In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.
Levels of evidence (Ia-IV) and grading of recommendations (A-C) are defined at the end of the "Major Recommendations" field.
Possible Aetiological Factors in Chronic Pelvic Pain
The concept of the biophysical model describes this complex interplay of physical and psychosocial factors. Possible contributory factors are separated out for the purposes of discussion, but the problem must be seen as a whole by both patient and doctor.
C - Pelvic pain which varies considerably over the menstrual cycle may be due to a variety of hormonally driven conditions (Scialli, 1999).
C - It is thought that adhesions may be a cause of pain, particularly on organ distension or stretching. Dense vascular adhesions are likely to be a cause of chronic pelvic pain, as dividing them appears to relieve pain. However, adhesions may be asymptomatic.
Adhesions may be caused by endometriosis, previous surgery, or previous infection. Two distinct forms of adhesive disease are recognised: residual ovary syndrome (a small amount of ovarian tissue inadvertently left behind following oophorectomy which may become buried in adhesions) and trapped ovary syndrome (in which a retained ovary becomes buried in dense adhesions following hysterectomy). Removal of all ovarian tissue or suppression using a gonadotropin-releasing hormone (GnRH) agonist may relieve pain.
B - Symptoms suggestive of irritable bowel syndrome or interstitial cystitis are often present in women with chronic pelvic pain. These conditions may be a primary cause or a component of chronic pelvic pain.
B - Musculoskeletal pain may be a primary source of pelvic pain or an additional component resulting from postural changes.
C - Nerve entrapment in scar tissue, fascia, or a narrow foramen may result in pain and dysfunction in the distribution of that nerve.
B - Addressing psychological and social issues which commonly occur in association with chronic pelvic pain may be important in resolving symptoms.
Depression and sleep disorders are common in women with chronic pain. This may be a consequence rather than a cause of their pain but specific treatment may improve the woman's ability to function. [Evidence level III]
Assessment
History
B - Symptoms alone may be used to diagnose irritable bowel syndrome positively in this age group (Fass et al., 2001; Jones et al., 2000)
Several validated symptom-based tools are also available for the detection of psychological comorbidity. However, simply enquiring generally about things at home and symptoms such as sleep or appetite disturbance and tearfulness may be enough.
Examination
C - Suitable samples to screen for infection, particularly chlamydia and gonorrhoea, should be taken 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 (Pimenta et al., 2003).
A positive result from the cervix supports but does not prove the diagnosis of PID. The absence of infection does not rule out the diagnosis of PID. If PID is suspected clinically, this condition is best managed by a genitourinary medicine physician in order that up-to-date microbiological advice and contact tracing can be arranged. [Evidence level IV]
Initial Management
A - The multifactorial nature of chronic pelvic pain should be discussed and explored from the start. The aim should be to develop a partnership between clinician and patient to plan a management programme.
Many women with chronic pelvic pain can be managed in primary care. General practitioners might consider referral when the pain has not been explained to the woman's satisfaction or when pain is inadequately controlled.
Investigations
Laparoscopy
C - Diagnostic laparoscopy has been regarded in the past as the "gold standard" in the diagnosis of chronic pelvic pain. It may be better seen as a second line of investigation if other therapeutic interventions fail.
The risks and benefits of diagnostic laparoscopy and the possibility of negative findings should be discussed before the decision is made to perform a laparoscopy. Perhaps it should only be performed when the index of suspicion of adhesive disease or endometriosis requiring surgical intervention is high, or when the woman has specific concerns which could be addressed by diagnostic laparoscopy, such as the existence of endometriosis or adhesions potentially affecting her fertility.
B - Diagnostic laparoscopy may have a role in developing a woman's beliefs about her pain.
Imaging
B - Transvaginal scanning is an appropriate investigation to screen for and assess adnexal masses.
B - Transvaginal scanning and magnetic resonance imaging (MRI) are useful tests to diagnose adenomyosis. The role of MRI in diagnosing small deposits of endometriosis is uncertain.
While MRI lacks sensitivity in the detection of endometriotic deposits, it may be useful in the assessment of palpable nodules in the pelvis or when symptoms suggest the presence of rectovaginal disease. It may also reveal rare pathology. [Evidence level III]
Therapeutic Options
A - Women with cyclical pain should be offered a therapeutic trial using the combined oral contraceptive pill or a GNRH agonist for a period of 3-6 months before having a diagnostic laparoscopy. The levonorgestrel-releasing intrauterine system could also be considered.
A - Women with irritable bowel syndrome should be offered a trial of antispasmodics.
B - Women with irritable bowel syndrome should try amending their diet to control symptoms.
Summary
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, 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.
Where pain is strikingly cyclical and no abnormality is palpable at vaginal examination, a therapeutic trial of a GnRH agonist may be more helpful than a diagnostic laparoscopy. Other conditions, such as irritable bowel syndrome, require specific treatment. Even if no explanation for the pain can be found initially, attempts should be made to treat the pain empirically and to develop a management plan in partnership with the woman.
Definitions:
Grading of Recommendations
Grade A - Requires at least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation (evidence levels Ia, Ib)
Grade B - Requires the availability of well-conducted clinical studies but no randomised clinical trials on the topic of recommendations (evidence levels IIa, IIb, III)
Grade C - Requires evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities. Indicates an absence of directly applicable clinical studies of good quality (evidence level IV)
Levels of Evidence
Ia: Evidence obtained from meta-analysis of randomised controlled trials
Ib: Evidence obtained from at least one randomised controlled trial
IIa: Evidence obtained from at least one well-designed controlled study without randomisation
IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study
III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies
IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities
