Chronic Pelvic Pain in Women: The Right Clinical Information, Right Where It's Needed

Chronic pelvic
pain in women
The right clinical information, right where it's needed
Last updated: Mar 29, 2018

Table of Contents
Summary 3
Basics 4
Definition 4
Epidemiology 4
Aetiology 4
Pathophysiology 5
Prevention 6
Diagnosis 7
Case history 7
Step-by-step diagnostic approach 8
Risk factors 9
History & examination factors 10
Diagnostic tests 12
Differential diagnosis 13
Treatment 15
Step-by-step treatment approach 15
Treatment details overview 17
Treatment options 19
Emerging 28
Follow up 29
Recommendations 29
Complications 29
Prognosis 30
Guidelines 31
Diagnostic guidelines 31
Treatment guidelines 31
Online resources 33
References 34
Disclaimer 38
Summary
◊ Chronic pelvic pain is a syndrome of pain arising from one or more pelvic organs, and can include
any one or all pelvic viscera or muscles.
◊ A methodical, complete, criteria-based history is required to determine how many and which organ
systems are involved and to uncover comorbid psychiatric conditions, particularly depression or a
history of abuse.
◊ The physical examination must be methodical and complete, searching for point tenderness in
all individual pelvic muscles and organs, specifically including the vestibule, levator ani muscles,
bladder, cervix and uterus, adnexa, and lower abdominal wall.
◊ Diagnostic tests are determined by the organ systems generating pain and may include urinalysis
with culture, pelvic ultrasound, cystoscopy with hydrodistension, and diagnostic laparoscopy.
◊ Because chronic pain is sometimes a disorder of pain perception, minimal if any pathological change
may be found.
◊ Treatment is targeted at each organ system involved in pain production. Global pain in all organs or
refusal of non-narcotic management may represent drug-seeking behaviour.
◊ Complications are inherent to all treatments, which frequently include surgery.

Chronic pelvic pain in women Basics
Definition
Chronic pelvic pain is inconsistently defined, but the American College of Obstetricians and Gynecologists
recommended definition is pain lasting for 6 months or more localised to the pelvis, the anterior abdominal
BASICS
wall at or below the umbilicus, the lumbosacral back, or the buttocks, that is of sufficient severity to cause
functional disability or lead to medical care.[1]
Patients typically present with at least two of several common pain-related diagnoses: interstitial cystitis,
irritable bowel syndrome, fibromyalgia, levator ani syndrome (pelvic floor tension myalgia), endometriosis,
adenomyosis, leiomyoma, or vulvodynia. Common comorbid conditions include depression, anxiety, and
traumatic stress disorder.
Epidemiology
Chronic pelvic pain occurs mainly in people in the developed world. Women are affected in a ratio of 9:1 over
men, in whom this is sometimes called chronic prostatitis.[3]
The incidence of chronic pelvic pain varies widely depending on the definitions used and the population
studied. A commonly used estimate is that 15% to 40% of women of reproductive age experience chronic
pelvic pain.[4]
The majority of patients are untreated and undiagnosed. Women who are white, are younger than 35, and
have undergone marital discord or abuse are more likely to have chronic pelvic pain.[4] The incidence of
each associated diagnosis also varies widely, but generally matches the rates for chronic pelvic pain overall.
Aetiology
The underlying aetiology is unclear, but recent studies indicate that the anterior cingulate gyrus, insular
cortex, and amygdala have increased activity in many chronic pain syndromes, including those seen in
chronic pelvic pain.[5] Sexual abuse or trauma at a susceptible age also leads to dysregulation of these brain
structures.
Pain seems to spread from one organ system to another by a process of centrally mediated allodynia without
end-organ pathology. These features indicate that dysregulation of the limbic lobe may be responsible for
many of the features of chronic pelvic pain.
The aetiology of the associated diagnoses is similarly poorly understood. Pain may arise from one or more
organs, and the actual presentation and pathophysiology affecting each organ system may be variable.
One definition of chronic pelvic pain is dysmenorrhoea lasting for at least 6 months, which causes limitation
of activity. This type of cyclic gynaecological pain may represent adenomyosis or fibroids, both of which
are disorders of the uterus itself. Endometriosis is frequently considered to be the result of retrograde
menstruation, but the stage of endometriosis does not correlate with the severity of pain.[6] [7] A newer
hypothesis is that stressors lead to neuro-immune dysregulation, allowing the normal process of retrograde
menstruation to develop into sensory innervated endometriosis implants via peritoneal nerve growth factor
production.
Adenomyosis is a variant of endometriosis, and may also occur due to abnormal nidation of endometrial
tissue through unknown transport mechanisms, or at the time of pregnancy.[8]
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Mar 29, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Chronic pelvic pain in women Basics
Pathophysiology
The pathophysiology underlying the development of chronic pain is unknown. The hypothesis of limbic-
associated pelvic pain is designed to account for many of the features seen in these patients.
BASICS
This syndrome represents a state of hypervigilance for pain due to overactivity of limbic structures,
specifically the amygdala and anterior cingulate. This leads to focused attention on one (or more) sites
in the pelvis (typically a muscle or muscular organ), which respond by generating pain. This induces the
limbic system to increase pain vigilance in the area, which reinforces the pain and can spread to adjacent
organs.[9]
Most organs involved in pain generation do not have significant or detectable pathological change.[5]
For some of the associated conditions, end-organ pathological changes are demonstrable.
• Endometriosis is defined as the presence of endometrial glands and stroma outside of the uterine
lining.
• Adenomyosis is defined as the presence of endometrial glands and stroma inside the uterine wall.
• In interstitial cystitis there may be breakages in the glycosaminoglycan layer of the bladder, exposing
the underlying mucosa to the urine. A number of other changes can inconsistently be demonstrated in
the bladder epithelium and bladder wall.[10]
• Irritable bowel syndrome may represent dysregulation of the enteric neural plexus, potentially involving
serotonin receptors.[11]
• Fibromyalgia and vulvodynia do not demonstrate consistent pathological findings but appear to have a
disordered local neural milieu.[12]
• In pelvic congestion syndrome, excess blood flow to the uterus produces a feeling of heaviness.
Whether this exists as a separate entity is controversial.[13]
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Mar 29, 2018.
5
PREVENTION Chronic pelvic pain in women Prevention
Chronic pelvic pain in women Diagnosis
Case history
Case history #1
A 37-year-old woman (gravida 2, para 2) presents with a 4-year history of chronic pelvic pain, including
dyspareunia and dysuria. She has seen two physicians previously, tried an oral contraceptive pill and
ibuprofen, and had two laparoscopies in an attempt to relieve her pain. She currently rates her pain as
8/10 using a visual analogue scale. She is otherwise healthy, but slightly depressed and sleeps poorly.
Physical examination reveals point tenderness in the lower abdomen, pain with palpation of the levator
muscles on one side, moderate bladder tenderness, and pain with manipulation of the uterus or cervix.
Other presentations
Chronic pelvic pain rarely presents with a single diagnosis. When there is only one diagnosis, it is most
commonly gynaecological-based pain (endometriosis or adenomyosis) or interstitial cystitis (painful
bladder syndrome, which rarely occurs alone). Other pain diagnoses that present themselves in isolation
with an intermediate frequency include fibromyalgia, levator ani syndrome, irritable bowel syndrome, and
vestibulitis.
Endometriosis and adenomyosis classically present with cyclic pain, often worse during menses, but may
develop into constant pain. Advanced endometriosis can involve the bowel and induce a range of bowel-
related symptoms. Adenomyosis generally requires pathological examination of the uterus to diagnose
accurately. Endometriosis can be diagnosed at laparoscopy, but requires biopsy confirmation due to the
low accuracy of visual identification. Limited evidence suggests that high resolution MRI or ultrasound
may be able to detect higher-stage disease.
Interstitial cystitis (also called painful bladder syndrome) may be suspected based on history, physical
examination, and normal urinalysis, but requires cystoscopy with hydrodistension to diagnose according
to research-based (but not clinical) criteria. A patient who experiences pain relief with alkalinised lidocaine
bladder instillation has a high likelihood of having interstitial cystitis. A typical patient has had at least 2
DIAGNOSIS
negative urine cultures while complaining of urinary tract infection symptoms.
A physical examination is the only way to accurately diagnose myalgia of any muscle (abdominal or
levator ani) or vulvodynia through direct palpation and reproduction of the patient's pain. Upon palpation,
the levators will feel very stiff and the patient will complain of pain beyond the usual discomfort of a pelvic
examination. Most patients can distinguish the pressure of a pelvic examination from pain on palpation.
Pain in multiple locations suggests the presence of a central pain syndrome. Injection of local anaesthetic
(lidocaine 1%) into a tender point of a muscle suspected of being a pain generator can lead to immediate
and surprisingly prolonged relief (trigger-point injection). The full diagnostic criteria for fibromyalgia may
not be present.[2]
Irritable bowel syndrome is diagnosed based solely on history, which should include the Rome III criteria.
Pelvic adhesions from previous surgery, scarring from previous infections, or hernias may also cause
constant pain, but surgical management is not always effective.
The occurrence of psychiatric comorbidity cannot be underemphasised and will require additional
treatment in order to succeed in the management of chronic pain. Patients with higher degrees of pain will
have greater levels of neuroticism-axis personality traits and traumatic stress symptoms.
7
Step-by-step diagnostic approach

