Chronic Pelvic Pain in women
Pelvic pain is defined as chronic if it has been present for three cycles or more. The difference between this and ‘normal’ period pain is one of intensity and duration. It is one of the commonest reasons for referral to a gynaecology clinic and for a woman to attend the practice in the first place.
Differential diagnosis
Common Diagnoses
- Endometriosis
- Chronic Pelvic Inflammatory Disease
- Pelvic Congestion
- Irritable Bowel Syndrome
- Physiological (Mittelschmerz, Primary Dysmenorrhoea)
Occasional Diagnoses
- Recurrent UTI
- Musculoskeletal Pain (Back Pain, Pubic Symphysis Pain)
- Uterovaginal Prolapse
- Benign Tumours: Ovarian Cyst, Fibroids
- Chronic Interstitial Cystitis
- IUCD
- Adhesions (from Previous Surgery)
Rare Diagnoses
- Malignant Tumours (Ovary, Cervix, Bowel)
- Diverticulitis
- Lower Colonic Cancer
- Inflammatory Bowel Disease
- Subacute Bowel Obstruction
Ready reckoner
Key distinguishing features of the most common diagnoses
| Endometriosis | PID | Pelvic Congestion | IBS | Physiological | |
|---|---|---|---|---|---|
| Worse Around Period | Yes | Possible | Yes | Possible | Possible |
| Heavy Periods | Yes | Yes | Yes | No | Possible |
| Altered Bowel Habit | No | No | No | Yes | No |
| Subfertility | Possible | Yes | No | No | No |
| Ovarian Tenderness | Possible | Possible | Yes | No | No |
Possible investigations
Likely: MSU, CA-125.
Possible: Laparoscopy, ultrasound, HVS and cervical swab.
Small Print: FBC, ESR/CRP, bowel and back imaging.
- MSU detects UTI. Red cells alone may be present in interstitial cystitis.
- CA-125 – especially in women aged 50 or more to help rule out carcinoma of the ovary
- FBC, ESR/CRP: WCC, ESR/CRP may be raised during exacerbation of chronic PID.
- HVS and cervical swab for Chlamydia may help in determining the infective agent in PID
- Ultrasound is helpful if there is a palpable mass or if CA-125 is elevated
- Laparoscopy is the investigation of choice for diagnosing PID, endometriosis and pelvic congestion.
- Further investigations, such as bowel and back imaging, might be undertaken by the specialist after referral.
Top Tips
- A ‘forgotten’ coil can cause cyclical pelvic pain
- If the pain links with periods, establish whether it is primary or secondary dysmenorrhoea – the latter is far more likely to have a pathological cause.
- In some cases the diagnosis will remain obscure. Avoid colluding with obviously erroneous diagnoses and try to adopt a constructive approach without over-investigating the patient.
- Don’t overlook non-gynaecological causes.
- Bloating is a very common gynaecological symptom, but is characteristic of IBS. A trial of antispasmodics may aid diagnosis.
- Misdiagnosis of PID without reliable evidence will delay the real diagnosis and lead to repeated courses of unnecessary antibiotics.
Red Flags
- Women over 35 at first presentation and those with a mass should be referred for a gynaecological opinion.
- Ovarian cancer nearly always presents late. Have a low threshold for investigation.
- Even if endometriosis is confirmed at laparoscopy it may not be the cause of a women's pelvic pain. Remember that many women with similar findings are asymptomatic. Discuss this openly with the patient – this will help manage expectations if she does not improve with anti-endometriotic treatment.