Clinical overview
Chronic pelvic pain (CPP) is defined as non-cyclical pain of at least 6 months' duration, in the pelvic region of either sex, severe enough to cause functional disability or to lead to medical care. In gynaecology practice the figure is closer to 15–25% of women of reproductive age experiencing CPP at some point. It is a diagnosis where the registrar's job is not to find a single causal lesion and excise it — that approach fails most patients. The job is to characterise the pain, identify all contributing mechanisms, address each systematically, and walk alongside the patient through what is often a multi-year management arc.
CPP is the diagnosis where biomedical thinking alone fails. A purely structural lens ("find the lesion, cut it out") misses central sensitisation, comorbid mood disorder, sexual function impact, and the role of physiotherapy and psychology. The biopsychosocial model is not a soft optional add-on — it is the first-line approach. Conversely, a purely psychological framing is harmful when there is a treatable structural cause being missed. The skill is to hold both lenses simultaneously.
The chapter covers definition and epidemiology, the multiple contributing mechanisms (gynaecological, urological, gastrointestinal, musculoskeletal, neuropathic, central sensitisation, psychosocial), systematic assessment, evidence-based interventions, and the place of surgery — which is smaller than registrars often assume.
Core knowledge
Mechanisms contributing to CPP
Chronic pelvic pain usually reflects overlapping gynaecological, urological, bowel, pelvic floor and neuropathic contributors.
It is almost always multifactorial. The contributors:
Gynaecological.
- Endometriosis — see Endometriosis pathophysiology. Up to 70% of women with CPP have endometriosis at laparoscopy, but the correlation between lesion volume and pain severity is poor.
- Adenomyosis — myometrial endometriosis-equivalent, presents with dysmenorrhoea + heavy menstrual bleeding + bulky tender uterus.
- Pelvic adhesions — from previous surgery, PID, endometriosis. Evidence that adhesiolysis improves CPP is weak overall; reserved for selected cases.
- Pelvic congestion syndrome — ovarian vein incompetence with engorged pelvic veins. Worse on standing and after sex.
- Chronic PID / hydrosalpinx — residual inflammation post acute infection.
- Fibroids — see Fibroids; rarely the sole cause of pain, more often heavy bleeding.
- Ovarian remnant syndrome — residual ovarian tissue post-oophorectomy causing cyclical pain.
Urological.
- Interstitial cystitis / bladder pain syndrome — bladder filling pain, urgency, frequency, nocturia, often dramatically improved on void.
- Recurrent UTI.
- Urethral diverticulum.
Gastrointestinal.
- Irritable bowel syndrome — Rome IV criteria; coexists with CPP in up to 50%.
- Inflammatory bowel disease — needs exclusion in any chronic pain with bowel symptoms.
- Coeliac disease — rarely presents as CPP but should be considered.
- Chronic constipation, diverticular disease.
Musculoskeletal.
- Myofascial pain syndromes — trigger points in pelvic floor (levator ani spasm), abdominal wall, gluteal muscles.
- Pubic symphysis dysfunction, sacroiliac joint dysfunction.
- Hip pathology referred (e.g., labral tear).
- Pelvic floor hypertonicity / non-relaxing pelvic floor — a common, treatable cause that requires specific pelvic floor physiotherapy.