Because chronic pelvic pain is a collection of associated diagnoses, there is no overall definitive test, except
for the patient's subjective complaint of pain.
The optimal approach to chronic pelvic pain is with a structured history and physical examination designed
to diagnose many of the common associated conditions.[17] A history and physical examination form is
available free from the International Pelvic Pain Society. [International Pelvic Pain Society: history and
physical form] Guidelines are available that provide algorithms for the assessment of chronic pelvic pain.
When using these algorithms, it is important to remember that multiple causes may be present in some
patients.[18]
History
Previous caesarean sections, miscarriages, a history of endometriosis, adhesions, or pelvic inflammatory
disease provide a pathological basis for chronic pain symptoms.
Key elements of the history are a thorough description of the course of a patient's pain, with particular
attention to aggravating factors, such as menses, physical activity, and stress.
• Pain that varies with the menstrual cycle is more likely to be adenomyosis or endometriosis.
• Pain that worsens later in the day or with activity may represent fibromyalgia.
• Pain that worsens following intercourse may represent pelvic congestion syndrome.
• Pain with initial penetration at intercourse may represent vulvodynia.
• Bladder pain or irritative voiding symptoms may represent interstitial cystitis once bladder infection
has been ruled out. Interstitial cystitis is typically considered a diagnosis of exclusion, and a number
of other urological conditions can present in a similar manner.[19]
• Irritable bowel syndrome is diagnosed solely on historical criteria.
Other symptoms include:
DIAGNOSIS
• Dysuria
• Dyspareunia
• Dysmenorrhoea
• Abdominal pain
• Nocturia
• Incomplete voiding
• Dyschezia
• Low back pain
• Headache.
A history of sexual abuse, drug abuse, anxiety, or depression can indicate a higher risk of developing
chronic pelvic pain.[15] A thorough psychiatric evaluation is extremely helpful in assessing common
comorbidities.
Physical examination
The objective of the examination is to isolate each part of the pelvis and determine whether it is involved
in pain generation.
The physical examination should be carefully and systematically performed, usually with one finger. The
standard fibromyalgia syndrome trigger points should be palpated, followed by a careful lower abdominal
and pelvic examination. Trigger points are those sites that cause pain when 4 kg of pressure is applied.
Starting with non-tender areas first will improve the patient tolerance and accuracy of the examination.
Vulvodynia is diagnosed solely on the basis of a careful physical examination of the introitus. Using a
cotton tip swab to gently indent the skin of the vestibule can localise areas of pain, which frequently
include only the posterior portion (fossa navicularis).
For myalgia, either levator ani or of the abdominal wall, palpation of a tender trigger point, and infiltration
with a local anaesthetic provides both a diagnostic and therapeutic approach.
Tenderness of the urethra may represent a chronic infection and tenderness of the bladder is common in
interstitial cystitis.
Pain with manipulation of the uterus is common in adenomyosis and pain or nodularity of the uterosacral
ligaments is found in endometriosis. Pain in the adnexa can represent adhesions or endometriosis.
Laboratory evaluation and imaging

Once the pain-generating organs have been isolated, further testing of these organ systems may be
useful.
A basic urinalysis and/or culture is useful to rule out the possibility of infective cystitis or urethritis. A pap
test and probes for gonorrhoea and chlamydia are useful to rule out current infections. Pelvic ultrasound
may be useful to find fibroids, adenomyosis, or large ovarian cysts. Pelvic computed tomography can be
used to further characterise any pelvic masses found on ultrasound. Magnetic resonance imaging is a
more sensitive diagnostic test than ultrasound for the identification of adenomyosis.
Endometriosis can be confirmed only with laparoscopic biopsy, which still has a 10% false-negative rate
for this diagnosis. Similarly, although adenomyosis may be suggested by pelvic ultrasound, pathological
diagnosis is the definitive test.
DIAGNOSIS
Interstitial cystitis is also diagnosed in the operating room based on the findings of glomerulations
or Hunner's ulcers following instillation or hydrodistension. Whether a laparoscopy or cystoscopy is
warranted is based on the patient's symptoms and the expected course of therapy.
Trigger-point injection can be used to diagnose abdominal wall myalgias or levator ani syndrome.[20] [21]
Risk factors
Strong
sexual abuse
• Substantial evidence supports the relationship between a history of abuse and the development of
chronic pelvic pain, and supports the limbic association of chronic pelvic pain.[14] [15]
pelvic inflammatory disease

