Musculoskeletal Causes of Chronic Pelvic Pain What a Gynecologist Should Know Anthony Gyang, MD, Melissa Hartman, DO, and Georgine Lamvu, MD, MPH Ten percent of all gynecologic consultations are for chronic pelvic pain, and 20% of patients require a laparos- copy. Chronic pelvic pain affects 15% of all women annually in the United States, with medical costs and loss of productivity estimated at $2.8 billion and $15 billion per year, respectively. Chronic pelvic pain in women may have multifactorial etiology, but 22% have pain associated with musculoskeletal causes. Unfortunately, pelvic musculo- skeletal dysfunction is not routinely evaluated as a cause of pelvic pain by gynecologists. A pelvic musculoskeletal examination is simple to perform, is not time-consuming, and is one of the most important components to inves- tigate in all chronic pelvic pain patients. This article describes common musculoskeletal causes of chronic pelvic pain and explains how to perform a simple muscu- loskeletal examination that can be easily incorporated into the gynecologist physical examination. (Obstet Gynecol 2013;121:645–50) DOI: http://10.1097/AOG.0b013e318283ffea C hronic pelvic pain affects 15% of all women annu- ally in the United States, with medical costs and loss of productivity estimated at $2.8 billion and $15 billion per year, respectively. 1,2 Chronic pelvic pain is defined as the presence of pain in the pelvic region for more than a 6-month period that can orig- inate from the gynecologic, urologic, gastrointestinal, and musculoskeletal systems. Fifteen percent of women will experience pelvic pain at some time in their lives, with yearly direct medical costs estimated at approximately $2.8 billion. 2 Of the estimated 10 million women with chronic pelvic pain, less than 70% will receive proper diagnosis and treatment plans and 61% of patients will remain undiagnosed. 3 Many patients with pelvic pain will go on to have develop- ment of chronic pain syndrome with depression, pain out of proportion to pathology, and changing roles in marriage, family, and career. 3 The location of pain may be vague and difficult for patients to define, or it may include specific symptoms of dyspareunia, voiding dysfunction, con- stipation, and low back, buttock, vaginal, vulvar, and lower abdominal pain. 4 In 1991, Reiter et al reported the prevalence of musculoskeletal disorders to be 8% in the United States; however, a study by Frank Tu et al in 2006 estimated the prevalence to be in a much higher range of 14%–22%. 5,6 Therefore, in addition to gynecologic causes, it is important to evaluate other potential etiologies including the pelvic musculoskel- etal system. Unrecognized musculoskeletal pain may result in unnecessary surgery and also may be impor- tant in the development and maintenance of other pain syndromes such as painful bladder syndrome. 7 The purpose of this article is to describe common musculoskeletal causes of chronic pelvic pain and to explain how to perform a simple musculoskeletal examination that can be easily incorporated into the gynecologist physical examination. ANATOMY To understand how musculoskeletal dysfunction causes chronic pelvic pain, we must first have a clear understanding of the anatomy of the pelvis. The pelvic floor muscles consist of deep, superficial layers and their fascia providing support for the pelvic organs. The deep levator ani layer, which consists of the pubococcgyeus, puborectalis, iliococcygeus, and coccygeus muscles, have their origin from the arcus From Advanced and Minimally Invasive Gynecology, Florida Hospital, and Family and Women’s Health at Avalon Park, Orlando, Florida. Corresponding author: Anthony Gyang, MD, Advanced and Minimally Invasive Gynecology, 2415N Orange Avenue, Orlando, FL 32804; e-mail: tonygyang@ hotmail.com. Financial Disclosure The authors did not report any potential conflicts of interest. © 2013 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/13 VOL. 121, NO. 3, MARCH 2013 OBSTETRICS & GYNECOLOGY 645 Current Commentary