Chronic pelvic pain

The list of differentials is vast and a full clinical picture is required. A full list is given on this page - although the most common are:

• Endometriosis

  • Cyclical pain in early endometriosis, progressing to continuous pain. Diagnosed based on the presence of endometrial glands and stroma outside of the uterine cavity

  • Laparoscopy and biopsy; endometrial glands and stroma

• Adenomyosis

  • Ectopic endometrial tissue within the uterine myometrium

  • Initially cyclic pain, typically beginning after pregnancy. Requires pathological examination of the excised uterus for definitive diagnosis

  • Ultrasound may be suggestive; definitively diagnosed on pathological examination of removed uterus

• Chronic PID

  • History of previous infection or multiple sexual partners with tenderness on manipulation of the uterus or adnexa

  • Diagnosed at laparoscopy

• Interstitial cystitis

  • Elevated bladder pain or the presence of irritative voiding symptoms

  • Suggested by questionnaire and a response to alkalinised lidocaine instillation; definitively diagnosed at cystoscopy with hydrodistension

• Vulvodynia

  • Pain with insertion at intercourse

  • Diagnosed by physical examination - tenderness limited to areas of the vestibule only

• Haemorrhage ovarian cysts

  • Typically cause severe, acute pain but may evolve into chronic pain. Will frequently resolve with time. Persistent larger cysts (>3cm) will need to be excised.

  • Ultrasound may demonstrate fine fibrinous strands suggestive of clot formation within the cystic mass.

• Levator ani syndrome (pelvic floor tension myalgia)

  • Only a portion of the levator muscle may be generating pain

  • Diagnosed by physical examination

Gynaecological

• Adhesions

• Adenomyosis

• Adnexal cysts

• Chronic endometritis

• Gynecologic malignancies

• Leiomyomata

  • Smooth muscle tumour (benign)

• Pelvic congestion syndrome

  • Pelvic venous insufficiency and pelvic varicosities. Presents with non cyclical positional lower back, pelvis and upper thigh pain. Dyspareunia and prolonged postcoital discomfort.

• PID

• Fibroids

Urological

• Bladder malignancy

• Chronic UTI

• Interstitial cystitis

• Radiation cystitis

• Urolithiasis

Gastrointestinal

• Coeliac disease

• IBDs

• Colon cancer

• IBS

MSK

• Degenerative disk disease

• Fibromyalgia

• Levator ani syndrome

  • Pelvic floor dysfunction

• Peripartum pelvic pain syndrome

• Stress fractures