• Previous pelvic scarring from surgery or infection often leads to chronic pain.[16]
9
anxiety or depression
• All pain syndromes are worsened in the presence of anxiety or depression. The actual causal
relationship is less clear.
drug or alcohol abuse

• Patients with chronic pain frequently self-medicate with alcohol. Narcotic addiction may precede or
result from chronic pain.
pregnancy
• Adenomyosis is considered to occur only following pregnancy of some type. It is unclear whether
miscarriage or term delivery increases the risk for adenomyosis. Adenomyosis is associated with
chronic pelvic pain.
polymenorrhoea
• The actual cause of endometriosis is unknown, but it is felt to be associated with having many
menstrual periods, during which time endometrial tissue has more of an opportunity to seed the pelvis
through retrograde flow. Endometriosis is associated with chronic pelvic pain.
previous caesarean section

• Adhesions from surgery or seeding of the uterus or abdomen with endometriosis may occur at
caesarean delivery.
endometriosis
• Endometriomas provides a pathological basis for chronic pain symptoms.
Weak
adhesions
• Adhesive disease provides a pathological basis for chronic pain symptoms.
DIAGNOSIS
History & examination factors

Key diagnostic factors
presence of risk factors (common)
• Key risk factors include sexual abuse, pelvic inflammatory disease, endometriosis, and current or
previous psychiatric disease.
dysuria (common)
• Typically occurs with other irritative voiding symptoms.
dyspareunia (common)
• Deep dyspareunia is considered more frequent in endometriosis.
dysmenorrhoea (common)
• Indicates uterus or gynaecological organs as 1 source of pain.
abdominal trigger points (common)
• Highly localised tenderness, typically at the lateral margin of the rectus sheath or an old scar.
Responds well to anaesthetic infiltration.
levator ani tenderness (common)

• Often unilateral. The pinpoint location of tenderness must be isolated if anaesthetic infiltration is to be
helpful.
cervical motion tenderness (common)

• Indicates upper pelvic organs are likely involved: uterus, ovaries. May also occur with bladder pain.
uterine tenderness (common)

• Indicates pain of gynaecological origin.
abdominal tenderness (uncommon)

• If diffuse, suggests a more acute condition overlapping with chronic pain.
vestibular tenderness (uncommon)

• May be only a portion of the vestibule. Must be distinguished from hymenal remnant pain.
rectal tenderness (uncommon)

• Suggests a component of endometriosis involving the bowel. May indicate an inflammatory bowel
disease.
adnexal tenderness (uncommon)

• If unilateral, suggests the need for ultrasound characterisation of potential cysts or masses. May be
difficult to distinguish following uterine examination.
bladder tenderness (uncommon)

• Suggests interstitial cystitis, but is not definitive.
urethral tenderness (uncommon)
DIAGNOSIS
• Strongly suggests urethritis or urethral diverticulum.
Other diagnostic factors

abdominal pain (common)
• Generally in the lower abdomen; suggests a trigger point if at the location of an old scar.
nocturia (common)
incomplete voiding (common)

headache (common)
• Commonly associated and suggests multiple pain generators are involved.
dyschezia (uncommon)
11
• A required component for the diagnosis of irritable bowel syndrome.
low back pain (uncommon)

• Commonly associated and suggests multiple pain generators are involved.
Diagnostic tests
1st test to order
Test Result
urinalysis positive/negative
• Useful to rule out the possibility of infective cystitis or urethritis.
urine culture positive/negative
• Useful to rule out the possibility of infective cystitis or urethritis.
cervical swab positive/negative
• Useful to rule out current STDs: for example, chlamydia or
gonorrhoea.
pelvic ultrasound may identify fibroids,
adenomyosis, or large
ovarian cysts
alkalinised lidocaine instillation into bladder relief of bladder pain

symptoms
• Relief of bladder pain symptoms at the time of alkalinised lidocaine
instillation is diagnostic for pain of bladder origin.
cystoscopy with hydrodistension distension
• For patients with interstitial cystitis, distension is both diagnostic and
therapeutic.
Other tests to consider

DIAGNOSIS
Test Result
pelvic CT further characterisation
of pelvic mass previously
seen on ultrasound
pelvic MRI may identify adenomyosis

• A more sensitive diagnostic test than ultrasound for the identification
of adenomyosis.
laparoscopic biopsy histological
characteristics of
• Definitive test for confirming diagnosis of endometriosis and
endometriosis or
adenomyosis.
adenomyosis
Differential diagnosis
Condition Differentiating signs / Differentiating tests

symptoms
Endometriosis • Cyclical pain in early • Laparoscopy and biopsy:
endometriosis, progressing endometrial glands and
to continuous pain. stroma.
Diagnosed based on the
presence of endometrial
glands and stroma outside of
the uterine cavity.
Adenomyosis • Initially cyclic pain, typically • Ultrasound may be

beginning after pregnancy. suggestive; definitively
Requires pathological diagnosed on pathological
examination of the excised examination of removed
uterus for definitive uterus.
diagnosis.
Pelvic adhesions • Suggested by a history • Diagnosed at laparoscopy.

of previous surgery or
infection with tenderness on
manipulation of the uterus or
adnexa.
Chronic pelvic • Suggested by a history • Diagnosed at laparoscopy.

inflammatory disease of previous infection or
multiple sexual partners with
tenderness on manipulation
of the uterus or adnexa.
Interstitial cystitis • Elevated bladder pain or the • Suggested by questionnaire

presence of irritative voiding and a response to alkalinised
symptoms. lidocaine instillation;
DIAGNOSIS
definitively diagnosed
at cystoscopy with
hydrodistension.
Vulvodynia • Pain with insertion at • Diagnosed by physical

intercourse. examination. Tenderness
limited to areas of the
vestibule only.
Levator ani syndrome • Only a portion of the levator • Diagnosed by physical

