Case of the Month #4: Lower abdominal pain in a young woman

Chronic pelvic pain accounts for around 20% of all gynaecology consultations¹. 

What is chronic pelvic pain?

The Royal College of Obstetrics and Gynaecology Green Top Guidelines on the management of chronic pelvic pain describe it as an intermittent, constant pain in the lower abdomen or pelvic that occurs in women for at least 6 months, that is not exclusively associated with menstruation, intercourse or pregnancy². However, due to new International Association of the Study of Pain classification of chronic pain for the ICD-11, this definition is likely to encompass pain that lasts longer than 3 months^2,3.   

The aetiology of chronic pelvic pain is complex, as there are multiple organs in the pelvis, all or some of which may contribute to the pain experienced. Consequently there are multiple biological, psychological and social factors which can contribute. A comprehensive review of these can be found in an up to date review by Vincent and Evans³, however they include gynaecological conditions such as endometriosis, dysmenorrhoea, vulval pain syndrome, fibroids and pelvic inflammatory disease; gastrointestinal conditions such as inflammatory bowel disease and irritable bowel syndrome; urogenital conditions such as interstitial cystitis; nerve entrapment; chronic post surgical pain; adhesions; chronic pain conditions; musculoskeletal dysfunction, especially of the pelvic floor; and important psychological contributors such as adverse childhood experiences, sleep disorders, anxiety, depression, stress and high pain catastrophising ³.   

How does it present? 

As already described the complex anatomical makeup of the pelvis combined with multiple contributing conditions, means symptoms can be multiple and span different pain modalities including visceral, neuropathic and nociceptive.  Additional functional symptoms including dysuria, diarrhoea and heavy menstrual bleeding may all occur.   

How is it assessed and investigated? 

Chronic pelvic pain is unlikely to be secondary to a single pathology and therefore all possible contributing factors should be assessed for. Often by the time of the first consultation in the pain clinic, women have been extensively investigated and seen multiple healthcare professionals. This can be accompanied by feelings of being dismissed by other healthcare teams therefore time needs to be taken to explore all previous interactions, explanations of their pain, investigations and treatments.  

The initial consultation also needs to ensure any red flag symptoms for serious conditions such as malignancy have been ruled out. These include rectal bleeding, new bowel symptoms in women over 50-years-old, new pain after the menopause, pelvic masses, suicidal ideation, excessive weight loss, irregular vaginal bleeding in under 40-year-olds and post coital bleeding. A detailed history of symptoms needs to be obtained including sexual history, gynaecological and obstetric history, gastrointestinal and urinary symptoms, influence of movement and posture on pain and a psychological history. Targeted physical examination can be performed but may not be necessary if recent reviews by other specialties including gynaecology. 

A thorough review of previous investigations and all treatments and surgeries.  In the chronic pain clinic it is unlikely additional investigations will be required but ensure screening for serious causes included sexually transmitted diseases and malignancy have been performed, if relevant. 

Management and prognosis 

Chronic pelvic pain requires a multidisciplinary team approach to management.  This is best delivered by specialist services that have experience in delivering multi-professional integrated services for chronic pelvic pain. Often patients have had a long journey to get to the clinic and need time to discuss previous diagnoses and explanations given by other healthcare professionals.  There is little evidence regarding use of analgesics however non-steroidal anti-inflammatory can be helpful.  

Pharmacotherapy should avoidance opioids, as there is little evidence supporting their use in chronic pain and they may exacerbate bowel and hormonal symptoms. Hormonal therapies especially for women with cyclical symptoms and dysmenorrhoea is helpful, however details of prescribing practice is outside the scope of this case report and is summarised well by Vincent and Evans in their reference below³.  Physiotherapy represents a key component of care, especially if a woman has pelvic floor dysfunction, however this needs to be delivered by someone experienced in working in women's health and pelvic pain. 

The second key component to care is psychological approaches that need to be tailored to patient.  These may focus on psychological strategies used in other pain settings such as cognitive behavioural therapy or acceptance commitment therapy however may involve individual counselling, psychosexual or relationship counselling.