Chronic Pelvic Pain Signs and Symptoms

Introduction

• A persistent, distressing, and severe pain symptom of >6 months duration (not a clinical diagnosis)
• Occurs intermittently, cyclically, or situationally
• Localizes to the pelvis of either men or women, anterior abdominal wall at or below the umbilicus, the lumbosacral back, or the buttocks
• May be severe enough to cause functional disability or need medical care
• Not restricted to intercourse or menstruation in females and is not associated with pregnancy

Definition

• Chronic primary pelvic pain syndrome (CPPPS)
  • Considered when there is no proven infection or without obvious pathology but still including biological mechanisms that may account for the pain being experienced
  • Should be further subdivided into its corresponding phenotype
• Chronic secondary pelvic pain
  • There is well-defined pathology or specific disease-associated pain

Etiology

• The following are the common causes of CPP
• Treatment is directed towards the specific condition and according to its specific guidelines

The following are the common causes of CPP Treatment is directed towards the specific condition and according to its specific guidelines
Gastrointestinal:	Gynecological:	Musculoskeletal:	Psychiatric/Neurological:	Urological:	Others:
Irritable bowel syndrome1	Endometriosis1	Myofascial pain (trigger points)	Depression1	Interstitial cystitis	Infectious diseases
Inflammatory bowel disease1	Dysmenorrhea1	Pelvic floor myalgia and spasms/prolapse	History of or current physical or sexual abuse	Urethral syndrome	Mesh infection
Abscess	Pelvic adhesions	Pelvic girdle pain	Sleep disturbance	Chronic urinary tract infection1	Sickle cell disease
Chronic appendicitis	Pelvic inflammatory disease1	Coccygodynia	Nerve entrapment syndrome	Bladder stones or dysfunction	Porphyria
Constipation1	Vulvodynia	Stress fractures	Psychological stress (work, marital)	Urolithiasis1	Hyperparathyroidism1
Diverticulitis1	Chronic endometritis	Chronic back pain	Substance abuse	Urological malignancies1	Herpes zoster1
Neoplastic lesions	Adenomyosis	Disc disease	Neurologic dysfunction	Chronic prostatitis	Heavy metal poisoning
Chronic intermittent bowel obstruction	Gynecologic malignancies1	Levator ani syndrome	Neuropathic pain1		Genetic mechanisms
Hemorrhoids1	Deformities/prolapse	Hernias	Somatoform pain disorders
Anal fissure1	Ovarian cysts/mass1	Musculoskeletal and connective tissue disease or malignancies	Schizophrenia1, schizotypal and delusional disorders
Proctitis	Residual ovary syndrome
	Ovarian remnant syndrome
	Post-hysterectomy pain
	Pelvic congestion syndrome
	Fibroids or leiomyomas1
1Please refer to the corresponding disease management chart for further information

Pathophysiology

• A complex and not well understood with several contributory factors
• Mechanisms include:
  • Acute pain which may be due to affectation of the visceral and/or somatic tissues
  • Chronic pain which may be due to:
    • The effects of inflammatory and chemical mediators and hormones on the nervous system
    • Abnormalities or dysfunction of the cognitive, behavioral, emotional, and sexual responses and mechanisms