(pelvic floor tension muscle may be generating examination.
myalgia) pain.
Haemorrhagic ovarian • Typically causes severe, • Ultrasound may demonstrate

cysts acute pain but may evolve fine fibrinous strands
into chronic pain. Will suggestive of clot formation
frequently resolve with within the cystic mass.
time. Persistent, larger (>3
cm) cysts may need to be
excised.
13
Condition Differentiating signs / Differentiating tests

symptoms
Irritable bowel syndrome • Requires at least 2 of 3 • Rome III criteria; no specific
major criteria and as many diagnostic test.
minor criteria as possible to
secure the diagnosis.
Fibromyalgia • Tenderness to palpation of • Diagnosed by physical

individual muscles. In pelvic examination.
pain, these typically include
the lower, lateral borders of
the rectus sheath.
Central pain syndrome • Pain at multiple locations. • Pinprick testing reveals

Spread of pain from one increased sensation
location to another without toward the anterior midline
an obvious aetiology. compared with the back, or
allodynia (feeling a pinprick
when touched with a cotton
swab).
DIAGNOSIS
Chronic pelvic pain in women Treatment
Step-by-step treatment approach

The objective of treatment is to minimise the symptoms produced by the identified pain generators using
targeted therapy. In addition, management of psychiatric comorbidity is essential to improving outcomes.
A comprehensive history and careful physical examination is used to identify the individual pain diagnoses
present. Following this, each diagnosis is approached separately.
Gynaecological pain
A fundamental principle of medicine is the assignment of a tissue-specific aetiology as a diagnosis.
Chronic pelvic pain in women that is related to the time of menses or that is reproduced by uterine
manipulation can generally be termed gynaecological pain. Within this category, there are a wide variety
of diagnoses, including adenomyosis, endometriosis, uterine fibroids, and pelvic adhesions.[7] For most
gynaecological pain, management begins with non-steroidal anti-inflammatory drugs (NSAIDs), typically
combined with some form of ovulation suppression.[22] First-line treatment options include medical
ovarian suppression with intermittent combination oestrogen/progestin therapy (pills, patches, rings).
Intermittent dosing results in a monthly withdrawal bleed. If cyclic contraceptive management fails or the
patient has severe symptoms, a trial of continuous ovarian suppression, with the objective of eliminating
menses altogether, can be done. Medroxyprogesterone acetate provides an injectable management
option with the objective of inducing amenorrhoea. Other second-line options include the use of long-
acting hormonal contraception or the levonorgestrel-releasing IUD.[22] The levonorgestrel-releasing IUD
has been more extensively studied and has a proven efficacy in chronic pelvic pain.[23]
Induction of menopause with gonadotrophin antagonists (which can include add-back oestrogen
replacement therapy) provides the final medical management option. Several medicines and routes are
available. For convenience, and to improve compliance, some can be dosed once every 3 months.
For patients unresponsive to medical management, laparoscopy can be both diagnostic and therapeutic,
although there are significant limitations to its long-term benefit.[22] [24] As a diagnostic procedure,
endometriosis, adhesions, and other anatomical problems related to chronic pelvic pain can be found.
Often these entities can be dealt with at the same time, through fulguration or excision of endometriosis
and lysis of adhesions. When endometriosis is found and treated, follow-up treatment with menstrual
suppression improves the effect of the surgery. There remains significant questions regarding the
relationship of endometriosis and pain.[25] Nerve sprouting into endometriosis implants and central
sensitisation may be important factors in the development and maintenance of pain in some patients.[26]
Patients with inoperable endometriosis may be candidates for medically-induced menopause. Without
inducing menopause (either medically or surgically) endometriosis can be expected to recur, resulting in
repeated laparoscopy. Due to the increase in complications with every subsequent surgery, this approach
should be avoided if possible. The benefits of surgical compared to medical management have not
been conclusively demonstrated; an individualised approach based on careful patient counselling and
management of expectations can provide the best results.[27]
If childbearing is complete, hysterectomy can be very effective for gynaecological-based pain,[28] but as
TREATMENT
many as 20% of patients may return for an oophorectomy later. To completely eradicate endometriosis
a concomitant oophorectomy may also be required. Careful evaluation for other causes of chronic pelvic
pain is required to provide optimal surgical outcomes.
15
Interstitial cystitis
Many patients with interstitial cystitis (also called painful bladder syndrome) can identify dietary triggers
for their pain, which may include caffeine, acidic foods, spicy foods, and a wide range of other dietary
items. Some patients will get significant relief from careful dietary modification. This approach, while
requiring vigilance on the part of the patient, should be first-line therapy for all patients suspected of
having interstitial cystitis.[29] [30] Maintaining a food diary can help in identifying possible dietary triggers.
Medical management includes medicine - such as pentosan - to protect the lining of the bladder.
Pentosan is only effective in about 50% of patients following 6 months of therapy.[31] Pentosan is related
to heparin, and so should be avoided in patients taking concurrent anticoagulation or those at risk for
serious consequences from bleeding.
Other medical options include directly suppressing the central pain perception pathways using
amitriptyline or attempting to decrease peripheral nerve activity using gabapentin.
Bladder instillation therapy can be used with various different mixtures of drugs placed 2 or 3 times per
week for 6 weeks. Instillation is then repeated as needed. Many individual components have been tried,
including alkalinised lidocaine, heparin, dimethyl sulfoxide, and others, used in various combinations.[32]
The urethra and vulva are cleaned using a sterile antiseptic solution, and a urological syringe of lidocaine
jelly is applied to the urethra, passing the lidocaine jelly into the bladder. A thin, straight bladder catheter
is then passed through the urethra into the bladder and the instillation mixture is poured into the bladder.
Patients are asked to hold the solution as long as possible and indicate the extent, if any, of relief they
experience with the solution in their bladder. Some patients may experience prolonged relief, even after
voiding, and the change in symptoms helps gauge the probability of interstitial cystitis. The overall risks
are very low, but include urinary tract infection, which must be ruled out before therapy begins.[29]
Relief of bladder pain symptoms at the time of alkalinised lidocaine instillation is diagnostic for pain of
bladder origin, which will be interstitial cystitis if infections have been excluded. For patients who report
relief of bladder pain with instillation (for any amount of time), most can be assured of longer-term relief
from hydrodistension.
For patients with interstitial cystitis, hydrodistension is both diagnostic and therapeutic. Many different
protocols have been summarised and reviewed.[33] However, not all patients will respond to distension.
Interstitial cystitis represents a relapsing disease and distension may need to be repeated as frequently as
every 3 months. The major complication specific to distension is rupture of the bladder, which may occur
as frequently as 10% in some series. Optimisation of medical management decreases the need for repeat
hydrodistension. Other surgical approaches to interstitial cystitis, such as enterocystoplasty, should be
avoided.[29]
A neurostimulator implantation is used when all other efforts to control pain have failed.[34] Several
different devices are available, all of which rely on placement of an electrode onto the pudendal nerve
or other nerve root under anaesthesia guidance. An electrical pulse is then tonically produced to
suppress nerve action. The response rate varies between 40% and 70%; however the data supporting
neurostimulator use are limited.[35]
TREATMENT
Fibromyalgia
Fibromyalgia and muscle-based pain can be managed with anti-inflammatory medicines and
physiotherapy as first-line therapy.
Medical management can further include amitriptyline and gabapentin.[36]
Trigger-point injection is a second-line therapy and can be done using a variety of agents. Initially, precise
infiltration of the tender area with local anaesthetics (such as 1% lidocaine) can produce immediate relief
and be both diagnostic and therapeutic. Patient response to trigger-point injection may include prolonged
relief, minimal relief, or a short-term flare of symptoms once the anaesthetic has worn off. Patients who
cannot identify a discrete trigger point (or points) are unlikely to benefit. A reproducible tender area should
be discerned before injection. Patients should be queried during injection to assure that the actual trigger
point is treated. Failure to relieve symptoms indicates either that the trigger point was missed, or that the
patient does not have a trigger point amenable to injection therapy. Patients with trigger points who have
the correct point injected will report immediate relief of symptoms, which should be reproducible by the
examiner. Due to the action of local anaesthetics, a burning sensation will always precede pain relief.
Repeat injections may be necessary and can also be done using botulinum toxin, or dry needling
(acupuncture). Some patients will respond to trigger-point release massage or physiotherapy.[20]
Some controversy exists regarding treating patients empirically with neurolytics. A detailed examination
to support the diagnosis of central pain can help to determine whether these medications are worth the
risks.
Levator ani syndrome (pelvic floor tension myalgia)

