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Chronic Pelvic Pain Syndrome (in Women) Glos Care Pathway

This pathway has been designed to clarify the management of Chronic Pelvic Pain Syndrome in women in Gloucestershire.

Chronic pelvic pain is common, affecting perhaps one in six of the adult female population. Much

remains unclear about its aetiology, but chronic pelvic pain should be seen as a symptom with a number of contributory factors rather than as a diagnosis in itself.

As with all chronic pain it is important to consider psychological and social factors as well as physical causes of pain. Many non-gynaecological conditions such as nerve entrapment or irritable bowel syndrome (IBS) may be relevant. Women often present because they seek an explanation for their pain.

The assessment process should allow enough time for the woman to be able to tell her story. This may be therapeutic in itself. A pain diary may be helpful in tracking symptoms or activities associated with the pain.

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Presentation

​Woman with more than or equal to 6 months localised pain to the anatomic pelvis, anterior abdominal wall at or below the umbilicus, lumbosacral back, or buttocks

  • intermittent or constant
  • not exclusive to menstruation or intercourse, not associated with pregnancy
  • severe enough to cause functional disability or require medical care
  • considered a symptom, not a diagnosis
Red Flags
Red Flag Symptoms:
  • Bleeding per rectum
  • New bowel symptoms in patients over 50 years old
  • New pain after the menopause
  • Pelvic mass
  • Suicidal ideation
  • Excessive weight loss
  • Irregular vaginal bleeding in patients over 40 years old
  • Postcoital bleeding
RED FLAG CONDITIONS – ADMIT DIRECT VIA ED
  • Suspected appendicitis
  • Suspected strangulated hernia
  • Suspected ectopic pregnancy
Suspected Cancer – Refer via 2ww Pathway
Initial Primary Care Assessment

  • Initial history should include questions about the pattern of the pain and its association with other problems. These may include bladder and bowel symptoms and the effect of movement and posture on the pain.
  • Questions should be addressed regarding psychological and social issues.
  • Although many symptom complexes (eg. IBS) and pain perception itself may vary a little with the menstrual cycle (50% of women experience a worsening of their symptoms in association with their period), strikingly cyclical pain is usually gynaecological in nature - e.g. endometriosis.

Abdomen

Assess for:

  • focal tenderness
  • enlargement or masses
  • identification of highly localised trigger points in abdominal wall
  • surgical scars

 

Pelvic

Assess for:

  • focal tenderness
  • enlargement or masses
  • distortion or tethering
  • pelvic organ prolapse
  • identification of highly localised trigger points in pelvic wall
  • dorsal lower back pain, tender sacroiliac joints or symphysis pubis may indicate musculoskeletal origin
  • pelvic tenderness and nodularity on palpitation of uterosacral ligament and rectovaginal fascia may indicate endometriosis
  • check for cervical discharge
  • cotton-tipped swab test - to assess for pain response genital structures are gently probed with a cotton tip swab

  • Samples to screen for infection (particularly chlamydia and gonorrhoea) should be considered in all those who are sexually active.
  • If there is any suspicion of pelvic inflammatory disease (PID). Ideally, all sexually active women below the age of 25 years who are being examined should be offered opportunistic screening for chlamydia.
  • Urinalysis, midstream specimen of urine (MSU).
  • High vaginal swab (HVS) for bacteria and endocervical swab.
  • Pregnancy test.
  • FBC.
  • Transvaginal ultrasound is an appropriate investigation to screen for and assess adnexal masses.
  • Urgent ultrasound (if miscarriage or ectopic pregnancy is suspected).
  • Laparoscopy.​
Causes / Diagnosis

Often multifactorial - common causes include:

Musculoskeletal:

Musculoskeletal pain may be a primary source of pelvic pain or an additional component resulting from postural changes.

Nerve entrapment:

Nerve entrapment in scar tissue, fascia or a narrow foramen may result in pain and dysfunction in the distribution of that nerve.

Psychological and social causes of chronic pelvic pain may include:

Initial Primary Care Management

Management is focussed on identifying and treating the cause but the psychosocial causes and effects of chronic pelvic pain should also be considered. The management of chronic pelvic pain is challenging, as despite interventions involving surgery, many women remain in pain without a firm gynaecological diagnosis.

The multifactorial nature of chronic pelvic pain should be discussed and explored from the start. The aim should be to develop a partnership between the clinician and the woman to plan a management programme.

Completing a daily pain diary for two to three menstrual cycles may help the woman and the doctor identify provoking factors or temporal associations. The information may be useful in understanding the cause of the pain.

If pain is not adequately controlled, there may be a need to refer the patient to a pain management team.  Consultant colleagues with a special interest in Abdominopelvic Pain syndromes are available in Cheltenham.

  • Hormonal treatment for a period of 3–6 months:
    • Oral contraceptive pill, progestogens, danazol or Gonadotropin-releasing hormone (GnRH) analogues
    • Levonorgestrel-releasing intrauterine system
  • Antispasmodics for irritable bowel syndrome (IBS)
  • Referral to a pain management team if necessary
  • Dietary modification for IBS
  • Analgesics for pain
When to Refer
  • Referral is required if the diagnosis cannot be established and/or if there is no response to treatment in primary care.
  • If the history suggests a non-gynaecological component to the pain, referral to a gastroenterologist, urologist, genitourinary specialist, physiotherapist (see the GHFT website for chronic pelvic pain physiotherapy information), psychologist or psychosexual counsellor should be considered.
  • If pain is not adequately controlled, there may be a need to refer the patient to a pain management team.  Consultant colleagues with a special interest in Abdominopelvic Pain syndromes are available in Cheltenham.
Secondary Care Management

Secondary care management may include:

  • Hysterectomy
  • Laparoscopic surgical destruction may be considered for:
    • endometriosis lesions
    • pelvic peritoneal defect
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