CHRONIC PELVIC PAIN © 2005 The Medicine Publishing Company Ltd 5 WOMEN’S HEALTH MEDICINE 2:1 Chronic pelvic pain: a practical approach Rajesh Varma Janesh Gupta Chronic pelvic pain is a complex disorder associated with multiple and often overlapping conditions. It is therefore vital to have a holistic approach to management and not one that is focused on a potential solitary pathology. A systematic approach to history and examination is mandatory to establish appropriate investigation, treatment and referral. Chronic pelvic pain is more common than was previously recognized. • Population-based studies report the prevalence of chronic pelvic pain among women aged 18–50 years in the US and UK to be 15% and 24% respectively. 1,2 • In the UK, the annual prevalence of chronic pelvic pain in pri- mary care is estimated to be 3.8% in women aged 15–73 years, which is higher than the prevalence of migraine (2.1%), and is similar to that of asthma (3.7%) and back pain (4.1%). 3 • Chronic pelvic pain accounts for 10% of all outpatient referrals to gynaecologists, 40% of gynaecological diagnostic laparoscopies, and 10–15% of all hysterectomies. 4 Direct annual costs of health care for chronic pelvic pain in the United States is around $880 million, which escalates to over $2 billion when combined with indirect costs (e.g. time off work). 1 There is substantial overlap between chronic pelvic pain, gynaecological and non-gynaecological disorders. However, there is only limited epidemiological evidence supporting a causal role for many of these disorders. This ambiguity between association and causality is presented in Figure 1 where predisposing factors are classified by the level of causality evidence. Women may develop chronic pelvic pain at all ages, although the prevalence of different diagnoses varies at different ages. Medical, surgical and psycho- logical therapies have been shown to help women with chronic pelvic pain, but treatment needs to be individualized given the multiple possible aetiologies and biopsychosocial circumstances. Assessment The assessment process is vital to establish underlying pathol- ogy and also represents a powerful therapeutic opportunity. It is imperative the clinician acknowledges the symptoms, adopts a non- judgemental sympathetic approach, and also makes it clear from the outset that a definitive diagnosis may not be attainable. Rajesh Varma is a MRC Clinical Fellow in Obstetrics and Gynaecology at Birmingham Women’s Hospital, UK. He qualified from University of Cambridge and Guy’s and St Thomas’ Medical School in 1995. He is currently researching the genetic basis of endometriosis and associated ovarian cancer in collaboration with the Medical Research Council, Cancer Research UK and Oxford University Endometriosis Group. Janesh Gupta is Senior Lecturer in Obstetrics and Gynaecology at Birmingham Women’s Hospital, UK. He qualified in Leeds in 1987. He is currently undertaking multicentre clinical trials in the treatment of pelvic pain (LUNA trial), endometriosis (ELITE study) and menorrhagia (HTA grant). He provides a nationally recognized centre for the management of endometriosis and pelvic pain. History and examination In most women, the findings of a comprehensive history and physical examination are likely to provide a basis for a differential diagnosis. Knowledge of the risk factors and conditions associated with chronic pelvic pain should be taken into account. 5–7 The indi- vidual patterns of present and absent factors can then be used to infer the most likely underlying disorder(s). Realizing that every anatomical structure in the abdomen and pelvis could have a role in the aetiology of pain is an aide mémoire to the components of the history and examination. Examination should be conducted in the presence of a chaperone at all times. A pre-written pelvic pain questionnaire (available online from the International Pelvic Pain Society) 8 may also be admin- istered. This could be completed in privacy by the woman prior to the next consultation, and help prepare the woman for any awkward or embarrassing questions the ‘face-to-face’ consulta- tion may pose. Multi-disciplinary approach It is important to distinguish gynaecological from any co-existing non-gynaecological causes. This is particularly important in primary care, where diagnoses related to gastrointestinal and urological disorders are more common in women with chronic pelvic pain than gynaecological disorders (37% and 31% vs. 20% respectively). 9,10 A UK questionnaire study showed that 50% of women with chronic pelvic pain also had either genitourinary symptoms or irritable bowel syndrome, or both. 11 Because two or more disorders often co-exist, problems have been encountered when designing validated diagnostic algorithms and clinical care pathways for women with chronic pelvic pain. 6,12 Consequently, assessment should adopt a multi-disciplinary approach, which should consider all contributing biological, psy- chological, and social factors. In primary care, this may involve consultation with the practice nurse, psychologist or counsellor. In secondary care, pain specialists from nursing, psychological or anaesthetic backgrounds should form part of a multi-disciplinary pelvic pain clinic. 13–16 Referrals to other clinical disciplines, such as gastroenterology, general surgery, psychiatry, orthopaedics and neurology, could then be made after initial assessment or after investigative tests. ‘Chronic pelvic pain accounts for 10% of all outpatient referrals to gynaecologists...’