Levator ani syndrome (pelvic floor tension myalgia) is treated similarly to fibromyalgia. Initial management
includes NSAIDs and physiotherapy, often called Thiele massage. Most patients can tolerate some level
of physiotherapy, particularly massage. The addition of physiotherapy can frequently improve symptoms
in compliant patients.[37] Stretching exercises of the affected muscle groups may also be beneficial.
Exercise may exacerbate muscle-based symptoms.
Trigger-point injection has demonstrated benefit, although some patients decline this approach.[20]
Vulvodynia
A topical anaesthetic applied to the affected area prior to coitus may control vulvodynia and permit
comfortable intercourse.[38] Using lidocaine on a long-term basis failed to provide significant response
beyond placebo.[39]
Amitriptyline or gabapentin can be used as an adjunct in a manner similar to fibromyalgia.[40]
If first-line approaches fail, careful excision of the painful area can be considered. Partial removal of the
vestibule can be considered in carefully selected patients. Such patients should have clear evidence
of provoked pain localised to small areas of the vestibule and have failed conservative management.
Caution must be taken to avoid vaginal stenosis following excision.
Treatment details overview

TREATMENT
Consult your local pharmaceutical database for comprehensive drug information including contraindications,
drug interactions, and alternative dosing. ( see Disclaimer )
Ongoing ( summary )
17
Ongoing ( summary )
interstitial cystitis
1st avoidance of dietary triggers ± pentosan
adjunct amitriptyline or gabapentin
2nd bladder instillation or hydrodistension, or

neurostimulator implantation
gynaecological pain
1st NSAIDs + cyclical ovarian suppression
plus paracetamol
2nd NSAIDs + continuous ovarian suppression
adjunct paracetamol
3rd NSAIDs + induced menopause
adjunct paracetamol
4th surgery
fibromyalgia or levator ani syndrome
1st NSAIDs + physiotherapy
adjunct paracetamol
adjunct amitriptyline or oral gabapentin
2nd trigger-point injection
vulvodynia
1st topical local anaesthetic
1st topical gabapentin
2nd excision
TREATMENT
Treatment options
Ongoing
interstitial cystitis
1st avoidance of dietary triggers ± pentosan

Primary options
» dietary modification
Secondary options
» pentosan polysulfate sodium: 100 mg orally

three times daily
» Many patients with interstitial cystitis (also

called painful bladder syndrome) can identify
dietary triggers for their pain, which may include
caffeine, acidic foods, spicy foods, and a wide
range of other dietary items. Some patients
will get significant relief from careful dietary
modification. This approach, while requiring
vigilance on the part of the patient, should be
first-line therapy for all patients suspected of
having interstitial cystitis.[29] [30] Maintaining a
food diary can help in identifying possible dietary
triggers.
» Medical management includes medicines to

protect the lining of the bladder. Pentosan is
effective only in about 50% of patients following
6 months of therapy.[31] Pentosan is related to
heparin, and so should be avoided in patients
taking concurrent anticoagulation or those at risk
for serious consequences from bleeding.
» Pentosan may also be added following

discovery of glomerulations or Hunner's ulcers at
the time of hydrodistension.
Primary options
» amitriptyline: 10-25 mg orally once daily at

night
OR
» gabapentin: 300 mg orally once daily on the

first day, followed by 300 mg twice daily on
day 2, followed by 300 mg three times daily
TREATMENT
on day 3, then increase dose according to

response, maximum 3600 mg/day
» Other medical options include directly

suppressing the central pain perception
pathways using amitriptyline or attempting
19
Ongoing
to decrease peripheral nerve activity using
gabapentin.
2nd bladder instillation or hydrodistension, or
neurostimulator implantation
Primary options
» bladder instillation
OR
» cystoscopy with hydrodistension
Secondary options
» neurostimulator implantation
» In patients not responding to oral medical

therapy, bladder instillation or hydrodistension
may be used.
» Bladder instillation therapy can be done with

several different drug combinations placed 2 or 3
times per week for 6 weeks.
» Instillation is then repeated as needed. The

overall risks are very low, but include urinary
tract infection, which must be ruled out before
therapy begins.[29]
» There are many individual components

that have been tried in interstitial cystitis,
including alkalinised lidocaine, heparin, dimethyl
sulphoxide, and others. All can be mixed
into various cocktails. There is no standard
approach.
» Relief of bladder pain symptoms at the time

of alkalinised lidocaine instillation is diagnostic
for pain of bladder origin, which will be interstitial
cystitis if infections have been excluded. For
patients who report relief of bladder pain with
instillation (for any amount of time), most
can be assured of longer-term relief from
hydrodistension.
» For patients with interstitial cystitis,

hydrodistension is both diagnostic and
therapeutic. There are many different protocols
that have been summarised and reviewed.[33]
» Not all patients will respond to distension.

