Key Learning Points

• Chronic pelvic pain (CPP) is pelvic pain that has persisted for six months or more. The amount of pain is often greater than the degree of pathology.

• Gynecologic causes of CPP can be divided into noncyclic and cyclic.

• Primary and secondary dysmenorrhea are cyclic. Primary dysmenorrhea is best treated with nonsteroidal antiinflammatory drugs (NSAID) and hormonal contraceptives; treatment of secondary dysmenorrhea depends on the etiology, but both may respond to menstrual supression.

• The most prevalent cyclic gynecologic cause of CPP is endometriosis.

• The pain with endometriosis is most likely associated with deeply infiltrating lesions. Numerous medical and surgical techniques are available for treatment.

• Pelvic pain, urinary urgency, urinary frequency, and frequent nocturia without evidence of urinary tract infection are suggestive of painful bladder syndrome or interstitial cystitis.

• Eliciting a trigger point or localizing tenderness to a specific branch of a somatic nerve is indicative of neuropathic pain. Injection of local anesthetic can be diagnostic as well as therapeutic.

• Psychological factors impact the perception and maintenance of pain. Depression and a history of physical and/or sexual abuse are common and should be addressed. Cognitive behavioral therapy is an important component of multidisciplinary management.

• Physical examination should encompass not only the pelvic viscera system, but also the musculoskeletal and neurologic systems.

• Management of CPP should involve a multidisciplinary approach for maximal benefit. Individual components of therapy may include:

- pharmacologic therapy: NSAIDs, antidepressants, anticonvulsants, and possibly narcotics, depending on the presumed etiology of the pain, trigger point injections, and local anesthetic nerve blocks.

- physical therapy including consideration of transcutaneous electric nerve stimulation (TENS) unit device in cases where there is a myofascial contribution to the pain.

• Vulvar vestibulitis, vestibulodynia vulvar dermatoses, cyclic vulvovaginitis, and dysesthetic vulvodynia are subtypes of vulvodynia.

• The etiology of vulvodynia may be infectious, trauma, allergens, underlying dermatologic, neurologic, urologic, or systemic conditions.

• Vulvar vestibulitis is vulvar pain characterized by entry dyspareunia, vestibular erythema, and vestibular tenderness.

• Therapies for vulvodynia depend on results of evaluation, and may include antifungal agents, antihistamines, topical corticosteroids, topical or injected local anesthetics, and estrogen.

• Tricyclic antidepressants, anticonvulsants, biofeedback and physical therapy of pelvic floor muscles, and cognitive-behavioral therapy may enhance the above therapies.

• Surgical intervention (perineoplasty - total or subtotal) should be offered in cases of vulvar vestibulitis resistant to medical therapy.

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