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ESSENTIALS OF DIAGNOSIS

ESSENTIALS OF DIAGNOSIS

  • Noncyclic pain.

  • Duration of 3–6 months or more.

  • Localized to anatomic pelvis, anterior abdominal wall at or below the umbilicus, the lumbosacral back, or buttocks.

  • Associated with functional disability.

GENERAL CONSIDERATIONS

Chronic pelvic pain is defined as noncyclic pain lasting at least 3–6 months that localizes to the pelvic girdle region; it must be of sufficient severity to cause functional disability or necessitate medical care. This disorder is common, accounting for 10–20% of outpatient visits to a gynecologist, and is associated with decreased quality of life, depression, and sexual dysfunction. Patients with chronic pelvic pain may also experience marital stress, altered relationships at home, and decreased work capacity.

Chronic pelvic pain is a symptom that can arise from a diverse group of disorders, including gynecologic, urologic, GI, musculoskeletal, or neurologic abnormalities. Specific gynecologic conditions that can cause chronic pelvic pain include endometriosis, pelvic adhesions, chronic pelvic inflammatory disease, ovarian remnant, pelvic congestion syndrome, and adenomyosis. Interstitial cystitis (also called bladder pain syndrom), irritable bowel syndrome, and pelvic floor myalgia have all been associated with chronic pelvic pain. Musculoskeletal and neurologic causes of pelvic discomfort should also be considered, including disk herniation, lumbar spondylosis, and nerve entrapment. Many women may have more than one diagnosis contributing to their pain, with studies showing that multiple pelvic pain syndromes often coexist such as bladder pain syndrome and irritable bowel syndrome. Chronic pelvic pain may also be diagnosed in the absence of clear identifiable underlying pathology.

Given the overlap of symptoms in many chronic pelvic pain disorders, pathophysiologic models highlight the shared afferent and efferent neurologic pathways between visceral and somatic structures in the pelvis, which can help inform a clinician's approach to these disorders where persistent input from visceral sources leads to perceived pain in somatic structures, and vice versa. Thus, a patient with (somatic) pelvic floor muscle dysfunction may exhibit (visceral) symptoms of urinary frequency or urgency. The mechanisms that exacerbate chronic pelvic pain often include contributions from central pain sensitization, from adverse childhood experiences (eg, abuse or trauma) and from psychological distress or coexisting mental health diagnoses. History, physical examination, and treatment approaches should address each of these domains along with possible gynecologic or nongynecologic diagnoses as noted above.

CLINICAL FINDINGS

A. Symptoms and Signs

Certain features of the history and physical examination can provide clues to the underlying diagnosis. Patients should be asked about the location, quality, and intensity of their pain as well as the relationship with the menstrual cycle, sexual activity, urination, and defecation. Dysmenorrhea and dyspareunia are often experienced by patients with endometriosis, whereas dysuria, urgency, and frequency in association with pelvic pain are characteristic of interstitial cystitis or myofascial pain syndromes. Patients with irritable bowel syndrome often report abdominal pain, distention, and diarrhea or constipation. ...

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