TREATMENT
Interstitial cystitis represents a relapsing disease

and distension may need to be repeated as
frequently as every 3 months.
» The major complication specific to distension

is rupture of the bladder, which may occur as
Ongoing
frequently as 10% in some series. Interstitial
cystitis is a relapsing disease in many cases,
so patients should expect multiple treatments.
Optimisation of medical management decreases
the need for repeat hydrodistension.
» A neurostimulator implantation is used when

all other efforts to control pain have failed.[34]
Several different devices are available, all of
which rely on placement of an electrode onto
the pudendal nerve or other nerve root under
anaesthesia guidance. An electrical pulse is then
tonically produced to suppress nerve action. The
response rate varies between 40% and 70%;
however the data supporting neurostimulator use
are limited.[35]
gynaecological pain
1st NSAIDs + cyclical ovarian suppression

Primary options
» ibuprofen: 400-800 mg orally every 4-6

hours when required, maximum 2400 mg/day
-or-
» naproxen: 500 mg orally twice daily when
required, maximum 1250 mg/day
-or-
» diclofenac potassium: 50 mg orally
(immediate-release) two to three times daily
when required, maximum 150 mg/day
-or-
» celecoxib: 100 mg orally twice daily when
required
--AND--
» oral contraceptive (cyclical): consult product
literature for guidance on dosage
» For gynaecological pain caused by

endometriosis, adenomyosis, or dysmenorrhoea,
or of unknown aetiology, management begins
with non-steroidal anti-inflammatory drugs
(NSAIDs) typically combined with some form of
ovulation suppression.[22]
» Continuous (not 'as required') NSAID

administration is appropriate and effective
for patients with chronic pain from all organ
systems. These act at the end-organ level to
decrease prostaglandins, inflammation, and
nociception.
TREATMENT
» Most NSAIDs are well tolerated, and all have a

very similar level of efficacy in equivalent doses.
» Standard oral contraceptive precautions apply:

that is, pregnancy must be ruled out and therapy
21
Ongoing
should be avoided in smokers older than 35
and in those with oestrogen-sensitive cancer or
thrombophilia. It is recommended that regimens
are not changed more frequently than every 3
months, because most side effects will abate
during this time.
» Alternatives to cyclic suppression with oral,

transdermal, vaginal,[41] or injected hormones
include levonorgestrel-releasing intrauterine
devices.
plus paracetamol
Primary options
» paracetamol: 500-1000 mg orally every 4-6

» Non-steroidal anti-inflammatory drugs should

not be used alone with the expectation of pain
control but combined with paracetamol as
required.
2nd NSAIDs + continuous ovarian suppression
Primary options

-or-
-or-
-or-
required
--AND--
» oral contraceptive (continuous): consult
product literature for guidance on dosage
-or-
» medroxyprogesterone: 150 mg
intramuscularly every 3 months; 104 mg
subcutaneously every 3 months
-or-
» levonorgestrel intrauterine device: insert
into uterus and replace every 3-5 years as
required
» If cyclical ovarian suppression treatment fails,

TREATMENT
a trial of non-steroidal anti-inflammatory drugs

(NSAIDs) with continuous ovarian suppression
(with the objective of eliminating menses
altogether) can be tried.
Ongoing
» Standard oral contraceptive precautions apply:
that is, pregnancy must be ruled out and therapy
should be avoided in smokers older than 35
and in those with oestrogen-sensitive cancer or
thrombophilia. It is recommended that regimens
are not changed more frequently than every 3
months, because most side effects will abate
during this time.
» Pregnancy must be ruled out and an

appropriate start date chosen for ovarian
suppression. Medroxyprogesterone provides an
injectable management option. Levonorgestrel-
releasing devices provide menstrual suppression
through localised delivery of a progesterone to
the uterus. They last for 3 to 5 years depending
upon brand; small devices are more suitable for
nulligravidas.

nociception. Most are well tolerated and all have
a very similar level of efficacy in equivalent
doses.
adjunct paracetamol
Primary options


required.
3rd NSAIDs + induced menopause
Primary options

-or-
-or-
-or-
TREATMENT

required
--AND--
» leuprorelin: 3.75 mg intramuscularly once
monthly; or 11.25 mg every 3 months
23
Ongoing
Given in combination with oestrogen-
replacement therapy.
» In patients who have failed to respond to

cyclical and continuous ovarian suppression
treatment, induction of menopause with
gonadotrophin antagonists (which can include
oestrogen-replacement therapy) is the final
medical management option. Several medicines
and routes are available. For convenience and to
improve compliance, some can be dosed once
every 3 months.
» Two injectable medicines have proven

beneficial: medroxyprogesterone and leuprorelin.
For induced menopausal symptoms, add-back
therapy with oestrogen may be required, but this
does not decrease the efficacy of the treatments.
» Continuous (not 'as required') non-steroidal

anti-inflammatory drug (NSAID) administration
is appropriate and effective for patients
with chronic pain from all organ systems.
These act at the end-organ level to decrease
prostaglandins, inflammation, and nociception.
Most are well tolerated and all have a very
similar level of efficacy in equivalent doses.
adjunct paracetamol
Primary options


required.
4th surgery
» If a patient has failed to respond to all attempts

at medical management, surgical options can
then be considered. Laparoscopy may be both
diagnostic and therapeutic. Even with no visible
pathology, laparoscopy may provide symptom
relief for some patients. Endometriosis visible
on laparoscopy typically is deeply invading
the underlying structure and will need to be
resected rather than fulgurated to provide
optimal response.
» If childbearing is complete, hysterectomy can

TREATMENT
be very effective for gynaecological-based pain.

A trial of medical therapy is mandatory before
undergoing the risks of surgery.
» Hysterectomy alone is frequently effective, but

as many as 20% of patients may return for an
Ongoing
oophorectomy later.[28] To completely eradicate
endometriosis a concomitant oophorectomy may
also be required.
» This will result in an absolute loss of

childbearing capability and result in surgical
menopause, which may be poorly tolerated
by younger women. Oestrogen replacement
therapy will be required, with its attendant
risks of thrombosis and cancer. For patients
with endometriosis, oophorectomy represents
definitive management.
fibromyalgia or levator ani syndrome
1st NSAIDs + physiotherapy

Primary options

-or-
-or-
-or-
required
--AND--
» physiotherapy
» Fibromyalgia and muscle-based pain

such as levator ani syndrome (pelvic floor
tension myalgia) can be managed with non-
steroidal anti-inflammatory drugs (NSAIDs)
and physiotherapy as first-line therapy.
Most patients can tolerate some level of
physiotherapy, particularly massage. The
addition of physiotherapy can frequently improve
symptoms in compliant patients.[37] Stretching
exercises of the affected muscle groups may
also be beneficial. Exercise may exacerbate
muscle-based symptoms.

