Chronic Pelvic Pain
What is chronic pelvic pain? By definition, it is pain that is located in the lower abdominal or groin region. It is noncyclical in nature. It has been present for more than 3 to 6 months and is not exclusively associated with intercourse or menstruation. Twenty-five percent of adult-community-living women have issues of chronic pelvic pain, and in the majority of women the etiology is never fully elucidated.
The limitations of the above definition are obvious. It does not address the male population. Men also have issues of chronic pelvic pain; however, they are less likely to seek out medical evaluation.
Establishing the diagnosis presents a challenge. Many times the interplay between the urological, gynecological, as well as gastrointestinal systems can complicate the presentation. Additionally neurological, endocrinologic, and psychological issues can all add confounding layers to the presentation and pain. Lastly the musculoskeletal system can have dramatic impact on pelvic pain or can be the primary source generator for pelvic pain.
Unfortunately the musculoskeletal system is not typically thought of as a source of pelvic pain until many providers have been seen, multiple tests have been performed, and in many instances many procedures have been done. In essence it becomes the default organ system.
Common Presenting Complaints and Symptoms
Chronic pelvic pain (CPP) patients commonly present with complaints of pain with Valsalva type activities, such as straining to have a bowel movement. They may note pain with ambulation, prolonged sitting, lumbar flexion, and/or extension. A quick look at the following complaints leads one to realize the lack of specificity of these complaints. They can be seen in lumbar degenerative disc disease, disc herniation, as well as in posterior element dysfunction, such as facet joint arthritis. Pain with extension and ambulation can be seen in spinal stenosis. Groin pain with ambulation may be secondary to degenerative joint disease of the hip. Patients may additionally complain of urinary urgency, frequency, as well as sensory dysesthesias in the perineum. Males can complain of erectile dysfunction. The complaints of urinary urgency and frequency can be seen not only in primary urological issues such as benign prostatic hypertrophy, but are frequently noted in patients with cervical or thoracic level myelopathy. Sensory dysesthesias can be seen in myelopathies as well as cauda equine level dysfunction. Erectile dysfunction can be seen in both upper motor neuron and lower motor neuron dysfunction. Realizing that pelvic pain can arise from multiple pathologies, the criticality of the history and physical cannot be overemphasized.
This section will focus primarily on the musculoskeletal system as the source generator for pelvic pain, as it is the most frequently overlooked system.
The physical exam starts with observation. Note how the patient ambulates. Do they walk with a compensated Trendelenburg gait pattern? Primary hip pathology, as well as a possible profound L5 radiculopathy, needs to be explored. In the setting of an L5 radiculopathy that is severe enough to cause a compensated Trendelenburg, an associated foot drop should also be noted. If one is not present, the diagnosis of L5 radiculopathy is highly unlikely, as nerve function recovers proximal to distal. However, isolated superior gluteal nerve neuropathy, gluteus medius muscle tear, or primary hip pathology all remain in the differential. Observe sitting posture. Patients that are comfortable sitting or sitting forward flexed may have facet joint arthritis, or spinal stenosis. Patients that prefer to stand or sit with lumbar support may have issues of discogenic pain.
A complete pelvic pain workup must include a thorough examination of the musculoskeletal system. It should include an assessment of lumbosacral spine motion and gait evaluation. Additionally, manual muscle testing should be performed on both lower extremities to compare side to side, and should include assessment of strength of the hip flexors, knee extensors, as well as ankle toe dorsiflexors and plantar flexors. Given the strength of the ankle plantar flexors, having the patient perform multiple calf raises will sometimes elucidate subtle weakness of S1 innervated musculature not appreciated on manual muscle testing. In addition, heel walking may bring out slight weakness of ankle dorsiflexors not appreciated on physical exam.
