Chronic Pelvic Pain

Question 1

Chronic pelvic pain definition

Answer 1

Persistent, non cyclic pain perceived to be in structures related to the pelvis and lasts more than 6 months

Question 2

What is the differential diagnosis of chronic pelvic pain syndrome

Answer 2

Gynecologic

• endometriosis
• intrabdominal adhesions
• adenomyosis
• PID

GI based

• IBS
• IBD
• colonic cancer
• constipation

Urologic

• interstitial cystitis (bladder pain syndrome)
• recurrent UTI
• bladder diverticulum

MSK

• fibromyalgia
• osteitis pubis
• myofascial pain syndrome

Neurologic

• nerve injures/entrapment
• chronic pain syndrome

Psychiatric

• depression
• opioid/domestic abuse
• sleep disorders

Question 3

Red flags of chronic pelvic pain

Answer 3

Postcoital bleeding

Postmenopausal bleeding

Pain onset of postmenopause

Unexplained weight loss

Adnexal mass

Gross/microscopic hematuria

Mass on US

Question 4

3 types of physiological pain

Answer 4

Nociceptive pain = caused by tissue damage

Neuropathic pain = caused by nerve damage
- treatment = Gabapentin, pregabalin

Psychogenic pain = caused by psychological factors
- treatment = TCA’s/SSRIs

Question 5

Chronic pelvic pain syndrome in men

“Chronic prostitis”

Answer 5

Chronic pelvic pain for at least 3 out of 6 months in the absence of any identifiable causes

Usually associated with sexual dysfunction or urinary symptoms

4 most common Locations of pain

• perineum (63%)
• testes (58%)
• suprapubic (42%)
• penis (32%)

Symptoms (other than pain)

• dysuria
• urgency and frequency
• pain with ejaculation
• erectile dysfunction
• premature ejaculation

Question 6

Diagnostic approach for male chronic pelvic pain

Answer 6

1) must rule out or in bacterial infection

2) evaluate for:
- urogential cancer
- spinal cord injury
- abdominal mass/hernia
- testicular tumor
- orchitis

3) confirm findings/symptoms associated with chronic pelvic pain syndrome

Question 7

Treatment for chronic pelvic pain syndrome in men

Answer 7

Non pharmacologic

• PT
• CBT
• acupuncture

Pharmacological

• alpha blocker + ibuprofen
• pregabalin
• 5a-reductase inhibitors
• PDE-5 inhibitors

Question 8

Treatment for chronic pelvic pain in women

Answer 8

Non pharmacologic

• PT and pelvic floor therapy
• CBT
• nerve blocks
• exercise

Pharmacologic

• Gabapentin + amitriptyline (best for pelvic pain)
• OCPs and NSAIDs ( good for endometriosis and pelvic pain)

Surgical

• laparoscopy
• lysis of adhesions
• hysterectomy