TREATMENT
nociception. Most are well tolerated and all have

a very similar level of efficacy in equivalent
doses.
adjunct paracetamol
Primary options
25
Ongoing

required.
adjunct amitriptyline or oral gabapentin
Primary options

night
OR
» gabapentin: 300 mg orally once daily on the

first day, followed by 300 mg twice daily on
day 2, followed by 300 mg three times daily
» Other medical options include directly

suppressing the central pain perception
pathways using amitriptyline or attempting
to decrease peripheral nerve activity using
gabapentin.
2nd trigger-point injection
» If a patient is not responding to non-steroidal

anti-inflammatory drugs (NSAIDs) and
physiotherapy, a second-line option is trigger-
point injection.
» Trigger-point injection can be done using a

variety of agents. Initially, precise infiltration of
the tender area with local anaesthetics (such as
1% lidocaine) can produce immediate relief and
be both diagnostic and therapeutic.
» Patient response to trigger-point injection

may include prolonged relief, minimal relief,
or a short-term flare of symptoms once the
anaesthetic has worn off.
» 10 mL of 0.5% bupivacaine with epinephrine

(adrenaline) 1:200,000 would be appropriate for
longer-term pain control.
» Repeat injection may be necessary and can

also be done using botulinum toxin, or dry
TREATMENT
needling.
vulvodynia
1st topical local anaesthetic
Ongoing
» A topical anaesthetic applied to the affected
area prior to coitus may control vulvodynia and
permit comfortable intercourse.[38]
» Another approach is to apply lidocaine jelly to

the vestibule every night for several weeks in a
row in an effort to induce a remission.
Primary options

night
OR
» gabapentin: 300 mg orally once daily on

the first day, followed by 300 mg twice daily
on day 2, followed by 300 mg 3 times daily
» Amitriptyline or gabapentin can be used as an

adjunct in a manner similar to fibromyalgia.
1st topical gabapentin
Primary options
» gabapentin topical: (5% gel) apply to vulva

twice daily
» Topical gabapentin is not routinely available,

but is effective.[42] This formulation requires
preparation by the pharmacist.
2nd excision
» If first-line approaches fail, careful excision of

the painful area can be considered.
» Partial removal of the vestibule can be

considered in carefully selected patients. Such
patients should have clear evidence of provoked
pain localised to small areas of the vestibule and
have failed conservative management. Caution
must be taken to avoid vaginal stenosis following
excision.
TREATMENT
27
Emerging
Meditation
Depending on patient motivation and skill at meditation, significant reductions in pain can be achieved.[43]
Meditation (through any means, including yoga, tai chi, or transcendental meditation) activates the prefrontal
cortex and induces a reduction of activity in limbic structures, particularly the anterior cingulate gyrus.[44]
[45]
Aerobic exercise
Vigorous and prolonged (45 minutes or more) aerobic exercise induces the production of cerebral
endorphins, which decrease ascending pain signals. This can be very effective in chronic pain.[46]
Focused imagery
This is an experimental version of meditation that is performed within a magnetic resonance imaging (MRI)
magnet. Using functional MRI (fMRI) sequences, the activity of the anterior cingulate cortex (ACC) is
determined and a proportional, analogous image produced of a bonfire. The patient in the MRI is then shown
the image through special video glasses, and she attempts to decrease the size of the bonfire, all while
the fMRI continues to calculate the ACC activity. This process relies on prefrontal cortex to directly control
the anterior cingulate. Patients require extensive training to accomplish this task, and access to a specially
equipped MRI. Preliminary results have been encouraging, but mostly support the use of medicine for pain
control.[47]
Ondansetron
A small placebo-controlled study demonstrated significant relief with intravenous administration for patients
with chronic pain. This is postulated to work through modulation of limbic serotonin receptors.[48]
TREATMENT
Chronic pelvic pain in women Follow up
Recommendations
Monitoring
FOLLOW UP
Many patients with chronic pelvic-pain-associated diagnoses will require frequent follow-up and should
expect a lifetime of medical management. The interval for monitoring is usually chosen by the patient or
when a pain flare occurs.
Patient instructions
These are based on the underlying diagnosis and the stage of the patient's treatment. For all patients,
exercise, meditation, and guided imagery (directed thoughts that lead to a relaxed state) can provide
benefit with little risk. When multiple diagnoses are present, a pain diary or journal can assist the
physician in determining times of day or stressors that can be related to pain. Similarly, a food diary can
often aid in the diagnosis of interstitial cystitis or irritable bowel syndrome. Both of these can have dietary
triggers, which can be avoided.
Complications
Complications Timeframe Likelihood

surgical complications short term medium
A wide range of complications are possible, most presenting in the acute period.
Surgical complications are generally managed surgically. Individual circumstances will dictate appropriate
options.
drug-seeking behaviour long term low
Some patients with narcotic addiction will present with chronic pain in an effort to secure their supply of
narcotics.
Patients with primarily drug-seeking behaviour will often demonstrate global pain in all areas and
will refuse all management options that do not include narcotics. Insistence on non-narcotic first-line
management will deter these patients.
failure of pain management variable high
Failure to manage chronic pain is the most common complication and the most difficult to manage. Even
with an optimal medical evaluation and management, some patients will still have intractable, cryptogenic
pain.
Supportive counselling and encouragement of lifestyle changes such as exercise and meditation may
permit more accurate diagnosis when pain can be at least somewhat controlled. For these patients,
avoidance of mutilating interventions is important.
29
Chronic pelvic pain in women Follow up
Prognosis
FOLLOW UP
Many conditions in chronic pelvic pain are controllable but not curable. Most have a relapsing-remitting
course and may require a lifetime of treatment.
Some gynaecological conditions such as fibroids, adenomyosis, or endometriosis can be definitively

managed with extirpative surgery. This is not an option for other associated conditions such as interstitial
cystitis, irritable bowel syndrome, and fibromyalgia. These diseases frequently follow a relapsing-remitting
course with variable response at any one time to any particular treatment. Stress from life events will usually
precipitate a flare of symptoms.
Patients may still have pain following definitive surgery due to other, undiagnosed, pain generators. Some
patients have a brain predisposed to pain perception, and when all pain generators are optimally managed,
they may present with a new pain in a different area, such as the low back, or leg.
Chronic pelvic pain in women Guidelines
Diagnostic guidelines
Europe
Guidelines on chronic pelvic pain

Published by: European Association of Urology Last published: 2017
ESHRE guideline on the management of women with endometriosis

Published by: European Society of Human Reproduction and Last published: 2013
Embryology
North America
ACR-SPR-SSR practice parameter for the performance and interpretation of

magnetic resonance imaging (MRI) of the hip and pelvis for musculoskeletal
GUIDELINES
disorders
Published by: American College of Radiology; Society for Pediatric Last published: 2016
Radiology; Society of Skeletal Radiology
Diagnosis and treatment of interstitial cystitis/bladder pain syndrome

Published by: American Urological Association Last published: 2014
Treatment guidelines
Europe
United Kingdom national guideline for the management of pelvic

inflammatory disease
Published by: British Association for Sexual Health and HIV Last published: 2018
Guidelines on chronic pelvic pain

Published by: European Association of Urology Last published: 2017
ESHRE guideline on the management of women with endometriosis

Published by: European Society of Human Reproduction and Last published: 2013
Embryology
Sexually transmit ted infections in primary care (2nd ed.)

