chronic pelvic pain is thought to occur in up to one out of seven women, and in many cases, no cause is found. A multifaceted and multidisciplinary approach while maintaining support and good rapport with the patient is paramount. For more, see Singh MK and Puscheck EE. Chronic pelvic pain: differential diagnoses & workup (available at emedicine.medscape.com/article/258334-diagnosis. Accessed May 12, 2009).
—Claire Babcock O’Connell, MPH, PA-C