Evaluation of reflexes is critical. Notation of hyperreflexia, ankle clonus, crossed adductors, and positive Babinski raises the specter of a central nervous system level dysfunction. Abnormal findings in the upper extremities manifesting with overflow reflex activity and hyperreflexia, Hoffmann’s sign, with associated sensory symptoms in the hands, and concomitant cervical radicular distribution of weakness raise the specter of cervical level dysfunction. Brain level dysfunction needs to be considered in the setting of diffuse upper and lower extremity hyperreflexia, with long tract signs without a clear-cut cervical radicular pattern of weakness that localizes a cervical root level issue in concert with cervical cord compression. A clear radicular level of weakness in the upper extremities on manual muscle testing with hyperreflexia below is classic for a radiculo-myelopathy and warrants magnetic resonance imaging (MRI) of the cervical spine. Diffuse hyperreflexia, with associated weakness in a more diffuse or patchy nonradicular distribution, especially in young women with appropriate historical data, including changing neurological symptoms over time in addition to issues of vision loss, transient foot drop, or wrist drop, should raise an index of suspicion for multiple sclerosis. At that point, MRI of the brain and spinal cord both with and without contrast would be very reasonable. Diffuse lower extremity hyporeflexia can be seen in peripheral neuropathies, or polyradiculopathies. Unilateral sensory dysesthesias involving the perineum should raise the question of a symptomatic Tarlov cyst. It is important to remember that not all Tarlov cysts are asymptomatic or incidental findings, and their symptomatic presentation is commonly limited to the perineum, with sensory complaints noted. Additionally, males may note erectile dysfunction, and women may note changes in clitoral sensitivity. In this scenario, detailed physical exam to assess sensation in the perineum as well as reflex testing of the bulbocavernosus reflex in men and the clitoral-anal reflex in women is critical. Workup for a suspected Tarlov cyst should include sacral MRI as well as needle electromyography (EMG) of the right and left anal sphincter musculature looking for denervation, as well as changes in typical motor unit morphology. Needle EMG of the anal sphincter should only be done by people with significant experience in evaluating this muscle as the normal anal sphincter motor units look abnormal in comparison to typical motor units seen in appendicular skeletal muscles. Work by Podnar et al. revealed that in males, abnormal penile sensation in concert with an abnormal or absent bulbocavernosus reflex on physical exam was highly correlative to abnormal electrodiagnostic testing. Unfortunately in women, the clitoral-anal reflex can be difficult to obtain on physical exam, and as such in this group, electrophysiologic testing, including reflex testing and anal sphincter EMG, may have great utility. Normal reflexes in the upper extremities with loss of reflexes in the lower extremities can be seen in patients with peripheral neuropathy. The history will be critical at that point to determine whether or not this is potentially a hereditary neuropathy that has now progressed to the point where it is becoming symptomatic versus an acquired neuropathy. Causes of acquired neuropathies can range from cryptogenic to toxic metabolic to autoimmune, inflammatory mediated, and require detailed workup to avoid missing treatable causes. Other causes of lower motor neuron findings isolated to the lower extremities can include cauda equina, but this will typically manifest with marked lower extremity weakness in a polyradicular pattern weakness, as well as marked sensory dysfunction in the perineum. While myopathies are not a common cause of pelvic pain, patients who note that their symptoms worsen throughout the day and note cramping pelvic pain, especially after straining during a bowel movement, may be exhibiting findings of muscle fatigue of proximal musculature with prolonged activity. Physical examination and detailed manual muscle testing may reveal a proximal to distal gradient of motor weakness or possibly patterns of weakness such as scapula humeral peroneal or facial scapula humeral peroneal. In these instances, preexercise and postexercise creatine phosphokinase (CPK) levels may be very illustrative, as the patient may have a normal to minimally elevated CPK at rest only to have it rise markedly 24 to 36 hours postregular and routine exercise. This group of patients may note on direct questioning that they are always sore in their muscles after they exercise, but assume it is normal, as they have always felt this way. In most instances, the complaints of pelvic level pain in patients with myopathy is secondary to altered gait mechanics, with subsequent overload of the SI joint of lumbar facet joints in patients who stand and walk with excessive lumbar lordosis as a result of manifest proximal weakness. Typically in adults this would be seen in limb girdle dystrophies or adult onset myopathies.
Hip joint pathology can be a common source of pelvic region pain. True intraarticular hip joint pathology will classically cause groin pain. Patients will complain of pain with weight bearing and walking. Pain will improve when they are sedentary. Additionally, use of a cane in the contralateral hand will ease their pain. Startup pain is a common phenomenon, but unfortunately is not unique to hip joint pathology. Physical exam findings will classically include replication of groin pain with internal rotation of the affected hip. Proxy referral patterns of pain include radiating anterior thigh pain or referral to the knee with internal rotation of the hip. Intraarticular hip joint pathology can present many challenges when it becomes part of the differential diagnosis for the workup for pelvic pain. It is not an uncommon finding in an aging population, and as such can also be associated with degenerative changes in the lumbar spine. The physical exam may help delineate the driver of the patient’s pain, but if doubt persists as to the role the hip is playing in the patient’s pain complaints, a diagnostic and potentially therapeutic intraarticular hip joint injection, done either under fluoroscopic guidance or ultrasound, can easily be done. A markedly positive response to the injection will quickly confirm the clinical suspicion, and a negative response efficiently removes the joint from the equation and allows the physician to turn his or her attention to other potential source generators.