Published by: Royal College of General Practitioners; British Last published: 2013
Association for Sexual Health and HIV
The initial management of chronic pelvic pain

Published by: Royal College of Obstetricians and Gynaecologists Last published: 2012
31
Chronic pelvic pain in women Guidelines
Europe
Laparoscopic uterine nerve ablation (LUNA) for chronic pelvic pain

Published by: National Institute for Health and Care Excellence Last published: 2007
Laparoscopic techniques for hysterectomy

Published by: National Institute for Health and Care Excellence Last published: 2007
North America
Sexually transmit ted diseases treatment guidelines, 2015: clinical prevention

guidance
Published by: Centers for Disease Control and Prevention Last published: 2015
Sexually transmit ted diseases treatment guidelines, 2015: pelvic

GUIDELINES
inflammatory disease
Published by: Centers for Disease Control and Prevention Last published: 2015
Diagnosis and treatment of interstitial cystitis/bladder pain syndrome

Published by: American Urological Association Last published: 2014
Management of endometriosis
Published by: American College of Obstetricians and Gynecologists Last published: 2010 (re-
affirmed 2017)
Chronic pelvic pain in women Online resources
Online resources
1. International Pelvic Pain Society: history and physical form (external link)
ONLINE RESOURCES
33
Chronic pelvic pain in women References
Key articles
• Engeler D, Baranowski AP, Borovicka J, et al; European Association of Urology. Guidelines on chronic
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• American College of Obstetricians and Gynecologists. Practice bulletin no. 114: management of
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• Yunker A, Sathe NA, Reynolds WS, et al. Systematic review of therapies for noncyclic chronic pelvic
pain in women. Obstet Gynecol Surv. 2012 Jul;67(7):417-25. Abstract
• Hanno PM, Erickson D, Moldwin R, et al; American Urological Association. Diagnosis and
treatment of interstitial cystitis/bladder pain syndrome: AUA guideline amendment. J Urol. 2015
May;193(5):1545-53. Abstract
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37
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Contributors:
// Authors:
Bradford W. Fenton, MD, PhD

Consultant
Obstetrics and Gynecology, Independence Park Medical Services, Anchorage, AK
DISCLOSURES: BWF has served as a consultant for Advance Medical and a Guidepoint Global Board
Member for the International Pelvic Pain Society.
// Acknowledgements:
Dr Bradford W. Fenton would like to gratefully acknowledge the assistance of Dr Jennifer J. Schmitt in
producing this topic. JJS declares that she has no competing interests.
// Peer Reviewers:
Howard Sharp, MD
Associate Professor and Chief
General Division of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
DISCLOSURES: HS has been reimbursed for attending and participating in conferences on pelvic varicosity
pain syndrome by Cook Inc.
Chris Spencer, MD
Consultant Obstetrics
Obstetrics and Gynaecology, Middlesex Hospital, London, UK
DISCLOSURES: CS declares that he has no competing interests.
Dan Selo-Ojeme, MBA, FWACS, FMCOG, MRCOG

Consultant Obstetrician and Gynaecologist
Barnet and Chase Farm Hospitals NHS Trust, Urogynaecology Services, Chase Farm Hospital, Enfield, UK
DISCLOSURES: DS-O declares that he has no competing interests.

Chronic Pelvic Pain in Women: The Right Clinical Information, Right Where It's Needed

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Chronic pelvic

The right clinical information, right where it's needed

Last updated: Mar 29, 2018

◊ Complications are inherent to all treatments, which frequently include surgery.

Step-by-step diagnostic approach

Laboratory evaluation and imaging

pelvic inflammatory disease

drug or alcohol abuse

previous caesarean section

History & examination factors

abdominal trigger points (common)

levator ani tenderness (common)

cervical motion tenderness (common)

uterine tenderness (common)

abdominal tenderness (uncommon)

vestibular tenderness (uncommon)

rectal tenderness (uncommon)

adnexal tenderness (uncommon)

bladder tenderness (uncommon)

urethral tenderness (uncommon)

Other diagnostic factors

incomplete voiding (common)

low back pain (uncommon)

alkalinised lidocaine instillation into bladder relief of bladder pain

Other tests to consider

pelvic MRI may identify adenomyosis

Condition Differentiating signs / Differentiating tests

Adenomyosis • Initially cyclic pain, typically • Ultrasound may be

Pelvic adhesions • Suggested by a history • Diagnosed at laparoscopy.

Chronic pelvic • Suggested by a history • Diagnosed at laparoscopy.

Interstitial cystitis • Elevated bladder pain or the • Suggested by questionnaire

Vulvodynia • Pain with insertion at • Diagnosed by physical

Levator ani syndrome • Only a portion of the levator • Diagnosed by physical

Haemorrhagic ovarian • Typically causes severe, • Ultrasound may demonstrate

Condition Differentiating signs / Differentiating tests

Fibromyalgia • Tenderness to palpation of • Diagnosed by physical

Central pain syndrome • Pain at multiple locations. • Pinprick testing reveals

Step-by-step treatment approach

Levator ani syndrome (pelvic floor tension myalgia)

Amitriptyline or gabapentin can be used as an adjunct in a manner similar to fibromyalgia.[40]

Treatment details overview

1st avoidance of dietary triggers ± pentosan

adjunct amitriptyline or gabapentin

2nd bladder instillation or hydrodistension, or

1st NSAIDs + cyclical ovarian suppression

2nd NSAIDs + continuous ovarian suppression

3rd NSAIDs + induced menopause

fibromyalgia or levator ani syndrome

1st NSAIDs + physiotherapy

adjunct amitriptyline or oral gabapentin

2nd trigger-point injection

1st topical local anaesthetic

adjunct amitriptyline or gabapentin

1st topical gabapentin

1st avoidance of dietary triggers ± pentosan

» pentosan polysulfate sodium: 100 mg orally

» Many patients with interstitial cystitis (also

» Medical management includes medicines to

» Pentosan may also be added following

» amitriptyline: 10-25 mg orally once daily at

» gabapentin: 300 mg orally once daily on the

on day 3, then increase dose according to

» Other medical options include directly