Pelvic pain: Clinical features

There is not a consensus on chronic pelvic pain definition; its common clinical characterization is a noncyclic pain perceived in the pelvic area that persists continuously or episodically for 3–6 months or longer and is unrelated to pregnancy. The prevalence of chronic pelvic pain ranges from 4 to 16 percent among fertile women but is very difficult to investigate because of lack of concordance on the definition and referral pattern. It has a great number of potential etiologies due to multiple components; indeed, differential diagnosis includes a wide range of pathologies involving various organs and functions. The most common causes of chronic pelvic pain involve gynecological, urological, gastrointestinal, and musculoskeletal diseases, followed by neurological and psychosocial disorders. However, in many cases nonspecific etiology can be identified. A correct evaluation of cause and, consequently, appropriate management of diagnosis and therapy require a targeted evaluation of the syndrome. The location and the characteristics of the pain, and the factors that provoke or alleviate it, are necessary to perform differential diagnosis. Moreover, an accurate physical examination is essential to achieve a correct evaluation of chronic pelvic pain, including complete abdominal and pelvic examinations, and psychosocial evaluation, with assessment for mental health issues and social disability. Diagnostic strategy should be targeted on symptoms, epidemiology, and physical examination, to avoid an excess of tests with increase of costs without any benefits. Some first-line screening tests for the most frequent causes of chronic pelvic pain are widely recommended, such as urinalysis, to exclude urinary tract infection, pregnancy test, and microbiologic tests for sexually transmitted infections. Imaging tests are not recommended routinely. Pelvic ultrasonography is the most common method used to investigate the pelvis and highlight the main organ-specific pathologies related to chronic pelvic pain, such as endometriosis, adenomyosis, or pelvic and adnexal masses. Indeed, magnetic resonance imaging should be performed in women suspected of having deep infiltrating endometriosis; computerized tomography scan can be performed when an unclear abdominal acute process is present or when acute enteritis or colitis is suspected; and pelvic venography can be suggested in case of pelvic venous congestion doubt, if skilled operators are available. Furthermore, anal manometry has a role in the suspicion of irritable bowel syndrome, and urodynamic testing could be used in women with bladder pain. Given the lack of specificity and the uncertainty on the mechanisms that cause the pain, the multifactorial nature of chronic pelvic pain should always be discussed with the patient, and management should be agreed with her from the beginning.