Anterior groin pain and associated pelvic level pain in younger patients may be due to labral pathology. Patients may note that their pain worsens with standing and walking. Unlike hip pain from degenerative joint disease (DJD), patients with femoral acetabular impingement (FAI) with labral pathology may also complain of pain while seated. Additionally, FAI may also have replication of groin pain with external rotation of the hip as well as hip abduction. Complaints of sudden sharp pain with clicking and a sensation of give way weakness can also be seen with FAI. The differential diagnosis is rather extensive when FAI is entertained and includes such entities as iliopsoas impingement, subspine impingement, and ischiofemoral impingement. Iliopsoas impingement, more common in women than men, may be secondary to repetitive traction injury to the tendon with subsequent scarring and adherence of the tendon to the capsule-labrum complex of the hip. This can be seen in younger patients involved in sports and activities that place the patient in positions of extreme hip extension or rapid eccentric loading of the hip flexors. Subspine impingement, more common in men than women, is thought to be the result of a prominent anterior superior iliac spine (ASIS) abnormally contacting the distal femoral neck. Symptoms in this case are typically seen with attempts at deep hip flexion (catchers in softball and baseball). The etiology of the prominent ASIS may be secondary to repetitive avulsion type injury to the ASIS during repetitive knee flexion with hip extension type activities (soccer players). Ischiofemoral impingement is typically more commonly seen in women than men. It results from a tight space between the ischial tuberosity and the lesser trochanter, causing repetitive impingement and trapping of the quadratus femoris muscle. This is typically a congenital issue, but can develop after hip fracture, or in association with early superior and medial migration of the femoral head in early hip DJD. While imaging studies clearly have a role and place in the workup of anterior groin and pelvic level pain, all findings need to be placed into context. The context grows from the physical exam. Previous work by Silvis et al. revealed a high prevalence of abnormal findings on MRI of pelvis, hip, and groin regions on a cohort of asymptomatic college and professional hockey players. These abnormalities included common adductor and rectus abdominus tendonitis, with associated bone edema in the symphysis pubis. Additionally, partial tears as well as complete tears of the above muscles off the pubis were noted. Finally, hip abnormalities including labral tears, as well as osteochondral lesions of the femoral head, were noted. To further cloud the picture, similar findings have been noted on lumbar MRIs in asymptomatic patients (Brandt-Zawadz et al).
As one can see, hip joint pathology and its associated groin level pain can present unique challenges as part of the workup for pelvic pain. The physical exam is critical in helping delineate the driver of the patient’s pain. Sometimes, even after detailed physical exam, it may still be difficult to determine if intraarticular or extraarticular sources are the primary source generator for the patient’s groin and pelvic level pain. In these scenarios where doubt persists as to the role intraarticular joint pathology is playing in the patient’s pain complaints, a diagnostic and potentially therapeutic intraarticular hip joint injection, done either under fluoroscopic guidance or ultrasound, can easily be done. A markedly positive response to the injection will quickly confirm the clinical suspicion, and a negative response efficiently removes the joint from the equation and allows the physician to turn his or her attention to other potential source generators.
In summary, pelvic pain presents many unique challenges for the treating physician. Many of these patients have seen multiple providers and have had multiple procedures performed. These patients not uncommonly present with a high level of frustration as well as a degree of mistrust for the medical community, as they have often been shuffled from provider to provider. Obtaining a detailed history and performing a thorough physical can go a long way to elucidating the problem. Sometimes just getting the patient to understand why they have their pain goes a long way in helping them manage their pain. It all starts with the history and physical and the trust that develops over time as the patient grows to realize that you as the treating physician are taking a measured, thoughtful approach to their pain.
- 1. Chronic pelvic pain may result from a variety of etiologies, including intrapelvic sources and pain that is referred from nonpelvic sources.
- 2. Numerous medications may contribute to chronic lower abdominal pain; thus, this needs to be considered when evaluating a patient with chronic pelvic pain.
- 3. Chronic pelvic pain does not only occur in women.
- 4. EDX specifically needle EMG of the anal sphincter is highly sensitive for evaluation of S2-S4 nerve function.
- 5. Physical examination of the pelvic pain patient must include assessment of lower extremity strength and reflexes.